Medical Policy


Subject:SPECT (Single Photon Emission Computed Tomography) Scans and Scintimammography
Policy #:  RAD.00023Current Effective Date:  01/14/2009
Status:ReviewedLast Review Date:  11/20/2008

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. Radioimmunoscintigraphy of the breast, a specialized form of SPECT that is also called scintimammography, is also addressed in this document. 

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 conditions:

  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.
  3. Epilepsy—for presurgical detection of a seizure focus.
  4. Ischemic heart disease (e.g., myocardial infarction, myocardial ischemia) to assess the severity of known or suspected coronary artery disease or to assess myocardial viability in those with known coronary artery disease. (For patient selection criteria see CG-RAD-16 Cardiac Radionuclide Imaging)
  5. Unexplained ventricular arrhythmia.
  6. Liver hemangioma—using labeled red blood cells to further define lesions identified by other imaging modalities.
  7. Localization of abscess/infection/inflammation in soft tissues or cases of fever of unknown origin.
  8. Lymphoma—for initial staging and response to chemotherapy.
  9. Neuroendocrine tumors (e.g., adenomas, carcinoid, pheochromocytomas, neuroblastoma, vasoactive intestinal peptide (VIP) secreting tumors, thyroid carcinoma, adrenal gland tumors)—using a monoclonal antibody (OctreoScan) or I-131 meta-iodobenzyl-guanidine (MIBG).
  10. Parathyroid imaging

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: 

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

  1. Chronic fatigue syndrome.
  2. Neuropsychiatric disorders without evidence of cerebrovascular disease.
  3. Attention Deficit and Hyperactivity Disorder.
  4. Scintimammography for breast cancer.
  5. Malignancies other than those listed as medically necessary.
  6. Colorectal carcinoma—used with the monoclonal antibody or IMMU-4 and CEA-Scan®.
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 detection and assessment of known or suspected coronary artery disease, myocardial viability, unexplained ventricular arrhythmia, the diagnosis and evaluation of selected oncologic diseases, the evaluation of some specific central nervous system (CNS) disorders (brain tumor, toxoplasmosis, epilepsy) 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. There is sufficient evidence in the peer-reviewed medical literature to support the use of SPECT to evaluate myocardial viability in patients with known coronary artery disease (Choiu, 2003; Coover, 2004; Frondrinier, 2004). 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.

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

Radioimmunoscintigraphy, a specialized form of SPECT, may also be called scintimammography when used in breast imaging. Scintimammography has not been shown to improve health outcomes in patients with breast cancer, populations being screened for breast cancer or as an adjunct for diagnostic or surgical treatment planning. An assessment on scintimammography reported the following conclusions:

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.

A search of the peer-reviewed literature found that the use of SPECT for dementias such as Alzheimer's disease and motor system disorders such as Parkinson's disease is being investigated. However, at this time, the studies are limited to a small number of patients.

Background/Overview

Single photon emission computed tomography (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 computed tomography (CT), magnetic resonance imaging (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 or decreased activity such as diminished blood flow to the heart in the presence of coronary artery disease. Patterns of distribution of the radiotracer can be correlated with various diseases. SPECT has been of particular use in early detection in heart, brain and bone disorders, as well as development of some types of malignancies. The radiotracer used and imaging protocol are 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 patient 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. Computed tomography (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: collection of pus, often caused by the body's response to an infection

Adenoma: a benign tumor that arises in or resembles glandular tissue

Angina: chest pain due to an inadequate supply of oxygen to the heart muscle

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

Colorectal carcinoma: cancer of the colon and rectum; a malignant tumor arising from the inner wall of the large intestine

Coronary artery disease: a major cause of illness and death, coronary artery disease (CAD) begins when hard cholesterol substances (plaques) are deposited within a coronary artery

Epilepsy: a condition characterized by a pattern of repeated seizures; a seizure is caused when nerve cells in the brain fire electrical impulses at a rate of up to four times higher than normal, causing a sort of electrical storm in the brain

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

Lymphoma: tumor of the lymphoid tissue

Myocardial infarction: also known as a heart attack; a condition due to deprivation of circulating blood to the heart, resulting in the death of heart tissue

Myocardial ischemia: inadequate blood supply to the heart muscle due to blockage of the blood vessels supplying the heart

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

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.  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.

