Download Single Photon Emission Computed Tomography (SPECT) (NCD

UnitedHealthcare® Medicare Advantage
Policy Guideline
SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY
(SPECT) (NCD 220.12)
Guideline Number: MPG285.03
Table of Contents
Page
INSTRUCTIONS FOR USE .......................................... 1
POLICY SUMMARY .................................................... 1
APPLICABLE CODES ................................................. 2
DEFINITIONS .......................................................... 2
REFERENCES ........................................................... 3
GUIDELINE HISTORY/REVISION INFORMATION ........... 5
Approval Date: April 12, 2017
Related Medicare Advantage Policy Guideline

Positron Emission Tomography (PET) Scan
(Including NCDs 220.6-220.6.20)
Related Medicare Advantage Coverage Summaries

Non-Covered Services (including Services/
Complications Related to Non-Covered Services)

Radiologic Diagnostic Procedures
INSTRUCTIONS FOR USE
This Policy Guideline is applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its
affiliates for health care services submitted on CMS 1500 forms and, when specified, to those billed on UB04 forms
(CMS 1450), or their electronic comparative. The information presented in this Policy Guideline is believed to be
accurate and current as of the date of publication.
This Policy Guideline provides assistance in administering health benefits. All reviewers must first identify member
eligibility, any federal or state regulatory requirements, Centers for Medicare and Medicaid Services (CMS) policy, the
member specific benefit plan coverage, and individual provider contracts prior to use of this Policy Guideline. When
deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific
benefit plan document may differ greatly from the standard benefit plan upon which this Policy Guideline is based. In
the event of a conflict, the member specific benefit plan document supersedes this Policy Guideline. Other Policies and
Guidelines may apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Policies and Guidelines
as necessary.
UnitedHealthcare follows Medicare coverage guidelines and regularly updates its Medicare Advantage Policy Guidelines
to comply with changes in CMS policy. UnitedHealthcare encourages physicians and other healthcare professionals to
keep current with any CMS policy changes and/or billing requirements by referring to the CMS or your local carrier
website regularly. Physicians and other healthcare professionals can sign up for regular distributions for policy or
regulatory changes directly from CMS and/or your local carrier. This Policy Guideline is provided for informational
purposes. It does not constitute medical advice.
POLICY SUMMARY
Overview
The single photon emission computed tomography (SPECT) acquires information on the concentration of radionuclides
introduced into the patient's body. It is useful in the diagnosis of several clinical conditions including:

Stress fracture

Spondylosis

Infection (e.g., discitis)

Tumor (e.g., osteoid osteoma)

