Over the past 10 years, there has been a continuous rise in the utilization and cost of echocardiograms, the most widely used diagnostic imaging test for heart disease. Since 2009, utilization has doubled. As a result, concerns were raised about overutilization or misuse of this procedure, and Appropriate Use criteria were subsequently developed by leading cardiologists. Utilization of echocardiography is especially high in the Pittsburgh region, according to Highmark, and not all physicians are complying with the Appropriate Use guidelines. On Jan. 1, 2019, Highmark announced the Advanced Imaging and Cardiology Services Program, which requires prior authorization for specific outpatient, non-emergent, elective cardiology services, including transthoracic echocardiograms and nuclear imaging.