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MEDICAL POLICY – 6.01.502
Single Photon Emission Computed Tomography (SPECT)
for Non-cardiac Indications
Effective Date: Oct. 1, 2019
Last Revised: Sept. 5, 2019
Replaces: N/A
RELATED MEDICAL POLICIES:
6.01.54 Dopamine Transporter Imaging with Single-photon Emission
Computed
Tomography
Select a hyperlink below to be directed to that section.
POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING
RELATED INFORMATION | EVIDENCE REVIEW | REFERENCES | HISTORY
∞ Clicking this icon returns you to the hyperlinks menu
above.
Introduction
SPECT is a type of nuclear imaging test that uses a radioactive
dye, also called a tracer, and a
special camera to create a three-dimensional (3-D) image of the
organs in the body. The images
created by tracking the dye in the blood stream can show areas
of increased/decreased blood
flow and progressive changes in the body. SPECT is proposed to
help diagnose or monitor
certain tumors, bone disorders, and heart problems.
SPECT imaging of the brain for mental health disorders is used
as a research tool in clinical trials.
Research has not shown the utility of SPECT brain imaging for
differential diagnosis or for
assessing or predicting an individual’s risk of getting a mental
health disorder.
Dopamine transporter imaging with single-photon emission
computed tomography (DAT-
SPECT) is addressed in another policy (see Related Medical
Policies).
Note: The Introduction section is for your general knowledge and
is not to be taken as policy coverage criteria. The
rest of the policy uses specific words and concepts familiar to
medical professionals. It is intended for
providers. A provider can be a person, such as a doctor, nurse,
psychologist, or dentist. A provider also can
be a place where medical care is given, like a hospital, clinic,
or lab. This policy informs them about when a
service may be covered.
https://www.lifewisewa.com/medicalpolicies/6.01.54.pdfhttps://www.lifewisewa.com/medicalpolicies/6.01.54.pdf
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Policy Coverage Criteria
Procedure Medical Necessity
SPECT scan SPECT scans may be considered medically necessary for
any of
the following non-cardiac conditions or symptoms:
• Brain tumor recurrence versus radiation necrosis
• Liver hemangioma versus tumor identification
• Localization of abscess, suspected or known localized
infection
vs. inflammation
• Assessment of osteomyelitis (bone vs. soft tissue
infection)
• Lymphoma evaluation (tumor vs. necrosis)
• Neuroendocrine tumors (carcinoid, pheocromoctyoma, thyroid
carcinoma, adrenal gland tumors) [OctreoScan™ or MIBG]
• Parathyroid disease
• Renal function and renal scarring evaluation
(Dimercaptosuccinic acid [DMSA] scan)
• Seizure foci localization for patients with intractable
epilepsy (in
place of positron emission tomography [PET])
• Vertebral abnormalities evaluation (such as spondylosis,
spondylolisthesis, or stress fractures not visible on x-ray)
SPECT scan SPECT scans are considered not medically necessary
for any of
the following conditions or symptoms:
• Cerebrovascular accident (also called CVA, stroke, or
brain
attack)
• Subarachnoid hemorrhage
• Transient ischemic attack (TIA)
Procedure Investigational
SPECT scan SPECT scans are considered investigational for all
other non-
cardiac conditions, including any of the following:
• Attention deficit hyperactivity disorder (ADHD)
• Autism spectrum disorders
• Colorectal cancer (eg, with CEA-Scan, IMMU-4)
• Head trauma – evaluation of brain morphology
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Procedure Investigational • Mental health disorders (diagnosis,
prediction, response to
medication)
• Movement disorder evaluation
• Prostate cancer (eg, with ProstaScint®)
• Unclassified dementia evaluation (eg, Alzheimer disease)
Documentation Requirements
The medical records submitted for review should document that
medical necessity
criteria are met. Include history and physical supporting that
patient has ANY of the
following symptoms or conditions:
• Brain tumors, to differentiate between recurrent tumor versus
radiation changes, infection
• Liver hemangioma, to further define the mass
• Localization of abscess, infection, or inflammation
• Lymphoma evaluation
• Neuroendocrine tumors
• Parathyroid disease
• Renal function and renal scarring evaluation
(dimercaptosuccinic acid [DMSA] scan)
• Patients with intractable epilepsy, when seizure focus cannot
be localized
• Evaluation of vertebral abnormalities (such as spondylosis,
spondylolysis, spondylolisthesis,
degenerative joint disease/arthritis of the facet joints, stress
fractures)
Coding
Code Description
HCPCS A9507 Indium in-111 capromab pendetide, diagnostic, per
study dose, up to 10 millicuries
Note: CPT codes, descriptions and materials are copyrighted by
the American Medical Association (AMA). HCPCS codes,
descriptions and materials are copyrighted by Centers for
Medicare Services (CMS).
