Download Nuclear Imaging including Single

CIGNA HEALTHCARE COVERAGE POSITION
Subject Nuclear Imaging including
Single-Photon Emission
Computed Tomography
(SPECT)
Table of Contents
Coverage Position............................................... 1
General Background ........................................... 2
Coding/Billing Information ................................. 19
References ........................................................ 23
Revised Date ........................... 10/15/2006
Original Effective Date ............. 9/15/2004
Coverage Position Number ............. 0169
Hyperlink to Related Coverage Positions
AcuTect™
Monoclonal Antibody (MAb) Imaging or
Radioimmunoscintigraphy
Positron Emission Tomography (PET)
Scintimammography
INSTRUCTIONS FOR USE
Coverage Positions are intended to supplement certain standard CIGNA HealthCare benefit plans. Please note, the terms of a
participant’s particular benefit plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage,
Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which
these Coverage Positions are based. For example, a participant’s benefit plan document may contain a specific exclusion related to
a topic addressed in a Coverage Position. In the event of a conflict, a participant’s benefit plan document always supercedes the
information in the Coverage Positions. In the absence of a controlling federal or state coverage mandate, benefits are ultimately
determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require
consideration of 1) the terms of the applicable group benefit plan document in effect on the date of service; 2) any applicable
laws/regulations; 3) any relevant collateral source materials including Coverage Positions and; 4) the specific facts of the particular
situation. Coverage Positions relate exclusively to the administration of health benefit plans. Coverage Positions are not
recommendations for treatment and should never be used as treatment guidelines. ©2006 CIGNA Health Corporation
Coverage Position
CIGNA HealthCare covers nuclear imaging scintigraphy (including single-photon emission
computed tomography (SPECT) and SPECT with concurrently-acquired computed tomography
[SPECT/CT]) as medically necessary for ANY of the following when other imaging studies are
inconclusive or contraindicated:
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bone and skeletal disorders
brain disorders (e.g., dementia including Alzheimer’s disease (AD), cerebrovascular disease,
epilepsy, encephalitis, head injury, central nervous system disorders)
gastrointestinal disorders
hepatobiliary and hepatosplenic disorders
infections and inflammation
lung disorders
parathyroid disorders
renal and urinary disorders
acute and subacute scrotal pain (i.e., testicular torsion, epididymitis, orchitis)
thyroid disorders
tumors
CIGNA HealthCare covers SPECT myocardial perfusion imaging (MPI) OR MUGA scanning
(multiple gated acquisition, equilibrium radionuclide angiography/ ventriculography ERNA, RVG,
or gated blood pool imaging), as medically necessary for ANY of the following:
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detection of obstructive coronary artery disease (CAD) for EITHER of the following:
¾ patients at intermediate CAD risk on standardized risk assessment
¾ patients at high risk factor for CAD (e.g., diabetes mellitus, peripheral or cerebral vascular
disease).
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risk stratification for ANY of the following:
¾ post myocardial infarction patients before discharge
¾ patients with chronic stable CAD to differentiate a low risk state that can be managed medically
from a high-risk state for which coronary revascularization should be considered
¾ acute coronary syndrome patients when a diagnosis of acute myocardial infarction has been
excluded but a strong suspicion of ischemia remains
¾ before noncardiac surgery in patients with known CAD or those considered at high risk for CAD
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evaluation of a change in symptoms suggestive of worsening ischemia in patients with a previous
invasive treatment for CAD
CIGNA HealthCare does not cover nuclear imaging scintigraphy including SPECT or SPECT/CT for
any of the following because it is considered experimental, investigational or unproven:
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chronic fatigue syndrome
multiple myeloma
psychiatric and neuropsychiatric disorders
scrotal tumors, chronic inflammation or cryptorchidism
screening for coronary artery disease
General Background
Nuclear medicine is a subspecialty within the field of radiology. X-ray and nuclear medicine imaging share
in common the use of ionizing radiation. X-ray images are produced by recording the differential
absorption of x-rays by body tissues. Nuclear medicine images are obtained by mapping the distribution
of radioactivity of an administered radiopharmaceutical within the body. Gamma-rays and x-rays are
photons, or electromagnetic radiation, that can penetrate matter and be detected by an external detection
system.
In order to produce a nuclear medicine image, several steps must be completed. First, a pharmaceutical
with appropriate biological behavior must be chosen. This compound must be successfully bound to
some radioactive material without changing the biological behavior of the original pharmaceutical. The
resulting radioactive compound is referred to as a radiopharmaceutical. Once it has been administered to
the patient, radiation detectors are used to record the internal spatial distribution of the
radiopharmaceutical in the body in two or three dimensions. The detectors used are usually some kind of
scintillation detector, either a large field of view gamma camera with one to three heads, or a ring
detector. Temporal changes in distribution can also be recorded, creating a dynamic image. In general, it
is functional information that is derived from the distribution of the radiopharmaceutical, whether from
dynamic images or ‘static’ images recorded at a single time point. Additional information, in both imaging
and numerical form, is often obtained from further computer processing of the original images.
The ultimate goal of nuclear medicine is to provide an accurate, three-dimensional (3D) map of the
distribution of a radiopharmaceutical within a patient, and possibly also to measure changes in distribution
with time.
Emission computed tomography (ECT) provides an in vivo three-dimensional distribution of
radiopharmaceuticals within the body, generated from a set of two-dimensional projectional images. ECT
is considered functional imaging, whereas magnetic resonance imaging (MRI) or computed tomography
(CT) are considered anatomical. ECT improves image contrast and quantification and includes singlephoton emission computed tomography (SPECT) and positron emission tomography (PET). SPECT is
more readily available in practice than PET because it utilizes commercially available isotopes and does
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not require an on-site cyclotron. SPECT involves the detection of gamma rays emitted singly (singlephoton) from radionuclides such as technetium-99m (Tc-99m) and thallium-201 (Tl 201).
Conventional planar imaging provides only a two-dimensional projection of a three-dimensional
distribution of activity. Planar imaging may be used for patients who do not tolerate the position that must
be maintained during a SPECT acquisition, those who have difficulty coping with the larger SPECT
camera being so close to the body, or those with large body habitus that surpasses the weight and size
limits of SPECT systems. SPECT scintigrams allow 3D information to be gained in addition to standard
planar views. They are used to give depth information (e.g., in kidney studies) or aid localization of a
particular lesion (e.g., for bone scintigrams). Alternatively, SPECT can be used for myocardial studies or
various brain imaging techniques (e.g., for diagnosis of dementia and evaluation of cerebral blood flow).
More recently, dual-headed cameras have entered the market, and these are capable of automatically
acquiring whole-body scintigrams in one pass. They have reduced the acquisition time for many studies
when compared with the single-headed cameras, including SPECT sequences, while allowing the
simultaneous collection of two or more images (e.g., anterior and posterior or lateral or oblique views).
Some of these dual-headed cameras have a fixed geometry of 180° separation between the two heads,
whereas the newest that have variable angle gantries are especially useful for the increasing cardiac
workload (Grainger, et al., 2003).
Nuclear medicine images can assist the physician in diagnosing diseases. Tumors, infection and other
disorders can be detected by evaluating organ function. Some applications of nuclear medicine include:
• analysis of kidney function
• imaging blood flow and function of the heart
• scanning lungs for respiratory and blood-flow problems
• identification of gallbladder blockage
• bone evaluation for fracture, infection, arthritis or tumor
• determining the presence or spread of cancer
• identification of bleeding into the bowel
• locating the presence of infection
• measuring thyroid function to detect an overactive or underactive thyroid
(Radiology Society of North America, 2005)
U.S. Food and Drug Administration (FDA)
Radiopharmaceuticals and imaging systems are regulated by the U.S. Food and Drug Administration
(FDA). Premarket 510(k) notification is required by the FDA for an emission computed tomography
diagnostic device or nuclear tomography system, which are Class II medical devices.
Radiopharmaceutical approvals may or may not specify the types of imaging systems they can be used
with or the types of conditions or diagnoses they can be used to help detect.
Bone / Skeletal - Literature Review
Bone or skeletal scintigraphy is performed for numerous indications, including but not limited to: primary
and metastatic bone neoplasms; occult fracture; osteomyelitis; arthritides; bone viability [grafts, infarcts,
osteonecrosis]; reflex sympathetic dystrophy; otherwise unexplained bone pain; and distribution of
osteoblastic activity before radionuclide therapy for bone pain (American College of Radiology [ACR],
2003; Society of Nuclear Medicine [SNM], 2003).
Skeletal scintigraphy is a sensitive method for detecting numerous conditions involving the skeletal
system. Although certain patterns are suggestive of individual disease entities, correlation of abnormal
activity with clinical information, conventional radiographs, and other imaging techniques, including CT,
magnetic resonance imaging (MRI), and other radiopharmaceutical imaging studies, is frequently helpful
for diagnosis.
Radionuclide scanning has become a useful imaging adjunct in the diagnosis of osteomyelitis. While xray and CT scans give a structural or anatomical picture, radionuclide scanning gives a more
physiological picture. Radionuclide scanning also is useful in patients with metallic implants in whom CT
and MRI scans are of limited value because of contraindications and metallic-generated artifact. The
three most commonly used radioisotopes are Tc-99m phosphate, gallium 67 citrate (67Ga), and indium
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111 (111In)-labeled leukocytes. Tc-99m phosphate can detect osteomyelitis within 48 hours after clinical
onset of infection (Canale, 2003).
Bone scintigraphy using Tc-99m methylene diphosphonate (MDP) can be used to exclude infection or
neoplasm in children with joint symptoms (Grainger, et al., 2003).
Spondylolysis usually can be detected as a defect in the pars interarticularis on a 45-degree oblique x-ray
of the lumbar spine. Lateral x-rays are used to document the degree of spondylolisthesis. In children and
adolescents, SPECT is useful to show a pars defect that is not apparent on x-ray and is useful to
determine whether a spondylolytic lesion is acute enough to merit immobilization (Frontera, et al., 2002).
