Single Photon Emission Computed Tomography (SPECT)

Policy ID: R-6-023

Section: Radiation Therapy & Nuclear Medicine

Effective Date: July 01, 2018

Revised Date: July 31, 2019

Last Reviewed: August 10, 2020

Applies To: Non-migrated Commercial and Medicaid Expansion

This policy has been retired effective October 5, 2020. Click the Archive tab above for more information.

Policy ID: R-6-023

Section: Radiation Therapy & Nuclear Medicine

Effective Date: July 01, 2018

Revised Date: July 31, 2019

Last Reviewed: August 10, 2020

Archived Date: October 05, 2020

Applies To: Commercial and Medicaid Expansion

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

78607

78710

78803

78807

78320

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

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 8-10-2020 Retiring policy effective October 5, 2020

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