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Coverage requirements for Absolute Quantitation of Myocardial Blood Flow

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Q.

Does CPT® code 78434 require pre-authorization?

A.

The answer to this question is payor specific, and we recommend you check each payor’s website for a list of codes and/or procedures requiring a pre-authorization. Another way to determine if a pre-authorization is if you have had a denial due to no pre-authorization. For payors that require pre-authorization for nuclear medicine procedures, the answer is yes, code 78434 likely needs pre-authorization by that specific payor. 

At present, Medicare does not require preauthorization for this service. However, when the Appropriate Use Criteria (AUC) program goes fully live, code 78434 is listed as one of those services that must have a Clinical Decision Support Mechanism (CDSM) consult. The code and full description are as follows:

78434 Absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress (List separately in addition to code for primary procedure)