How requests are reviewed
ProCare MSO performs delegated utilization management for the health plans and independent physician associations it administers. These criteria describe how prior authorization requests for the services below are reviewed. They are published so that a requesting provider can see, before submitting, what the review will look for.
Exactly one source governs each requested code. The order of significance is the Procare clinical criteria policy UM-00101: a national coverage determination first, then a Medicare local coverage determination or article for the member’s own Medicare contractor, then the Medicare Internet Only Manuals, then MCG, then health plan medical policy, and last peer reviewed literature and recognised professional standards. Where a higher source is empty for a service, the guideline says so and names the source actually applied.
A nurse reviewer may approve. Only the Medical Director may deny on medical necessity. Members are held harmless and may not be balance billed for a service that is not approved, under 42 CFR 422.504(g)(1)(iii).
Guidelines on this page
- Podiatry, Routine Foot Care and Related Foot Services
- Cardiac Myocardial Perfusion Imaging: SPECT and PET
The full criteria library, including the CMS coverage determinations and MCG guidelines these guidelines refer to, is at /clinical-criteria.
Prior Authorization Guideline
Podiatry, Routine Foot Care and Related Foot Services
Procare MSO and the IPAs it administers, including Premier Patient Care IPA
Download this guideline (PDF, 135 KB)
| Field | Entry |
|---|---|
| Guideline | Podiatry, Routine Foot Care and Related Foot Services |
| Version | 09/27/2026. |
| Applies to | All practitioners and facilities requesting podiatry and foot care services for a member whose utilization management is delegated to Procare MSO. Medicare Advantage, D-SNP and C-SNP, and Commercial. |
| Policy number | To be assigned by Compliance before posting. |
| Effective date | To be entered on approval by the Utilization Management Committee. |
| Review cycle | Annual, and on any change to a coverage determination cited below. |
| Questions | Utilization Management, outpatient. authorization@procaremso.com, (657) 206-8700, fax (855) 405-2288. |
THE POINT THAT DECIDES MOST OF THESE REQUESTS. Routine foot care is EXCLUDED FROM MEDICARE BY STATUTE. It is not a service that is covered and then measured for medical necessity. Where an exception applies the service is covered and is then assessed like any other; where no exception applies the service is non-covered and no clinical criteria are reached at all. The difference is not academic. It decides who may make the decision, what the notice says, and what an appeal is about.
1. How Procare decides
Medical necessity criteria are applied in the order set by Procare policy UM-00101, Clinical Criteria: (A) a CMS National Coverage Determination; (B) the Local Coverage Determination or Article of the Medicare contractor for California, which is Noridian Healthcare Solutions, Jurisdiction E, and for durable medical equipment the Noridian DME MAC, together with any State requirement that exceeds the federal one; (C) the CMS Internet Only Manuals; (D) MCG Health 30th Edition, in the absence of a Medicare source and with the higher rungs documented as unavailable; (E) the member's health plan medical policy; (F) peer reviewed literature and professional standards. Exactly one rung governs each code and the walk stops there.
A policy issued by a Medicare contractor other than Noridian is not applied to a California member. THE SOCIAL SECURITY ACT IS NOT A STEP IN THAT ORDER. It is the statute the whole order implements: section 1862(a)(1)(A) for the reasonable and necessary standard, or the specific statutory exclusion where one applies.
2. Routine foot care is a statutory exclusion, and that changes everything downstream
Section 1862(a)(13)(C) of the Social Security Act excludes routine foot care from Medicare coverage. 42 CFR 411.15(l) and the Medicare Benefit Policy Manual, CMS Publication 100-02, Chapter 15, Section 290 set out the exclusion and the exceptions to it.
| Because it is an exclusion and not a necessity question | What follows |
|---|---|
| The decision is a BENEFIT decision. | It is finalized by a nurse reviewer or a utilization management coordinator. It does not require the Medical Director, and it should not be routed to him as a necessity question. |
| The notice cites the EXCLUSION. | It names section 1862(a)(13)(C), 42 CFR 411.15(l) and Publication 100-02 Chapter 15 Section 290, states which exception was considered and what the record does not show for it, and carries NO medical necessity language at all. |
| The member DOES receive a written notice. | A non-covered benefit determination is an adverse organization determination. The member receives notice with appeal rights and is held harmless. |
| What the appeal is about is different. | Not whether the service was needed, but whether an exception to the exclusion is established. A notice that argues necessity invites an appeal on the wrong question and usually loses it. |
| This holds whoever signed it. | If a determination on an excluded service happens to be rendered by the Medical Director, and even if it uses the words medical indication not met, the ground is still the exclusion and the notice still cites the exclusion. The determination decides the outcome; the ground decides the basis, the rendering authority and the letter. |
2a. The exception, and what the record must contain to reach it
Routine foot care becomes payable where the member has a qualifying systemic condition of a severity that makes it hazardous for a non-professional to perform the care, or on the other exceptions the manual sets out including mycotic nails with documented symptoms. To reach the exception the record must contain all of the following.
