Coverage Guideline


Subject:  Single Photon Emission Computed Tomography (SPECT) Scans for Noncardiovascular Indications
Document #:  RAD.00023Current Effective Date:  10/08/2013
Status:ReviewedLast Review Date:  08/08/2013

Description/Scope

Single photon emission computed tomography (SPECT) provides three-dimensional images of the concentration of a radiopharmaceutical within various tissues and organs, and is an established imaging modality for a number of different indications. This document addresses the use of SPECT for noncardiovascular indications.

Note: Please see the following related document for additional information:

Position Statement

Medically Necessary: 

SPECT scans are considered medically necessary for any of the following:

  1. Bone and joint conditions—to differentiate between infectious, neoplastic, avascular or a traumatic process.
  2. Brain tumors—to differentiate between lymphomas and infections such as toxoplasmosis particularly in the immunosuppressed, or recurrent tumor vs. radiation changes, when PET is not available.
  3. Liver hemangioma—using labeled red blood cells to further define lesions identified by other imaging modalities.
  4. Localization of abscess/infection/inflammation in soft tissues or cases of fever of unknown origin.
  5. Neuroendocrine tumors (e.g., adenomas, carcinoid, pheochromocytomas, neuroblastoma, vasoactive intestinal peptide [VIP] secreting tumors, thyroid carcinoma, adrenal gland tumors)—using a monoclonal antibody (OctreoScan [Covidien, Hazelwood, MO]) or I-131 meta-iodobenzyl-guanidine (MIBG).
  6. Parathyroid imaging.
  7. Renal - Dimercaptosuccinic acid (DMSA) scan to assess the status of kidney for scarring and function.

Not Medically Necessary: 

SPECT scans are considered not medically necessary for the evaluation or management of cerebrovascular accident (CVA, stroke), subarachnoid hemorrhage, or transient ischemic attack.

Investigational and Not Medically Necessary: 

For noncardiovascular indications, SPECT scans are considered investigational and not medically necessary, for all other purposes, including, but not limited to:

  1. Attention Deficit and Hyperactivity Disorder.
  2. Chronic fatigue syndrome.
  3. Colorectal carcinoma (e.g., used with the monoclonal antibody or IMMU-4 and CEA-Scan® [Immunomedics Inc., Morris Plains, New Jersey]).
  4. Dopamine transporter (DaT) scan for all indications.
  5. Malignancies other than those listed as medically necessary.
  6. Neuropsychiatric disorders without evidence of cerebrovascular disease.
  7. Pervasive development disorders (PDD).
  8. Prostate carcinoma (e.g., used with the monoclonal antibody ProstaScint® [EUSA Pharma, Langhorne, PA], with or without fusion imaging with computed tomography or magnetic resonance imaging).
  9. Scintimammography for breast cancer.
  10. SPECT/SISCOM for the preoperative evaluation of individuals with intractable focal epilepsy to identify and localize area(s) of epileptiform activity when other techniques designed to localize a focus are indeterminate.
Rationale

Currently there is sufficient evidence in the peer-reviewed medical literature in the form of properly randomized controlled clinical trials to support the use of SPECT in a variety of disease processes. The literature supports the clinical effectiveness and safety of this imaging for the diagnosis and evaluation of selected oncologic diseases, the evaluation of some specific central nervous system (CNS) disorders (e.g., brain tumor, toxoplasmosis) and the investigation of bone, joint and soft tissue disorders for inflammation or infection. SPECT has been shown to be safe and effective for the monitoring of changes in these conditions over time, comparable to the gold standard of positron emission tomography (PET) scanning. In addition, non-randomized but controlled clinical trials have established the safety and efficacy of SPECT in identifying infections. Early identification of acute infection, such as in appendicitis, may be critical to early intervention and positive outcome.

A DMSA renal scan using Technetium-99m labeled DSMA is a diagnostic imaging exam that evaluates the function, size, shape and position of the kidneys and detects scarring caused by frequent infections. Mohkam and colleagues (2010) evaluated 1476 children with pyelonephritis who had renal ultrasound, voiding cystourethrography (VCUG) and DMSA scanning. A total of 79% of the children with pyelonephritis had evidence of pyelonephritis on DMSA scan. Renal ultrasound results were abnormal in 31.5% of children, VCUG showed vesicoureteral reflux in 25.9% of the children. The National Institute for Health and Clinical Excellence 2007 guideline for Urinary tract infection in children: diagnosis, treatment and long-term management recommends DMSA scanning when power Doppler ultrasound is not available or if the diagnosis still cannot be confirmed. The American Urological Association 2010 Clinical Practice Guideline for management and screening of primary vesicoureteral reflux in children recommends DMSA scan for children with vesicoureteral reflux to detect new renal scarring when renal ultrasound is abnormal.

The use of SPECT for the evaluation and management of cerebrovascular disease, including cerebrovascular accident (CVA, stroke), subarachnoid hemorrhage, and transient ischemic attack has been superseded by newer more accurate imaging modalities. In recent years the use of magnetic resonance angiography (MRA) and computed tomography angiography (CTA) has become the standard of care for these conditions and the use of SPECT has become obsolete in the presence of superior technologies and perfusion magnetic resonance imaging (MRI) and computed tomography (CT) perfusion are more akin to SPECT which measures perfusion, not vessel anatomy. Advances in other imaging modalities such as PET, has also led to SPECT no longer being used for certain types of cancer including lymphoma.

The efficacy of SPECT for other applications has not been firmly established due to the lack of comprehensive studies for each application.

The diagnosis of PDD can be complex and difficult due to the diversity of the presentation of symptoms and their severity. Due to the multitude of possible causes, and potential confusion with other conditions, many tests exist that may or may not be appropriate. It is vital that parents of children suspected of having a PDD seek early diagnosis and care for their child to increase any potential benefits of treatment. The American Academy of Neurology Practice Guideline for screening and diagnosis of autism states "There is no evidence to support a role for functional neuroimaging studies in the clinical diagnosis of autism at the present time" (Filipek, 2000).