Related Information
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Definition of Terms
Abscess: A mass filled with pus (made up of dead white blood
cells and dead tissue, bacteria,
and blood serum) that collects anywhere in the body as a result
of the body's response to an
infection.
Adenoma: A noncancerous (benign) epithelial tumor that may
affect various organs in the body.
The adenoma often comes from or resembles glandular tissue,
though some grow in
nonglandular areas.
Autism spectrum disorders : Refers to a group of disorders
defined as delays in the
development of socialization and communication skills often
accompanied by cognitive and
language delays.
Carcinoid tumors: Carcinoid tumors are slow growing and usually
start in the gastrointestinal
tract (anywhere between the stomach and the rectum) or the lung.
These tumors make and
release (secrete) large amounts of hormones, including cortisol,
histamine, insulin and serotonin.
Carcinoid tumors are a type of neuroendocrine tumor.
Liver hemangioma: A noncancerous tumor (mass) that forms in or
on the liver. It is made up of
small blood vessels. Liver hemangiomas are more common in women
than men.
Lymphoma: A cancer of the white blood cells (lymphocytes) of the
body’s immune system. It
develops in the lymph nodes and lymphatic system.
Movement disorders: A group of diseases that includes abnormally
slow movement
(bradykinesia), rigidity, tremor at rest, and postural
instability.
Neuroendocrine tumors: A diverse group of tumors that form from
cells of the hormone and
nervous systems. They may be found in the intestine and also
occur in the thyroid, lung and
other parts of the body.
Transient ischemic attack (TIA): A temporary lack of adequate
blood and oxygen (ischemia) to
the brain. The neurological signs and symptoms are similar to a
brain attack (stroke), but go
away within a short period of time. This may also be referred to
as a mini-stroke.
Evidence Review
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Background
SPECT is an imaging modality that provides information about the
functional level of a particular
body part. It requires the injection of a low-level radioactive
isotope (chemical tracer) into the
bloodstream. Images then reflect how the tracer is processed by
the body. This is in contrast to
structural information provided by CT, MRI or ultrasound. Scans
are made with a device that
detects radioactivity in the body. A SPECT tomograph generates
detailed information as the
radiotracers used with a SPECT attach to elements appropriate
for obtaining specific
information. An example of this is how antibodies attach to
specific types of tumors. A
radiotracer can be attached to an antibody that will then bind
to a tumor, which is then
identified and located by a SPECT scan.
SPECT provides information about the cellular or level of
chemical activity within an organ or
system, including structural information about that system. This
process can show areas of
increased activity, such as inflammation seen in an abscess.
Patterns of distribution can then be
correlated with particular diseases. The selection of a
radiotracer and imaging protocol is
specific to the disease process being investigated. SPECT
cameras can image large areas of the
body as the emitted radiation from the radiotracers travel
through the body.
Information obtained by SPECT complements or confirms data
obtained by other forms of
testing and may provide additional information in some
situations. For many conditions, SPECT
has been found to be as useful as PET, even though PET images
tend to be of higher quality
than those of SPECT, SPECT tends to be more available. Both PET
and SPECT can diagnose
disease prior to the onset of clinical symptoms or structural
manifestations of disease as they
provide information regarding the functional level of a body
system.