When services are Medically Necessary: 

CPT

 

78320

Bone and joint imaging; tomographic (SPECT)

78807

Radiopharmaceutical localization of inflammatory process; tomographic (SPECT)

 

 

ICD-9 Diagnosis

 

 

All diagnoses

When Services are also Medically Necessary:

CPT

 

78205

Liver imaging (SPECT)

78206

Liver imaging (SPECT); with vascular flow

78464

Myocardial perfusion imaging; tomographic (SPECT), single study (including attenuation correction when performed), at rest or stress (exercise and/or pharmacologic), with or without quantification

78465

Myocardial perfusion imaging; tomographic (SPECT), multiple studies (including attenuation correction when performed), at rest and/or stress (exercise and/or pharmacologic) and redistribution and/or rest injection, with or without quantification

78469

Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification

78494

Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing

78607

Brain imaging, tomographic (SPECT)

78803

Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT)

 

 

HCPCS

 

S8085

Fluorine-18 fluorodeoxyglucose (F-18 FDG) imaging using dual-head coincidence detection system (non-dedicated PET scan)

 

 

ICD-9 Diagnosis

 

159.0

Malignant neoplasm of intestinal tract, part unspecified

191.0-191.9

Malignant neoplasm of brain

193

Malignant neoplasm of thyroid gland

194.0

Malignant neoplasm of adrenal gland

194.1

Malignant neoplasm of parathyroid gland

196.0-196.9

Secondary and unspecified malignant neoplasm of lymph nodes

198.3

Secondary malignant neoplasm, brain and spinal cord

199.0

Malignant neoplasm without specification of site, disseminated

200.0-202.98

Lymphosarcoma and reticulosarcoma

209.00-209.69

Neuroendocrine tumors

225.0-225.2

Benign neoplasm of brain, cranial nerves, cerebral meninges

227.1

Benign neoplasm of parathyroid gland

228.04

Hemangioma of intra-abdominal structures

228.09

Hemangioma of other sites

237.4

Neoplasm of uncertain behavior of other and unspecified endocrine glands

237.5

Neoplasm of uncertain behavior, brain and spinal cord

239.6

Neoplasms of unspecified nature, brain

252.00-252.9

Disorders of parathyroid gland

259.2

Carcinoid syndrome

339.00-339.89

Other headache syndromes

345.00-345.91

Epilepsy

346.00-346.93

Migraine

347.00-347.11

Cataplexy and narcolepsy

348.0-348.9

Other conditions of brain

410.00-414.9

Ischemic heart disease

426.0-427.9

Conduction disorders, cardiac dysrhythmia

428.1

Left heart failure

780.31-780.39

Convulsions

780.60

Fever, unspecified

784.0

Headache

784.2

Swelling, mass, or lum in head or neck

786.04

Cheyne-Stokes respiration

786.05

Shortness of breath

786.09

Symptoms involving respiratory system and other chest symptoms; other

786.50-786.59

Chest pains

787.01-787.99

Symptoms involving digestive system (e.g. nausea and vomiting)

789.1

Hepatomegaly

789.30-789.39

Abdominal or pelvic swelling, mass, or lump (code range indicates unspecified to specified site)

793.0-793.99

Nonspecific abnormal findings on radiological and other examination of body structure

794.30-794.39

Abnormal electrocardiogram

794.8

Abnormal liver scan

V12.53

Personal history of sudden cardiac arrest

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

ICD-9 Diagnosis

 

430

Subarachnoid hemorrhage

435.9

Unspecified transient cerebral ischemia

436

Acute but ill-defined cerebrovascular disease, unspecified

437.0-437.1

Cerebral atherosclerosis

437.7

Transient global amnesia, unspecified

437.8-437.9

Other and ill-defined cerebrovascular disease; other and unspecified

780.02

Transient alteration of awareness

780.09

Drowsiness, somnolence, semicoma, stupor, unconsciousness

780.2

Syncope and collapse

852.00-852.09

Subarachnoid hemorrhage following injury without mention of open intracranial wound