Early diagnosis of brain death allows for discontinuation of artificial ventilation and early organ transplants. Brain death is determined by clinical findings such as absent brainstem reflexes and unresponsiveness to external stimuli. Diagnostic tests can also be used to assist in the diagnosis of brain death including electroencephalography (EEG), evoked potentials, Doppler ultrasound, angiography, and SPECT. The typical SPECT finding of brain death is an empty skull appearance. The use of SPECT has been studied in helping to confirm the diagnosis of brain death. But current literature consists of small group sizes (Bertagna, 2009; Munari, 2005; Okuyaz, 2004).

Okuyaz and colleagues (2004) reported on 8 deeply comatose and clinically brain dead children who had SPECT and then observation for at least 24 hours following their SPECT. Six of the children showed lack of perfusion in the cerebrum and empty skull appearance. The two newborns had 2 consecutive SPECT scans. The first SPECT showed perfusion which was not consistent with brain death image. The second SPECT scans showed no perfusion. The authors conclude that while SPECT may confirm the diagnosis of brain death, clinical findings are still the mainstay for the diagnosis. Munari and colleagues (2005) compared SPECT to cerebral angiography in 20 clinically brain dead individuals. In order to avoid time lag, after SPECT, all individuals immediately underwent angiography before data analysis and map reconstruction. The results of the SPECT were interpreted by a specialist in nuclear medicine. The angiography results were interpreted by a neuroradiologist. Both were blind to the results of the other investigation. Both SPECT and angiography confirmed brain death, showing absence of brain perfusion in 19 of 20 individuals. Further studies with larger groups are necessary to check if SPECT has an unerring capability of diagnosing the absence of brain perfusion. Joffe and colleagues (2010) reported on a literature review to determine the usefulness of SPECT testing to confirm the diagnosis of brain death. Using clinically confirmed brain death as the gold standard of comparison, the sensitivity of SPECT was 109 out of 121 and the specificity was 12 out of 12. Using cerebral angiography as the gold standard of comparison, the sensitivity of SPECT was 34 out of 34 and the specificity could not be determined as there were no individuals without clinical brain death having the tests. The authors conclude that since SPECT is being used to diagnose the state of death, specificity of SPECT should be clarified.

Ioflupane I 123 is a molecular imaging agent used during SPECT scan to determine the location and concentration of dopamine transporters in the synapses of striatal dopaminergic neurons. It has shown efficacy for detecting the degeneration of the dopaminergic pathway allowing separation of those individuals with essential tremor from those with Parkinsonian syndromes.

Kupsch and colleagues (2012) reported on a randomized (non-blinded) trial which compared DaT scanning in 102 individuals to a control group of 112 individuals. The goal was to look at clinical management of Parkinson's, diagnosis, confidence of diagnosis, quality of life, health resource use and safety in those with uncertain diagnosis. Participants were evaluated at baseline, 4 weeks, 12 weeks and 1 year. SPECT scans were done at baseline and then evaluated for changes in clinical management plan, confidence of diagnosis. The most frequent change in clinical management at 12 weeks and 1 year was the initiation of medication not previously considered at baseline (50% in the imaging group had changes compared to 21% in the control group). More participants in the imaging group had a change in their clinical management at 12 weeks post treatment when compared with the control group. This remained the same at 1 year. Other changes in clinical management included more aggressive dopaminergic therapy and initiation of dopaminergic therapy. Forty-five (45) % of the DaT group had a change in diagnosis from baseline compared to 9% of the control group at 4 weeks. Forty-six (46) % of the DaT group had a change in diagnosis from baseline compared to 12% in the control group at 12 weeks. Fifty-four (54) % of the DaT group had a change in diagnosis from baseline compared to 23% in the control group at 1 year. These changes were in the direction of better agreement between clinical diagnosis and imaging results. Confidence of diagnosis for participants suspected of Parkinson's or non-Parkinson's was higher at the 4 week, 12 week and 1 year visits with DaT imaging when compared to control group. Quality of life questionnaires and health resource use were similar between the imaging and control groups (no significant changes noted here). It is noted that changing the medications and initiating medications didn't appear to have much of an impact on the participant's quality of life questionnaires as evidenced by the similarities between the 2 groups and the study didn't show clinical utility.

ProstaScint, a monoclonal antibody (capromab pendetide) combined with radioactive indium-111, is used to detect prostate cancer. It is injected into the body and a gamma camera (designed to detect radioactivity) is then used to locate any prostate cancer cells. ProstaScint shows potential benefit, but in the current peer-reviewed literature there is a paucity of evidence demonstrating improved progression-free survival following ProstaScint scans (including fusion with computed tomography or magnetic resonance imaging). In a study by Koontz (2008), forty individuals who had prostate specific antigen (PSA) recurrence after total prostatectomy were scanned prior to salvage prostate bed radiotherapy. Twenty individuals had negative scans and twenty individuals had locally positive scans. Two-year progression-free survival rates were 60% for those individuals with a negative scan and 74% for those individuals with a positive scan. The researchers concluded that individuals "with locally positive scans did not have statistically different progression-free survival than those with a negative scan result."

Pucar and colleagues (2008) concluded that "ProstaScint has no added benefit over other imaging modalities in evaluating post-radical prostatectomy recurrence, due to its low sensitivity for detecting local recurrences and bone metastases." A prospective trial of 25 hormone-naive men with clinically localized prostate cancer who received ProstaScint scanning with blinded correlation by a radiologist and pathologist found that sensitivity ranged from only 37% to 87%, and specificity from 0% to 50%, and that the scan seemed to have comparable affinity for both benign and malignant prostate tissue (Mouraviev, 2009).