A radionuclide bone scan is valuable to determine if more than one skeletal site is involved with Paget's
disease (Noble, 2001). Radionuclide bone scans are more sensitive than standard radiographs in
identifying metastatic lesions (other than the plasmacytomas of multiple myeloma) and are also useful in
characterizing the spondylolysis associated with isthmic spondylolisthesis. Nuclear medicine studies are
sometimes helpful in identifying abscesses and osteomyelitis (Noble, 2001).
Brain - Literature Review
Radionuclide imaging of the brain requires radiopharmaceuticals that cross the blood–brain barrier.
Clinical applications include but are not limited to: dementia including Alzheimer’s disease (AD),
cerebrovascular disease, epilepsy, encephalitis, head injury, and other less common disorders that result
in abnormal cerebral perfusion. SPECT can be used to image uptake at neurotransmitter receptors
(Grainger, et al., 2003; ACR, 2003; SNM, 1999, 2003).
In acute stroke, SPECT with Tc-99m hexamethylpropyleneamineoxime (HMPAO) or Tc-99m ethyl
cysteinate dimer (ECD) will show a perfusion defect as soon as vascular occlusion occurs but will not
exclude intracranial hemorrhage. HMPAO SPECT is superior to clinical examination and CT in predicting
short-term outcome following stroke, and quantitation of degree of ischemia will predict risk of intracranial
hemorrhage following intra-arterial thrombolysis. Diffusion-weighted MRI may be the most sensitive
imaging study for acute stroke; however, SPECT imaging can identify areas of decreased blood flow in
patients with acute infarcts (Grainger, et al. 2003; Goetz, 2003).
In general, patients have an imaging study at the time of the initial diagnosis of dementia. A repeat of the
imaging study is typically considered in patients with acute deterioration in function, particularly with
development of new focal neurologic signs or any history of head trauma. A CT scan of the head or an
MRI may be performed. SPECT scanning may also have a role in the evaluation of patients with
dementia. Characteristic patterns have been described in AD and Pick's disease but have not been fully
substantiated with clinicopathologic correlations. The test involves the infusion of a radionuclide followed
by a relatively brief period of imaging. It requires some patient cooperation, but most patients can tolerate
the procedure. At this stage, results should be considered supportive but not diagnostic. SPECT scans
are not part of a routine evaluation at this stage (Noble, 2001). Zakzanis et al. (2003) notes the most
frequently indexed aspects of physiological function in Alzheimer’s disease (AD) include glucose
metabolism and blood flow as measured with PET and SPECT. It is important to note that each of these
imaging methods has its strengths and limitations in clinical practice. Accordingly, these various
techniques are considered complementary to one another in terms of diagnosis and documenting the
clinical progression of disease in general. SPECT of the Alzheimer brain primarily addresses resting-state
regional cerebral blood flow using both single- and multi-head gamma-camera based systems.
In severe head trauma, SPECT may characterize prognosis of focal lesions as well as cases of more
widespread diffuse axonal injury (Goetz, 2003).
CT, MRI, and electroencephalography (EEG) are the primary noninvasive methods used to localize an
epileptic focus but do not always identify a lesion. These patients may require invasive placement of
depth electrodes to definitively elucidate a seizure focus. SPECT has been helpful in demonstrating
regional decreased cerebral blood flow within a seizure focus between seizures and increased regional
ictal cerebral blood flow. HMPAO is the SPECT radionuclide of choice. There is an additional increased
sensitivity if an ictal SPECT scan can be obtained. Tc-99m HMPAO SPECT reveals hypoperfusion in the
epileptogenic temporal lobe during the interictal state in over 50% of patients with temporal lobe epilepsy.
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Research suggests that a more stable SPECT imaging agent, ECD, which is chemically more stable than
HMPAO, has the potential to become the radionuclide of choice (Goetz, 2003).
SPECT, using Tc-99m HMPAO, is a sensitive technique to study regional cerebral blood flow. SPECT is
particularly useful in investigating cerebral vascular disease in children (e.g., systemic lupus
erythematosus), as well as herpes encephalitis, and for localization of focal epileptiform discharges and
recurrent brain tumors (Behrman, et al., 2004).
The National Institute for Health and Clinical Excellence Clinical Guideline on Parkinson’s disease (June,
2006) states SPECT should be considered for people with tremor where essential tremor cannot be
clinically differentiated from Parkinsonism.
For other indications (e.g., neuropsychiatric disorders, chronic fatigue syndrome), the findings of SPECT
brain perfusion imaging have not been fully characterized (ACR; SNM; Frontera, et al., 2002).
Brain - Professional Societies/Organizations
American Academy of Neurology: Using clinical evaluation as the comparator, five class III studies
demonstrated that (1r)-2 β -carbomethoxy-3 β -(4-iodophenyl)tropane (β-CIT) and 123I iodobenzamide
(IBZM) SPECT had 8% to 100% specificity in identifying clinically diagnosed PD patients, as compared to
other parkinsonian syndromes. Sensitivity varied from 30 to 100%. AAN concluded β-CIT and IBZM
SPECT are possibly useful in distinguishing PD from essential tremor. There is insufficient evidence to
determine if these modalities are useful in distinguishing PD from other forms of Parkinsonism
(Suchowersky, et al., 2006).
In determining brain death in adults, Tc-99m HMPAO brain scan should show no uptake of isotope in
brain parenchyma ("hollow skull phenomenon") (AAN, 2003).
Near infrared spectroscopy, nuclear medicine (SPECT and PET), and functional MRI are other major
imaging technologies not discussed in this neuroimaging of the neonate practice parameter because of
lack of data; these technologies are under evaluation for use in the assessment of the developing brain
(Ment, et al., 2002).
For the differentiation of AD versus non-AD dementia, hypoperfusion in the temporal–parietal lobe(s) was
reported to be 86-95% sensitive and 42-73% specific. Although encouraging, these figures are not
consistently better than those obtained by diagnosis with established clinical criteria (Knopman, et al.,
2001).
Functional imaging modalities such as functional MRI (fMRI), SPECT, or PET are currently only research
tools in the evaluation of autism. There is no evidence to support a role for functional neuroimaging
studies in the clinical diagnosis of autism at the present time (AAN, 2000).
There was insufficient evidence to make any recommendations regarding the role of SPECT scans or
evoked potentials in children with cerebral palsy (Ashwal, et al., 2004).
American Academy of Pediatrics (AAP): Brain imaging studies and electroencephalography do not
show reliable differences between children with Attention-Deficit/Hyperactivity Disorder (ADHD) and
controls (AAP, 2000).
American Heart Association: SPECT cerebral blood flow studies can be used to determine the relative
risks of hemorrhage following thrombolysis of acute stroke patients, whatever the time after onset of
symptoms (grade A) (Latchaw, et al., 2003).
American Psychiatric Association (APA): Preliminary evidence indicates that there may be a use for
SPECT in the diagnosis of Alzheimer’s disease (Rabins, 2006).
APA Psychiatric Evaluation of Adults APA Guideline (2006) states that “neuroimaging techniques are
currently used in identifying central nervous system processes such as infection, malformations,
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cerebrovascular events, and malignancy. Accumulating evidence also suggests other applications of
neuroimaging in psychiatric evaluation. In cognitive disorders of late life, such as Alzheimer’s disease,
neuroimaging techniques have been evaluated for use as surrogate markers for the microscopic
neuropathologies that characterize the illness. Functional neuroimaging with positron emission
tomography or single-photon emission computed tomography has demonstrated an association between
reduced regional activity (metabolism or perfusion) in temporoparietal regions and the presence and
severity of Alzheimer’s disease, whereas other dementing illnesses do not show this temporoparietal
feature. The reproducibility of these findings has enhanced the differentiation between Alzheimer’s
disease and other dementing illnesses. Ongoing work aims to confirm the clinical utility of such
information.
In patients with schizophrenia and mood and anxiety disorders, structural and functional neuroimaging
studies have reported differences between patients and healthy control persons as well as differences in
some patient subgroups and in responders and nonresponders to some treatments. Nevertheless, the
clinical utility of neuroimaging techniques for planning of individualized treatment has not yet been shown.
Further research is needed to demonstrate a clinical role for structural and functional neuroimaging in
establishing psychiatric diagnoses, monitoring illness progression, and predicting prognoses.”
American College of Radiology (ACR): Primary indications include: seizures, cranial nerve dysfunction,
diplopia, ataxia, acute and chronic neurologic deficits, suspicion of neurodegenerative disease, primary
and secondary neoplasm, aneurysm, cortical dysplasia and other morphologic brain abnormalities,
vasculitis, encephalitis, brain maturation, headache, mental status change, hydrocephalus, ischemic
disease and infarction, suspected pituitary dysfunction, inflammation or infection of the brain or meninges
or their complications, postoperative evaluation, demyelination and dysmyelination disorders, vascular
malformations, and arterial or venous/dural sinus abnormalities. Extended indications include: suspicion
of acute intracranial hemorrhage or evaluation of chronic hemorrhage, neuroendocrine dysfunction,
functional imaging, brain mapping, blood flow and brain perfusion study, image guidance for intervention
or treatment planning, spectroscopy (including the evaluation of brain tumor, infectious processes, brain
development and/or degeneration, and ischemic conditions), and post-traumatic conditions (ACR, 2003).
Cardiac - Literature Review
Cardiac nuclear imaging is used to examine the anatomy and function of the heart. There are several
types of cardiac nuclear imaging studies:
SPECT Myocardial Perfusion Imaging (MPI): SPECT MPI scanning gives you two key results. One is
perfusion, by comparing rest and stress images to look for fixed or reversible defects. The other is
function; by giving you wall motion, including ejection fraction. SPECT is preferable to planar for
myocardial perfusion scintigraphy. Currently utilized myocardial perfusion tracers for SPECT imaging
include Thallium-201 (Tl-201) and two Tc-99m agents (Tc-99m sestamibi and Tc-99m tetrofosmin). Some
radiopharmaceutical doses fall outside of manufacturer’s package insert guidelines, but are now
commonly used in the clinical practice of nuclear cardiology. There are other abnormal findings that
provide additional information beyond that provided by the perfusion pattern alone, including lung uptake
of tracer (particularly Tl-201) and transient ischemic dilation of the left ventricle. Both have been
associated with angiographically extensive and severe coronary artery disease (CAD).