| Required | Detail |
|---|---|
| The qualifying systemic condition | Named, with its diagnosis code. |
| Active care for that condition | THE NAME OF THE PHYSICIAN TREATING THE SYSTEMIC CONDITION AND THE DATE THE MEMBER WAS LAST SEEN BY THAT PHYSICIAN. This is the element most often missing, and it is the element the exception turns on. |
| The class findings | The documented class findings supporting the exception, recorded from the examination rather than asserted. |
| For nail debridement specifically | Mycosis, WITH documented pain or a marked limitation of ambulation. Thickened or discoloured nails alone do not establish it. |
| The correct modifier | Apply the Q modifier that corresponds to the class findings documented. |
Without these the service is non-covered, and no clinical criteria are reached or cited.
3. The contractor check, because this is where routine foot care goes wrong
California is served by Noridian Healthcare Solutions, Jurisdiction E. NORIDIAN HAS NO LOCAL COVERAGE DETERMINATION ON ROUTINE FOOT CARE. Verified against the Medicare Coverage Database on 09/18/2026.
Five other Medicare contractors do publish one. They are easy to find, they say broadly similar things, and NONE of them applies to a member in California. Borrowing one is a wrong-contractor rejection.
| Policy | Contractor | Applies to a Procare California member? |
|---|---|---|
| L34246 Routine Foot Care and Debridement of Nails | CGS Administrators | NO |
| L33636 Routine Foot Care and Debridement of Nails | Wellpoint Federal | NO |
| L37643 Routine Foot Care | Palmetto GBA | NO |
| L35138 Routine Foot Care | Novitas Solutions | NO |
| L33941 Routine Foot Care | First Coast Service Options | NO |
So for a Procare member the governing authority on routine foot care is the STATUTE and the MANUAL, at rungs A and C, and not a local coverage determination at rung B. Rung B is empty and the document says so with the date it was searched.
4. Services, authority applied, and what the request must show
| Service and codes | Authority applied | The request must document |
|---|---|---|
| ROUTINE FOOT CARE. Paring or cutting of benign hyperkeratotic lesions 11055, 11056, 11057. Nail trimming and debridement 11719, 11720, 11721, G0127. | STATUTORY EXCLUSION. Social Security Act section 1862(a)(13)(C); 42 CFR 411.15(l); CMS Publication 100-02, Chapter 15, Section 290. No Noridian local coverage determination. | Everything in section 2a. Excluded by statute unless an exception is established. |
| NAIL AND SOFT TISSUE PROCEDURES. Nail plate avulsion 11730, 11732. Excision of nail and matrix 11750. Nail biopsy 11755. Incision and drainage 10060, 10061. Lesion shaving and excision 11305, 11420. | Section 1862(a)(1)(A). No National Coverage Determination and no Noridian local coverage determination on these codes. | The diagnosis; the symptoms and their duration; the conservative measures already tried and their result; and, for a repeat procedure on the same site, what has changed. Note that where the documented service is maintenance debridement of a callus, an excision code does not describe it and the service remains routine foot care under section 2. |
| WOUND CARE. Subcutaneous tissue debridement 11042, 11043. Open wound selective debridement 97597. Low frequency non-contact ultrasound 97610. | Section 1862(a)(1)(A). MCG Health, GRG Wound and Skin Management, 30th Edition, where applicable. | Wound location, measurements and depth; the tissue actually removed and the instrument used; the treatment plan; and, on serial debridement, the measured response since the last one. |
| NON-INVASIVE VASCULAR STUDIES AND VASCULAR TREATMENTS. Arterial physiologic studies 93922, 93923, 93924; arterial and venous duplex 93925, 93926, 93930, 93931, 93970, 93971; carotid and abdominal duplex 93880 to 93893 and 93975 to 93979; venous ablation and sclerotherapy 36465 to 36479 and 37700 to 37780; arterial revascularization. | OUTSIDE THE PODIATRIC SCOPE OF PRACTICE. Social Security Act section 1861(r); 42 CFR 410.20(b); California Business and Professions Code section 2472(b); 42 CFR 410.32(a). National Coverage Determination 20.14, Plethysmography, recorded, not applied. See section 5. | Not reviewed for medical necessity from a podiatry office. The request is cancelled and the referral is redirected through the member's primary care provider to a cardiologist or vascular surgeon, who submits the request. |
| EXTREMITY ULTRASOUND AND GUIDANCE. 76881, 76882. Ultrasound guidance for needle placement 76942. | Section 1862(a)(1)(A). | The clinical question the study answers; a permanent recorded image; and a written interpretation. For 76942, why guidance was required for that injection and the image showing needle placement. |