El-Zawahry (2010) reported on a study using capromab pendetide (ProstaScint) with SPECT images to detect and localize prostate cancer of 69 participants with prostate cancer that had radiation therapy. The goal of their study was to select appropriate individuals with biochemical recurrence of prostate cancer following radiation therapy and then offer cryosurgical ablation of the prostate and avoid premature androgen deprivation therapy. Six participants had metastatic signal on SPECT scanning and were not considered candidates for cryosurgical ablation. Sixty-three (63) participants had prostate biopsy, 6 out of 63 had negative biopsy and were excluded from cryosurgical ablation. A total of 59 participants underwent cryosurgical ablation. Using the SPECT scanning in combination with prostate biopsy spared 2 participants from cryosurgical ablation and spared 44 participants from premature androgen deprivation therapy. While the use of SPECT imaging shows promise, this study is limited by a small group size and per the authors "more patients will be needed to confirm our results" (El-Zawahry, 2010).

Ellis and colleagues (2011) evaluated the use of capromab pendetide imaging with SPECT in primary prostate cancer for pretreatment staging and localization for radiotherapy dose escalation. The authors hypothesized that SPECT with ProstaScint could improve pretreatment prostate cancer staging. A total of 239 participants were evaluated for tumor stage using conventional staging and SPECT. Distant metastatic disease was identified in 22 participants, but this could not be clinically confirmed. Seven participants had uptake in the pelvic lymphatic chain and 15 participants had uptake in other sites suspicious of metastatic disease. In 65 participants, neither conventional imaging, nor any other staging method could confirm the presence of distant metastatic uptake suggested by SPECT. These findings were thought to represent false positive results. And while a 10 year follow-up showed overall survival was 84.8%, this study shows limitations in that it was not randomized nor did it have a control group.

The American College of Radiology in their 2012 Appropriateness Criteria® for Prostate Cancer — Pretreatment Detection, Staging, and Surveillance  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 remain unproven." In the American College of Radiology 2011 Appropriateness Criteria for Post-treatment Follow-up of Prostate Cancer they state "there are still questions remaining regarding its optimal use. Further, the scans are challenging to interpret and expensive to perform." The National Comprehensive Cancer Network (2012) does not address ProstaScint as a recommendation in the work-up of individuals with a recurrence after prostatectomy or radiation therapy.

Radioimmunoscintigraphy, a specialized form of SPECT, may also be called scintimammography when used in breast imaging. Scintimammography is the use of radiotracers with nuclear medicine imaging as a diagnostic tool for abnormalities of the breast. Breast-specific gamma imaging (BSGI), or molecular breast imaging (MBI), refers to the specific types of imaging machines that are used in conjunction with scintimammography.

Scintimammography has not been shown to improve health outcomes in individuals with breast cancer, populations being screened for breast cancer or as an adjunct for diagnostic or surgical treatment planning. At this time, literature is limited to small, uncontrolled studies that do not document outcome improvement with this imaging method (Ozulker, 2010). An assessment on scintimammography reported the following conclusions:

Pan and colleagues (2010) reported on a meta-analysis of 5 types of non-invasive imaging methods (ultrasound, computed tomography, magnetic resonance imaging, scintimammography, and positron emission tomography) for the evaluation of breast cancer recurrence and metastases. Ultrasound showed a sensitivity of 0.857 and specificity of 0.962. Computed tomography sensitivity was 0.848 with specificity of 0.753. Magnetic resonance imaging sensitivity was 0.950 and specificity 0.929. Scintimammography had a sensitivity of 0.900, specificity 0.798. Positron emission tomography sensitivity was 0.953 with a specificity of 0.863. Ultrasound had the highest specificity and positron emission tomography had the highest sensitivity. This meta-analysis revealed that scintimammography does not have the highest specificity or sensitivity when compared to other modalities. And there are advantages and disadvantages to all forms of non-invasive imaging methods.

A 2012 retrospective study by Weigert et al reported on 1042 individuals who underwent pathological analysis or follow-up imaging after having had at least one of the following: equivocal or negative mammogram or sonogram and an unresolved clinical concern, personal history of breast cancer or current cancer diagnosis, palpable masses negative on mammographic and sonographic examination, radiodense breast tissue, or high risk for breast cancer. Pathological analysis or follow-up imaging resulted in 250 positive findings and 792 negative findings. Individuals who had breast-specific gamma imaging were found to have positive results in 408 individuals and negative results in 634 individuals. While the authors concluded that "breast-specific gamma imaging significantly contributed to the detectionof malignant or high-risk lesions in patients with negative or indeterminate mammographic findings" there is no data showing improved clinical outcomes.

The American College of Radiology Appropriateness Criteria® for breast cancer (2012) concludes that there is insufficient evidence to support the use of scintimammography breast cancer screening, citing that radiation dose from scintimammography is higher than the dose of a digital mammogram, and it is not indicated for screening in its present form.

A 2013 TEC Assessment by the Blue Cross Blue Shield Association evaluated the use of BSGI, MBI, or scintimammography with breast-specific gamma camera as a diagnostic modality for screening to detect breast tumors and concluded that there is no evidence of improved health outcomes in the investigational setting.

SPECT has also been studied for its application in the preoperative evaluation for those individuals with focal intractable epilepsy. A specialized type of SPECT scan, subtraction peri-ictal SPECT coregistered to MRI (SISCOM), is a recently developed neuroimaging modality that has been proposed to guide localization of seizure foci prior to epileptic surgery by measuring the differences in cerebral blood flow caused by changes in neuronal activity across the interictal, ictal and postictal states.

Tan (2008) reported on 50 individuals with focal epilepsy who had SPECT/SISCOM imaging prior to surgery. The authors reported on how the results of SPECT/SISCOM alter surgery decisions. A consensus decision was made after presentation of data from a noninvasive evaluation (SPECT/SISCOM data was not provided initially). Consensus decisions were documented again following the presentation of SPECT/SISCOM data. For those individuals with localizing SPECT/SISCOM results, consensus decisions changed in 10 out of 32 individuals. For those individuals with nonlocalizing SPECT/SISCOM results, consensus decisions changed in 1 out of 18 individuals.

