Single Photon Emission Computed Tomography (SPECT)

Section: Radiation Therapy & Nuclear Medicine
Effective Date: July 01, 2018
Revised Date: July 31, 2019
Last Reviewed: July 16, 2019

Description

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.

Criteria

SPECT imaging may be considered medically necessary for ANY of the following:

  • Bone and joint conditions—to differentiate between infectious, neoplastic, avascular or a traumatic process; or
  • 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; or
  • Liver hemangioma—using labeled red blood cells to further define lesions identified by other imaging modalities; or
  • Localization of abscess/infection/inflammation in soft tissues or cases of fever of unknown origin; or
  • Neuroendocrine tumors (e.g., adenomas, carcinoid, pheochromocytomas, neuroblastoma, vasoactive intestinal peptide [VIP] secreting tumors, thyroid carcinoma, adrenal gland tumors)—using a monoclonal antibody or meta-iodobenzyl-guanidine (MIBG); or
  • Parathyroid imaging; or
  • Renal —Dimercaptosuccinic acid (DMSA) scan to assess the status of kidney for scarring and function.

Procedure Codes

78071 78072 78205 78206 78320 78607 78710
78803 78807

SPECT imaging of the kidneys may be considered medically necessary in the diagnosis and treatment of renal diseases, conditions, and disorders, including but not limited to ANY of the following (Note: this is not an all-inclusive list):

  • Acute, chronic or recurrent kidney infections (e.g., pyelonephritis); or
  • Evaluations of kidney tumors and trauma; or
  • Pediatric patients with urinary tract infection; or
  • Congenital anomalies of the kidneys; or
  • Renal cortical damage or defects; or
  • Renal infarction or renal masses; or
  • Vesicoureteral reflux in children; or
  • Assessing the integrity of renal parenchyma in cases of renal wasting diseases.

Procedure Codes

78710

Dopamine transporter imaging with single-photon emission computed tomography (DaT-SPECT/DaTscan) may be considered medically necessary for ANY of the following indications:

  • Individuals for whom the diagnosis of Parkinson’s Disease (PD) is unclear after serial clinical evaluations, such as those with long-standing essential tremor whose tremor evolves to have characteristics of PD but fails to respond unequivocally to levodopa; or
  • Individuals suspected of having drug-induced parkinsonism; or
  • Individuals who are possible candidates for deep brain stimulation but for whom the diagnosis of essential tremor versus PD versus some other cause (e.g., dystonia) is unclear and where an accurate diagnosis determines the target of deep brain stimulation (e.g., thalamic ventral intermediate nucleus versus subthalamic nucleus/globus pallidus interna).

DaT-SPECT/DaTscan for all other indications is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

78607 A9584

For non-cardiovascular indications for any other reason than indicated above, SPECT imaging is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature. These include, but are not limited to:

  • Attention Deficit and Hyperactivity Disorder
  • Chronic fatigue syndrome
  • Colorectal carcinoma (e.g., used with the monoclonal antibody or IMMU-4 and CEA-Scan®
  • Malignancies other than those listed as medically necessary
  • Neuropsychiatric disorders without evidence of cerebrovascular disease
  • Pervasive development disorders (PDD)
  • Prostate carcinoma (e.g., used with the monoclonal antibody ProstaScint, with or without fusion imaging with computed tomography or magnetic resonance imaging)
  • Scintimammography for breast cancer
  • 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

Procedure Codes

78607 78803 S8080

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

Procedure Codes

78607

Payment can be made for either a planar (standard) or SPECT study. However, when both are performed on the same day by the same provider on the same anatomic area and reported separately, payment should only be made for the SPECT study. The planar study is denied as not medically necessary.

Payment for a planar study is eligible only when a review of the information in the patient’s clinical record establishes the medical necessity for both studies.

Procedure Codes

78070 78071 78072 78205 78206 78302 78607
78710 78803 78807

When a radiopharmaceutical diagnostic imaging agent is reported in conjunction with a covered nuclear medicine study, payment is made for the agent under the appropriate code for the radiopharmaceutical administered.

The diagnostic imaging agent/contrast material used in conjunction with an eligible imaging procedure is also eligible when administered by the health care professional in a setting other than a hospital, or a skilled facility.

