Mutual of Omaha
Health Care Management Operations

Medical Necessity Criteria


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

Assistant Surgeon:

Cross References: HCMO Criteria Manual 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**


1. Cardiac:
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

2. Brain
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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2002 Bibliography
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Updated: February 17, 2003
Updated: 11/30/2004
Updated: 12/19/2005
Reviewed: 03/24/2006

Date Archive: 11/21/2006