Mutual of Omaha
Health Care Management Operations
Effective Date: 12/14/1998
Revision Date: 03/24/2006, 12/19/2005, 11/30/2004, 02/17/2003, 01/20/2003, 10/16/2000, 09/20/99,
CPT: Heart 78464-78465, Myocardial Imaging tomographic 78469
Brain tomographic 78607
Cross References: Please cross-reference the PET (Positron Emission Tomography) criteria
*NOTE* A PET Scan can be used in place of a SPECT Scan but not in addition to it.
Please refer ALL other requests for SPECT (Single Photon Emission Computed Tomography) to the Medical Director for review along with supporting medical records. Due to limited data the efficacy remains unproven for all other SPECT scan indications. **Please request the TEC file for All other Indications**
*PLEASE REVIEW COMPLIANCE STATE LAWS AND POLICY LANGUAGE FOR DEFINITIONS FOR ANY EXCLUSIONS, LIMITATIONS OR POLICY REQUIREMENTS FOR MEDICAL NECESSITY AND EXPERIMENTAL/ INVESTIGATIONAL
MEDICAL NECESSITY MAY BE INDICATED:
1. Symptomatic patients and their risk factors place them at Intermediate Risk for having CAD
(Coronary Artery Disease) with inconclusive thallium stress tests/treadmills.
a. Men with symptoms of typical angina or atypical angina in the 30-70+ age group
b. Men with symptoms of nonspecific chest pain in the 60-70+ age group
c. Women with symptoms of typical angina in the 30-70+ age group
d. Women with symptoms of atypical angina in the 40-70+ age group
2. Identifying viable myocardium, thereby correctly predicting the outcome of revascularization
procedures (e.g. Coronary Artery Disease or Angioplasty) or pharmacological intervention
3. Analyze blood flow to the heart, as in the case of myocardial viability to differentiate ischemic heart
disease from dilated cardiomyopathy
1. Medically unmanageable epilepsy to determine epileptic regions for surgical intervention.
2. Symptomatic patients with a previous history of radiation to the head for which a determination
cannot be made as to tumor regrowth or irradiation scarring (radionecrosis).
In the case of myocardial viability, FDG PET may be used following a SPECT that was found to be inconclusive. However, SPECT may not be used following an inconclusive FDG PET performed to evaluate myocardial viability.
a. Typical Angina: Transient discomfort or distressing sensation occurring in the precordium, typically provoked by exertion and relieved promptly by rest and use of nitroglycerin.
b. Atypical Angina: Similar symptoms as Typical Angina but with the absence of one or more of the criteria for Typical Angina. (ex. Pain is not relieved by rest)
c. Nonspecific Chest Pain: Chest wall pain that is vaguely described, long in duration lasting for hours or days, and usually not exertion related. Movement of arms, breathing, or twisting the thorax may aggravate the symptoms.
Approved By: Date:
James Bowden, MD
Corporate Medical Director
Medical Management Division
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Cerebrovascular disease, 11(35), March 1997, 1-29.
2. BlueCross and BlueShield Technology Assessment Center (TEC). PET or SPECT in the Diagnosis
and Management or Brain Tumors, 11(34), March 1997, 1-25.
3. BlueCross and BlueShield Technology Assessment Center (TEC). PET or SPECT in the Management of Seizure Disorders, 11(33), March 1997, 17.
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5. ECRI Executive Briefings. Gamma Camera Used to Obtain PET-Like Images; Results Mixed, April 1995.
Mustafa, B.; Kirshner, H.S.; Wertz, R.T. Crossed Aphasia. ARCH Neurology, 53, October 1996, 1026-1032.
6. Food and Drug Administration. Telephone memo, subject: SPECT, October 3, 1997.
7. HAYES, Inc. Single Photon Emission Computed Tomography (SPECT) , April 26, 1996, 1-70.
8. Hosen, K.; Ansari, A.; Berman, D.; Friedman, J.; Siegal, R. Abnormal Myocardial Perfussion Single Photon Emission Computed Tomography and Normal Coronary Arteriogram: The Role of Intracoronary Vascular Ultrasound in Providing Diagnostic Confirmation. American Heart Journal, 130 (1), July 1995, 182-186.
9. Masdeu, J.C.; Brass, L.M.; Holman, L.; Kushner, M.J. Brain Single-Photon Emission Computed Tomography. Neurology, 44, October 1994, 1970-1977.
10. Moser, W. Roles in Functional Brain Imaging: PET vs. SPECT. Advance Radiological Science Professionals 10 (10), May 1997, 3 & 46.
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15. Williams, M.; Pisano, E.; Schnall, M.; Fajardo, L. Future Directions in Imaging of Breast Diseases. Radiology, 206, 1998, 297-300.
Bibliography update 2000
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17. FDA. Guidance for the Submission of Premarket Notifications for Emission Computed Tomography Devices and Accessories (SPECT and PET) and Nuclear Tomography Systems. Issued on December 3, 1998. Accessed wesite 5/26/2000 http://www.fda.gov
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19. Lee KS, et al. Correlation of gallium-67 SPECT and CT findings in primary gynecologic lymphoma. Clin Imaging. Mar-Apr 1999, 23(2), 119-24.
20. Merck Manual for Diagnosis and Therapy. Noninvasive Procedures. Section 16 Caridovascular Disorders. Myocardial Perfusion Imaging. Accessed 5/26/2000 http://www.merck.com/pubs/mmanual/seciton16/chapter198/198b.htm
21. O'Brien, TJ, et al. Subtraction ictal SPECT co-registered to MRI improves clinical usefulness of SPECT in localizing the surgical seizure focus. Neurology 1998, 50:445-454. (Abstract)
22. O'Brien, TJ, et al. Subtraction SPECT co-registered to MRI improves postictal SPECT localization of seizure foci. Neurology 1999, 52, 137. (Abstract)
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Updated: February 17, 2003
Date Archive: 11/21/2006