Diagnosis Codes

The following covered diagnosis codes apply only to procedure code 78710

B52.0 C64.1 C64.2 C64.9 C65.1 C65.2 C65.9
C79.00 C79.01 C79.02 D30.00 D30.01 D30.02 D30.10
D30.11 D30.12 D41.00 D41.01 D41.02 D41.10 D41.11
D41.12 D41.20 D41.21 D41.22 E08.21 E08.22 E08.29
E09.21 E09.22 E09.29 E10.21 M32.14 M32.15 M35.04
N00.0 N00.1 N00.2 N00.3 N00.4 N00.5 N00.6
N00.7 N00.8 N00.9 N01.0 N01.1 N01.2 N01.3
N01.4 N01.5 N01.6 N01.7 N01.8 N01.9 N02.0
N02.1 N02.2 N02.3 N02.4 N02.5 N02.6 N02.7
N02.8 N02.9 N03.0 N03.1 N03.2 N03.3 N03.4
N03.5 N03.6 N03.7 N03.8 N03.9 N04.0 N04.1
N04.2 N04.3 N04.4 N04.5 N04.6 N04.7 N04.8
N04.9 N05.0 N05.1 N05.2 N05.3 N05.4 N05.5
N05.6 N05.7 N05.8 N05.9 N06.0 N06.1 N06.2
N06.3 N06.4 N06.5 N06.6 N06.7 N06.8 N06.9
N07.0 N07.1 N07.2 N07.3 N07.4 N07.5 N07.6
N07.7 N07.8 N07.9 N08 N10 N11.0 N11.1
N11.8 N11.9 N12 N13.6 N13.9 N13.70 N13.71
N13.721 N13.722 N13.729 N13.731 N13.732 N13.739 N14.0
N14.1 N14.2 N14.3 N14.4 N15.0 N15.1 N15.8
N15.9 N16 N17.0 N17.1 N17.2 N17.8 N17.9
N18.1 N18.2 N18.3 N18.4 N18.5 N18.6 N18.9
N19 N25.0 N25.1 N25.9 N25.81 N25.89 N26.1
N26.9 N28.0 N28.84 N28.85 N28.86 N39.0 Q60.0
Q60.1 Q60.2 Q60.3 Q60.4 Q60.5 Q60.6 Q61.2
Q61.3 Q61.4 Q61.5 Q61.8 Q61.9 Q61.00 Q61.01
Q61.02 Q61.11 Q61.19 Q63.0 Q63.1 Q63.2 Q63.3
Q63.8 Q63.9

The following covered diagnosis codes apply only to procedure code 78607 (Brain)