Seo and colleagues (2011) reported on a retrospective review of 14 children with intractable focal epilepsy. All 14 children subsequently underwent resective epilepsy surgery. The authors studied their records for clinical characteristics, surgical outcome, and localizing features on 3 preoperative diagnostic tests; SPECT/SISCOM, positron emission tomography (PET), and magnetoencephalography (MEG). Each test was localized by comparing the concordance to intracranial electroencephalogram (iEEG). MEG and SPECT/SISCOM showed the most concordance with iEEG at 79% (11 out of 14 children). PET showed a 13% concordance with iEEG (3 out of 14 children). While using a multiple modality approach may enhance the ability to localize the epileptogenic zone in focal epilepsy, the use of iEEG cannot be completely excluded because the extent of curative resection may not be accurately determined without proper iEEG monitoring. The authors concluded that larger prospective trials may be necessary to clearly define the role of multiple imaging modalities.

A 2011 observational study by von Oertzen and colleagues reported on the use of SISCOM in the presurgical evaluation of epilepsy in 175 individuals with drug-resistant epilepsy. The individuals had either nonlesional MRI or discordant results with the standard set of presurgical tests. The authors concluded that while the study had large numbers it may still have been too small to show significant effects in the statistical analysis and "logistic regression analysis did not show any influencing factors with regard to the gold standard comparison." This current study may not be sufficient to identify parameters indicating the reliability of the SISCOM result and larger participant groups are necessary to establish parameters on replacing electrode implantation.

Background/Overview

SPECT is an imaging method designed to provide information about the functional level of a specific part of the body. SPECT involves the injection of a low-level radioactive chemical, called a radiotracer, into the bloodstream. The images obtained reflect the manner in which the tracer is processed by the body and thus this technology provides functional information in contrast to the structural information provided by CT, MRI and ultrasound. Using various imaging protocols, scans are made with a device that can detect radioactivity in the body. Detailed information is generated by a SPECT camera, gamma camera, or tomograph. Such imaging is called tomography. Each radiotracer used with SPECT is a radiation emitting substance that is used alone or attached to an element appropriate for obtaining specific information. For example, certain types of proteins called antibodies attach to specific types of tumors. The radiotracer can be attached to the antibodies so that they bind to the tumors, and thus can be identified and located.

SPECT can provide information about the level of chemical or cellular activity within an organ or system as well as provide structural information. This process may show areas of increased activity such as the inflammation in an abscess. Patterns of distribution of the radiotracer can be correlated with various diseases. SPECT has been of particular use in early detection in brain and bone disorders, as well as development of some types of malignancies. The radiotracer used and imaging protocol is specific to the disease process being investigated. SPECT scans may be repeated to follow the course of a disease.

SPECT is typically performed without the need of a hospital stay. The individual is given a dose of a radiotracer, which circulates in the bloodstream and binds to specific target cells. The emitted radiation from the radiotracer travels through body with little interference and is imaged. SPECT cameras can image large areas of the body, or the entire body.

Information acquired by SPECT frequently adds or confirms observations obtained by other testing. SPECT may also provide information not obtainable by means other than PET. PET is a newer technology and may provide additional information in some settings. The images obtained through PET tend to be of a higher quality than those provided by SPECT however, the availability, sensitivity and specificity and impact on clinical outcomes using PET varies by clinical condition. For many conditions, SPECT has been found to be as useful as PET and it is generally more available.

Both PET and SPECT may reveal the presence of disease prior to the appearance of any symptoms or structural expressions of disease, by providing information about the level of function within a body system. CT, MRI, and planar scintigraphy are alternatives for providing structural information. However, these techniques provide no information about function and are often inadequate to diagnose or evaluate disease processes.

Definitions

Abscess: A collection of pus often caused by the body's response to an infection.

Adenoma: A benign tumor that arises in or resembles glandular tissue.

Carcinoid syndrome: A syndrome due to carcinoid tumors that secrete large amounts of the hormone serotonin. Carcinoid tumors usually arise in the gastrointestinal tract, anywhere between the stomach and the rectum and may metastasize (spread) to the liver.

Colorectal carcinoma: A cancer of the colon and rectum which is a malignant tumor arising from the inner wall of the large intestine.

Liver hemangioma: The most common benign tumor of the liver. It is made up of small blood vessels and is 4-6 times more common in women than men.

Neuroendocrine tumors: A diverse group of tumors, such as carcinoid, islet cell tumors, neuroblastoma, and small cell carcinomas of the lung. All have dense granules and produce polypeptides that can be identified by immunochemical methods.

Parkinsonian syndromes: A group of diseases that share similar cardinal signs of parkinsonism characterized by bradykinesia, rigidity, tremor at rest, and postural instability.

Pervasive developmental disorders: Refers to a group of disorders characterized by delays in the development of socialization and communication skills which are often accompanied by cognitive and language delays.

Pyelonephritis: A type of urinary tract infection that can affect one or both kidneys.

Subarachnoid hemorrhage: Bleeding in the space between the two membranes that surround the brain.