Analyze blood flow to an organ, as in the case of myocardial viability

Differentiate ischemic heart disease from dilated cardiomyopathy
Guidelines
In the case of myocardial viability, FDG positron emission tomography (PET) may be used following a SPECT that was
found to be inconclusive. However, SPECT may not be used following an inconclusive FDG PET performed to evaluate
myocardial viability.
Frequency Limitations: Medicare Administrative Contractor discretion.
Single Photon Emission Computed Tomography (SPECT) (NCD 220.12)
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APPLICABLE CODES
The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in
this guideline does not imply that the service described by the code is a covered or non-covered health service.
Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws
that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or
guarantee claim payment. Other Policies and Guidelines may apply.
CPT Code
78071
Description
Parathyroid planar imaging (including subtraction, when performed); with
tomographic (SPECT)
78072
Parathyroid planar imaging (including subtraction, when performed); with
tomographic (SPECT), and concurrently acquired computed tomography (CT) for
anatomical localization
78205
Liver imaging (SPECT)
78206
Liver imaging (SPECT); with vascular flow
78320
Bone and/or joint imaging; tomographic (SPECT)
78451
Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction,
qualitative or quantitative wall motion, ejection fraction by first pass or gated
technique, additional quantification, when performed); single study, at rest or stress
(exercise or pharmacologic)
78452
Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction,
qualitative or quantitative wall motion, ejection fraction by first pass or gated
technique, additional quantification, when performed); multiple studies, at rest
and/or stress (exercise or pharmacologic) and/or redistribution and/or rest
reinjection
78469
Myocardial imaging, infarct avid, planar; tomographic (SPECT) with or without
quantification
78494
Cardiac blood pool imaging, gated equilibrium, (SPECT), at rest, wall motion study
plus ejection fraction, with or without quantitative processing
78607
Brain imaging, tomographic (SPECT)
78647
Cerebrospinal fluid flow, imaging (not including introduction of material);
tomographic (SPECT)
78710
Kidney imaging morphology; tomographic (SPECT)
78803
Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical
agent(s); tomographic (SPECT)
78807
Radiopharmaceutical localization of inflammatory process; tomographic (SPECT)
0332T
Myocardial sympathetic innervation imaging, planar qualitative and quantitative
assessment; with tomographic (SPECT)
CPT® is a registered trademark of the American Medical Association
Modifier
26
Description
Professional component
80
Assistant surgeon (allowed with documentation)
TC
Under certain circumstances, a charge may be made for the technical component
alone. Under those circumstances the technical component charge is identified by
adding modifier ‘TC’ to the usual procedure number. Technical component charges
are institutional charges and not billed separately by physicians. However, portable
x-ray suppliers only bill for technical component and should utilize modifier TC. The
charge data from portable x-ray suppliers will then be used to build customary and
prevailing profiles.
DEFINITIONS
SPECT: Single Photon Emission Computed Tomography
Single Photon Emission Computed Tomography (SPECT) (NCD 220.12)
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REFERENCES
CMS National Coverage Determinations (NCDs)
NCD 220.12 Single Photon Emission Computed Tomography (SPECT)
Reference NCD: NCD 220.6 Positron Emission Tomography (PET) Scans
CMS Local Coverage Determinations (LCDs)
LCD
Medicare Part A
L33777 (Non-covered Services) First
FL, PR, VI
Coast
L34555 (Non-Covered Category III
CPT Codes) Palmetto
Medicare Part B
FL, PR, VI
NC, SC, WV, VA
L35008 (Non-Covered Services)
Noridian
AK, AZ, ID, MT, ND, OR, SD, UT, WA,
WY
AK, AZ, ID, MT, ND, OR, SD, UT, WA,
WY
L35094 (Services That Are Not
Reasonable and Necessary) Novitas
AR, CO, DC, DE, LA, MD, MS, NJ,
NM, OK, TX, PA
AR, CO, DC, DE, LA, MD, MS, NJ,
NM, OK, TX, PA
L33272 (Bone and/or Joint Imaging)
First Coast
FL, PR, VI
FL, PR, VI
L33457 (Cardiac Radionuclide
Imaging) Palmetto
NC, SC, WV, VA
NC, SC, WV, VA
L34279 (Radiology: Myocardial
Perfusion Imaging (MPI)) Cahaba
AL, GA, TN
AL, GA, TN
L35083 (Cardiovascular Nuclear
Medicine) Novitas
AR, CO, DC, DE, LA, MD, MS, NJ,