Abscess/Infection
Labeled white blood cells are infused prior to SPECT imaging of
the suspected clinical site of
infection. This infusion helps with localization of tissue
inflammation.1
Autism Spectrum Disorders
Autism spectrum disorders can be difficult to diagnose due to
the variety and severity of the
presentation of symptoms. The American Academy of Neurology
Practice Guideline states the
following: "There is no evidence to support a role for
functional neuroimaging studies in the
clinical diagnosis of autism at the present time"25
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Surgical Repair
SPECT can be useful in distinguishing between tumor regrowth and
radiation necrosis in
patients with cerebral metastases.2
Cerebrovascular Disease (CVA, stroke, brain attack, TIA)
The use of SPECT has become outdated for the evaluation and
management of cerebrovascular
disease, including cerebrovascular accidents (CVA or stroke),
subarachnoid hemorrhages, and
transient ischemic attacks (TIA). Newer imaging techniques are
more common such as
computed tomography angiography (CTA) and magnetic resonance
angiography (MRA).3-5
Epilepsy Seizure Foci
Ictal SPECT may be applicable for patients being considered for
surgery to treat intractable
epilepsy, when seizure focus cannot be localized by EEG,
video-EEG, or MRI. Effective surgical
treatment of patients with intractable epilepsy is dependent on
accurate localization of the
epileptic focus and precise delineation of the eliptogenic
region. Ictal SPECT uses the
physiologic increase in regional cerebral blood flow during
seizures to localize the epileptogenic
region. This testing aids in identifying the source or sources
of the seizures as well as assess
brain function. SPECT may offer a safe and accurate alternative
to quantitative MRI or PET for
the pre-surgical ictal detection of seizure focus. It should be
performed in a hospital setting.6,7
Kidney (renal)
Using Technetium-99m labeled dimercaptosuccinic acid (DSMA) for
diagnostic imaging may be
useful to evaluate kidney function and identify scarring that
may be the result of frequent
infections.8,9 The National Institute for Health and Clinical
Excellence 2007 guideline
recommends DMSA scanning when the diagnosis cannot be confirmed
by Doppler ultrasound.10
The American Urological Association 2010 Clinical Practice
Guideline recommends DMSA scan
when a renal ultrasound is abnormal in children with
vesicoureteral reflux to detect the presence
of any renal scarring.11
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Liver Hemangioma versus Primary Hepatoma or Metastases
Technetium-labeled red blood cells are infused prior to SPECT
imaging of the liver. There is risk
of hemorrhage in a percutaneous biopsy of liver hemangiomas, so
non-invasive methods of
testing are useful for differentiating between the blood pool of
an hepatic hemangioma from
other solid hepatic masses. Review articles and published
studies support SPECT as an
appropriate diagnostic tool to differentiate between hepatic
lesions versus hemangiomas.12
Lymphoma
SPECT scans may be useful to distinguish tumor from radiation
necrosis in the chest and
abdomen. An initial study can be compared with a follow-up study
after the completion of
treatment. SPECT is not appropriate for initial staging of
lymphoma.13
Mental Health Disorders
SPECT imaging of the brain for mental health disorders is used
as a research tool in clinical trials.
The National Institute of Mental Health (NIMH) made the
following statement in their brochure
titled “Neuroimaging and Mental Illness: A window into the
brain”:
No scientific studies to date have shown that a brain scan by
itself can be used for
diagnosing a mental illness or to learn about a person’s risk
for disease. Brain scans alone
cannot be used to diagnose a mental disorder, such as autism,
anxiety, depression,
schizophrenia, or bipolar disorder. Other types of tests are
needed for a mental illness to be
properly diagnosed.14,15
Mild Cognitive Impairment (MCI) Conversion to Alzheimer’s
Disease (AD)
The utility of SPECT to predict conversion from mild cognitive
impairment (MCI) to Alzheimer’s
disease (AD) is limited.16,17 A technology assessment of SPECT
for dementia and AD by the
Institute for Clinical Effectiveness and Health Policy
concluded: “SPECT has not clearly
demonstrated its usefulness in assessing patients with dementia,
and it has no precise
indications for diagnosis, evaluation of prognosis or monitoring
response to treatment.”18
Controlled studies of SPECT in AD show the sensitivity of this
testing varies from 50 to 95%. The
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American Academy of Neurology does not recommend SPECT for
routine use in the differential
diagnosis of dementia.19
Neuroendocrine Tumors
SPECT for the diagnosis and staging of neuroendocrine tumors may
be done using a
monoclonal antibody (OctreoScan™) or I-131
meta-iodobenzyl-guanidine (MIBG) because
carcinoids and other neuroendocrine tumors have somatostatin
receptors and can be imaged
with somatostain analogs tagged with an appropriate
radioisotope.20, 21
Parathyroid Disease
Guidelines on parathyroid scintigraphy from the Society of
Nuclear Medicine22 state that there is
a developing consensus that SPECT and SPECT/CT are most useful
for improving the precision of
anatomic localization. The Parathyroid Task Group of the EANM21
state that the use of SPECT/CT
has a major role for obtaining anatomical details on ectopic
foci. However, its use as a routine
procedure before target surgery is still investigational.