SPECT MPI is usually accomplished in an outpatient setting. There are only two indications for two-day
protocols. For technetium-based studies, they may be required when obesity requires large doses of
isotope. For thallium scanning, a second dose may be required at 24 hours to look for viable myocardium
when planning revascularization. Dual isotope scans using Thallium and technetium are very efficient
(rest and then stress portions can be done in as little as 90 minutes.
SPECT MPI can be performed at rest, or under stress caused by exercise or pharmacologically. Exercise
or pharmacological stress Tl-201 or Tc-99m sestamibi SPECT MPI in patients with chest pain yields
sensitivity for detecting CAD in the 85 to 90% range. Specificity for excluding CAD is in the 90% range
when electrocardiography (ECG)-gated SPECT MPI is used. Exercise SPECT MPI and pharmacological
SPECT MPI both yield sensitivities and specificities for CAD detection that are superior to those of
exercise ECG testing alone. Stress SPECT MPI can be used for assessment of prognosis of patients
evaluated for CAD. Data reported from the literature demonstrate that patients with normal regional
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myocardial perfusion and normal left ventricular function on gated SPECT scans have an excellent
prognosis, whereas patients with abnormal scans have an increased rate of cardiac death and nonfatal
infarction during follow-up. The greater the extent of stress-induced hypoperfusion and reversibility, the
greater the probability of an event.
The incorporation of ECG-gated SPECT imaging into a SPECT acquisition is now standard of care in MPI
and is recommended as standard by contemporary guidelines. The addition of left ventricular (LV)
function data to the perfusion information provides incremental and independent prognostic information
as well as being of practical importance in management decisions. Gated SPECT MPI has also been an
important advance in helping to differentiate attenuation artifacts from infarct, as regions with persistent
low counts that show normal motion and thickening represent soft tissue artifacts rather than scar. Thus,
gated SPECT MPI has improved the specificity of perfusion imaging for ruling out CAD, particularly in
women (Zipes, et al., 2005; American Society of Nuclear Cardiology [ASNC], 2006).
Equilibrium Radionuclide Angiography or Ventriculography (i.e., Gated Blood Pool Imaging): The
equilibrium technique is often referred to as multiple gated acquisition (MUGA) scanning, or by ERNA or
RVG. In equilibrium RVG studies, data are recorded in a computer system synchronized with the R wave
of the patient's ECG, similar to ECG-gated SPECT. It is used to determine global and regional measures
of ventricular function (primarily LV function) at rest and/or during exercise stress or pharmacologic
intervention. These measures of ventricular function may include evaluations of ventricular wall motion,
EF, and other parameters of systolic and diastolic function. Most commonly, Tc-99m labeling is applied to
red blood cells or albumin. Image contrast is usually better with Tc-99m-labeled red blood cells, but Tc99m-labeled albumin is preferable in patients in whom red blood cell labeling may be difficult (Zipes, et
al., 2005; ASNC, 2006).
First-pass Radionuclide Angiography or Ventriculography: First-pass can also assess LV and right
ventricular (RV) function at rest or during stress (evaluation of wall motion, ejection fraction [EF], and
other systolic and diastolic parameters); also to assess and measure left-to-right shunts. First pass
studies are very rarely performed any more. They have been replaced by RVG (Zipes, et al., 2005;
ASNC, 2006).
Cardiac - Professional Societies/Organizations
*American Society of Nuclear Cardiology (ASNC): ASNC Imaging Guidelines for Nuclear Cardiology
Procedures addresses some of the following points: (July, 2006)
MPI SPECT is preferable to planar for myocardial perfusion scintigraphy. Myocardial Perfusion SPECT
evaluates regional myocardial perfusion and function. The majority of stress myocardial perfusion
radionuclide studies currently are acquired as gated SPECT data. However, there is mounting evidence
that the information content of the post-stress acquisition may be different from that of the resting data,
most likely due to post-ischemic stunning of myocardium. Providing that there is adequate count density,
particularly with regard to the lower dose acquisitions, both stress and rest SPECT perfusion studies may
be acquired as gated data sets. Because of the substantial benefit of the information obtained, gated
studies of ventricular function should be a routine part of myocardial perfusion SPECT. Exercise is the
preferred stress modality in patients who are able to exercise to an adequate workload (at least 85% of
age-adjusted maximal predicted heart rate and five estimated metabolic equivalents of exercise (METS).
Exercise stress test indications:
• detection of obstructive CAD in:
¾ patients with an intermediate pre-test probability of CAD based on age, gender and
symptoms, and in
¾ patients with high risk factors for CAD (e.g. diabetes mellitus, peripheral or cerebral vascular
disease).
• risk stratification of post myocardial infarction patients before discharge (submaximal test at 4-6
days), early (symptom limited at 14-21 days) or late (symptom limited at 3-6 weeks) after
discharge.
• risk stratification of patients with chronic stable CAD into a low-risk category that can be managed
medically, or into a high-risk category that should be considered for coronary revascularization.
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risk stratification of low-risk acute coronary syndrome patients (without active ischemia and/or
heart failure 6-12 hours after presentation), and of intermediate-risk acute coronary syndrome
patients 1-3 days after presentation (without active ischemia and/or heart failure symptoms).
risk stratification before noncardiac surgery in patients with known CAD or those with high risk
factors for CAD.
to evaluate the efficacy of therapeutic interventions (anti-ischemic drug therapy or coronary
revascularization) and in tracking subsequent risk based on serial changes in myocardial
perfusion in patients with known CAD.
Absolute contraindications:
• high risk unstable angina. However, patients with suspected unstable angina at presentation, who
are otherwise stable and pain free, can undergo exercise stress testing.
• decompensated or inadequately controlled congestive heart failure
• uncontrolled hypertension (blood pressure >200/110 mm of Hg)
• uncontrolled cardiac arrhythmias (causing symptoms or hemodynamic compromise)
• severe symptomatic aortic stenosis
• acute pulmonary embolism
• acute myocarditis or pericarditis
• acute aortic dissection
• severe pulmonary hypertension
• acute myocardial infarction (<4 days)
Relative contraindications:
• known left main coronary artery stenosis
• moderate aortic stenosis
• hypertrophic obstructive cardiomyopathy or other forms of outflow tract obstruction
• significant tachyarrhythmias or bradyarrhythmias
• high degree atrioventricular block
• electrolyte abnormalities
• mental or physical impairment leading to inability to exercise adequately
• if combined with imaging, patients with complete LBBB, permanent pacemakers and ventricular
• pre-excitation (W-P-W) should preferentially undergo pharmacological vasodilator stress test (not
• dobutamine stress test)
Exercise stress testing has a limited value in patients who cannot achieve an adequate heart rate and
blood pressure response due to a noncardiac physical limitation such as pulmonary, peripheral vascular,
musculoskeletal abnormalities or due to lack of motivation. These patients should undergo
pharmacologically-induced stress imaging.
Equilibrium Radionuclide Angiocardiography (ERNA) – ERNA is used to determine global and regional
measures of ventricular function (primarily LV function) at rest and/or during stress. These measures of
ventricular function may include evaluations of ventricular wall motion, EF, and other parameters of
systolic and diastolic function.
First-Pass Radionuclide Angiography (FPRNA) – FPRNA is performed: to assess LV and right ventricular
(RV) function at rest or during stress (evaluation of wall motion, EF, and other systolic and diastolic
parameters); and to assess and measure left-to-right shunts.
*American College of Cardiology Foundation (ACCF)/American Society of Nuclear Cardiology
(ASNC): ACCF/ASNC Appropriateness Criteria for SPECT Myocardial Perfusion Imaging (SPECT MPI)
complements existing guidelines and performance measures, examining indications for SPECT MPI in
the context of scientific evidence, physician judgment, patient specifics and the health care environment
(Brindis, et al., 2005). The Working Group devised clinical scenarios to score each indication. They were
rated as follows:
• “Appropriate” test for that specific indication (test is generally acceptable and is a reasonable
approach for the indication).
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“Uncertain” or possibly appropriate test for that specific indication (test may be generally acceptable
and may be a reasonable approach for the indication. Uncertainty also implies that more research
and/or patient information is needed to classify definitively the indication as appropriate and to update
the criteria.)
• “Inappropriate” test for that specific indication (test is not generally acceptable and is not a reasonable
approach for the indication).
The panel of experts from the ACC and ASNC rated 52 indications. The experts ranked 27 indications
appropriate (52%) and 12 possibly appropriate or uncertain (23%), recommending reimbursement for
those 39 indications (75%). They found 13 indications to be inappropriate (25%) and encourage
physicians to prepare to document exceptions when ordering an SPECT MPI for one of those indications.
