Coverage of Conditions and Treatments (Coverage Decisions)

Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.

List also available in PDF format.

Archived Coverage Decisions.

See Treatment Guidelines and Resources for additional information.

Occupational Health Best Practices and L&I header

Coronary angiography is the gold standard for diagnosis of coronary artery disease, which primarily documents the anatomic presence of significant stenosis. Cardiac nuclear imaging tests have been developed to provide perfusion data. Single photon emission computed tomography (SPECT) uses a radioactive tracer and gamma camera to obtain 3-dimensional images of tracer uptake, and areas of poor uptake are associated with abnormal levels of perfusion. Positron emission tomography (PET) scanners are also used with a radiotracer, and are felt by some to provide better image resolution in heavier patients and those with dense breast tissue.

Conditions of Coverage

SPECT (Single Photon Emission Computed Tomography) is covered for:

  • Patients with symptoms of myocardial ischemia (symptomatic) who are:
    • At high risk of coronary artery disease (CAD), or
    • At low to intermediate risk of CAD, and
      • Have abnormal/indeterminate exercise treadmill test (ETT), or
      • Unable to perform ETT, or
      • Electrocardiogram (ECG) abnormality that prevents accurate interpretation of ETT.
  • Patients with known CAD, monitoring:
    • Changes in symptoms.

PET (Positron Emission Tomography) is covered for:

  • Patients under the same conditions as SPECT when:
    • SPECT is not technically feasible; or
    • SPECT is inconclusive.

Cardiac Nuclear Imaging is not a covered benefit for:

  • Asymptomatic patients*
  • Patients with known CAD and no changes in symptoms.

* Does not apply to pre-operative evaluation of patients undergoing high-risk non-cardiac surgery or patients who have undergone cardiac transplant.

Background information

The State Health Technology Clinical Committee (HTCC) reviewed cardiac nuclear imagingon September 20, 2013. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that cardiac nuclear imaging is a covered benefit with conditions. Complete information on this HTCC determination is available here:

Implementation of the Determination

Cardiac nuclear imaging tests may be used only for care of a condition accepted on the claim. Temporary authorization may be given to address an unrelated condition that is directly impeding worker’s recovery from their work-related condition. All requests require prior authorization.