Preliminary data suggest that SPECT/CT
has lower sensitivity in the neck area compared to pinhole
imaging.22-24
Prostate Cancer
ProstaScint, a monoclonal antibody combined with radioactive
indium-111, is used to detect
prostate cancer. It is injected into the body and then a gamma
camera is used to locate prostate
cancer cells. There is little evidence demonstrating
improvements in health outcomes following
ProstaScint scans. One study showed 60% progression-free
survival (PFS) of 60% for those study
participants with a negative scan and 74% for those with a
positive scan. The researchers of the
study concluded that the individuals with positive scans did not
have a statistically significant
difference in PFS than those with a negative scan result.26
Pucar concluded that “ProstaScint has
not added benefit over other imaging modalities in evaluating
post-radical prostatectomy
recurrence, due to its low sensitivity for detecting local
recurrences and bone metastases.”27
The American College of Radiology (ACR) states: “The reliability
and usefulness of indium-111
radiolabeled capromab pendetide (a first-generation monoclonal
antibody against prostate-
specific membrane antigen [PSMA]) scan as a method to stage
prostate cancer remains
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unproven.”28 They also note that the optimal use of the scan
remains to be determined as the
scans are difficult to interpret and are costly to
perform.29
Spondylolysis and Stress Fractures
SPECT scans may be useful in evaluating chronic back or neck
pain that is atypical, that may be
caused by spondylolysis or stress fractures that are undiagnosed
by conventional imaging. Bone
SPECT may provide diagnostic information in cases of low back
pain that is not available with
routine imaging. One study of 34 patients with chronic low back
pain compared findings from
radiography, computed tomography (CT) and bone scintigraphy with
SPECT. The majority of
lesions (89%) seen on SPECT corresponded to identifiable disease
on CT.30 SPECT was also
found to be more sensitive than planar bone scintigraphy in
identifying patients with painful
defects in the pars interarticularis compared to radiographic
evidence of spondolysis and/or
spondylolisthesis in 19 adult patients studied. 31 Bencardino et
al (2016) in the Expert Panel on
Musculoskeletal Imaging. American College of Radiology
Appropriateness Criteria states: “planar
scintigraphy combined with SPECT is more accurate in diagnosing
stress injuries than planar
scintigraphy alone.”32
Vertebral Abnormalities
SPECT scans may be useful in evaluating chronic back or neck
pain that is atypical, that may be
caused by spondylolysis or stress fractures that are undiagnosed
by conventional imaging
studies.30,31
References
1. Bybel B, Brunken RC, DiFilippo FP, Neumann DR, Wu G,
Cerqueira MD. SPECT/CT imaging: clinical utility of an emerging
technology. Radiographics. 2008 Jul-Aug;28(4):1097-113. PMID
18635631
2. Serizawa T, Saeki N, Higuchi Y et al. Diagnostic value of
thallium-201 chloride single-photon emission computerized
tomography in differentiating tumor recurrence from radiation
injury after gamma knife surgery for metastatic brain tumors. J
Neurosurg 2005; 102 (Suppl):266-271. PMID 15662823
3. Lewis DH. Functional brain imaging with cerebral perfusion
SPECT in cerebrovascular disease, epilepsy, and trauma.