| INJECTIONS. Tendon sheath, ligament or aponeurosis 20550. Small and intermediate joint arthrocentesis or injection 20600, 20605. Peripheral nerve block 64450. Drug J0702. | Section 1862(a)(1)(A). | The exact site; the agent and dose; the response to any prior injection at the same site; and the conservative measures tried. |
| STRAPPING, CASTING AND SUPPLIES. 29405, 29540, Q4038. | Section 1862(a)(1)(A). CMS Publication 100-02, Chapter 15. | The injury or condition treated, the material applied, and why the application was needed on that date rather than dispensed as a supply. |
| THERAPEUTIC SHOES AND INSERTS FOR PERSONS WITH DIABETES. A5500, A5501, A5512, A5513, A5514. | Social Security Act section 1861(s)(12). CMS Publication 100-02, Chapter 15, Section 140. DME MAC Local Coverage Determination L33369, Therapeutic Shoes for Persons with Diabetes, Noridian DME MAC. | The certifying statement from the physician MANAGING THE DIABETES, who is not the supplier; the diabetes diagnosis; at least one qualifying foot condition; the in-person examination; the prescription; and the annual limit of one pair of shoes and three pairs of inserts per calendar year. The insert rides with the shoe and is not authorized separately. |
| ORTHOSES. Ankle-foot orthoses L4397, L4361, L1902. Knee orthoses L1971. | DME MAC Local Coverage Determination L33686, Ankle-Foot / Knee-Ankle-Foot Orthosis, Noridian DME MAC. For knee orthoses, L33318, Knee Orthoses, Noridian DME MAC. | The covered indication in the determination; THE CONSERVATIVE TREATMENT ALREADY TRIED AND ITS RESULT, with dates; the fitting and measurements; and the supplier. |
| EVALUATION AND MANAGEMENT. 99202 to 99215. | Section 1862(a)(1)(A). CMS Publication 100-04, Chapter 12, Section 30.6. | The level billed must match the documented medical decision making or total time. Where a procedure is performed at the same encounter, a separately identifiable service must be documented and modifier 25 applied. One visit level per encounter: two levels of the same basis can never both be payable. |
| PHYSICAL PERFORMANCE TESTING 97750. AUTONOMIC AND SUDOMOTOR TESTING 95923. | Section 1862(a)(1)(A). | The specific test performed, the time spent, the measured result, a written report, and how the result will change management. |
5. Vascular studies and vascular treatments from a podiatry office are outside the scope of practice
A NON-INVASIVE VASCULAR STUDY OR A VASCULAR TREATMENT REQUESTED BY A PODIATRIST IS CANCELLED AS OUTSIDE THE PODIATRIC SCOPE OF PRACTICE, WHATEVER THE DIAGNOSIS. It is not reviewed for medical necessity, no clinical criteria are scored, and it is not a denial: the member is held harmless and no member denial notice issues. The requesting office receives a cancel letter stating the reason and the reference. The member's primary care provider is notified and asked to redirect the referral to a cardiologist or vascular surgeon, or is told of the cardiology or vascular surgery authorization the member already holds for the same studies. The cardiologist or vascular surgeon submits the request, which is then reviewed on its merits under the applicable coverage determination.
| Reference | What it establishes |
|---|---|
| Social Security Act section 1861(r); 42 CFR 410.20(b) | A doctor of podiatric medicine is a physician for Medicare purposes only with respect to the functions he or she is legally authorized by the State to perform. |
| California Business and Professions Code section 2472(b) | Podiatric practice in California is limited to the foot and ankle. Evaluation and treatment of the arterial and venous system of the limb is vascular medicine. |
| 42 CFR 410.32(a) | A diagnostic test is ordered by the physician who treats the beneficiary for the condition and who uses the result in managing it. A vascular study drives a revascularization or anticoagulation decision that a podiatrist does not make. |
| 42 CFR 422.4(a)(1)(ii); 42 CFR 422.112(a) | A Medicare Advantage coordinated care plan routes specialty care through the primary care provider and coordinates it. The redirect through the primary care provider is that mechanism. |
| National Coverage Determination 20.14, Plethysmography, effective 11/15/1980 | Recorded, not applied. Its podiatric sentence reaches only "the preoperative podiatric evaluation of the diabetic patient or one who has intermittent claudication or other signs or symptoms indicative of peripheral vascular disease which have a bearing on the patient's candidacy for foot surgery", and it is the coverage determination the cardiologist or vascular surgeon's request is reviewed under. |
THE PODIATRIC SENTENCE OF NCD 20.14, QUOTED IN FULL. It has three limbs, not two. A podiatry request does not reach it: the request is cancelled for scope before any coverage determination is applied. The limbs are set out here so the redirected specialist request can be read against them.