C70.0 C71.0 C71.1 C71.2 C71.3 C71.4 C71.5
C71.6 C71.7 C71.8 C71.9 C72.20 C72.21 C72.22
C72.30 C72.31 C72.32 C72.40 C72.41 C72.42 C72.50
C72.59 C77.0 C79.31 C79.32 C81.00 C81.01 C81.02
C81.03 C81.04 C81.05 C81.06 C81.07 C81.08 C81.09
C81.10 C81.11 C81.12 C81.13 C81.14 C81.15 C81.16
C81.17 C81.18 C81.19 C81.20 C81.21 C81.22 C81.23
C81.24 C81.25 C81.26 C81.27 C81.28 C81.29 C81.30
C81.31 C81.32 C81.33 C81.34 C81.35 C81.36 C81.37
C81.38 C81.39 C81.40 C81.41 C81.42 C81.43 C81.44
C81.45 C81.46 C81.47 C81.48 C81.49 C81.70 C81.71
C81.72 C81.73 C81.74 C81.75 C81.76 C81.77 C81.78
C81.79 C81.90 C81.91 C81.92 C81.93 C81.94 C81.95
C81.96 C81.97 C81.98 C81.99 C82.00 C82.01 C82.02
C82.03 C82.04 C82.05 C82.06 C82.07 C82.08 C82.09
C82.10 C82.11 C82.12 C82.13 C82.14 C82.15 C82.16
C82.17 C82.18 C82.19 C82.20 C82.21 C82.22 C82.23
C82.24 C82.25 C82.26 C82.27 C82.28 C82.29 C82.30
C82.31 C82.32 C82.33 C82.34 C82.35 C82.36 C82.37
C82.38 C82.39 C82.40 C82.41 C82.42 C82.43 C82.44
C82.45 C82.46 C82.47 C82.48 C82.49 C82.50 C82.51
C82.52 C82.53 C82.54 C82.55 C82.56 C82.57 C82.58
C82.59 C82.60 C82.61 C82.62 C82.63 C82.64 C82.65
C82.66 C82.67 C82.68 C82.69 C82.80 C82.81 C82.82
C82.83 C82.84 C82.85 C82.86 C82.87 C82.88 C82.89
C82.90 C82.91 C82.92 C82.93 C82.94 C82.95 C82.96
C82.97 C82.98 C82.99 C83.00 C83.01 C83.02 C70.0
C71.0 C71.1 C71.2 C71.3 C71.4 C71.5 C71.6
C71.7 C71.8 C71.9 C72.20 C72.21 C72.22 C72.30
C72.31 C72.32 C72.40 C72.41 C72.42 C72.50 C72.59
C77.0 C79.31 C79.32 C81.00 C81.01 C81.02 C81.03
C81.04 C81.05 C81.06 C81.07 C81.08 C81.09 C81.10
C81.11 C81.12 C81.13 C81.14 C81.15 C81.16 C81.17
C81.18 C81.19 C81.20 C81.21 C81.22 C81.23 C81.24
C81.25 C81.26 C81.27 C81.28 C81.29 C81.30 C81.31
C81.32 C81.33 C81.34 C81.35 C81.36 C81.37 C81.38
C81.39 C81.40 C81.41 C81.42 C81.43 C81.44 C81.45
C81.46 C81.47 C81.48 C81.49 C81.70 C81.71 C81.72
C81.73 C81.74 C81.75 C81.76 C81.77 C81.78 C81.79
C81.90 C81.91 C81.92 C81.93 C81.94 C81.95 C81.96
C81.97 C81.98 C81.99 C82.00 C82.01 C82.02 C82.03
C82.04 C82.05 C82.06 C82.07 C82.08 C82.09 C82.10
C82.11 C82.12 C82.13 C82.14 C82.15 C82.16 C82.17
C82.18 C82.19 C82.20 C82.21 C82.22 C82.23 C82.24
C82.25 C82.26 C82.27 C82.28 C82.29 C82.30 C82.31
C82.32 C82.33 C82.34 C82.35 C82.36 C82.37 C82.38
C82.39 C82.40 C82.41 C82.42 C82.43 C82.44 C82.45
C82.46 C82.47 C82.48 C82.49 C82.50 C82.51 C82.52
C82.53 C82.54 C82.55 C82.56 C82.57 C82.58 C82.59
C82.60 C82.61 C82.62 C82.63 C82.64 C82.65 C82.66
C82.67 C82.68 C82.69 C82.80 C82.81 C82.82 C82.83
C82.84 C82.85 C82.86 C82.87 C82.88 C82.89 C82.90
C82.91 C82.92 C82.93 C82.94 C82.95 C82.96 C82.97
C82.98 C82.99 C83.00 C83.01 C83.02 C86.1 C86.2
C86.3 C86.4 C86.5 C86.6 C88.0 C88.2 C88.3
C88.4 C88.8 C88.9 D32.0 D33.0 D33.1 D33.2
D33.3 D42.0 D43.0 D43.1 D43.2 D43.3 D49.6
G43.001 G43.009 G43.011 G43.019 G43.101 G43.109 G43.111
G43.119 G43.401 G43.409 G43.411 G43.419 G43.501 G43.509
G43.511 G43.519 G43.601 G43.609 G43.611 G43.619 G43.701
G43.709 G43.711 G43.719 G43.801 G43.809 G43.811 G43.819
G43.821 G43.829 G43.831 G43.839 G43.901 G43.909 G43.911
G43.919 G44.40 G44.41 G44.51 G44.52 G44.53 G44.59
G44.81 G44.82 G44.83 G44.84 G44.85 G44.89 G44.001
G44.009 G44.011 G44.019 G44.021 G44.029 G44.031 G44.039
G44.041 G44.049 G44.051 G44.059 G44.091 G44.099 G44.201
G44.209 G44.211 G44.219 G44.221 G44.229 G44.301 G44.309
G44.311 G44.319 G44.321 G44.329 G47.411 G47.419 G47.421
G47.429 G93.0 G93.1 G93.2 G93.3 G93.5 G93.6
G93.7 G93.9 G93.40 G93.41 G93.49 G93.81 G93.82
G93.89 R22.0 R50.2 R50.9 R50.81 R50.82 R50.83
R50.84 R51 R56.1 R56.9 R56.00 R56.01