Neurosurg
Clin N Am. 1997 Jul;8(3):337-344. PMID9188542
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Page | 10 of 12 ∞
4. Ueda T et al. Outcome in acute stroke with successful
intra-arterial thrombolysis and predictive value of initial single
photon
emission-computed tomography. J Cereb Blood Flow Metab. 1999
Jan;19(1):99-108. PMID 9886360
5. Lewis DH et al. Brain SPECT and the effect of cerebral
angioplasty in delayed ischemia due to vasospasm. J Nuc Med,
Oct.
1992; Vol. 33, No. 10:1789-1796. PMID 1403146
6. von Oertzen TJ, Mormann F, Urbach H, et al. Prospective use
of subtraction ictal SPECT coregistered to MRI (SISCOM) in
presurgical evaluation of epilepsy. Epilepsia. 2011;
52(12):2239-2248. PMID 22136078
7. Kumar A, Chugani HT. The role of radionuclide imaging in
epilepsy, Part 1: Sporadic temporal and extratemporal lobe
epilepsy.
J Nucl Med. 2013 Oct;54(10):1775-1781. PMID 23970368
8. Even-Sapir E, Gutman M, Lerman H et al. Kidney allografts and
remaining contralateral donor kidneys before and after
transplantation: assessment by quantitative (99m) TC-DMSA SPECT.
J Nucl Med 2002; 43(5):584-588. PMID 11994518
9. Mullerad M, Kastin A, Issaq E et al. The value of
quantitative 99M technetium dimercaptosuccinic acid renal
scintigraphy for
predicting postoperative renal insufficiency in patients
undergoing nephrectomy. J Urol 2003; 169(1):24-27. PMID
12478094
10. National Institute for Health and Care Excellence. Clinical
Guideline[CG54] Urinary tract infection in under 16s: diagnosis
and
management. Published date: August 2007. Last updated: October
2018. Available at:
https://www.nice.org.uk/guidance/cg54 Accessed September
2019.
11. American Urological Association. Clinical Practice
Guideline. Management and screening of primary vesicoureteral
reflux.
Reviewed 2017. Available at:
http://www.auanet.org/guidelines/vesicoureteral-reflux-(2010-reviewed-and-validity-
confirmed-2017) Accessed September 2019.
12. Jacobson AF, Teefey SA. Cavernous hemangiomas of the liver.
Association of sonographic appearance and results of Tc-99m
labeled red blood cell SPECT. Clin Nucl Med. 1994;19(2):96-99.
PMID 8187411
13. Bockisch A, Freudenberg LS, et al. Hybrid imaging by
SPECT/CT and PET/CT: proven outcomes in cancer imaging. Semin
Nucl
Med. 2009 Jul;39(4):276-289. PMID 19497404
14. American Psychiatric Association. Practice Guideline for the
Psychiatric Evaluation of Adults, Third Edition. August 2015.
Available at:
https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines
Accessed September 2019.
15. Farah MJ, Gillihan SJ. The Puzzle of Neuroimaging and
Psychiatric Diagnosis: Technology and Nosology in an Evolving
Discipline. AJOB neuroscience. 2012;3(4):31-41. PMID
23505613
16. Devanand DP, Van Heertum RL, Kegeles LS, et al. (99m)Tc
hexamethyl-propylene-aminoxime single-photon emission computed
tomography prediction of conversion from mild cognitive
impairment to Alzheimer disease. Am J Geriatr Psychiatry.
2010;18(11):959-972. PMID 20808143
17. McNeill R, Sare GM, Manoharan M, et al. Accuracy of
single-photon emission computed tomography in differentiating
frontotemporal dementia from Alzheimer’s disease. J Neurol
Neurosurg Psychiatry. 2007;78(4):350-355. PMID 17158559
18. Ferrante, D. SPECT for the diagnosis and assessment of
dementia and Alzheimer’s disease (summary). Report ITB No. 14.
Buenos Aires, Argentina: Institute for Clinical Effectiveness
and Health Policy (ICES); 2004.
19. Knopman DS, DeKosky ST, et al. Practice parameter: Diagnosis
of dementia (an evidence-based review). Report of the Quality
Standards Subcommitte of the American Academy of Neurology.
