Highmark Medical Policy Bulletin
Section: Radiation Therapy & Nuclear Medicine
Number: R-6
Topic: Single Photon Emission Computed Tomography (SPECT)
Effective Date: October 1, 2004
Issued Date: October 4, 2004
Date Last Reviewed: 08/2004

General Policy Guidelines

Indications and Limitations of Coverage

The following single photon emission computed tomography (SPECT) studies are recognized as eligible services:

  • liver (codes 78205, 78206)
  • spleen (codes 78215, 78216)
  • bone (code 78320)
  • myocardium (codes 78464, 78465, 78469, 78494)
  • brain (code 78607)
  • kidneys (code 78710)
  • tumor localization (code 78803)
  • abscess localization (code 78807)

SPECT imaging of the kidneys is eligible for reimbursement when medically necessary in the diagnosis and treatment of renal diseases, conditions, and disorders, including but not limited to the following (NOTE: this is not an all inclusive list):

  • acute, chronic or recurrent kidney infections (e.g., pyelonephritis)(580.0-580.4, 580.81-580.89, 580.9, 581.0-581.3, 581.81-581.89, 581.9, 582.0-582.4, 582.81-582.89, 582.9, 583.0-583.7, 583.81-583.89, 583.9, 584.5-584.9, 585-587, 590.00-590.01, 590.10-590.11, 590.2-590.3, 590.80-590.81, 590.9)
  • evaluations of kidney tumors and trauma (189.0, 189.1, 198.0, 236.91)
  • pediatric patients with urinary tract infection (599.0)
  • congenital anomalies of the kidneys (753.0, 753.10-753.19, 753.3)
  • renal cortical damage or defects (583.6, 584.6)
  • renal infarction or renal masses (593.81, 223.0, 223.1)
  • vesicoureteral reflux in children (593.70-593.73)
  • assessing the integrity of renal parenchyma in cases of renal wasting diseases (588.0-588.1, 588.81-588.89, 588.9)

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. A participating, preferred, or network provider cannot bill the member for the denied service. 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.

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.

For guidelines on cerebrospinal fluid (CSF) flow SPECT imaging (code 78647), see Medical Policy Bulletin G-21.

For guidelines on myocardial SPECT studies, see Medical Policy Bulletin R-5.

For guidelines on tumor localization by SPECT, see Medical Policy Bulletin R-7.

Description

SPECT, a type of emission computed tomography, is similar to CT scan imaging in that it provides three-dimensional images. However, SPECT yields higher resolution three-dimensional images by using a rotating gamma camera and nuclear medicine computer software designed to increase the speed of processing complex mathematical algorithms. In addition, the radiant source of the imaging is not transmitted through the body area. Rather, a radiopharmaceutical diagnostic imaging agent is injected or inhaled into the targeted area from which it emits the radiation that produces the images. Using the images obtained by the gamma camera, complex mathematical algorithms reconstruct and manipulate the multi-color images. While CT images the anatomy of a body area, SPECT evaluates the functioning.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

782057820678215782167832078464
784657846978494786077864778710
7880378807    

Traditional (UCR/Fee Schedule) Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

Comprehensive / Wraparound / PPO / Major Medical Guidelines

Refer to General Policy Guidelines

Any reference in this bulletin to non-billable services by a network provider may not be applicable to Major Medical.

Managed Care (HMO/POS) Guidelines

Refer to General Policy Guidelines

Publications

PRN References

12/1993, Single photon emission computed tomography
02/1999, Cerebrospinal fluid flow SPECT imaging classified as questionable
10/1999, Blue Shield now covers kidney imaging by SPECT

References

A Prospective Comparison of High-Resolution Planar, Pinhole, and Triple-Detector SPECT for the Detection of Renal Cortical Defects, Clinical Nuclear Medicine, Vol. 22, 10/97

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Glossary




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.