The ACCF/ASNC appropriateness review of SPECT MPI resulted in the following 52 indications:
Detection of CAD: Symptomatic, Evaluation of Chest Pain Syndrome is:
• Appropriate, if intermediate pre-test probability of CAD and ECG interpretable and able to exercise
• Appropriate, if intermediate pre-test probability of CAD and ECG uninterpretable or unable to exercise
• Appropriate, if high pre-test probability of CAD and ECG interpretable and able to exercise
• Appropriate, if high pre-test probability of CAD and ECG uninterpretable OR unable to exercise
• Uncertain, if low pre-test probability of CAD and ECG uninterpretable or unable to exercise
• Inappropriate, if low pre-test probability of CAD and ECG interpretable and able to exercise
Detection of CAD: Symptomatic, Acute Chest Pain (in Reference to Rest Perfusion Imaging) is:
• Appropriate, if intermediate pre-test probability of CAD and ECG – no ST elevation AND initial cardiac
enzymes negative
• Inappropriate, if high pre-test probability of CAD and ECG – ST elevation
Detection of CAD: Symptomatic, New-Onset/Diagnosed Heart Failure With Chest Pain Syndrome is:
• Appropriate, if intermediate pre-test probability of CAD
Detection of CAD: Asymptomatic (Without Chest Pain Syndrome) is:
• Inappropriate, if low CHD risk (Framingham risk criteria)
• Uncertain, if moderate CHD risk (Framingham)
Detection of CAD: Asymptomatic (Without Chest Pain Syndrome), New-Onset or Diagnosed Heart Failure
or LV Systolic Dysfunction Without Chest Pain Syndrome is:
• Appropriate, if moderate CHD risk (Framingham) and no prior CAD evaluation AND no planned
cardiac catheterization
Detection of CAD: Asymptomatic (Without Chest Pain Syndrome), Valvular Heart Disease Without Chest
Pain Syndrome is:
• Uncertain, if moderate CHD risk (Framingham) and to help guide decision for invasive studies
Detection of CAD: Asymptomatic (Without Chest Pain Syndrome), New-Onset Atrial Fibrillation is:
• Uncertain, if low CHD risk (Framingham) and part of the evaluation
• Appropriate, if high CHD risk (Framingham) and part of the evaluation
Detection of CAD: Asymptomatic (Without Chest Pain Syndrome), Ventricular Tachycardia is:
• Appropriate, if moderate to high CHD risk (Framingham)
Risk Assessment: General and Specific Patient Populations, Asymptomatic
• Inappropriate, if low CHD risk (Framingham)
• Uncertain, if moderate CHD risk (Framingham)
• Appropriate, if moderate to high CHD risk (Framingham) and high-risk occupation (e.g., airline pilot)
• Appropriate, if high CHD risk (Framingham)
Risk Assessment With Prior Test Results, Asymptomatic OR Stable Symptoms, Normal Prior SPECT MPI
Study
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•
•
Inappropriate, if normal initial RNI study and high CHD risk (Framingham) and annual SPECT MPI
study
Appropriate, if normal initial RNI study and high CHD risk (Framingham) and repeat SPECT MPI
study after 2 years or greater
Risk Assessment With Prior Test Results, Asymptomatic OR Stable Symptoms, Abnormal Catheterization
OR Prior SPECT MPI Study
• Inappropriate, if known CAD on catheterization OR prior SPECT MPI study in patients who have not
had revascularization procedure and symptomatic OR stable symptoms and less than 1 year to
evaluate worsening disease
• Appropriate, if known CAD on catheterization or prior SPECT MPI study and in patients who have not
had revascularization procedure and greater than or equal to 2 years to evaluate worsening disease
Risk Assessment With Prior Test Results, Worsening Symptoms, Abnormal Catheterization OR Prior
SPECT MPI Study
• Appropriate, if known CAD on catheterization OR prior SPECT MPI study
Risk Assessment With Prior Test Results, Asymptomatic, CT Coronary Angiography
• Uncertain, if stenosis of unclear significance
Risk Assessment With Prior Test Results Asymptomatic, Prior Coronary Calcium Agatston Score
• Appropriate, if Agatston score greater than or equal to 400
• Inappropriate, if Agatston score less than 100
Risk Assessment With Prior Test Results, UA/NSTEMI, STEMI, or Chest Pain Syndrome, Coronary
Angiogram
• Appropriate, if stenosis of unclear significance
Risk Assessment With Prior Test Results, Duke Treadmill Score
• Appropriate, if intermediate Duke treadmill score and Intermediate CHD risk (Framingham)
Risk Assessment: Preoperative Evaluation for Noncardiac Surgery, Low-Risk Surgery
• Inappropriate, if preoperative evaluation for noncardiac surgery risk assessment
Risk Assessment: Preoperative Evaluation for Noncardiac Surgery, Intermediate-Risk Surgery
• Inappropriate, if minor to intermediate perioperative risk predictor and normal exercise tolerance
(greater than or equal to 4 METS)
• Appropriate, if intermediate perioperative risk predictor or poor exercise tolerance (less than 4 METS)
Risk Assessment: Preoperative Evaluation for Noncardiac Surgery, High-Risk Surgery
• Uncertain, if minor perioperative risk predictor an normal exercise tolerance (greater than or equal to
4 METS)
• Appropriate, if minor perioperative risk predictor and poor exercise tolerance (less than 4 METS)
• Inappropriate, if asymptomatic up to 1 year post normal catheterization, noninvasive test, or previous
revascularization
Risk Assessment: Following Acute Coronary Syndrome STEMI—Hemodynamically Stable
• Appropriate, if Thrombolytic therapy administered and not planning to undergo catheterization
Risk Assessment: Following Acute Coronary Syndrome STEMI—Hemodynamically Unstable, Signs of
Cardiogenic Shock, or Mechanical Complications
• Inappropriate, if Thrombolytic therapy administered
Risk Assessment: Following Acute Coronary Syndrome UA/NSTEMI—No Recurrent Ischemia or No
Signs of HF
• Appropriate, if Not planning to undergo early catheterization
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Risk Assessment: Following Acute Coronary Syndrome ACS—Asymptomatic Post Revascularization
(PCI or CABG)
• Inappropriate, if routine evaluation prior to hospital discharge
Risk Assessment: Post-Revascularization (PCI or CABG), Symptomatic
• Appropriate, if evaluation of chest pain syndrome
Risk Assessment: Post-Revascularization (PCI or CABG), Asymptomatic
• Uncertain, if asymptomatic prior to previous revascularization and less than 5 years after CABG
• Uncertain, if symptomatic prior to previous revascularization and less than 5 years after CABG
• Appropriate, if asymptomatic prior to previous revascularization and greater than or equal to 5 years
after CABG
• Appropriate, if symptomatic prior to previous revascularization an greater than or equal to 5 years
after CABG
• Uncertain, if asymptomatic prior to previous revascularization and less than 2 years after PCI
• Inappropriate, if symptomatic prior to previous revascularization and less than 2 years after PCI
• Uncertain, if asymptomatic prior to previous revascularization and greater than or equal to 2 years
after PCI
• Uncertain, if symptomatic prior to previous revascularization and greater than or equal to 2 years after
PCI
Assessment of Viability/Ischemia, Ischemic Cardiomyopathy, Includes SPECT Imaging for Wall Motion
and Ventricular Function)
• Appropriate, if known CAD on catheterization and patient eligible for revascularization
Evaluation of Ventricular Function, Evaluation of Left Ventricular Function
• Appropriate, if non-diagnostic echocardiogram
Evaluation of Ventricular Function, Use of Potentially Cardiotoxic Therapy (e.g., Doxorubicin)
• Appropriate, if baseline and serial measurements
American Heart Association: The role of noninvasive testing in the clinical evaluation of women with
suspected CAD (Mieres, et al., 2005) notes that stress myocardial gated perfusion SPECT imaging
performed with contemporary techniques has high diagnostic and prognostic accuracy in the evaluation of
symptomatic women with an intermediate to high risk of CAD.
Gastrointestinal - Literature Review
Gastrointestinal scintigraphy is performed for numerous indications, including but not limited to:
demonstration of salivary gland function and tumors; detection of heterotopic functioning gastric mucosa;
demonstration of the presence and site of acute gastrointestinal bleeding; verification of aspiration;
evaluation and quantification of transit through and reflux into the esophagus; quantification of the rate of
emptying of liquid and/or solid meals from the stomach; transit through the small and large intestine;
Meckel’s diverticulum; assessment of peritoneovenous shunt patency; detection of congenital or acquired
perforation of the pleuroperitoneal diaphragm; demonstration of the presence or absence of peritoneal
loculations prior to intraperitoneal chemotherapy or radiopharmaceutical therapy.
Scintigraphy is used to assess motility disorders of the esophagus and in the investigation of gastroesophageal reflux disease. It is well established as the gold standard for the assessment of gastric
emptying. Radionuclide studies of gastric emptying and motility are the most physiologic studies available
for studying gastric motor function (ACR, 2005; SNM, 2004).
Scintigraphy for neuroendocrine tumors of the pancreas and bowel can be performed using radiolabelled
somatostatin analogues and vasoactive intestinal peptide (123I-vasoactive intestinal peptide [VIP]). The
main advantages of scintigraphy are its ability to image the whole body and to detect tumors or their
metastases as small as one centimeter in diameter, especially in areas not under clinical suspicion.
These imaging techniques can also be used to monitor the effects of therapy. These small tumors can
also be located at surgery using hand-held gamma probes (Grainger, et al., 2003).
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Radionuclide imaging plays an important role in the localization and management of carcinoids,
neuroendocrine neoplasms occurring most commonly within the gastrointestinal system. The ability of
these tumors to concentrate 123I- or 131I-metaiodobenzyl-guanidine (MIBG) allows scintigraphy to be
performed with a cumulative sensitivity of 71%. The most common midgut carcinoids (appendix and distal
ileum) probably concentrate the radiolabelled MIBG more readily than those in the foregut and hindgut.
The main use for 123I-MIBG scintigraphy is as a prelude to131I-MIBG therapy, for which good palliative
results have been obtained.111In-pentetreotide has also been used to image these tumors, which has a
higher sensitivity (86%) than MIBG. Scintigraphy with radiolabeled octreotide, a long-acting somatostatin
analog, is useful in localizing both primary and metastatic carcinoid tumors, with a sensitivity of about
90% (Grainger, et al., 2003; Noble, 2001).
