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)

Any conditions other than those listed as eligible will be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied services.

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. Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

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.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

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

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