| Limb | Reaches |
|---|---|
| 1. The diabetic patient | A member with diabetes. |
| 2. Intermittent claudication | A member with documented claudication. |
| 3. OTHER SIGNS OR SYMPTOMS INDICATIVE OF PERIPHERAL VASCULAR DISEASE | A non-diabetic member without claudication who has, for example, non-palpable pedal pulses. This limb is real and it is the one that was being missed. |
| Also required, and frequently missing | Detail |
|---|---|
| The bearing on candidacy for FOOT SURGERY | The qualifier governs all three limbs. A study ordered where no foot surgery is contemplated, or where surgery is expressly deferred, does not reach the podiatric sentence at all. A partial nail avulsion is not the kind of surgery the determination is addressed to. A podiatry request is cancelled for scope before this question arises; the limbs are read against the redirected specialist request. |
| THE DEVICE, BY NAME | Category I techniques are covered: segmental plethysmography (regional, differential, recording oscillometer, pulse volume recorder), electrical impedance, ultrasonic Doppler flow measurement, oculoplethysmography and strain gauge. CATEGORY II IS NATIONALLY NON-COVERED: inductance, capacitance, mechanical oscillometry and photoelectric. The record almost never names the device, and without it the study cannot be placed in Category I at all. |
| The office setting raises the bar, it does not lower it | For an office setting the determination says venous occlusive pneumoplethysmography is unsuitable for routine use in the physician office, and that for other techniques reimbursement for studies done by techniques other than venous occlusive pneumoplethysmography should be denied. Place of service 11 therefore makes the requirement stricter. |
| The descriptor | 93922 requires ankle brachial indices PLUS bidirectional Doppler waveform recording and analysis at one to two levels. An ankle brachial index alone does not meet the descriptor, and that is a coding question rather than a necessity question. |
NCD 220.5 covers peripheral Doppler flow studies as a MODALITY and non-covers B-scan for peripheral atherosclerosis. It is a list of accepted modalities with no patient level indication in it, so no record can be scored against it and it is never the source a necessity decision rests on.
6. Standing requirements for every podiatry request
| Requirement | Detail |
|---|---|
| Scope of practice | Both the service requested and the diagnosis supporting it must sit within the scope of podiatric practice, the foot and ankle, California Business and Professions Code section 2472(b). A request outside that scope is cancelled and redirected through the primary care provider to the appropriate specialist; it is never denied on medical necessity. Non-invasive vascular studies and vascular treatments are outside that scope, section 5. |
| Ordered by the treating practitioner | The service is ordered by the practitioner who will use the result in managing the specific problem. 42 CFR 410.32(a). |
| Serial and repeat visits | Where a member is seen repeatedly for the same condition, each request must document what has changed since the last encounter and why the service is needed again. Routine interval follow-up with no change in findings is not a covered indication. |
| Conservative treatment first | Where a device, an orthosis or a procedure has a recognised conservative alternative, the record must show that alternative was tried, with dates and result, or say why it is contraindicated. |
| Place of service and who furnished the service | The place of service on the request and on the claim is where the service was actually furnished. |
| Correct coding | Where a code is a component of another requested code, criteria are applied to the principal code and the component is not separately authorized. National Correct Coding Initiative edits apply. |
7. Determinations, notices and appeals
| Point | Detail |
|---|---|
| Who may deny | ONLY the Medical Director renders a denial based on medical necessity, and a nurse reviewer may not. A STATUTORY EXCLUSION, a benefit limit or a correct coding outcome is finalized by a nurse or utilization management coordinator and is not a medical necessity decision. A CANCELLATION for a service outside the requesting specialty's scope of practice, or for a duplicate of a service already rendered by another specialist, is likewise finalized by a nurse or utilization management coordinator, with the cancel letter to the requesting office and notice to the primary care provider. Where any requested line on an authorization is not met on medical necessity, the authorization is reviewed by the Medical Director. |
| What an adverse determination states | For a necessity denial: the criterion applied by name with its source and effective date, the element of it that is not met, and what the submitted records do not show against that element. For an excluded service: the statutory or regulatory exclusion, the exception considered, and what the record does not establish for it. The two are never mixed. |
| Denial is for absence of clinical need, never absence of paperwork | A determination does not read that a service was denied because something was "not in the notes". It names what the service clinically requires and what this member's record does not establish. |
| Member notice | A denial in whole or in part produces a written member notice with appeal rights, including on a non-covered benefit. 42 CFR 422.566 and 422.568. A correct coding outcome goes to the provider notice only. |
| Timeframes | Standard pre-service determinations no later than 7 CALENDAR DAYS from receipt. Expedited within 72 HOURS where the standard timeframe could seriously jeopardize the member. Expedited Part B drug within 24 HOURS. Retrospective within 30 CALENDAR DAYS. CMS-0057-F effective 01/01/2026, with 42 CFR 422.568 and 422.572. |
| Held harmless | The member is not billed for a service denied under this guideline. 42 CFR 422.504(g)(1)(iii). |
8. Submitting and contacts
| Purpose | Contact |
|---|---|
| Prior authorization | Provider portal https://procaremso.quickcap.net/procare/general/index.php | authorization@procaremso.com | (657) 206-8700 | fax (855) 405-2288 |
| Peer to peer | P2P@procaremso.com | (657) 206-8700 |
| A copy of the criteria applied, free of charge | UM@procaremso.com | (657) 206-8700 |
| Provider disputes and appeals | providerdisputes@procaremso.com | ProCare MSO, PO Box 25629, Santa Ana, CA 92799 |
| General | support@procaremso.com | (657) 206-8700 | www.procaremso.com | ProCare MSO, 1503 S Coast Drive, Suite 212, Costa Mesa, CA 92626 |
Licensed clinical criteria are proprietary and are not reproduced here. A copy of the specific criteria referenced in any authorization determination may be requested at any time by a provider or a member, free of charge, by emailing UM@procaremso.com or calling (657) 206-8700. Please reference the authorization number. Procare policy UM-00101.