Neurology. 2001;56 (9): 1143-1153
20. Schillaci O, Scopinaro F, Angeletti S, et al. SPECT improves
accuracy of somatostatin receptor scintigraphy in abdominal
carcinoid tumors. J Nuclear Med. 1996;37(9):1452-1456. PMID
8790191
21. Schillaci O, Corleto VD, Annibale B, et al. Single photon
emission computed tomography procedure improves accuracy of
somatostatin receptor scintigraphy in gastro-entero pancreatic
tumours. Ital J Gastroenterol Hepatol. 1999 Oct; 31 Suppl
2():S186-189. PMID 10604127
22. Greenspan BS, Brown ML, Dillehay GL, et al. The Society of
Nuclear Medicine Procedure Guideline for Parathyroid
Scintigraphy.
Version 3.0. Reston, VA: Society of Nuclear Medicine; June
2004.
https://www.nice.org.uk/guidance/cg54http://www.auanet.org/guidelines/vesicoureteral-reflux-(2010-reviewed-and-validity-confirmed-2017)http://www.auanet.org/guidelines/vesicoureteral-reflux-(2010-reviewed-and-validity-confirmed-2017)https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines
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Page | 11 of 12 ∞
23. Hindié E, Ugar O, Fuster D, et al; Parathyroid Task Group of
the EANM. 2009 EANM parathyroid guidelines. Eur J Nucl Med Mol
Imaging. 2009:36(7):1201-1216. PMID 19471928
24. Tunninen V, Varjo P, Schildt J, et al. Comparison of five
parathyroid scintigraphic protocols. Int J Mol Imaging.
2013;2013:921260. PMID 23431436
25. Filipek PS, Accardo PJ, Ashwal S, et al. Practice parameter:
screening and diagnosis of autism: report of the Quality
Standards
Subcommittee of the American Academy of Neurology and the Child
Neurology Society. Neurology. 2000; 55(4):468-479.
PMID: 10953176
26. Koontz BF, Mouraviev V, Johnson JL, et al. Use of local
(111) in-capromab pendetide scan results to predict outcome
after
salvage radiotherapy for prostate cancer. Int J Radiat Oncol
Biol Phys. 2008; 71(2):358-361.
27. Pucar D, Sella T, Schöder H. The role of imaging in the
detection of prostate cancer local recurrence after radiation
therapy and
surgery. Curr Opin Urol. 2008; 18(1):87-97.
28. American College of Radiology. ACR Appropriateness
Criteria®. Post-treatment Follow-up of Prostate Cancer (Revised
2017).
Available at: https://acsearch.acr.org/docs/69369/Narrative/
Accessed September 2019.
29. American College of Radiology. ACR Appropriateness
Criteria®. Prostate Cancer — Pretreatment Detection, Staging,
and
Surveillance (Revised 2016). Available at:
https://acsearch.acr.org/docs/69371/Narrative/ Accessed September
2019.
30. Ryan PJ et al. Chronic low back pain: Comparison of bone
SPECT with radiography and CT. Radiology 1992, Vol.
182:849-854.
PMID 1531544
31. Collier BD et al. Painful spondylolysis of spondylolisthesis
studied by radiography and single photon emission computed
tomography. Radiology 1985, Vol. 154:207-211. PMID 3155479
32. Bencardino, JT, Stone TJ, Roberts CC, et al.Expert Panel on
Musculoskeletal Imaging. ACR Appropriateness Criteria Stress
(fatigue/insufficiency) fracture, including sacrum, excluding
other vertebrae.. J Am Coll Radiol 2017; 14 (5S): S293-S306.
PMID:
28473086. https://acsearch.acr.org/docs/69435/Narrative/
Accessed September 2019.
33. Centers for Medicare & Medicaid Services. National
Coverage Decision (NCD) for Single Photon Emission Computed
Tomography (SPECT) (220.12). 2002.
https://www.cms.gov/medicare-coverage-database/details/ncd-
details.aspx?NCDId=271&ncdver=1&DocID=220.12&bc=gAAAAAgAAAAAAA%3d%3d&
Accessed September 2019.