Radionuclide scintigraphy is useful for investigating suspected intestinal bleeding, for detecting Meckel’s
diverticulum, and in the assessment of inflammatory bowel disease. Radionuclide studies, either Tclabeled red cells or sulphur colloid, may be valuable in the management of GI bleeding, usually as a
complementary technique to arteriography. Radionuclide methods are very sensitive in detecting blood
loss from the GI tract, but are less accurate than arteriography in localizing the site of bleeding. In many
canters, scintigraphy is used to establish whether or not active hemorrhage is occurring before submitting
the patient to arteriography in order to define the bleeding site precisely. The relative roles of the two
methods in the management of bleeding depend very much on the facilities and expertise locally
available. Radionuclide scintigraphy, using Tc-99m pertechnetate, is a well-established technique for
identifying a Meckel’s diverticulum that contains gastric mucosa, as this agent is concentrated in the
mucus-secreting cells and the parietal cells of the gastric mucosa in both the stomach and the
diverticulum. 111 In-labeled leukocytes can be used to image inflammatory bowel disease (Grainger, et al.,
2003).
Radionuclide scans may be used prior to angiography to determine which patients are bleeding
sufficiently to make a positive angiographic result more likely. Bleeding at rates as low as 0.1 ml/min can
be detected by using such radionuclide scans in the experimental setting. Tc-99m pertechnetate scan
(i.e., Meckel scan) selectively tags gastric mucosa; it is used most often for unexplained bleeding in
infants and young adults. Tc-99m sulfur colloid scan is very sensitive in detecting lesions with low
bleeding rates. Tc-99m-labeled RBC scan is useful for intermittent bleeding because the patient can be
monitored for gastrointestinal bleeding for 24 to 48 hours. Given its lack of side effects and noninvasive
nature, it is also a reasonable choice in patients who are initially clinically too unstable for a more invasive
procedure (Ferri, et al., 2004).
Gastrointestinal - Professional Societies/Organizations
American Gastroenterological Association: In the diagnosis and treatment of gastroparesis, gastric
emptying scintigraphy of a radiolabeled solid meal is the best accepted method to test for delayed gastric
emptying (Parkman, et al., 2004).
American College of Gastroenterology: In diverticular hemorrhage, urgent flexible sigmoidoscopy is an
appropriate initial approach. If no obvious etiology is found, then further evaluation with noninvasive
(nuclear scintigraphy) or invasive techniques (angiography, colonoscopy) can be undertaken in an
attempt to localize and/or treat the bleeding source (Stollman, et al., 1999).
In the diagnosis and management of achalasia, objective tests to better assess improvement after
pneumatic dilation include manometry (lower esophageal sphincter [LES] pressure, 10 mm Hg),
esophageal scintigraphy, and the timed barium esophagram. The adjunctive use of these tests may help
to improve the long-term success of pneumatic dilation, but this premise is still speculative (Vaezi, et al.,
1999).
Hepatobiliary - Literature Review
Hepatobiliary scintigraphy is performed for numerous indications, including but not limited to: evaluation
of acute cholecystitis; evaluation of common bile duct obstruction; evaluation of right upper quadrant pain
or mass; detection of enterogastric reflux; postoperative assessment of biliary enteric bypass; evaluation
of hepatic transplant function; evaluation of neonatal hyperbilirubinemia (biliary atresia vs. neonatal
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hepatitis “syndrome”); and assessment of chronic biliary tract disorders. Hepatobiliary scintigraphy
evaluates hepatocellular function and patency of the biliary system by tracing the production and flow of
bile from the liver through the biliary system into the small intestine (ACR, 2003; SNM, 2001).
Radionuclide imaging of the liver is commonly performed using Tc-99m sulphur colloid or albumin colloid,
which target the reticulo-endothelial system. Liver scintigraphy lacks anatomical specificity but provides a
global view of the liver and is unaffected by bowel gas and the majority of surgical clips and implants. It is
infrequently used as a primary diagnostic investigation but can help to further characterize known lesions
when CT and MRI are not available.
Scintigraphy using Tc-99m-labelled derivatives of iminodiacetic acid (HIDA and PIPIDA) is a simple and
highly accurate method of diagnosing acute cholecystitis. False-positives can occur in alcoholic liver
disease and in patients receiving parenteral nutrition (Grainger, et al., 2003).
Hepatosplenic - Literature Review
Hepatosplenic scintigraphy (e.g., liver/spleen imaging, liver blood pool imaging, hepatic artery perfusion)
is performed for numerous indications, including but not limited to: assessing the size, shape, and
position of the liver and spleen; detecting, measuring, and monitoring of masses of either organ;
differentiating hepatic hemangiomas and focal nodular hyperplasia from other liver lesions; measuring
and evaluating hepatic function in cases of acute or chronic liver disease; confirming the patency and
arterial distribution of hepatic arterial perfusion catheters; identifying functional splenic tissue; and
evaluating suspected functional asplenia (ACR, 2005; SNM, 2003).
Infections and Inflammation - Literature Review
Infection or inflammation scintigraphy is performed for numerous indications, including but not limited to:
fevers of unknown origin (FUO); disk space and joint space infections; potential infections in
immunocompromised patients; tuberculosis; sarcoidosis; pulmonary inflammation from therapeutic or
environmental agents; inflammatory bowel disease; osteomyelitis; vascular infections; and evaluation of a
painful prosthesis (ACR, 2004; SNM, 2004). Bone scanning does not detect the presence of infection but
instead reflects inflammatory changes or the reaction of bone to the infection (Canale, 2003).
Infections and Inflammation - Professional Societies/Organizations
Gallium (67Ga) whole body scintigraphy may be done to localize source of fever in patients with FUO.
67
Ga scintigraphy may be performed to: detect pulmonary and mediastinal inflammation/infection,
especially in the immunocompromised patient; evaluate and follow up active lymphocytic or
granulomatous inflammatory processes (e.g., sarcoidosis or tuberculosis); diagnose osteomyelitis and/or
disk space infection (67Ga is preferred over labeled leukocytes for disk space infection and vertebral
osteomyelitis); diagnose and follow up medical treatment of retroperitoneal fibrosis; evaluate and follow
up drug-induced pulmonary toxicity (e.g., bleomycin, amiodarone).
111
In-leukocyte scintigraphy may be performed to: detect sites of infection/inflammation in patients with
FUO; localize an unknown source of sepsis and to detect additional site(s) of infection in patients with
persistent or recurrent fever and a known infection site; survey for site(s) of abscess or infection in a
febrile postoperative patient without localizing signs or symptoms (fluid collections, ileus, bowel gas, fluid,
and/or healing wounds reduce the specificity of CT and ultrasound); detect site(s) and extent of
inflammatory bowel disease (Tc-99m-labeled leukocytes may be preferable for this indication); detect and
follow up osteomyelitis primarily when there is increased bone remodeling secondary to joint prostheses,
nonunited fractures, or sites of metallic hardware from prior bone surgery; detect osteomyelitis in diabetic
patients when degenerative or traumatic changes, neuropathic osteoarthropathy, or prior osteomyelitis
have caused increased bone remodeling; detect osteomyelitis involving the skull in postoperative patients
and for follow-up of therapy; and detect mycotic aneurysms, vascular graft infections, and shunt
infections.
Tc-99m HMPAO-labeled leukocyte scintigraphy may be performed to: detect suspected sites of acute
inflammation/ infection in the febrile patient with or without localizing signs or symptoms; detect and
determine the extent of inflammatory or ischemic bowel disease (may be more sensitive than
leukocyte scintigraphy for detection of disease, particularly involving the small bowel. 111In-leukocytes are
preferred for quantitative assessment); and detect and follow up musculoskeletal infection (e.g., septic
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arthritis, osteomyelitis) (may be more sensitive for detection of acute than chronic osteomyelitis,
combined 111In-white blood cell (WBC)/ Tc-99m diphosphonate bone and/or 111In-WBC/ Tc-99m sulfur
colloid marrow scans are preferred in difficult cases of osteomyelitis at sites with existing bone alteration
and/or adjacent soft-tissue infection) (SNM, 2004).
Lung - Literature Review
Pulmonary scintigraphy is performed for numerous indications, including but not limited to: assessing the
probability of acute or chronic pulmonary thromboembolic disease; establishing the presence of chronic,
unresolved pulmonary emboli; quantifying of differential pulmonary function; evaluating lung transplants;
evaluating the effects of congenital heart/lung disease; confirming the presence of bronchopleural
fistulae; and evaluating the effects of chronic pulmonary parenchymal disorders such as cystic fibrosis
(ACR, 2004; SNM, 2004).
Perfusion scintigraphy may be useful to identify target areas of emphysema for resection during lung
volume reduction surgery (LVRS). In vivo, computed tomography is the most accurate technique for
identifying and quantifying emphysema. Perfusion scintigraphy may be used to identify focal
heterogeneous emphysema. CT was a better predictor of improved function after LVRS than perfusion
scintigraphy; in general, however, neither technology has emerged as the dominant technique in patient
selection and surgical planning. In emphysema patients, both planar and SPECT perfusion scintigraphy
can be used to provide qualitative and/or quantitative assessment of differential pulmonary parenchymal
perfusion, extrapolating that areas of absent perfusion represent emphysema. Ventilation scintigraphy is
not useful (Grainger, et al., 2003).
Radioactive gallium scanning has been used to evaluate patients with interstitial lung disease. Its role
also remains somewhat controversial because of its non-specificity; varied types of pulmonary
inflammation as well as neoplasms can produce a positive result. Gallium scanning has been used to
follow the course of disease during treatment but has been disappointing in predicting responsiveness to
corticosteroid or immunosuppressive therapy; only 10% to 30% of patients with increased uptake may
respond to therapy. Favorable responses to therapy have been noted even when the gallium scans are
normal. Gallium scanning may be helpful in planning a biopsy procedure by identifying areas of active
inflammation and thus increasing the probability of a positive result (Noble, 2001).
Perfusion lung scanning has been in use for 30 years and is a sensitive but nonspecific method for
evaluating pulmonary perfusion. Macroaggregated albumin labeled with Tc-99m is injected intravenously,
and anterior, posterior, lateral, and oblique views of the chest are taken. Ventilation scanning is often
performed after the perfusion scan to increase its specificity. Xenon133 is inhaled for several minutes to
fill all areas of the lung. The patient then breathes ambient air, and the washout of the isotope is studied.