ProCare MSO, 1503 S Coast Drive, Suite 212, Costa Mesa, CA 92626. (657) 206-8700. www.procaremso.com
Prior Authorization Guideline
Cardiac Myocardial Perfusion Imaging: SPECT and PET
Procare MSO and the IPAs it administers, including Premier Patient Care IPA
Download this guideline (PDF, 150 KB)
| Field | Entry |
|---|---|
| Guideline | Cardiac Myocardial Perfusion Imaging: SPECT and PET |
| Version | 09/27/2026. |
| Applies to | All contracted and non-contracted practitioners and facilities requesting cardiac myocardial perfusion imaging for a member whose utilization management is delegated to Procare MSO. Medicare Advantage, D-SNP and C-SNP, and Commercial lines of business. |
| Services covered by this guideline | Myocardial perfusion imaging by single photon emission computed tomography (SPECT) and by positron emission tomography (PET and PET-CT), the radiopharmaceutical and pharmacologic stress agent supplied with those studies, and the supervision, tracing and interpretation of the stress performed as part of them. |
| Policy number | To be assigned by Compliance before posting. |
| Effective date | To be entered on approval by the Utilization Management Committee. |
| Review cycle | Annual, and on any change to the governing national coverage determination or to the clinical criteria referenced below. |
| Questions | Utilization Management, outpatient. authorization@procaremso.com, telephone (657) 206-8700, fax (855) 405-2288. |
THE STANDARD IN ONE PARAGRAPH. SPECT myocardial perfusion imaging is the first line study for the routine evaluation of known or suspected coronary artery disease. Cardiac PET is authorized where a documented clinical reason makes SPECT unsuitable or non-diagnostic FOR THIS MEMBER, or where a documented indication calls for PET specifically. A request for cardiac PET must say why PET is being requested rather than SPECT, and that reason has to be about this member. Separately from medical necessity, the entity that furnishes and bills the technical component of a PET study must hold current accreditation for advanced diagnostic imaging.
1. Purpose
This guideline states how Procare MSO decides prior authorization requests for cardiac myocardial perfusion imaging, what a complete request contains, and the accreditation, place of service and billing requirements that apply to the study once it is authorized. It is published so that a requesting office can see the standard before it submits, rather than after a determination is made.
This guideline does not create a benefit. Where a member's health plan publishes criteria that are more specific than this guideline, the plan criteria govern. For Medicare Advantage members, Medicare national and local coverage rules govern and this guideline is applied only where those rules leave the clinical question open.
2. Codes within scope
| Group | Codes | Notes |
|---|---|---|
| SPECT myocardial perfusion imaging | 78451, 78452, 78453, 78454 | Single study or multiple studies, with or without quantification and ejection fraction. |
| Cardiac PET myocardial perfusion imaging | 78429, 78430, 78431, 78432, 78433, 78434, 78459, 78491, 78492 | Includes PET performed with concurrent computed tomography for attenuation correction, and 78434 absolute quantitation of myocardial blood flow. |
| Radiopharmaceutical and stress agent | A9555 rubidium Rb-82, N-13 ammonia and other radiopharmaceuticals supplied with the study; J2785 regadenoson and other pharmacologic stress agents | Authorized WITH the study and not separately. If the study is not authorized, these are not authorized, and they are decided on the ground of the study rather than on a ground of their own. |
| Stress supervision, tracing and interpretation | 93015, 93016, 93017, 93018 | Where performed as part of the imaging study these are part of that study and are decided with it. |
3. Clinical criteria applied, and the order they are applied in
Criteria are applied in the order set by Procare policy UM-00101, Clinical Criteria: (A) a CMS National Coverage Determination; (B) the Local Coverage Determination or Article of the Medicare contractor for California, which is Noridian Healthcare Solutions, Jurisdiction E; (C) the CMS Internet Only Manuals; (D) MCG Health; (E) the member's health plan medical policy; and (F) peer reviewed literature and professional standards recognised in the United States. Exactly one of these governs each code, and the walk stops there.