The following covered diagnosis codes apply to procedure code A9584 when billed with 78607

G20 G21.19 G25.0

The following covered diagnosis codes apply only to procedure codes 78205 and 78206 (Liver)

D13.4 D18.03 D18.09 D37.6 R10.0 R10.2 R10.9
R10.10 R10.11 R10.12 R10.13 R10.30 R10.31 R10.32
R10.33 R10.83 R10.84 R10.811 R10.812 R10.813 R10.814
R10.815 R10.816 R10.817 R10.819 R10.821 R10.822 R10.823
R10.824 R10.825 R10.826 R10.827 R10.829 R16.0 R16.2
R17 R18.0 R18.8 R19.00 R19.01 R19.02 R19.03
R19.04 R19.05 R19.06 R19.07 R19.09 R93.2

The following covered diagnosis codes apply only to procedure code 78803 (Neuroendocrine Tumors)

C7A.1 C7A.8 C7A.00 C7A.010 C7A.011 C7A.012 C7A.019
C7A.020 C7A.021 C7A.022 C7A.023 C7A.024 C7A.025 C7A.026
C7A.029 C7A.090 C7A.091 C7A.092 C7A.093 C7A.094 C7A.095
C7A.096 C7A.098 C7B.1 C7B.8 C7B.00 C7B.01 C7B.02
C7B.03 C7B.04 C7B.09 C73 C74.00 C74.01 C74.02
C74.10 C74.11 C74.12 C74.90 C74.91 C74.92 C75.0
C79.70 C79.71 C79.72 C80.0 D3A.8 D3A.00 D3A.010
D3A.011 D3A.012 D3A.019 D3A.020 D3A.021 D3A.022 D3A.023
D3A.024 D3A.025 D3A.026 D3A.029 D3A.090 D3A.091 D3A.092
D3A.093 D3A.094 D3A.095 D3A.096 D3A.098 D35.1 D35.00
D35.01 D35.02 D44.0 D44.2 D44.10 D44.11 D44.12
E20.0 E20.1 E20.8 E20.9 E21.0 E21.1 E21.2
E21.3 E21.4 E21.5 E34.0 R10.0 R10.2 R10.9
R10.10 R10.11 R10.12 R10.13 R10.30 R10.31 R10.32
R10.33 R10.83 R10.84 R10.811 R10.812 R10.813 R10.814
R10.815 R10.816 R10.817 R10.819 R10.821 R10.822 R10.823
R10.824 R10.825 R10.826 R10.827 R10.829 R11.0 R11.2
R14.0 R14.1 R14.2 R14.3 R19.4 R19.5 R19.6
R19.8 R19.00 R19.01 R19.02 R19.03 R19.04 R19.05
R19.06 R19.07 R19.09 R19.11 R19.12 R19.15 R19.30
R19.31 R19.32 R19.33 R19.34 R19.35 R19.36 R19.37
R50.2 R50.9 R50.81 R50.82 R50.83 R50.84 R93.3
R93.5

Non-covered Diagnosis Codes

C18.0 C18.1 C18.2 C18.3 C18.4 C18.5 C18.6
C18.7 C18.8 C18.9 C61 F84.5 F84.8 F84.9
F90.1 F90.2 F90.8 G40.001 G40.019 G40.111 G40.119
G40.211 G40.219 I61.0 I61.1 I61.2 I61.3 I61.4
I61.5 I61.6 I61.8 I61.9 I62.1 I62.9 I62.00
I62.01 I62.02 I67.0 I67.1 I67.2 I67.3 I67.4
I67.5 I67.6 I67.7 I67.9 I67.81 I67.82 I67.83
I67.89 I67.841 I67.848 R53.82 S06.5X0A S06.5X0D S06.5X0S
S06.5X1A S06.5X1D S06.5X1S S06.5X2A S06.5X2D S06.5X2S S06.5X3A
S06.5X3D S06.5X3S S06.5X4A S06.5X4D S06.5X4S S06.5X5A S06.5X5D
S06.5X5S S06.5X6A S06.5X6D S06.5X6S S06.5X9A S06.5X9D S06.5X9S
S06.360A S06.360D S06.360S S06.361A S06.361D S06.361S S06.362A
S06.362D S06.362S S06.363A S06.363D S06.363S S06.364A S06.364D
S06.364S S06.365A S06.365D S06.365S S06.366A S06.366D S06.366S
S06.369A S06.369D S06.369S

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