With normal ventilation, the lungs clear rapidly and symmetrically. Areas of retained radioactivity indicate
abnormal ventilation. Areas of normal ventilation with abnormal perfusion (mismatch) are very suggestive
of PE (Noble, 2001).
Multiple Myeloma - Literature Review
Tc-99m bone scanning is inferior to conventional radiography and should not be routinely used, as
abnormalities on bone scan only correlate with sites of blastic change and thus lytic disease can be
missed (Abeloff, et al., 2004). Bone scintigraphy has no place in the routine investigation of myeloma, as
CT is more sensitive (Smith, et al., 2006).
Parathyroid - Literature Review
Parathyroid scintigraphy is performed for numerous indications, including but not limited to: are prior to
surgery to facilitate identification and removal of abnormal parathyroid tissue; and subsequent to surgery
in patients with persistent or recurrent hyperparathyroidism to detect aberrant or ectopic hyperplastic or
neoplastic glands (ACR, 2004; SNM, 2004). Preoperative technetium Tc-99m sestamibi scanning can
accurately localize 80% to 90% of the single adenomas that account for 75% to 85% of cases. Sestamibi
scanning also can identify the occasional mediastinal adenoma and thereby direct the surgeon away from
neck exploration. On the other hand, because the sensitivity of sestamibi scanning ranges from 75% to
90% and the technique is least reliable in the presence of multiglandular disease (hyperplasia or double
adenomas), the test may falsely localize an adenoma or miss the presence of bilateral disease in 10% to
20% of patients (Larsen, et al., 2003).
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Parathyroid - Professional Societies/Organizations
American Association of Clinical Endocrinologists (AACE): In primary hyperparathyroidism (PHPT),
ultrasonography or SPECT sestamibi scanning (or both) of the parathyroid glands should be used for
operative planning. Specifically, if preoperative ultrasonography or sestamibi scanning localizes an
adenoma, this information facilitates a focused or minimally invasive surgical approach. Although some
surgeons do not obtain preoperative imaging for patients at high risk of hyperplasia, preoperative
ultrasonography or sestamibi scanning can be helpful in localizing an ectopic parathyroid gland (AACE,
2005).
SNM: Parathyroid scintigraphy may be performed to localize hyperfunctioning parathyroid tissue
(adenomas or hyperplasia) in primary hyperparathyroidism or in patients with persistent or recurrent
disease (usually adenomas). Dual-phase or double-phase imaging refers to utilizing Tc-99m sestamibi
and acquiring early and delayed images. Dual-isotope or subtraction studies refer to protocols using two
different radiopharmaceuticals for imaging acquisition (SNM, 2004).
Renal / Urinary - Literature Review
Renal or urinary scintigraphy is performed for numerous indications, including but not limited to: detection,
evaluation, and quantification of possible urinary tract obstruction; detection and evaluation of
renovascular disease; detection of pyelonephritis and parenchymal scarring; detection and evaluation of
functional and anatomic abnormalities of transplanted kidneys; qualitative measurement of renal function;
detection of congenital and acquired anatomic renal abnormalities; quantification of certain parameters of
renal function, such as effective renal plasma flow, excretory index, glomerular filtration rate, and
differential renal function; renal cortical scintigraphy for the detection of the cortical defects of acute
pyelonephritis and scarring related to chronic pyelonephritis; ad radionuclide cystography for the
detection and evaluation of vesicoureteral reflux and quantification of postvoid bladder residual (ACR,
2003, 2005; SNM, 2003). Radionuclide imaging may be used in a wide variety of ways for studying the
function of the renal tract; clearance techniques; dynamic renal imaging; renal transplant; vesico-ureteric
reflux; residual bladder volume; captopril scan. For urinary obstruction, radionuclide techniques provide
important information on urine transport and renal function in patients with known or possible obstruction.
Radionuclide techniques offer more functional information than excretory urography, US, or CT, but
cannot match them with respect to morphological detail. Quantitative radionuclide scans offer the best
noninvasive assessment of individual renal function after release of obstruction (Grainger, et al., 2001).
SPECT using Tc-99m dimercaptosuccinate (Tc-99m DMSA) is slightly more sensitive than CT for
identifying areas of inflammation within the kidney in pyelonephritis, which can be advantageous if the
initial diagnosis is in question. However, it cannot distinguish between frank abscesses and inflamed but
viable tissue, and so it is of little help in evaluating the patient who fails to respond to the therapy (Cohen,
et al., 2004). Gallium scintigraphy has been used to determine the presence of interstitial inflammation in
drug-induced allergic interstitial nephritis (Noble, 2001).
In urinary stone disease, renal radionuclide studies provide rapid and safe information about total and
differential renal function. These tests are specifically advantageous because the radionuclide evaluation
is not invasive, requires no bowel preparation or specific preoperative preparation, subjects the patient to
only minimal radiation exposure, and is apparently free of allergic complications (Noble, 2001).
Renal / Urinary - Professional Societies/Organizations
American Urological Association (AUA): In a child with vesicoureteral reflux (VUR), the upper urinary
tract can be evaluated by one of several techniques, including renal cortical scintigraphy (renal scan),
excretory urography (intravenous pyelography [IVP]), and renal ultrasound. Radiopharmaceuticals used
for renal scanning include dimercaptosuccinic acid (DMSA), glucoheptonate, and mercaptoacetyltriglycine
(MAG-3). Following an episode of pyelonephritis, renal scarring usually is apparent on scintigraphy within
three months, but may not be apparent on an IVP or sonography until one-two years later (AUA, 1997).
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In the AUA Prostate Cancer Guideline (1995), it notes that a staging radionuclide bone scan may no
longer be necessary for the patient with newly diagnosed, untreated prostate cancer who has no skeletal
symptoms and a serum PSA concentration of 10 ng/ml or less.
Scrotum - Literature Review
Scrotal scintigraphy is performed for differentiation of specific causes of acute and subacute scrotal pain,
especially testicular torsion and epididymitis/orchitis. The procedure is not indicated in evaluating
cryptorchidism, tumors, or chronic inflammation (ACR, 2004).
Thyroid - Literature Review
Thyroid scintigraphy is performed for numerous indications, including but not limited to: detection of focal
and/or global abnormalities of thyroid anatomy, correlation of anatomy with function, detection of aberrant
or metastatic functioning thyroid tissue or residual normal tissue after therapy, thyroid uptake in
hyperthyroidism, and whole-body imaging for thyroid carcinoma (ACR, 2004; SNM, 1999).
Radioisotope imaging with radioiodine (123I) is commonly utilized to determine the overall activity of the
gland in patients with thyrotoxicosis (24-hour radioactive iodine uptake [RAIU]) as well as to provide
information regarding the function of parts of the gland, such as nodules. Radioisotope imaging with Tc99m pertechnetate provides information on the regional function within the gland but is less informative
regarding the overall function of the gland. Whereas RAIU distinguishes etiology based on iodine uptake,
thyroid radionuclide imaging can distinguish different forms of goiter. A thyroid scan is generally
performed when the thyroid gland appears to be nodular on physical examination to establish the
diagnosis of toxic nodular or multinodular goiter. In addition, a thyroid scan may be ordered in a patient
with Graves' disease when a thyroid nodule is palpated so as to rule out a coexistent cold nodule (Noble,
2001).
Thyroid - Professional Societies/Organizations
American Association of Clinical Endocrinologists (AACE): Thyroid scan, with either 123-I (preferably)
or Tc-99m pertechnetate, is not a thyroid function test but is done to help determine the cause of the
hyperthyroidism. The scan may also be useful in assessing the functional status of any palpable thyroid
irregularities or nodules associated with a toxic goiter (AACE, amended 2006).
Tumor - Literature Review
Tumor scintigraphy is performed for numerous indications, including but not limited to: detection of certain
primary, metastatic, and recurrent tumors, evaluation of abnormal imaging and nonimaging findings in
patients with a history of certain tumors, and reassessment of patients for residual tumor burden after
therapy. Specific clinical applications depend on the specific radiopharmaceutical:
• 67 Gallium citrate (e.g., Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, melanoma, lung cancer, and
hepatoma, sarcoma, testicular tumors, multiple myeloma, head and neck tumors)
• radioiodinated MIBG (i.e., neuroendocrine tumors)
• radiolabeled monoclonal antibodies (e.g., OncoScint®,ProstaScint®, and CEA-SCAN®)
• 111 In Octreotide (Octreoscan®) (e.g., medullary thyroid carcinoma, gastrinoma, pheochromocytoma,
neuroblastoma, and carcinoid)
• NeoTect (Tc-99m Detreotide) ( i.e., noninvasive characterization of pulmonary masses)
• Thallium-201 (Thallous Chloride) (e.g., glioblastoma, osteosarcoma, lymphoma, thyroid carcinoma,
breast tumors)
• Tc-99m sestamibi (e.g., Miraluma®) (ACR, 2005; SNM, 2001)
The majority of brain tumor investigation imaging has been with PET. SPECT has a more limited role in
the evaluation of brain tumors. SPECT has been used to distinguish between low-grade and high-grade
gliomas and radiation change. Tumors expressing somatostatin receptors, such as certain pituitary
adenomas and meningiomas, can be identified with 111In -octreotide scintigraphy. Radionuclide studies
are rarely used in the investigation of meningiomas, but when other imaging findings are atypical,
somatostatin receptor scintigraphy with 111In-octreotide can confirm a diagnosis of meningioma and can
detect residual or recurrent tumor postoperatively. Radionuclide studies, although rarely used, may
provide useful information in selected cases. Some pituitary macroadenomas express somatostatin
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receptors and 111In-octreotide uptake has been demonstrated reliably in growth hormone-secreting
adenomas and in some prolactin adenomas. Trans-sphenoidal surgery for macroadenomas may result in
incomplete tumor resection due to involvement of adjacent structures such as the cavernous sinus, and
111
In-octreotide scintigraphy is useful in distinguishing residual or recurrent tumor from postoperative
scarring. 111In octreotide scintigraphy can also identify which patients with pituitary macroadenoma may
respond to octreotide therapy (Grainger, et al. 2003; Goetz, 2003).
