Is the use of code 0698T for quantitative tissue analysis of the heart in a Cardiac MRI considered experimental or investigational for a patient with cardiac siderosis?

Is CPT Code 0698T for Cardiac Quantitative Tissue Analysis Considered Experimental/Investigational for Cardiac Siderosis?

CPT code 0698T for quantitative cardiac tissue analysis in this 10-year-old with documented cardiac siderosis should NOT be authorized, as cardiac T2 MRI—not code 0698T—is the established standard of care for cardiac iron assessment in transfusion-dependent thalassemia patients.* 1, 2

The Established Standard: Cardiac T2* MRI

The validated method for cardiac siderosis monitoring is T2 gradient echo MRI, which has been the clinical standard since 2001 and is specifically recommended for patients with transfusion-dependent thalassemia.* 1

• The American Heart Association recommends cardiac T2* MRI specifically for patients with high iron burden (LIC >15 mg/g dry weight) for ≥2 years or evidence of cardiac dysfunction, which applies directly to this patient with documented cardiac siderosis (T2* = 20 ms). 2

• The American College of Cardiology suggests validated T2* method with mid-ventricular septal measurement as the best marker of global myocardial iron content. 2

• Cardiac T2* values provide established risk stratification: T2* >20 ms = low risk (green zone), T2* 10-20 ms = intermediate risk (yellow zone) requiring closer monitoring, and T2* <10 ms = high risk (red zone) requiring immediate chelation intensification. 1, 2

Why Code 0698T Does Not Apply

Code 0698T describes quantitative magnetic resonance for analysis of tissue composition (fat, iron, water content) using multiparametric data acquisition—a technology distinct from the established T2 gradient echo technique.* 2

• The insurance policy explicitly states that 0698T (quantitative MR like LiverMultiScan) is not covered, and the policy's cardiac MRI section references T2* mapping as the appropriate technique without mentioning 0698T. 2

• T2* gradient echo sequences measure the time constant of signal decay due to iron's paramagnetic effect, with shorter T2* values indicating higher iron content—this is fundamentally different from the multiparametric tissue composition analysis described by 0698T. 1

• The coefficient of variation for inter-study reproducibility of cardiac T2* is 5%, and this technique has been validated in multiple studies showing progressive decline in ejection fraction as myocardial iron increases, with all patients having ventricular dysfunction showing T2* <20 ms. 1

Clinical Evidence Supporting T2* (Not 0698T)

Cardiac T2 MRI has demonstrated clinical utility in monitoring cardiac siderosis and guiding chelation therapy, with substantial evidence showing it reduces cardiac mortality in thalassemia patients.* 3, 4

• In a study of 119 thalassemia major patients, cardiac T2* MRI identified 17.6% with cardiac siderosis, and during five-year follow-up, patients with severe cardiac siderosis showed significant improvement from baseline T2* of 8.5 ± 1.49 ms to 33.9 ± 1.9 ms with optimized chelation. 3

• Cardiac T2* showed no correlation with serum ferritin, liver iron concentration, or left ventricular ejection fraction, demonstrating that it provides unique information not obtainable from other tests. 3, 4

• Early diagnosis and treatment of patients at risk using cardiac T2* MRI is a reasonable method of reducing the substantial cardiac mortality burden associated with myocardial siderosis. 3

The Correct Authorization Approach

The appropriate order should specify "Cardiac MRI with T2 assessment for cardiac siderosis monitoring" rather than code 0698T.* 2

• The American Society of Hematology recommends documenting the indication clearly as "Assessment of transfusional iron overload in patient with beta thalassemia" along with the exact genotype. 2

• The order should request validated T2* method with mid-ventricular septal measurement, left ventricular ejection fraction, volumes, and mass assessment. 2

• The American Society of Hematology recommends specifying that the same method must be used longitudinally for accurate comparison. 2

• Documentation should include transfusion regimen details, current chelation therapy (Jadenu monotherapy in this case), and recent ferritin trends. 2

Meeting the Experimental/Investigational Criteria

Code 0698T meets multiple criteria for experimental/investigational designation under the policy when applied to cardiac siderosis assessment.

• The policy states a procedure may be considered experimental if it "is being used in place of other, more conventional and proven methods of treatment" (criterion k)—T2* MRI is the conventional proven method for cardiac siderosis. 2

• The policy notes that procedures "associated with a Category III CPT code developed by the American Medical Association" are experimental (criterion l)—0698T is a Category III code. 2

• The policy specifies that lack of "positive endorsement of supporting medical literature published in an established, peer reviewed scientific journal" (criterion i) for the specific indication constitutes experimental status—the literature supports T2* MRI, not 0698T, for cardiac siderosis. 1, 3

Critical Pitfall to Avoid

Do not conflate the validated use of 0698T for liver iron assessment (LiverMultiScan technology) with cardiac iron assessment, as these are distinct applications with different evidence bases. The policy explicitly discusses 0698T under hepatic fibrosis assessment but does not endorse it for cardiac tissue quantification, and the cardiac MRI section references only T2* mapping. 2