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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) Page 1 of 5 UnitedHealthcare Medicare Advantage Policy Guideline Approved 04/12/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc. 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) Page 2 of 5 UnitedHealthcare Medicare Advantage Policy Guideline Approved 04/12/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc. 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) Page 3 of 5 UnitedHealthcare Medicare Advantage Policy Guideline Approved 04/12/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc. 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) Page 4 of 5 UnitedHealthcare Medicare Advantage Policy Guideline Approved 04/12/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc. 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) Page 5 of 5 UnitedHealthcare Medicare Advantage Policy Guideline Approved 04/12/2017 Proprietary Information of UnitedHealthcare. Copyright 2017 United HealthCare Services, Inc.