Transient ischemic attack (TIA): A neurological event with the signs and symptoms of a stroke, but which go away within a short period of time. Also called a mini-stroke, a TIA is due to a temporary lack of adequate blood and oxygen (ischemia) to the brain.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Parathyroid; bone and joint; renal; inflammatory processes
When services are Medically Necessary: 

CPT 
78071Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT)
78320Bone and joint imaging; tomographic (SPECT)
78710Kidney imaging morphology; tomographic (SPECT)
78807Radiopharmaceutical localization of inflammatory process; tomographic (SPECT)
  
ICD-9 Diagnosis 
 All diagnoses
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
 All diagnoses

Brain
When Services may be Medically Necessary when criteria are met:

CPT 
78607Brain imaging, tomographic (SPECT) [when not specified as DaT scan]
  
ICD-9 Diagnosis 
191.0-191.9Malignant neoplasm of brain
196.0-196.9Secondary and unspecified malignant neoplasm of lymph nodes
198.3Secondary malignant neoplasm, brain and spinal cord
200.00-202.98Lymphosarcoma and reticulosarcoma
225.0-225.2Benign neoplasm of brain, cranial nerves, cerebral meninges
237.5Neoplasm of uncertain behavior, brain and spinal cord
239.6Neoplasms of unspecified nature, brain
339.00-339.89Other headache syndromes
346.00-346.93Migraine
347.00-347.11Cataplexy and narcolepsy
348.0-348.9Other conditions of brain
780.31-780.39Convulsions
780.60Fever, unspecified
784.0Headache
784.2Swelling, mass, or lump in head or neck
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
C70.0Malignant neoplasm of cerebral meninges
C71.0-C71.9Malignant neoplasm of brain
C72.20-C72.59Malignant neoplasm of cranial nerves
C77.0Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck
C79.31-C79.32Secondary malignant neoplasm of brain and cerebral meninges
C81.00-C88.9Lymphomas
D32.0Benign neoplasm of cerebral meninges
D33.0-D33.2Benign neoplasm of brain
D33.3Benign neoplasm of cranial nerves
D42.0Neoplasm of uncertain behavior of cerebral meninges
D43.0-D43.2Neoplasm of uncertain behavior of brain
D43.3Neoplasm of uncertain behavior of cranial nerves
D49.6Neoplasm of unspecified behavior of brain
G43.001-G43.919Migraine
G44.001-G44.89Other headache syndromes
G47.411-G47.429Narcolepsy and cataplexy
G93.0-G93.9Other disorders of brain
R22.0Localized swelling, mass and lump, head
R50.2-R50.9Fever of other and unknown origin
R51Headache
R56.00-R56.9Convulsions, not elsewhere classified

When services are Not Medically Necessary:
For the procedure codes listed above, for the following diagnoses

ICD-9 Diagnosis 
430Subarachnoid hemorrhage
435.9Unspecified transient cerebral ischemia
436Acute but ill-defined cerebrovascular disease, unspecified
437.0-437.1Cerebral atherosclerosis
437.7Transient global amnesia, unspecified
437.8-437.9Other and ill-defined cerebrovascular disease; other and unspecified
780.02Transient alteration of awareness
780.09Drowsiness, somnolence, semicoma, stupor, unconsciousness
780.2Syncope and collapse
852.00-852.09Subarachnoid hemorrhage following injury without mention of open intracranial wound
852.10-852.19Subarachnoid hemorrhage following injury with open intracranial wound
852.20-852.29Subdural hemorrhage following injury without mention of open intracranial wound
852.30-852.39Subdural hemorrhage following injury with open intracranial wound
853.00-853.09Other and unspecified intracranial hemorrhage following injury; without mention of open intracranial wound
853.10-853.19Other and unspecified intracranial hemorrhage following injury; with mention of open intracranial wound
V12.54Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
G45.0-G45.9Transient cerebral ischemic attacks and related syndromes
G46.0-G46.8Vascular syndromes of brain in cerebrovascular disease
I60.00-I60.9Nontraumatic subarachnoid hemorrhage
I61.0-I61.9Nontraumatic intracerebral hemorrhage
I62.00-I62.9Other and unspecified nontraumatic intracranial hemorrhage
I63.00-I63.9Cerebral infarction
I65.01-I65.9Occlusion and stenosis of precerebral arteries, not resulting in cerebral infarction
I66.01-I66.9Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction
I67.0-I67.9Other cerebrovascular diseases
R40.0-R40.2364Somnolence, stupor, coma
R40.4Transient alteration of awareness
R55Syncope and collapse
S06.360A-S06.366STraumatic hemorrhage of cerebrum, unspecified
S06.369A-S06.369STraumatic hemorrhage of cerebrum, unspecified
S06.5X0A-S06.5X6STraumatic subdural hemorrhage
S06.5X9A-S06.5X9STraumatic subdural hemorrhage
S06.6X0A-S06.6X6STraumatic subarachnoid hemorrhage
S06.6X9A-S06.6X9STraumatic subarachnoid hemorrhage
Z86.73Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above when criteria are not met, for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

When Services are also Investigational and Not Medically Necessary:

CPT 
78607Brain imaging, tomographic (SPECT) [when specified as DaT scan]
  
HCPCS 
A9584Iodine I-123 ioflupane, diagnostic, per study dose, up to 5 millicuries [DaT scan]
  
ICD-9 Diagnosis 
 All diagnoses
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
 All diagnoses

Liver
When Services are Medically Necessary:

CPT 
78205Liver imaging (SPECT)
78206Liver imaging (SPECT); with vascular flow
  
ICD-9 Diagnosis 
211.5Benign neoplasm of liver and biliary passages
228.04Hemangioma of intra-abdominal structures
228.09Hemangioma of other sites
235.3Neoplasm of uncertain behavior of liver and biliary passages
789.1Hepatomegaly
789.30-789.39Abdominal or pelvic swelling, mass, or lump (code range indicates unspecified to specified site)
793.3Nonspecific abnormal findings on radiological and other examination of biliary tract
794.8Abnormal liver scan
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
D13.4Benign neoplasm of liver
D18.03Hemangioma of intra-abdominal structures
D18.09Hemangioma of other sites
D37.6Neoplasm of uncertain behavior of liver, gallbladder and bile ducts
R10.0-R10.9Abdominal and pelvic pain
R16.0Hepatomegaly, not elsewhere classified
R16.2Hepatomegaly with splenomegaly, not elsewhere classified
R17Unspecified jaundice
R18.0-R18.8Ascites
R19.00-R19.09Intra-abdominal and pelvic swelling, mass and lump
R93.2Abnormal findings on diagnostic imaging of liver and biliary tract

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above, for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary. 