History
Date Comments 09/01/16 New policy, approved August 9, 2016. Add
to Medicine section. SPECT may be
considered medically necessary when criteria are met for select
non-cardiac
indications. SPECT is not medically necessary for
cerebrovascular indications. SPECT is
investigational when criteria are not met.
06/01/17 Annual review, approved May 23, 2017. Policy
reorganized for clarity; no change in
policy statements.
07/01/18 Annual Review, approved June 12, 2018. Policy updated
with literature search through
April 2018, References 10, 11,18, 19, 26-29 added. Added
assessment of osteomyelitis
to medical necessity criteria. Deleted degenerative joint
disease/arthritis of the facet
joints from the vertebral abnormalities medical necessity
criteria.
https://acsearch.acr.org/docs/69369/Narrative/https://acsearch.acr.org/docs/69371/Narrative/https://acsearch.acr.org/docs/69435/Narrative/https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=271&ncdver=1&DocID=220.12&bc=gAAAAAgAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=271&ncdver=1&DocID=220.12&bc=gAAAAAgAAAAAAA%3d%3d&
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Page | 12 of 12 ∞
Date Comments 10/01/19 Annual Review, approved September 5,
2019. Policy updated with literature search
through August 2019. References 32 and 33 added. Minor edits
made for clarity.
Otherwise, policy statements unchanged. Added HCPCS code A9507,
removed CPT
code 78607.
Disclaimer: This medical policy is a guide in evaluating the
medical necessity of a particular service or treatment. The
Company adopts policies after careful review of published
peer-reviewed scientific literature, national guidelines and
local standards of practice. Since medical technology is
constantly changing, the Company reserves the right to review
and update policies as appropriate. Member contracts differ in
their benefits. Always consult the member benefit
booklet or contact a member service representative to determine
coverage for a specific medical service or supply.
CPT codes, descriptions and materials are copyrighted by the
American Medical Association (AMA). ©2019 Premera
All Rights Reserved.
Scope: Medical policies are systematically developed guidelines
that serve as a resource for Company staff when
determining coverage for specific medical procedures, drugs or
devices. Coverage for medical services is subject to
the limits and conditions of the member benefit plan. Members
and their providers should consult the member
benefit booklet or contact a customer service representative to
determine whether there are any benefit limitations
applicable to this service or supply. This medical policy does
not apply to Medicare Advantage.
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https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone
at: U.S. Department of Health and Human Services 200 Independence
Avenue SW, Room 509F, HHH Building Washington, D.C. 20201,
1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
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037336 (07-2016)
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(TTY: 800-842-5357).
https://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsfmailto:[email protected]
-
้
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Health Plan of
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ອຮັກສາຄວາມຄຸ້ມຄອງປະກັນສຸຂະພາບ ຫຼື ຄວາມຊ່ວຍເຫຼື ອເລ່ື ອງຄ່າໃຊ້
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ភាសាែខមរ (Khmer):
ມູ ຮັ ສິ
ມູ ຂໍ້
ສໍ
ຈ່
ວັ
ມູ ຂໍ້ ມີ ໝັ
ຊ່
Română (Romanian): Prezenta notificare conține informații
importante. Această notificare poate conține informații importante
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tatau e maua atu i lenei fa’asilasilaga ma lenei fa’matalaga i
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le telefoni 800-592-6804 (TTY: 800-842-5357).
Español (Spanish): Este Aviso contiene información importante.
