Description
Multiple-gated acquisition (MUGA) scanning uses radiolabeled red blood cells to scan right and left ventricular images in a cine loop format that is synchronized with the electrocardiogram.

A prior MUGA scan is not an indication for repeat MUGA (if another modality would be suitable, i.e., TTE).

Abbreviations

BACKGROUND
The two types of radionuclide studies commonly used for cardiac evaluation are myocardial perfusion imaging and ventriculography. Myocardial perfusion imaging is used primarily for the evaluation of coronary artery disease. Ventriculography is sometimes referred to as multiple gated acquisition scanning (MUGA) and is primarily used to evaluate valvular disease and cardiomyopathies. Either type of study may be obtained at rest or stress.

Radionuclide Ventriculography is a medical imaging test used to determine a patient's cardiac function in the right, or more typically, left ventricle. Cardiac ventriculography involves injecting a radioisotope into the heart's ventricle(s) through a peripheral vein to measure the volume of blood pumped. Both regional and global left ventricular function (ejection fraction) as well as left ventricular size is measured.

AUC Score
A reasonable diagnostic or therapeutic procedure care can be defined as that for which the expected clinical benefits outweigh the associated risks, enhancing patient care and health outcomes in a cost effective manner.⁸

Appropriate Care ⁠— Median Score 7 – 9
May be Appropriate Care ⁠— Median Score 4 – 6
Rarely Appropriate Care ⁠— Median Score 1 – 3

Policy
GENERAL INFORMATION
It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Multiple Gates Acquisition (MUGA) Scan are considered medically necessary for the following indications:

Indications for Multiple Gated Acquisition (MUGA) Scan¹⁰

• To evaluate left ventricular function in a patient with coronary artery disease, valvular heart disease, myocardial disease, or congenital heart disease, in any of the following scenarios:
  • When ventricular function is required for management, and transthoracic echocardiography (TTE) or other imaging has proven inadequate^1,11
  • When there are conflicting results between other testing (i.e., Myocardial Perfusion Imaging and TTE) in the measurement of ejection fraction (EF), and the results of the MUGA will help in the management of the patient
  • Prior TTE has demonstrated systolic dysfunction (EF < 50%) and management will change based on the results of the MUGA scan
• In the course of treatment with cardiotoxic medication when TTE images are inadequate to evaluate left ventricular systolic function^{1,11,12,13,14}
  • Baseline assessment prior to initiation of therapy.
  • Monitoring during therapy. The frequency of testing should be left to the discretion of the ordering provider but in the absence of new abnormal findings, generally no more often than every 6 weeks while on active therapy.
  • Long term surveillance after completion of therapy may be required, especially for those who have been exposed to anthracycline medication. The frequency of testing is generally every 6 – 12 months, or at the discretion of the provider.

All other uses of this technology are investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY.

References 

1. Patel M, White R, Abbara S, Bluemke D, Herfkens R et al. 2013 ACCF/ACR/ASE/ASNC/SCCT/SCMR appropriate utilization of cardiovascular imaging in heart failure: a joint report of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Foundation Appropriate Use Criteria Task Force. J Am Coll Cardiol. 2013; 61: 2207-31. 10.1016/j.jacc.2013.02.005.
2. Friedman J, Berman D, Borges-Neto S, Hayes S, Johnson L et al. First-pass radionuclide angiography. J Nucl Cardiol. Nov 2006; 13: e42-55. 10.1016/j.nuclcard.2006.08.006.
3. Mitra D, Basu S. Equilibrium radionuclide angiocardiography: Its usefulness in current practice and potential future applications. World J Radiol. 2012; 4: 421-30. 10.4329/wjr.v4.i10.421.
4. Ritchie J, Bateman T, Bonow R, Crawford M, Gibbons R et al. Guidelines for clinical use of cardiac radionuclide imaging. Report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Radionuclide Imaging), developed in collaboration with the American Society of Nuclear Cardiology. J Am Coll Cardiol. Feb 1995; 25: 521-47. 10.1016/0735-1097(95)90027-6.
5. Bonow R, Douglas P, Buxton A, Cohen D, Curtis J et al. ACCF/AHA Methodology for the Development of Quality Measures for Cardiovascular Technology. Circulation. 2011; 124: 1483 - 1502. 10.1161/CIR.0b013e31822935fc.
6. Fitch K, Bernstein S, Aguilar M, Burnand B, LaCalle J et al. The RAND/UCLA Appropriateness Method User’s Manual. 2001.
7. Hendel R, Patel M, Allen J, Min J, Shaw L et al. Appropriate Use of Cardiovascular Technology: 2013 ACCF Appropriate Use Criteria Methodology Update: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force. Journal of the American College of Cardiology. 2013; 61: 1305 - 1317. https://doi.org/10.1016/j.jacc.2013.01.025.
8. Hendel R C, Lindsay B D, Allen J M, Brindis R G, Patel M R et al. ACC Appropriate Use Criteria Methodology: 2018 Update: A Report of the American College of Cardiology Appropriate Use Criteria Task Force. Journal of the American College of Cardiology. 2018; 71: 935 - 948. https://doi.org/10.1016/j.jacc.2018.01.007.
9. Patel M, Spertus J, Brindis R, Hendel R, Douglas P et al. ACCF proposed method for evaluating the appropriateness of cardiovascular imaging. Journal of the American College of Cardiology. 2005; 46: 1606-13.
10. Doherty J U, Kort S, Mehran R, Schoenhagen P, Soman P et al. ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2019; 73: 488-516. 10.1016/j.jacc.2018.10.038.
11. Heidenreich P, Bozkurt B, Aguilar D, Allen L, Byun J et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022; 145: e876-e894. 10.1161/cir.0000000000001062.
12. Plana J, Galderisi M, Barac A, Ewer M, Ky B et al. Expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: a report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. Sep 2014; 27: 911-39. 10.1016/j.echo.2014.07.012.
13. Zamorano J, Lancellotti P, Rodriguez Muñoz D, Aboyans V, Asteggiano R et al. 2016 ESC Position Paper on cancer treatments and cardiovascular toxicity developed under the auspices of the ESC Committee for Practice Guidelines: The Task Force for cancer treatments and cardiovascular toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016; 37: 2768-2801. 10.1093/eurheartj/ehw211.
14. Baldassarre L, Ganatra S, Lopez-Mattei J, Yang E, Zaha V et al. Advances in Multimodality Imaging in Cardio-Oncology: JACC State-of-the-Art Review. J Am Coll Cardiol. 2022; 80: 1560-1578. 10.1016/j.jacc.2022.08.743.
15. Washington State Health Care Authority. WSHCA Health Technology Clinical Committee: 20211105A – Noninvasive Cardiac Imaging for Coronary Artery Disease. [Final Adoption: March 18, 2022]. 2022; https://www.hca.wa.gov/assets/program/noninvasive-cardiac-imaging-final-findings-and- decision-2022-03-18.pdf.

Coding Section 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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