Mutual of Omaha
Health Care Management Operations

Medical Necessity Criteria


SPECT (SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY)

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

ICD-9:
GLOS:
Assistant Surgeon:

Cross References: HCMO Criteria Manual Please cross-reference the PET (Positron Emission Tomography) criteria
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. 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.

Definitions:
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





Bibliographies:
SPECT Scan
1. BlueCross and BlueShield Technology Assessment Center (TEC). PET or SPECT for the Assessment of
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.
4. Botvinick, E.H. Stress Imaging: Current Clinical Options for the Diagnosis, Localization, and Evaluation or Coronary Artery Disease. Medical Clinics of North America, 79 (5), 1995, 1025-1061.
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.
11. Podoloff, D.A.; Kim, E.E.; Haynie, T. SPECT in the Evaluation of Cancer Patients. Radiology, 183 (2), May 1992, 305-317.
12. Report. Guidelines for Clinical Use of Cardiac Radionuclide Imaging. American College of Cardiology / American Heart Association Task Force, 25 (2), January 1995, 521-547.
13. Saha, G.B.; Macintyre, W.J.; Brunken, R.C.; Go, R.T.; Raja, S.; Wong, C.O.; Chen, E.Q. Present Assessment of Myocardial Viability by Nuclear Imaging. Seminars in Nuclear Medicine, 26 (4), October, 1996, 315-335.
14. Special Article. Assessment of Brain SPECT: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology, 46, January, 1996, 278-285.
15. Williams, M.; Pisano, E.; Schnall, M.; Fajardo, L. Future Directions in Imaging of Breast Diseases. Radiology, 206, 1998, 297-300.
Bibliography update 2000
16. American Academy of Neurology. Assessment of brain SPECT- Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 1996, 46, 278-285. Official AAN Practice Statement. Accessed website 5/25/2000 http://www.aan.org
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
18. Gemano G, et al. A new algorithm for the quantitation of myocardial perfusion SPECT. 1: technical principles and reproducibility. J Nucl Med April 2000, 41(4), 712-19. (Abstract)
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)
23. Sharir T, et al. A new algorithm for the quantitation of myocardial perfusion SPECT II: validation and diagnostic yield. J Nucl Med April 2000, 41(4), 720-7. (Abstract)
24. Sigel A, Mazurek R. Early dynamic SPECT acquisition for the imaging of hepatic hemangiomas utilizing Tc-99m labeled red blood cells. Clin Nucl Med. November 1997, 22(11), 745-8. (Abstract)
25. Society of Nuclear Medicine. Procedure guideline for myocardial perfusion imaging. February 1999. 27 p. Accessed website 5/25/2000 http://www.guideline.gov/index.asp
2002 Bibliography
26. Aetna US Healthcare. Coverage Policy Bulletins. Single Photon Emission Computed Tomography (SPECT). Number 0376, 01/2002. Internet accessed 12/10/02: www.aetna.com/cpb/data/CPBA0376.html
27. BCBS of Masschucetts . Policy 330, Reviewed 9/2002. Single Photon Emission Computed Tomography (SPECT). Discusses updates to BSBS of MA coverage for SPECT – see below. Internet accessed 12/10/2002: www.bsma.com/common/en_US/medical_policies/330.htm
28. CMS. Centers for Medicare and Medicaid Services. Medicare coverage manual. September 27, 2002. Section 50-58 Single photon emission tomography covered. Internet accessed: 12/10/2002.
29. Empire Medicare Services Medical Policy Bulletin Freedom of Information. Centers for Medicare and Medicaid (CMS). Revised January 1, 2001. Internet accessed 12/10/2002: www.empiremedicare.com/NewJpolicy/policy/r6d.htm
30. Kohn. Robert G., MD. Imaging the Brain- Spect Overview. 2002. Internet accessed 12/11/2002:
http://www.brain-spect.com/faq.html
31. Reuter’s Health. Spinal Rehabilitation Group. SPECT Increases Accuracy of Alzheimer’s Diagnosis. 04/19/2001, Internet accessed 12/11/2002: www.spinalrehab.com.au/
32. Scott, Williams, MD; Brain SPECT Imaging in Dementia: Alzheimer’s Dementia. 2002. Internet accessed 12/10/2002: www.auntminnie.com/ScottWilliamsMD2/nucmed/CNS/Dementia%2
33. Shaw, Leslee; PHD. Utility of normal perfusion studies: results from a multicenter clinical registry. March 2002, 1-3. Internet accessed 12/10/2002: www.medscape.com/viewarticle/431816
Updated: February 17, 2003
Updated: 11/30/2004
Updated: 12/19/2005
Reviewed: 03/24/2006

Date Archive: 11/21/2006