Es posible que este aviso contenga información importante acerca de
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រងរបស់អន
LifeWise Health Plan of Washington ។ របែហលជាមាន កាលបរ ិ ឆ ំ ់
េចទសខានេនៅ
មានយ៉ា ំ ់ ត ងសខាន។ េសចក ំណឹងេនះរបែហល
កតាមរយៈ
ងេសចកត ី នដណងេនះ។ អករបែហលជារតវការបេញញសមតភាព ដល់ ណត់ ំ ឹ ន ូ ច ថ
កំ ជូ កន ុ determinadas fechas para mantener su cobertura médica o
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costos. Usted tiene derecho a recibir esta información y ayuda en
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ក sin costo alguno. Llame al 800-592-6804 (TTY: 800-842-5357). ជ
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ទធ នួ ល។ អន នួ ិ ួលព័ ៌ ិងជំ ន ុងភាសារបស ទទ តមានេនះ ន យេនៅក អន
់
800-592-6804 (TTY: 800-842-5357)។
រស័
ਅੰ
ਜਾਬੀ (Punjabi): paunawa na ito ay maaaring naglalaman ng
mahalagang impormasyon ਇਸ ਨੋ ਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹੈ. ਇਸ ਨੋ ਿਟਸ ਿਵਚ
LifeWise Health Plan of tungkol sa iyong aplikasyon o pagsakop sa
pamamagitan ng LifeWise
Health Plan of Washington. Maaaring may mga mahalagang petsa
dito sa Washington ਵਲ ਤੁ ਜ ਅਤੇ ਅਰਜੀ ਬਾਰੇ ਮਹਤਵਪੂ ੋ ਸਕਦੀ ਹਾਡੀ ਕਵਰੇ ੱ
ਰਨ ਜਾਣਕਾਰੀ ਹ
ពទ
paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa
ilang ਹੈ ੋ ਿਜਸ ਜਵਚ ਖਾਸ ਤਾਰੀਖਾ ਹੋ ਂ ਹਨ. ਜੇ ੁ ੇ ੱ ਖਣੀ ਹੋ ੇ mga
itinakdang panahon upang mapanatili ang iyong pagsakop sa . ਇਸ ਨ
ਸਕਦੀਆ ਕਰ ਤਸੀ ਜਸਹਤ ਕਵਰਜ ਿਰ ਵ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵੱਚ ਮਦਦ ਦੇ ੱ ੁ ੋ ਤਾਂ ਤੁ
ੰ ੂ ਤਮ ਤਾਰੀਖ਼ ਤ ਪਿਹਲਾਂ ਕੁ kalusugan o tulong na walang gastos. May
karapatan ka na makakuha ng ਇਛਕ ਹ ਹਾਨ ੱ ਝ ਖਾਸ
ganitong impormasyon at tulong sa iyong wika ng walang gastos.
Tumawag ਕਦਮ ਚੁਕਣ ਦੀ ਲੜ ਹੋ ਸਕਦੀ ਹ ੈ,ਤੁ ੰ ੂ ਮੁ ੱ ਚ ਤੇ ੱ ਚ ਜਾਣਕਾਰੀ ਅਤੇ
ੱ ੋ ਹਾਨ ਫ਼ਤ ਿਵ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵ ਮਦਦ sa 800-592-6804 (TTY: 800-842-5357).
ਪ੍ਰ ੈਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹ ,ਕਾਲ 800-592-6804 (TTY: 800-842-5357).
ਪੰ
Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng
mahalagang impormasyon. Ang
ไทย (Thai): ประกาศน ้ีมีข้อมลูสําคญั ประกาศน
้ีอาจมีข้อมลูที่สําคญัเกี่ยวกบัการการสมคัรหรือขอบเขตประกนั
(Farsi): فارسی فرم بارهدر ھمم اطالعات حاوی است ممکن يهمالعا اين
. ميباشد ھمم اطالعات یوحا يهمالعا اين
สขุภาพของคณุผ่าน LifeWise Health Plan of Washington
และอาจมีกําหนดการในประกาศ طريق از ماش ای مهبي وششپ يا و تقاضا
LifeWise Health Plan of Washington به .باشدี น جهتو يهمالعا اين در
ھمم ھای خيتار يا تان بيمه وششپ حقظ برای است کنمم ماش . يدماين کمک
คณุอาจจะต้องดําเนินการภายในกําหนดระยะเวลาที่แน่นอนเพื่อจะรักษาการประกนัสขุภาพของคณุ
اجتياح صیاخ کارھای امانج برای صیمشخ ھای خيتار به تان، انیمدر ھای
زينهھ پرداخت درหรือการช่วยเหลือที่มีค่าใช้จ่าย
คณุมีสิทธิที่จะได้รับข้อมลูและความช่วยเหลือน ้ีในภาษาของคณุโดยไม่ม
ีباشيد داشته . رايگان ورط به ودخ انزب به را مکک و اطالعات اين که
داريد را اين حق ماش
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