| Rung and source | What it governs | How to obtain it |
|---|---|---|
| A. National Coverage Determination 220.6.1, PET for Perfusion of the Heart, CMS, effective 04/03/2009, last updated 08/19/2026. | COVERAGE of cardiac PET perfusion imaging. It sets two covered pathways: PET performed IN PLACE OF, but not in addition to, a SPECT; or PET performed FOLLOWING a SPECT found to be inconclusive, with the inconclusive result documented in the member's file. It establishes that the study is covered. It does not decide whether PET rather than SPECT is necessary for a particular member, and it contains no element against which that choice can be scored. | Published by CMS in the Medicare Coverage Database, publication 100-3. Free to the public. |
| B. Local Coverage Determination, Noridian Jurisdiction E. | EMPTY. Searched 09/18/2026. Noridian has no Local Coverage Determination and no Article on cardiac PET or cardiac radionuclide imaging. Policies on this subject exist at other Medicare contractors and are NOT applied to a California member. | Public. |
| C. CMS Internet Only Manuals. | Conditions of payment only, principally who may order a diagnostic test and the supervision required. A condition of payment cannot be met or failed on clinical grounds and does not carry a medical necessity decision. | Public. |
| D. MCG Health, Ambulatory Care, 30th Edition. | ON POINT AND NOT CURRENTLY HELD. MCG publishes ambulatory care imaging guidelines and the licensed set Procare holds was reviewed on 09/18/2026; it contains guidelines for cardiac computed tomography angiography, cardiac catheterization and angiography, patch-type cardiac monitors, implantable loop recorders and cardiac catheter ablation, and no myocardial perfusion or cardiac PET guideline. Procare does not score a request against a guideline it does not hold. The guideline is being obtained; until it is, rung F is applied and the document says so on its face. | Licensed and proprietary. When held, a copy of the specific guideline used in a determination is provided free of charge on request. |
| E. Health plan medical policy. | Searched 09/18/2026. None held on cardiac PET for the plans Procare administers. | From the plan. |
| F. Peer reviewed literature and professional standards. GOVERNS, in the absence of A to E on the modality question. | 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. Gulati M, Levy PD, Mukherjee D, et al. Journal of the American College of Cardiology 2021;78(22):e187-e285. It treats stress PET and stress SPECT as ALTERNATIVE modalities for the detection of inducible myocardial ischaemia. | Public. doi:10.1016/j.jacc.2021.07.053. Retrieved 09/18/2026. |
| Statute. | Social Security Act section 1862(a)(1)(A), reasonable and necessary. This is the statute the order above implements. IT IS NOT A STEP IN THE ORDER and it is never the criterion a record is scored against. | Public. |
4. SPECT is the first line study
For the routine evaluation of known or suspected coronary artery disease, SPECT myocardial perfusion imaging is the first line study and is authorized on the standard indications for stress perfusion imaging. A request for SPECT does not have to argue against PET.
| Question we are asked | Answer |
|---|---|
| Is PET always better? | No. Both modalities are accepted and the governing professional standard treats them as alternatives for detecting inducible ischaemia. PET has advantages in specific circumstances, principally where soft tissue attenuation degrades a SPECT study and where absolute myocardial blood flow measurement is clinically required. Those circumstances are the subject of section 6. |
| Does the member have to fail a SPECT before PET can be requested? | No. National coverage determination 220.6.1 gives two independent pathways and PET performed in place of a SPECT is one of them. A prior inconclusive SPECT is one route to authorization, not a precondition. |
| Can the member have both a SPECT and a PET for the same evaluation? | No. The national coverage determination covers cardiac PET performed in place of, but not in addition to, a SPECT. Where both are performed for the same evaluation episode, one of the two is not covered. |
| Is a concern about balanced multivessel ischaemia, on its own, a reason for PET? | Not on its own. It is an accepted clinical concern and it is uncommon. Where it is the reason for the request, state the findings that raise it for this member. |
4a. A general statement that PET outperforms SPECT is not an indication
Most cardiac PET requests we receive contain a paragraph on the general advantages of PET: higher diagnostic accuracy, better spatial resolution, routine attenuation correction, lower radiation exposure, quantitative myocardial blood flow. None of that is disputed and none of it is a finding about the member in front of us.
The question the criterion asks is what THIS MEMBER needs from PET that stress SPECT cannot deliver. A paragraph that would read identically for any patient does not answer it. Where such a paragraph is the only support in the record, the request does not meet the indication and will not be approved on it.
Two related points, because both have appeared in submitted records. A citation to a professional guideline is not a finding either, and where a guideline is quoted as preferring PET the quotation must be accurate; the 2021 chest pain guideline treats the two modalities as alternatives. And a justification paragraph that describes a different patient, of a different age or sex from the member, establishes nothing at all and should be corrected before the request is resubmitted.
4b. Inability to exercise supports pharmacologic stress, not PET
A documented inability to walk on a treadmill, or to undergo a stress echocardiogram, is a real and relevant finding. What it establishes is that the STRESS must be PHARMACOLOGIC. It does not establish that the IMAGING must be PET.
Regadenoson and comparable pharmacologic stress agents are used with SPECT as well as with PET. A member who cannot exercise can have a pharmacologic stress SPECT. So this finding, on its own, does not choose between the two modalities and is not an indication for PET under section 6b. Where the record relies on it, pair it with one of the indications in 6b.