NM, OK, PA, TX
AR, CO, DC, DE, LA, MD, MS, NJ,
NM, OK, PA, TX
L36209 (Cardiology – non-emergent
outpatient testing: exercise stress
test, stress echo, MPI SPECT, and
cardiac PET)First Coast
FL, PR, VI
FL, PR, VI
L33960 (Cardiovascular Nuclear
Medicine) CGS
KY, OH
KY, OH
L33392 (Category III CPT® Codes)
NGS
CT, IL, MA, ME, MN, NH, NY, RI, VT,
WI
CT, IL, MA, ME, MN, NH, NY, RI, VT,
WI
L33560 (Cardiovascular Nuclear
Medicine) NGS
CT, IL, MA, ME, MN, NH, NY, RI, VT,
WI
CT, IL, MA, ME, MN, NH, NY, RI, VT,
WI
L36219 (Non Covered Services)
Noridian
AS, CA, GU, HI, MP, NV
AS, CA, GU, HI, MP, NV
L34886 (Non-Covered Services)
Noridian Retired 07/16/2016
AK, AZ, ID, MT, ND, OR, SD, UT, WA,
WY
L34212 (Cardiovascular Nuclear
Medicine: Myocardial Perfusion
Imaging and Cardiac Blood Pool
Studies) Noridian
Retired 05/13/2016
AS, CA, GU, HI, MP, NV
AS, CA, GU, HI, MP, NV
L34625 (Myocardial Perfusion
Imaging and Cardiac Blood Pool
Studies) WPS Retired 05/01/2016
AK, AL, AR, AZ, CT, FL, GA, IA, ID,
IL, IN, KS, KY, LA, MA, ME, MI, MN,
MO, MS, MT, NC, ND, NE, NH, NJ,
OH, OR, RI, SC, SD, TN, UT, VA, VI,
VT, WA, WI, WV, WY
IA, IN, KS, MI, MO, NE
L25275 (Non-covered Services) NGS
Retired 09/30/2015
CT, IL, MA, ME, MN, NH, NY, RI, VT,
WI
CT, IL, MA, ME, MN, NH, NY, RI, VT,
WI
L29288 (Non-covered Services) First
Coast Retired 09/30/2015
FL
FL
L29398 (Non-covered Services) First
Coast Retired 09/30/2015
PR, VI
PR, VI
L31711 (Non-Covered Category III
CPT Codes) Palmetto
Retired 09/30/2015
NC, SC, VA, WV
NC, SC, VA, WV
Single Photon Emission Computed Tomography (SPECT) (NCD 220.12)
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Approved 04/12/2017
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LCD
L28764 (Bone and/or Joint Imaging)
First Coast Retired 09/30/2015
Medicare Part A
Medicare Part B
FL
FL
L28765 (Bone and/or Joint Imaging)
First Coast Retired 09/30/2015
PR, VI
PR, VI
L26859 (Cardiovascular Nuclear
Medicine) NGS
Retired 09/30/2015
CT, IL, MA, ME, MN, NH, NY, RI, VT,
WI
CT, IL, MA, ME, MN, NH, NY, RI, VT,
WI
L29108 (Cardiovascular Nuclear
Imaging Studies) First Coast
Retired 06/29/2015
PR, VI
PR, VI
L30053 (Radiology: Myocardial
Perfusion Imaging (MPI)) Cahaba
Retired 09/30/2015
AL, GA, TN
AL, GA, TN
L31072 (Myocardial Perfusion
Imaging and Cardiac Blood Pool
Studies) WPS Retired 09/30/2015
AK, AL, AR, AZ, CT, FL, GA, IA, ID,
IL, IN, KS, KY, LA, MA, ME, MI, MN,
MO, MS, MT, NC, ND, NE, NH, NJ,
OH, OR, RI, SC, SD, TN, UT, VA, VI,
VT, WA, WI, WV, WY
IA, IN, KS, MI, MO, NE
L31187 (Cardiovascular Nuclear
Medicine) Novitas
Retired 09/30/2015
DC, DE, MD, NJ, PA
DC, DE, MD, NJ, PA
L31361 (Radiopharmaceutical
Agents) WPS Retired 09/30/2015
AK, AL, AR, AZ, CT, FL, GA, IA, ID,
IL, IN, KS, KY, LA, MA, ME, MI, MN,
MO, MS, MT, NC, ND, NE, NH, NJ,
OH, OR, RI, SC, SD, TN, UT, VA, VI,
VT, WA, WI, WV, WY
IA, IN, KS, MO, NE, MI
L31700 (Cardiac Radionuclide
Imaging) Palmetto
Retired 09/30/2015
NC, SC, VA, WV
NC, SC, WV, VA
L31831 (Cardiovascular Nuclear
Medicine) CGS
Retired 09/30/2015
KY, OH
KY, OH
L32635 (Cardiovascular Nuclear
Medicine) Novitas
Retired 09/30/2015
AR, CO, LA, MS, NM, OK, TX
AR, CO, LA, MS, NM, OK, TX
L33680 (Cardiovascular Nuclear
Medicine: Myocardial Perfusion
Imaging and Cardiac Blood Pool
Studies) Noridian
Retired 09/30/2015
AS, CA, GU, HI, MP, NV
AS, CA, GU, HI, MP, NV
L35085 (Cardiovascular Nuclear
Medicine) Novitas
Retired 12/30/2015
DC, DE, MD, NJ, PA
DC, DE, MD, NJ, PA
L26859 (Cardiovascular Nuclear
Medicine) NGS
Retired 09/30/2015
CT, IL, MA, ME, MN, NH, NY, RI, VT,
WI
CT, IL, MA, ME, MN, NH, NY, RI, VT,
WI
CMS Claims Processing Manual
Chapter 4; § 250.16 Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Imaging Procedures
Rendered by Physicians
Chapter 13; § 60.2.1 Coverage for Myocardial Viability
CMS Transmittals
Transmittal 120, Change Request 6632, Dated 05/06/2010 (FDG PET for Solid Tumors and Myeloma)
MLN Matters
Article SE0665, Multiple Procedure Reduction on the Technical Component (TC) of Certain Diagnostic Imaging
Procedures and Cap on the TC of Imaging Procedures
Single Photon Emission Computed Tomography (SPECT) (NCD 220.12)
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Others
Siemens Frequently Asked Questions about Medicare Reimbursement for Positron Emission Tomography
UnitedHealthcare Medicare Solutions Criteria for Imaging)
GUIDELINE HISTORY/REVISION INFORMATION
Date
04/12/2017
Action/Description

Annual review
Single Photon Emission Computed Tomography (SPECT) (NCD 220.12)
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