Tumors of the pituitary gland are best diagnosed with MRI because it has better resolution than other
radiologic modalities for identifying soft tissue changes. SPECT has a sensitivity of about 1 cm and can
detect normal pituitary tissue receptor expression. Because most adenomas and normal tissue are
identified by this technique, its utility is limited for tumor detection, but it may be helpful for imaging
ectopic ACTH-secreting tumors (Larsen, et al., 2003).
Extraadrenal pheochromocytomas or very small adrenal tumors are harder to localize and may require
131
I-MIBG scanning. This isotope, although expensive, is specific for catecholamine-producing tissue and
has 80% sensitivity and over 95% specificity for localization of malignant pheochromocytomas.111Inpentetreotide (Octreoscan) is reported to be of similar sensitivity. Those who are found to have bilateral
adrenal tumors should be screened for other manifestations of the multiple endocrine neoplasia (MEN)
syndromes (Noble, 2001).
Tumor - Professional Societies/Organizations
National Comprehensive Cancer Network (NCCN): NCCN Clinical Practice Guidelines in Oncology™
state the following:
Bladder Cancer:
Bone scan if alkaline phosphatase elevated or symptoms.
Bone Cancer:
Osteosarcoma: A technetium bone scan, while uniformly abnormal at the lesion, may be useful to identify
additional synchronous lesions. Perhaps the best single study for osteosarcoma, MRI provides excellent
soft-tissue contrast.
Osteosarcoma Surveillance: Examination should include a complete physical, chest imaging, and plain
film of the extremity. Chest CT should be done if the plain chest radiograph becomes abnormal. Bone
scan may also be considered in this case.
Ewing's sarcoma family of tumors: If ESFT is suspected as a diagnosis, the patient should undergo
complete staging prior to biopsy. This should include CT of the chest, plain radiographs of the primary
site, as well as a CT or MRI of the entire involved bone or area. A technetium bone scan should also be
performed. Post-chemotherapy, bone scan is considered optional.
Breast Cancer: (See CIGNA's Scintimammography Coverage Position)
Stage I, IIA, IIB, or T3N1M0 Invasive Breast Cancer: Radionuclide bone scanning and abdominal imaging
with CT, ultrasound, or MRI are indicated for patients with T3N1M0 disease, if the patient has symptoms
related to bone or abdomen, or an elevated alkaline phosphatase. In the remaining patients, bone scan
and abdominal imaging are considered optional.
Stage III Invasive Breast Cancer: The workup includes history and physical exam, a complete blood cell
count, platelet count, a bone scan, chest imaging, pathology review, pre-chemotherapy determination of
tumor ER/PR receptor status and HER-2 status, diagnostic bilateral mammogram and breast ultrasound
as clinically warranted, and an abdominal CT, ultrasound, or MRI, even in the absence of symptoms, liver
enzyme abnormalities, or abnormal alkaline phosphatase.
CNS Cancers:
Neoplastic Meningitis: CSF flow scans are easily performed in most nuclear medicine departments. 111InDTPA is administered into the subcutaneous reservoir and ventricular catheter, and imaging of the brain
and spine is performed immediately after injection.
Kidney Cancer:
“Bone scan if indicated” listed under suspicious mass workup.
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Coverage Position Number: 0169
Neuroendocrine Tumors:
Octreoscan indicated numerous times within algorithm.
Non-Hodgkin’s Lymphoma:
PET scan (preferred) or 67Gallium scan (planar and SPECT) double dose with delayed images as an
alternative if PET not available.
Prostate Cancer:
Bone scan listed several times throughout algorithm.
Small Cell Lung Cancer:
Bone scan listed several times throughout algorithm.
Testicular Cancer:
Bone scan if clinically indicated.
Thyroid Cancer:
Whole-body 131I scans are often performed after surgery to assess the completeness of thyroidectomy
and the presence of residual disease.
American College of Chest Physicians: For noninvasive staging of non-small cell lung cancer,
experience with SPECT imaging for lung cancer is still very limited, and thus SPECT scanning should not
be considered as an alternative to FDG-PET scanning (Silvestri, et al., 2003).
American Society of Clinical Oncology (ASCO): Guideline Recommendations for Sentinel Lymph
Node Biopsy in Early-Stage Breast Cancer notes that lymphoscintigraphic imaging can be useful in
demonstrating unexpected draining nodes, especially in the internal mammary region and may guide
probe-based surgery. The clinical significance of such findings may include additional invasive
procedures to determine the nodal histology or the use of external beam irradiation of internal mammary
nodes—depending on the therapeutic intent. It is clear that lymphoscintigraphy is not a substitute for
probe-based surgery but is adjunctive. Lymphoscintigraphy is, however, a routine part of the practice
pattern in many centers where it precedes and can direct the performance of the radionuclide guided
probe-based sentinel node surgery (Lyman, et al., 2005).
SPECT/CT Imaging
SPECT and CT are proven diagnostic procedures. The first SPECT/CT system combined a dual-head
gamma camera and an integrated x-ray transmission system mounted on the same gantry. More recently,
additional integrated SPECT/CT devices have become available, including systems combining a state-ofthe-art multi-head gamma camera and multi-detector CT scanner side by side with a common imaging
table. Combined SPECT/CT devices provide both the functional information from SPECT and the
anatomic information from CT in a single examination. Some studies have demonstrated that the
information obtained by SPECT/CT is more accurate in evaluating patients than that obtained from either
SPECT or CT alone. Although techniques for registration and fusion of images obtained from separate
SPECT and CT scanners have been available for several years, the advantages of having SPECT and
CT integrated into a single device have resulted in the development of this technology (SNM, 2006).
Consistent with trends in PET/CT systems, hybrid SPECT systems have evolved, combining SPECT and
CT systems. In nuclear cardiology, SPECT components are typically large field of view variable angle
dual detector systems. These combined systems, in practice, demonstrate a range of capability and
integration. CT components range from non-diagnostic units suitable for use in anatomical localization
and attenuation correction to 16 slice systems capable of computed tomography angiography. The
SPECT detectors in SPECT/CT systems do not differ in any significant way from those of stand-alone
SPECT systems. These systems may be viewed from a protocol perspective as stand-alone systems
where an emission study is followed or preceded by a CT scan for attenuation correction. Depending
upon the number of CT slices acquired, the CT scanner may be used, as with stand-alone CT scanners,
for CTA and calcium scoring. The CT and SPECT components may then be analyzed independently or in
three dimensional image registrations, depending on the type of study (ASNC, 2006).
Page 18 of 29
Coverage Position Number: 0169
Society of Nuclear Medicine (SNM): SNM Procedure Guideline for SPECT/CT Imaging (May, 2006)
states that indications for SPECT/CT include but are not limited to imaging of the following:
• tumors
• thyroid disorders
• parathyroid disorders
• skeleton disorders
• inflammation or infection
• lymphatic system
• heart disorders
• brain disorders
• other organs
Summary
Evidence in the published peer-reviewed scientific literature, textbooks, and current clinical practice
demonstrate that nuclear imaging including single-photon emission computed tomography (SPECT) is a
proven and well-established imaging modality. Specific clinical applications depend on the specific
radiopharmaceutical. Nuclear imaging including SPECT may be utilized when other imaging studies are
inconclusive or contraindicated. Along with oncologic and cardiac indications, nuclear imaging with
SPECT has proven helpful in bone, brain, gastrointestinal, lung, endocrine and renal and urinary
disorders. SPECT has proven helpful in patients with suspected or known infection and inflammatory
processes.
The American Society of Nuclear Cardiology (ASNC) Imaging Guidelines for Nuclear Cardiology
Procedures (2006) and the American College of Cardiology Foundation (ACCF)/ASNC Appropriateness
Criteria for SPECT Myocardial Perfusion Imaging (2005) were the primary sources for CIGNA's cardiac
nuclear imaging coverage determinations.
Nuclear imaging has not been proven to be of value in chronic fatigue syndrome, multiple myeloma,
neuropsychiatric disorders, scrotal tumors, chronic scrotal inflammation or cryptorchidism, or for
screening for coronary artery disease.
NOTE: See CIGNA's Monoclonal Antibody (MAb) Imaging or Radioimmunoscintigraphy Coverage
Position and CIGNA's Scintimammography Coverage Position.
Coding/Billing Information
Note: This list of codes may not be all-inclusive.