Tumors
When Services are Medically Necessary:

CPT 
78803Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT)
  
ICD-9 Diagnosis 
159.0Malignant neoplasm of intestinal tract, part unspecified
193Malignant neoplasm of thyroid gland
194.0Malignant neoplasm of adrenal gland
194.1Malignant neoplasm of parathyroid gland
199.0Malignant neoplasm without specification of site, disseminated
209.00-209.79Neuroendocrine tumors
227.1Benign neoplasm of parathyroid gland
237.2Neoplasm of uncertain behavior of adrenal gland
237.4Neoplasm of uncertain behavior of other and unspecified endocrine glands
252.00-252.9Disorders of parathyroid gland
259.2Carcinoid syndrome
780.60Fever, unspecified
787.01-787.99Symptoms involving digestive system (e.g. nausea and vomiting)
789.30-789.39Abdominal or pelvic swelling, mass, or lump (code range indicates unspecified to specified site)
793.4Nonspecific abnormal findings on radiological and other examination of gastrointestinal tract
793.6Nonspecific abnormal findings on radiological and other examination of abdominal area, including retroperitoneum
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
C73Malignant neoplasm of thyroid gland
C74.00-C74.92Malignant neoplasm of adrenal gland
C75.0Malignant neoplasm of parathyroid gland
C7A.00-C7A.8Malignant neuroendocrine tumors
C7B.00-C7B.8Secondary neuroendocrine tumors
C79.70-C79.72Secondary malignant neoplasm of adrenal gland
C80.0Disseminated malignant neoplasm, unspecified
D35.00-D35.02Benign neoplasm of adrenal gland
D35.1Benign neoplasm of parathyroid gland
D3A.00-D3A.8Benign neuroendocrine tumors
D44.0Neoplasm of uncertain behavior of thyroid gland
D44.10-D44.12Neoplasm of uncertain behavior of adrenal gland
D44.2Neoplasm of uncertain behavior of parathyroid gland
E20.0-E20.9Hypoparathyroidism
E21.0-E21.5Hyperparathyroidism and other disorders of parathyroid gland
E34.0Carcinoid syndrome
R10.0-R10.9Abdominal and pelvic pain
R11.0-R11.2Nausea and vomiting
R14.0-R14.3Flatulence and related conditions
R19.00-R19.8Other symptoms and signs involving the digestive system and abdomen
R50.2-R50.9Fever of other and unknown origin
R93.3Abnormal findings on diagnostic imaging of other parts of digestive tract
R93.5Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above, for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary. 

Other
When services are also Investigational and Not Medically Necessary:
For the following procedure codes for all diagnoses, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

CPT 
78647Cerebrospinal fluid flow, imaging (not including introduction of material); tomographic (SPECT)
78699Unlisted nervous system procedure, diagnostic nuclear medicine [when specified as SPECT/SISCOM for the preoperative evaluation of individuals with intractable focal epilepsy]
  
HCPCS 
A9507Indium In-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries [Prostascint]
S8080Scintimammography (radioimmunoscintigraphy of the breast), unilateral, including supply of radiopharmaceutical
  
ICD-9 Diagnosis 
 All diagnoses
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
 All diagnoses
  
References

Peer Reviewed Publications:

