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Clinical Policy Bulletin:
Myopathy: Selected Tests
Number: 0862


Policy

Aetna considers pyrophosphate muscle scan in the evaluation of myalgia and myositis experimental and investigational because there is no clinical evidence to support the use of pyrophosphate muscle scan in the evaluation of myalgia and myositis.

Aetna considers the Myoglobinuria Test Panel experimental and investigational because there is no clinical evidence to support the use of the Myoglobinuria Test Panel.

For myositis antibody panel, see CPB Rheumatologic Diseases: Selected Tests.



Background

Myalgia is muscular pain or tenderness. Muscle pain can also involve ligaments, tendons and fascia, the soft tissues that connect muscles, bones and organs together. Myositis is an inflammation or swelling of the muscles and may be caused by injury, infection or an autoimmune disorder.

The Myoglobinuria Test Panel is used for individuals with exercise intolerance related weakness, pain, cramping and idiopathic myoglobulinuria. The test, using muscle tissue, detects specific enzymes related to metabolic function. Diseases tested for include Phosphofructokinase deficiency (PFK), McArdle's disease, Tarui's disease, Phosphoglycerate kinase deficiency (PGK), Phosphoglycerate mutase deficiency (PGAM), Lactate Dehydrogenase deficiency (LDH), Glycogen, Phosphorylase A+ total deficiency (Ph), Phosphorylase B kinase deficiency (PhK), Carnitine Palmitoyltransferase 2 deficiency (CPT2) and Myoadenylate Deaminase deficiency (MAD). The Myoglobinuria Test Panel is a proprietary test of Athena Diagnostics. There is no clinical evidence to support the use of the Myoglobinuria Test Panel.

The pyrophosphate muscle scan or scintigraphy, is a nuclear imaging technique evaluating the uptake of technetium-99m pyrophosphate to reflect muscle viability and activity. According to Rider and colleagues, 2002, several types of scintigraphy have been used to image the muscles of patients with idiopathic inflammatory myopathies, including antimyosin, 99mtechnetium pyrophosphate, and 67gallium, each demonstrating uptake in inflamed, but not atrophied, muscles. The clinical usefulness of scintigraphy in the assessment of myositis is not clear.
 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes not covered for indications listed in the CPB:
83615
84311
HCPCS codes not covered for indications listed in the CPB:
A9538 Technetium Tc-99m pyrophosphate, diagnostic, per study dose, up to 25 millicuries
ICD-9 codes not covered for indications listed in the CPB (not all inclusive) :
729.1 Unspecified myalgia and myositis


The above policy is based on the following references:
  1. Amato AA; Barohn RJ. Idiopathic inflammatory myopathies. Neurologic Clinics, 15(3) August 1997.
  2. Goldman: Cecil Textbook of Medicine. Twenty-First Edition. 2000.
  3. Habif: Clinical Dermatology. Fourth Edition. 2004.
  4. Mastaglia FL; Phillips BA. Idiopathic inflammatory myopathies: epidemiology, classification, and diagnostic criteria. Rheumatic Diseases of North America, 28(4) November 2002.
  5. Ruddy: Kelly’s Textbook of Rheumatology. Sixth Edition. 2001.
  6. Targoff IN. Laboratory testing in the diagnosis and management of idiopathic inflammatory myopathies. Rheum Dis Clin North Am, Vol 28 Num 4 November 2002.
  7. Daroff: Bradley's Neurology in Clinical Practice. Sixth Edition. 2012.

  8. Rider LG et al. Outcome assessment in the adult and juvenile idiopathic inflammatory myopathies. Rheumatic Diseases Clinics of North America, Volume 28, Issue 4  2002.



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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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