Covered when medically necessary:
CPT®* Codes
78000
78001
78003
78006
78007
78010
78011
78015
78016
78018
78020
78070
Description
Thyroid uptake; single determination
Thyroid uptake; multiple determinations
Thyroid uptake; stimulation, suppression or discharge (not including initial uptake
studies)
Thyroid imaging, with uptake; single determination
Thyroid imaging, with uptake; multiple determinations
Thyroid imaging; only
Thyroid imaging; with vascular flow
Thyroid carcinoma metastases imaging; limited area (e.g., neck and chest only)
Thyroid carcinoma metastases imaging; with additional studies (e.g., urinary recovery)
Thyroid carcinoma metastases imaging; whole body
Thyroid carcinoma metastases uptake
Parathyroid imaging
Page 19 of 29
Coverage Position Number: 0169
78075
78102
78103
78104
78110
78111
78120
78121
78122
78130
78135
78140
78185
78190
78191
78195
78199
78201
78202
78205
78206
78215
78216
78220
78223
78230
78231
78232
78258
78261
78262
78264
78270
78271
78272
78278
78282
78290
78291
78300
78305
78306
78315
78320
78414
78428
78445
Adrenal imaging, cortex and/or medulla
Bone marrow imaging; limited area
Bone marrow imaging; multiple areas
Bone marrow imaging; whole body
Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure);
single sampling
Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure);
multiple samplings
Red cell volume determination (separate procedure); single sampling
Red cell volume determination (separate procedure); multiple samplings
Whole blood volume determination, including separate measurement of plasma volume
and red cell volume (radiopharmaceutical volume-dilution technique)
Red cell survival study;
Red cell survival study; differential organ/tissue kinetics, (e.g., splenic and/or hepatic
sequestration)
Labeled red cell sequestration, differential organ/tissue, (e.g., splenic and/or hepatic)
Spleen imaging only, with or without vascular flow
Kinetics, study of platelet survival, with or without differential organ/tissue localization
Platelet survival study
Lymphatics and lymph nodes imaging
Unlisted hematopoietic, reticuloendothelial and lymphatic procedure, diagnostic nuclear
medicine
Liver imaging; static only
Liver imaging; with vascular flow
Liver imaging (SPECT)
Liver imaging (SPECT); with vascular flow
Liver and spleen imaging; static only
Liver and spleen imaging; with vascular flow
Liver function study with hepatobiliary agents, with serial images
Hepatobiliary ductal system imaging, including gallbladder, with or without
pharmacologic intervention, with or without quantitative measurement of gallbladder
function
Salivary gland imaging
Salivary gland imaging; with serial images
Salivary gland function study
Esophageal motility
Gastric mucosa imaging
Gastroesophageal reflux study
Gastric emptying study
Vitamin B-12 absorption study (e.g., Schilling test); without intrinsic factor
Vitamin B-12 absorption study (e.g., Schilling test); with intrinsic factor
Vitamin B-12 absorption studies combined, with and without intrinsic factor
Acute gastrointestinal blood loss imaging
Gastrointestinal protein loss
Intestine imaging (e.g., ectopic gastric mucosa, Meckel's localization, volvulus)
Peritoneal-venous shunt patency test
Bone and/or joint imaging; limited area
Bone and/or joint imaging; multiple areas
Bone and/or joint imaging; whole body
Bone and/or joint imaging; three phase study
Bone and/or joint imaging; tomographic (SPECT)
Determination of central c-v hemodynamics (non-imaging) (e.g., ejection fraction with
probe technique) with or without pharmacologic intervention or exercise, single or
multiple determinations
Cardiac shunt detection
Non-cardiac vascular flow imaging (i.e., angiography, venography)
Page 20 of 29
Coverage Position Number: 0169
78456
78457
78458
78460
78461
78464
78465
78466
78468
78469
78472
78473
78478
78480
78481
78483
78494
78496
78580
78584
78585
78586
78587
78588
78591
78593
78594
78596
78600
78601
Acute venous thrombosis imaging, peptide
Venous thrombosis imaging, venogram; unilateral
Venous thrombosis imaging, venogram; bilateral
Myocardial perfusion imaging; (planar) single study, at rest or stress (exercise and/or
pharmacologic), with or without quantification
Myocardial perfusion imaging; multiple studies, (planar) at rest and/or stress (exercise
and/or pharmacologic), and redistribution and/or rest injection, with or without
quantification
Myocardial perfusion imaging; tomographic (SPECT), single study (including attenuation
correction when performed), at rest or stress (exercise and/or pharmacologic), with or
without quantification
Myocardial perfusion imaging; tomographic (SPECT), multiple studies, (including
attenuation correction when performed), at rest and/or stress (exercise and/or
pharmacologic) and redistribution and/or rest injection, with or without quantification
Myocardial imaging, infarct avid, planar; qualitative or quantitative
Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique
Myocardial imaging, infarct avid, planar; tomographic SPECT with or without
quantification
Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress
(exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without
additional quantitative processing
Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus
ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without
additional quantification
Myocardial perfusion study with wall motion, qualitative or quantitative study (List
separately in addition to code for primary procedure)
Myocardial perfusion study with ejection fraction (List separately in addition to code for
primary procedure)
Cardiac blood pool imaging, (planar), first pass technique; single study, at rest or with
stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or
without quantification
Cardiac blood pool imaging, (planar), first pass technique; multiple studies, at rest and
with stress (exercise and/ or pharmacologic), wall motion study plus ejection fraction,
with or without quantification
Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus
ejection fraction, with or without quantitative processing
Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular
ejection fraction by first pass technique (List separately in addition to code for primary
procedure)
Pulmonary perfusion imaging, particulate
Pulmonary perfusion imaging, particulate, with ventilation; single breath
Pulmonary perfusion imaging, particulate, with ventilation; rebreathing and washout,
with or without single breath
Pulmonary ventilation imaging, aerosol; single projection
Pulmonary ventilation imaging, aerosol; multiple projections (e.g., anterior, posterior,
lateral views)
Pulmonary perfusion imaging, particulate, with ventilation imaging, aerosol, one or
multiple projections
Pulmonary ventilation imaging, gaseous, single breath, single projection
Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without
single breath; single projection
Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without
single breath; multiple projections (e.g., anterior, posterior, lateral views)
Pulmonary quantitative differential function (ventilation/perfusion) study
Brain imaging, limited procedure; static
Brain imaging, limited procedure; with vascular flow
Page 21 of 29
Coverage Position Number: 0169
78605
78606
78607
78610
78615
78630
78635
78645
78647
78650
78660
78700
78701
78704
78707
78708
78709
78710
78715
78725
78730
78740
78760
78761
78800
78801
78802
78803
78804
78805
78806
78807
78890
78891
HCPCS
Codes
Brain imaging, complete study; static
Brain imaging, complete study; with vascular flow
Brain imaging, complete study; tomographic (SPECT)
Brain imaging, vascular flow only
Cerebral vascular flow
Cerebrospinal fluid flow, imaging (not including introduction of material); cisternography
Cerebrospinal fluid flow, imaging (not including introduction of material);
ventriculography
Cerebrospinal fluid flow, imaging (not including introduction of material); shunt
evaluation
Cerebrospinal fluid flow, imaging (not including introduction of material); tomographic
(SPECT)
Cerebrospinal fluid leakage detection and localization
Radiopharmaceutical dacryocystography
Kidney imaging; static only
Kidney imaging; with vascular flow
Kidney imaging; with function study (i.e., imaging renogram)
Kidney imaging with vascular flow and function; single study without pharmacological
intervention
Kidney imaging with vascular flow and function; single study, with pharmacological
intervention (e.g., angiotensin converting enzyme inhibitor and/or diuretic)
Kidney imaging with vascular flow and function; multiple studies, with and without
pharmacological intervention (e.g., angiotensin converting enzyme inhibitor and/or
diuretic)
Kidney imaging, tomographic (SPECT)
Kidney vascular flow only
Kidney function study, non-imaging radioisotopic study
Urinary bladder residual study
Ureteral reflux study (radiopharmaceutical voiding cystogram)
Testicular imaging;
Testicular imaging; with vascular flow
Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical
agent(s); limited area
Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical
agent(s); multiple areas
Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical
agent(s); whole body, single day imaging
Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical
agent(s); tomographic (SPECT)
Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical
agent(s); whole body, requiring two or more days imaging
Radiopharmaceutical localization of inflammatory process; limited area
Radiopharmaceutical localization of inflammatory process; whole body
Radiopharmaceutical localization of inflammatory process; tomographic (SPECT)
Generation of automated data: interactive process involving nuclear physician and/or
allied health professional personnel; simple manipulations and interpretation, not to
exceed 30 minutes
Generation of automated data: interactive process involving nuclear physician and/or
allied health professional personnel; complex manipulations and interpretation,
exceeding 30 minutes
Description
No specific codes
Page 22 of 29
Coverage Position Number: 0169
ICD-9-CM
Diagnosis
Codes
Description
Multiple/varied codes
*Current Procedural Terminology (CPT®) ©2005 American Medical Association: Chicago, IL.
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http://interactive.snm.org/docs/pg_ch34_0403.pdf
56. Society of Nuclear Medicine Procedure Guideline for Brain Death Scintigraphy. Approved
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http://interactive.snm.org/docs/pg_ch20_0403.pdf
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http://interactive.snm.org/docs/pg_ch21_0403.pdf
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http://interactive.snm.org/docs/Breast_v2.0.pdf
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http://interactive.snm.org/docs/Gallium_Scintigraphy_in_Inflammation_v3.pdf
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http://interactive.snm.org/docs/pg_ch23_0403.pdf
62. Society of Nuclear Medicine Procedure Guideline for Gastric Emptying and Motility. Approved
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http://interactive.snm.org/docs/pg_ch08_0403.pdf
63. Society of Nuclear Medicine Procedure Guideline for Gated Equilibrium Radionuclide
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http://interactive.snm.org/docs/pg_ch01_0403.pdf
64. Society of Nuclear Medicine Procedure Guideline for General Imaging. Approved May 2004.
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http://interactive.snm.org/docs/General_Imaging_v3.0.pdf
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http://interactive.snm.org/docs/pg_ch10_0403.pdf
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67. Society of Nuclear Medicine Procedure Guideline for 111 leukocyte scintigraphy for suspected
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http://interactive.snm.org/docs/Lung%20Scintigraphy_v3.0.pdf
69. Society of Nuclear Medicine Procedure Guideline for Myocardial Perfusion Imaging. Approved
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http://interactive.snm.org/docs/pg_ch02_0403.pdf
70. Society of Nuclear Medicine Procedure Guideline for parathyroid scintigraphy. Approved June
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http://interactive.snm.org/docs/Parathyroid_v3.0.pdf
71. Society of Nuclear Medicine Procedure Guideline for Radionuclide Cystography in Children.
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http://interactive.snm.org/docs/pg_ch32_0703.pdf
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73. Society of Nuclear Medicine Procedure Guideline for Diagnosis of Renovascular Hypertension.
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http://interactive.snm.org/docs/pg_ch27_0403.pdf
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77. Society of Nuclear Medicine Procedure Guideline for Extended Scintigraphy for Differentiated
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78. Society of Nuclear Medicine Procedure Guideline for Thyroid Uptake Measurement. Approved
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