  1. Bertagna F, Barozzi O, Puta E, et al. Residual brain viability, evaluated by (99m)Tc-ECD SPECT, in patients with suspected brain death and with confounding clinical factors. Nucl Med Commun. 2009; 30(10):815-821.
  2. Brem RF, Fishman M, Rapeiyea JA. Detection of ductal carcinoma in situ with mammography, breast specific gamma imaging, and magnetic resonance imaging: a comparative study. Acad Radiol. 2007; 14(8):945-950.
  3. Chiou JF, Lin MC, Chen DR, et al. Usefulness of thallium-201 SPECT Scintimammography to differentiate benign from malignant breast masses in mammographically dense breasts. Cancer Invest. 2003; 21(6):863-868.
  4. Coover LR, Caravaglia G, Kuhn P. Scintimammography with dedicated breast camera detects and localizes occult carcinoma. J Nucl Med. 2004; 45(4):553-558.
  5. Ellis RJ, Kaminsky DA, Zhou EH, et al. Ten-year outcomes: the clinical utility of single photon emission computed tomography/computed tomography capromab pendetide (prostascint) in a cohort diagnosed with localized prostate cancer. Int J Radiat Oncol Biol Phys. 2011; 81(1):29-34.
  6. El-Zawahry AM, Clarke HS, Eskridge MR, et al. Capromab pendetide scanning has a potential role in optimizing patient selection for salvage cryosurgical ablation of the prostate. Urology. 2010; 76(5):1162-1167.
  7. Fondrinier E, Muratet JP, Anglade E, et al. Clinical experience with 99mTc-MIBI Scintimammography in patients with breast microcalcifications. Breast. 2004; 13(4):316-320.
  8. Gadzicki M, Bikiewicz M, Modkowska E, et al. Cortical scintigraphy in the evaluation of renal defects in children with vesico-ureteral reflux--optimization of the procedure and study interpretation. Nucl Med Rev Cent East Eur. 2004; 7(2):157-164.
  9. Haseman MK, Rosenthal SA, Kipper SL, et al. Central abdominal uptake of indium-111 capromab pendetide (ProstaScint) predicts for poor prognosis in patients with prostate cancer. Urology. 2007; 70(2):303-308.
  10. Joffe AR, Lequier L, Cave D. Specificity of radionuclide brain blood flow testing in brain death: case report and review. J Intensive Care Med. 2010; 25(1):53-64.
  11. Khalkhali I, Baum JK, Villanueva-Meyer J, et al. (99m)Tc sestamibi breast imaging for the examination of patients with dense and fatty breasts: multicenter study. Radiology. 2002; 222(1):149-155.
  12. 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.
  13. Kupsch AR, Bajaj N, Weiland F, et al. Impact of DaTscan SPECT imaging on clinical management, diagnosis, confidence of diagnosis, quality of life, health resource use and safety in patients with clinically uncertain parkinsonian syndromes: a prospective 1-year follow-up of an open-label controlled study. J Neurol Neurosurg Psychiatry. 2012; 83(6):620-628.
  14. Matsuda H, Matsuda K, Nakamura F, et al. Contribution of subtraction ictal SPECT coregistered to MRI to epilepsy surgery: a multicenter study. Ann Nucl Med. 2009; 23(3):283-291.
  15. Mohammed AA, Shergill IS, Vandal MT, Gujral SS. ProstaScint and its role in the diagnosis of prostate cancer. Expert Rev Mol Diagn. 2007; 7(4):345-349.
  16. Mohkam M, Maham S, Rahmani A, et al. Technetium Tc 99m dimercaptosuccinic acid renal scintigraphy in children with acute pyelonephritis: correlation with other imaging tests. Iran J Kidney Dis. 2010; 4(4):297-301.
  17. Mouraviev V, Madden JF, Broadwater G, et al. Use of 111in-capromab pendetide immunoscintigraphy to image localized prostate cancer foci within the prostate gland. J Urol. 2009; 182(3):938-947.
  18. Munari M, Zucchetta P, Carollo C, et al. Confirmatory tests in the diagnosis of brain death: comparison between SPECT and contrast angiography. Crit Care Med. 2005; 33(9):2068-2073.
  19. Nagda SN, Mohideen N, Lo SS, et al. Long-term follow-up of 111In-capromab pendetide (ProstaScint) scan as pretreatment assessment in patients who undergo salvage radiotherapy for rising prostate-specific antigen after radical prostatectomy for prostate cancer. Int J Radiat Oncol Biol Phys. 2007; 67(3):834-840.
  20. Noz ME, Chung G, Lee BY, et al. Enhancing the utility of prostascint SPECT scans for patient management. J Med Syst. 2006; 30(2):123-132.
  21. Okuyaz C, Gücüyener K, Karabacak NI, et al. Tc-99m-HMPAO SPECT in the diagnosis of brain death in children. Pediatr Int. 2004; 46(6):711-714.
  22. Ozülker T, Ozülker F, Ozpaçaci T, et al. The efficacy of (99m)Tc-MIBI scintimammography in the evaluation of breast lesions and axillary involvement: a comparison with X-rays mammography, ultrasonography and magnetic resonance imaging. Hell J Nucl Med. 2010; 13(2):144-149.
  23. Pan L, Han Y, Sun X, et al. FDG-PET and other imaging modalities for the evaluation of breast cancer recurrence and metastases: a meta-analysis. J Cancer Res Clin Oncol. 2010; 136(7):1007-1022.
  24. Proao JM, Sodee DB, Resnick MI, Einstein DB. The impact of a negative (111)indium-capromab pendetide scan before salvage radiotherapy. J Urol. 2006; 175(5):1668-1672.
  25. 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.
  26. Sampalis FS, Denis R, Picard D, et al. International prospective evaluation of Scintimammography with (99m)technetium sestamibi. Am J Surg. 2003; 185(6):544-549.
  27. Schillaci O, Scopinaro F, Spanu A, et al. Detection of axillary lymph node metastases in breast cancer with Tc-99m tetrofosmin scintigraphy. Int J Oncol. 2002; 20(3):483-487.
  28. Spanu A, Dettori G, Nuvoli S, et al. (99)mTc-tetrofosmin SPET in the detection of both primary breast cancer and axillary lymph node metastasis. Eur J Nucl Med. 2001; 28(12):1781-1794.
  29. Uchida Y, Minoshima S, Okada S, et al. Diagnosis of dementia using perfusion SPECT imaging at the patient's initial visit to a cognitive disorder clinic. Clin Nucl Med. 2006; 31(12):764-773.
  30. Vlaar AM, de Nijs T, Kessels AG, et al. Diagnostic value of 123I-ioflupane and 123I-iodobenzamide SPECT scans in 248 patients with parkinsonian syndromes. Eur Neurol. 2008; 59(5):258-266.
  31. 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.
  32. Weigert JM, Bertrand ML, Lanzkowsky L, et al. Results of a multicenter patient registry to determine the clinical impact of breast-specific gamma imaging, a molecular breast imaging technique. AJR Am J Roentgenol. 2012; 198(1):W69-75.
  33. Zhou M, Johnson N, Gruner S, et al. Clinical utility of breast-specific gamma imaging for evaluating disease extent in the newly diagnosed breast cancer patient. Am J Surg. 2009; 197(2):159-163.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American College of Radiology. ACR Appropriateness Criteria®. Available at: http://www.acr.org/Quality-Safety/Appropriateness-Criteria. Accessed on July 2, 2013.
    • Breast cancer screening (2012).
    • Post-treatment Follow-up of Prostate Cancer (2011).
  2. Prostate Cancer — Pretreatment Detection, Staging, and Surveillance (2012).  American Urological Association. Clinical Practice Guideline. Management and screening of primary vesicoureteral reflux. 2010. Available at: http://www.auanet.org/common/pdf/education/clinical-guidance/Vesicoureteral-Reflux-a.pdf. Accessed on July 5, 2013.
  3. Blue Cross Blue Shield Association. Breast-specific gamma imaging (BGSI), molecular breast imaging (MBI), with breast-specific gamma camera. TEC Assessment 2013; 28(2).
  4. Centers for Medicare and Medicaid Services. National Coverage Determination: Single Photon Emission Computed Tomography (SPECT). NCD #220.12. Effective October 1, 2002. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord=SPECT&KeyWordLookUp=Title&KeyWordSearchType
    =And&from2=index_chapter_list.asp&list_type=&bc=gAAAAAAAAAAAAA%3d%3d&=&. Accessed on July 5, 2013.
  5. Filipek PS, Accardo PJ, Ashwal S, et al. American Academy of Neurology and the Child Neurology Society. 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. Guideline-reaffirmed 07/10/2010. Available at: http://www.aan.com/go/practice/guidelines. Accessed on July 2, 2013.
  6. National Institute for Health and Clinical Excellence. Clinical guideline 54. Urinary tract infection in children: Diagnosis, treatment and long-term management. August 2007. Available at: http://www.nice.org.uk/nicemedia/live/11819/36032/36032.pdf. Accessed on July 2, 2013.
  7. NCCN Clinical Practice Guidelines in Oncology™. © 2012 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website: http://www.nccn.org/index.asp. Accessed on July 5, 2013.
    • Neuroendocrine Tumors (V.2.2013).
    • Prostate Cancer (V.2.2013).
  8. U.S. Food and Drug Administration New drug application. Adreview (Iobenguane sulfate I-123). Rockville, MD: FDA. September 9, 2008. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/nda/2008/022290s000_Approv.pdf. Accessed on July 5, 2013.
  9. U.S. Food and Drug Administration Biologics license application. Capromab Pendetide. Rockville, MD: FDA. October 28, 1996. Available at: http://www.fda.gov/downloads/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/ApprovalApplications
    /TherapeuticBiologicApplications/ucm094505.pdf. Accessed on July 2, 2013.
  10. U.S. Food and Drug Administration Biologics license application. CEA scan. BLA 103425. Rockville, MD: FDA. Available at: http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.Label_ApprovalHistory#apphist. Accessed on July 2, 2013.
  11. U.S. Food and Drug Administration Development approval process. Technetium TC-99m (DMSA Kidney Reagent). Rockville, MD: FDA. Available at: http://www.fda.gov/downloads/Drugs/DevelopmentApprovalProcess/UCM071120.pdf. Accessed on July 2, 2013.
  12. U.S. Food and Drug Administration New drug application. DaTscan (Ioflupane I 123) Injection. NDA 22-454. Rockville, MD: FDA. January 14, 2011. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/appletter/2011/022454s000ltr.pdf. Accessed on July 2, 2013.
  13. U.S. Food and Drug Administration New drug application. Indium in 111 pentetreotide. NDA 020314. Rockville, MD: FDA. June 2, 1994. Available at: http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.Label_ApprovalHistory#apphist. Accessed on July 2, 2013.
Index