5. Accreditation, place of service and billing
These requirements are separate from medical necessity. The supplier that furnishes and bills the TECHNICAL COMPONENT of a PET study must hold current accreditation for advanced diagnostic imaging under Social Security Act section 1834(e) and 42 CFR 414.68, from the American College of Radiology, the Intersocietal Accreditation Commission, The Joint Commission or RadSite. A current certificate naming the accrediting organization, the modality, the site or unit and the expiration date must be on file with Provider Relations at providercred@procaremso.com. A mobile PET unit is inside this requirement.
The place of service on the request and on the claim is where the service was actually furnished. Pharmacologic stress requires at least direct physician supervision under 42 CFR 410.32(b). A study may be billed globally only where the billing entity furnished both components; where the technical component or the interpretation is purchased from a supplier outside the practice, the anti-markup limitation at 42 CFR 414.50 applies. An approved authorization establishes medical necessity and nothing else.
6. When cardiac PET is authorized
BOTH parts must be satisfied: every general requirement in 6a, and at least one indication in 6b.
6a. General requirements, all of which apply
| Number | Requirement | Authority |
|---|---|---|
| 1 | The study is ordered by the treating physician who will use the result in the management of the member's specific problem. | 42 CFR 410.32(a) |
| 2 | The PET is requested IN PLACE OF, and not in addition to, a SPECT for the same evaluation episode. | NCD 220.6.1 |
| 3 | The request states, in the clinical note or on the request form, WHY PET IS BEING REQUESTED RATHER THAN SPECT FOR THIS MEMBER. A general statement about the modality does not satisfy this, and neither does inability to exercise on its own. See 4a and 4b. | This guideline |
| 4 | The entity that will furnish and bill the technical component holds current accreditation for advanced diagnostic imaging. | SSA 1834(e); 42 CFR 414.68 |
| 5 | Pharmacologic stress is performed under at least direct physician supervision. | 42 CFR 410.32(b) |
6b. Indications, at least one of which must be documented
| Number | Indication | What to submit |
|---|---|---|
| A | BODY HABITUS. A documented body mass index of 35 or above, or another body habitus or attenuation problem such that a SPECT study is expected to be non-diagnostic for this member. | Height, weight and body mass index from the record, or the specific attenuation problem documented by the requesting physician. A statement that the member is obese, large or difficult to image, with no number in the note, does not establish it. |
| B | PRIOR INCONCLUSIVE SPECT. A SPECT performed for the same evaluation was equivocal, technically uninterpretable, or discordant with the member's other clinical data. | The SPECT report itself. The national coverage determination requires the inconclusive result to be documented in the member's file. |
| C | ABNORMAL OR EQUIVOCAL PRIOR NON-INVASIVE TESTING requiring further functional evaluation, including an equivocal or positive exercise treadmill test, or coronary computed tomography angiography showing significant or inconclusive stenosis. | The report of the prior test. |
| D | CORONARY CALCIUM SCORE at a level that calls for functional assessment, in a member whose overall coronary heart disease risk is documented. | The calcium score report and the documented risk assessment. |
| E | ANOMALOUS OR CONGENITAL CORONARY ANATOMY requiring functional assessment, or surveillance for cardiac allograft vasculopathy after transplant. | The imaging or operative report establishing the anatomy, or the transplant history. |
| F | PRE-REVASCULARIZATION ASSESSMENT where objective evidence of ischaemia is required before an invasive procedure, or post-procedure assessment where the result will change management. | The plan for revascularization and what the study will decide. |
| G | OBJECTIVE ACUTE FINDINGS in an asymptomatic member, such as an elevated troponin or ischaemic changes on a resting electrocardiogram. | The laboratory result or the tracing. |
| H | ABSOLUTE MYOCARDIAL BLOOD FLOW QUANTITATION is clinically required, for suspected balanced multivessel disease or suspected coronary microvascular dysfunction. | The findings that raise the suspicion FOR THIS MEMBER. A general statement that quantitation is useful does not establish it. This is the indication for adding 78434 and it is decided on the same submission. |
7. What will not be authorized
| Request | Outcome |
|---|---|
| Cardiac PET supported only by a general statement of the advantages of PET over SPECT. | Denied. See 4a. This is the most common reason a cardiac PET request is not approved. |
| Cardiac PET supported only by a documented inability to exercise. | Denied. See 4b. Pharmacologic stress SPECT is available to the same member. |
| Cardiac PET in addition to a SPECT for the same evaluation episode. | Not covered on the national coverage determination. One of the two studies will be denied. |
| Cardiac PET where the only documented diagnosis is hypertension, dizziness or shortness of breath, with no objective finding, no abnormal prior test and no other indication in section 6b. | Denied. These diagnoses do not establish an indication for advanced cardiac perfusion imaging on their own. They may well support a first line evaluation, including SPECT. |
| Repeat myocardial perfusion imaging, by either modality, with no change in clinical status. | Denied unless the record documents a change in clinical status, a need for interval reassessment that may change the treatment plan, or imaging before or after an invasive procedure. |