852.10-852.19

Subarachnoid hemorrhage following injury with open intracranial wound

852.20-852.29

Subdural hemorrhage following injury without mention of open intracranial wound

852.30-852.39

Subdural hemorrhage following injury with open intracranial wound

853.00-853.09

Other and unspecified intracranial hemorrhage following injury; without mention of open intracranial wound

853.10-853.19

Other and unspecified intracranial hemorrhage following injury; with mention of open intracranial wound

V12.54

Personal 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, 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:
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

 

78647

Cerebrospinal fluid flow, imaging (not including introduction of material); tomographic (SPECT)

78710

Kidney imaging morphology; tomographic (SPECT)

 

 

HCPCS

 

S8080

Scintimammography (radioimmunoscintigraphy of the breast), unilateral, including supply of radiopharmaceutical

 

 

ICD-9 Diagnosis

 

 

All diagnoses

 

References

Peer Reviewed Publications:

  1. 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.
  2. Coover LR, Caravaglia G, Kuhn P. Scintimammography with dedicated breast camera detects and localizes occult carcinoma. J Nucl Med. 2004; 45(4):553-558.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. Liu C, Chin T, Wei C. Contralateral reflux after unilateral ureteral reimplantation--preexistent rather  than new-onset reflux. J Pediatr Surg. 1999; 34(11):1661-1664.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, American College of Physicians, Society for Academic Emergency Medicine, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2007; 50(7):e1–157.
  2. Centers for Medicare and Medicaid Services. National Coverage Determination: Prostate Cancer Screening Tests. NCD #210.1. Effective June 19, 2006. Available at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=210.1&ncd_version=2&show=all. Accessed on October 2, 2008.
  3. 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.hhs.gov/mcd/viewncd.asp?ncd_id=220.12&ncd_version=1&basket=ncd%3A220%2E12%3A1%3ASingle+Photon+Emission+Computed+Tomography++%28SPECT%29. Accessed on October 2, 2008.
  4. Hayes Inc. Medical Technology Directory. Single Photon Emission Computed Tomography (SPECT) for Assessing Myocardial Viability Lansdale, PA: Hayes, Inc.; March 7, 2007. Search updated April 11, 2008.
  5. Klocke FJ, Baird MG, Lorell BH, et al. American College of Cardiology; American Heart Association; American Society for Nuclear Cardiology. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). J Am Coll Cardiol. 2003; 42(7):1318-1333.
  6. Zipes DP, Camm AJ, Borggrefe M, et al ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/ American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:247-346.
Web Sites for Additional Information
  1. Society of Nuclear Medicine. http://www.snm.org/. Accessed on October 2, 2008.
Index

Scintimammography
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

Reviewed

11/20/2008

Medical Policy & Technology Assessment Committee (MPTAC) review.

Reviewed

11/19/2008

Hematology/Oncology Subcommittee Review. Updated references, websites and rationale section.

 

10/01/2008

Updated coding section with 10/01/2008 ICD-9 changes.

Reviewed

11/29/2007

MPTAC 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.

 

10/01/2007

Updated coding section with 10/01/2007 ICD-9 changes.

Reviewed

07/09/2007

Included note to see CG-RAD-16 Cardiac Radionuclide Imaging for use of radionuclide imaging for cardiac conditions.

Revised

12/07/2006

MPTAC review. Added "unexplained ventricular arrhythmia" as a medically necessary indication. Updated Rationale and Reference sections.

 

01/01/2007

Updated coding section with 01/01/2007 CPT/HCPCS changes.

Revised

06/08/2006

MPTAC review. Added cerebrovascular disease to not medically necessary section; revised rationale section. 

Revised

03/23/2006

MPTAC review. Removed Cerebrovascular accident from medically necessary and rationale sections.

 

11/21/2005

Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).

Revised

09/22/2005

MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. 

Revised

04/28/2005

MPTAC 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.00023

Single Emission Computed Tomography (SPECT) and Scintimammography

WellPoint Health Networks, Inc.

12/02/2004

Clinical Guideline

SPECT Scans

 

04/28/2005

4.11.03

Scintimammography

 

07/28/2004

4.01.18

Oncologic Applications of Radioscintigraphy using Targeted Radiotracers