DaT Scan
DMSA
Prostascint
Scintimammography
SISCOM
SPECT Scans

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History

Status

Date

Action

Reviewed08/08/2013Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Rationale and References.
 01/01/2013Updated Coding section with 01/01/2013 CPT changes.
Revised08/09/2012MPTAC review. Updated Description/Scope, Rationale, Definitions, Coding, References and Index. Added renal DMSA to Medically Necessary Position Statement. Added Pervasive Development Disorders to Investigational and Not Medically Necessary Position Statement. Added DaT scan to Investigational and Not Medically Necessary Position Statement. Removed Web Sites for Additional Information section.
Revised11/17/2011MPTAC review.
Revised11/16/2011Hematology/Oncology Subcommittee review. Updated Position Statement to include "Preoperative evaluation of individuals with intractable focal epilepsy to identify and localize area(s) of epileptiform activity when other techniques designed to localize a focus are indeterminate" in investigational and not medically necessary statement. Updated Description/Scope, Rationale, Coding, References, and Index.
Reviewed05/19/2011MPTAC review.
Reviewed05/18/2011Hematology/Oncology Subcommittee review. Updated Description/Scope, Rationale, and References.
Revised05/13/2010MPTAC review. Title change to Single Photon Emission Computed Tomography (SPECT) Scans for Noncardiovascular Indications. Removal of cardiac indications from Position Statement. Clarification of medically necessary statement for brain tumor to include when PET unavailable. Removal from medically necessary statements epilepsy and lymphoma. Clarification of investigational and not medically necessary statement for prostate carcinoma to include "with or without fusion imaging with computed tomography or magnetic resonance imaging" is also investigational and not medically necessary. Updated Description/Scope, Rationale, Background/Overview, Definitions, Coding and Reference sections.
Revised11/19/2009MPTAC review.
Revised11/18/2009Hematology/Oncology Subcommittee review. Added prostate cancer with the use of ProstaScint to "investigational and not medically necessary" statement. Updated Rationale, References and Web Sites. Updated Coding section to include 01/01/2010 CPT changes.
Reviewed11/20/2008MPTAC review.
Reviewed11/19/2008Hematology/Oncology Subcommittee review. Updated References, Web Sites and Rationale sections.
 10/01/2008Updated Coding section with 10/01/2008 ICD-9 changes.
Reviewed11/29/2007MPTAC review. No change to Position Statement. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." Updated Coding section with 01/01/2008 CPT changes.
 10/01/2007Updated Coding section with 10/01/2007 ICD-9 changes.
Reviewed07/09/2007Included note to see CG-RAD-16 Cardiac Radionuclide Imaging for use of radionuclide imaging for cardiac conditions.
Revised12/07/2006MPTAC review. Added "unexplained ventricular arrhythmia" as a medically necessary indication. Updated Rationale and Reference sections.
 01/01/2007Updated Coding section with 01/01/2007 CPT/HCPCS changes.
Revised06/08/2006MPTAC review. Added cerebrovascular disease to not medically necessary section; revised Rationale section. 
Revised03/23/2006MPTAC review. Removed Cerebrovascular accident from medically necessary and Rationale sections.
 11/21/2005Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Revised09/22/2005MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. 
Revised04/28/2005MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

04/27/2005

RAD.00023Single Emission Computed Tomography (SPECT) and Scintimammography
WellPoint Health Networks, Inc.

12/02/2004

Clinical GuidelineSPECT Scans
 

04/28/2005

4.11.03Scintimammography
 

07/28/2004

4.01.18Oncologic Applications of Radioscintigraphy using Targeted Radiotracers