| Cardiac PET as screening in an asymptomatic member with no qualifying indication. | Denied. Screening is not a covered indication for cardiac perfusion imaging. |
| A radiopharmaceutical or stress agent where the study it belongs to is denied. | Denied with the study. These exist only because the study was ordered and they carry the ground of the study, not a ground of their own. |
| The supervision, tracing and interpretation of the stress performed for a denied study. | Denied with the study, on the same ground, for the same reason. |
8. Submitting the request
| Submit | Detail |
|---|---|
| Where | Provider portal at https://procaremso.quickcap.net/procare/general/index.php, email authorization@procaremso.com, or fax (855) 405-2288. |
| What | The request form with the exact codes and units requested and the place of service; the clinical note supporting the indication; the reports named in section 6b for the indication relied on; and, for cardiac PET, the member-specific statement required by 6a.3 of why PET rather than SPECT. |
| Turnaround | Standard pre-service organization determinations are made as expeditiously as the member's health requires and no later than 7 CALENDAR DAYS from receipt. Where the standard timeframe could seriously jeopardize the member's life, health or ability to regain maximum function, request an expedited determination, made within 72 HOURS. An expedited request for a Part B drug is decided within 24 HOURS. A retrospective determination is made within 30 CALENDAR DAYS. CMS-0057-F, effective 01/01/2026, with 42 CFR 422.568 and 422.572. |
| Peer to peer | A requesting physician may ask to speak with the Medical Director. Call (657) 206-8700 or email P2P@procaremso.com. A peer to peer is informational and does not change a determination or extend an appeal deadline. |
9. How the determination is made, and appeal rights
| Point | Detail |
|---|---|
| Who may deny for medical necessity | ONLY the Medical Director renders a denial based on medical necessity. A nurse reviewer may approve a request and may not deny one on medical necessity. Where any requested line on an authorization is adverse, the whole authorization is reviewed by the Medical Director. |
| What an adverse determination will tell you | The specific criterion applied, by name, with its source and effective date; the element of that criterion that is not met; what the records submitted do not show against it; and that further clinical notes may be submitted for review. |
| Member notice | Where a request is denied in whole or in part, the member receives written notice with appeal rights, in the member's language where applicable. A partial approval, including approval of one study and denial of another, is a denial in part and the member receives notice. |
| Member appeal | A member, or a provider acting on the member's behalf with the member's consent, may appeal. The notice states how. 42 CFR 422.566 and 422.568. |
| Provider dispute | Payment disputes go to ProCare MSO, PO Box 25629, Santa Ana, CA 92799, or providerdisputes@procaremso.com. |
| Held harmless | The member is not billed for a service denied under this guideline. 42 CFR 422.504(g)(1)(iii). |
10. Contacts
| Purpose | Contact |
|---|---|
| Prior authorization, outpatient | authorization@procaremso.com | (657) 206-8700 | fax (855) 405-2288 |
| Peer to peer | P2P@procaremso.com | (657) 206-8700 |
| A copy of the criteria applied, free of charge | UM@procaremso.com | (657) 206-8700 |
| Accreditation certificates, credentialing and contracting | providercred@procaremso.com | (657) 206-8700 |
| Provider disputes and appeals | providerdisputes@procaremso.com | ProCare MSO, PO Box 25629, Santa Ana, CA 92799 |
| General | support@procaremso.com | (657) 206-8700 | www.procaremso.com | ProCare MSO, 1503 S Coast Drive, Suite 212, Costa Mesa, CA 92626 |
11. References
- Medicare national coverage determination 220.6.1, PET for Perfusion of the Heart, publication 100-3, effective 04/03/2009, last updated 08/19/2026.
- Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. J Am Coll Cardiol 2021;78(22):e187-e285. doi:10.1016/j.jacc.2021.07.053.
- Social Security Act section 1862(a)(1)(A), reasonable and necessary.
- Social Security Act section 1834(e) and 42 CFR 414.68, accreditation of suppliers furnishing the technical component of advanced diagnostic imaging.
- 42 CFR 414.50, anti-markup payment limitation.
- 42 CFR 410.32(a) and (b), ordering and supervision of diagnostic tests.
- 42 CFR 422.568 and 422.572, organization determination timeframes; 42 CFR 422.566, appeal rights; 42 CFR 422.504(g)(1)(iii), member held harmless.
- Procare policy UM-00101, Clinical Criteria.
ProCare MSO, 1503 S Coast Drive, Suite 212, Costa Mesa, CA 92626. (657) 206-8700. www.procaremso.com
Questions, and copies of the criteria applied. The specific criteria used in any determination are available to a provider or a member at any time, free of charge. Email UM@procaremso.com or call (657) 206-8700 and reference the authorization number.
Utilization Management, outpatient: authorization@procaremso.com. Peer to peer: P2P@procaremso.com or (657) 206-8700. UM fax (888) 972-1931. Prior authorization fax (855) 405-2288.
ProCare MSO, 1503 S Coast Drive, Suite 212, Costa Mesa, CA 92626. (657) 206-8700.
These guidelines are a statement of how requests are reviewed. They do not replace the member’s Evidence of Coverage, and they do not guarantee payment, which also depends on eligibility and benefits on the date of service.