Aetna SPECT Coverage & Prior Auth Update

inv-01: Non-Cardiac Indications (Medically Necessary)

Covered when ANY of the following non-cardiac indications are present:

noncardiac_list: Assessment of osteomyelitis to distinguish bone from soft tissue infection; detection of spondylolysis and stress fractures not visible on x-ray; diagnosing and assessing hemangiomas of the liver; diagnosing pulmonary embolism by SPECT ventilation/perfusion scintigraphy; differentiation of necrotic tissue from brain tumor; distinguishing Parkinson's disease from essential tremor (e.g., DaTSCAN/I-123 Ioflupane); evaluation of fever of unknown origin after initial studies; imaging of parathyroids in parathyroid disease; evaluation of liver metastases or primary liver tumors before and after hepatic artery chemotherapy infusion or chemoembolization; localization of abscesses for suspected or known localized infection or inflammatory process; lymphoma to distinguish tumor from necrosis; neuroendocrine tumor diagnosis and staging; pre-surgical ictal detection of seizure focus (in place of PET) for epilepsy; and thyroid cancer iodine imaging for initial and subsequent staging.

See policy CPT/ICD mappings in chunks 12 and 13.

inv-02: Parathyroid SPECT-CT Fusion (Medically Necessary)

Covered when ALL of the following are met:

parathyroid_spectct: Member has an enlarged parathyroid gland, parathyroid hyperplasia, or suspected parathyroid adenoma or carcinoma; AND laboratory evidence of hyperparathyroidism (parathyroid hormone >55 pg/mL and serum calcium >10.2 mg/dL).PTH >55 pg/mL; serum calcium >10.2 mg/dL

SPECT-CT fusion for parathyroid localization is medically necessary only when both anatomic indication and the specified laboratory criteria are met.

inv-03: Cardiac Indications (Medically Necessary per eviCore)

Cardiac myocardial perfusion SPECT is considered medically necessary when consistent with eviCore Cardiac Imaging Clinical Guidelines:

cardiac_evicore: Myocardial perfusion imaging (SPECT) is covered for diagnosis and prognostic assessment of coronary artery disease when the study and indication meet eviCore Healthcare Cardiac Imaging Clinical Guidelines; providers should follow eviCore criteria for specific indications and imaging frequency.See eviCore guidelines

eviCore Cardiac Imaging Clinical Guidelines govern cardiac SPECT medical necessity and prior authorization processes.

inv-04: Experimental and Investigational (Not Medically Necessary)

Not covered — considered experimental and investigational — for the following indications:

experimental_list: SPECT myocardial perfusion imaging for multiple routine screening or inappropriate uses per ACC appropriateness criteria (e.g., routine screening after PTCA/CABG prior to discharge; routine screening <2 years post-revascularization without symptom worsening and no CHF; immediate post-thrombolytic imaging for acute MI; routine preoperative screening in asymptomatic patients outside defined criteria); myocardial sympathetic innervation imaging; SPECT for absolute quantitation of myocardial blood flow (AQMBF); SPECT-CT fusion imaging for many non-parathyroid indications; and numerous non-cardiac applications listed as investigational including imaging markers of pre-diagnostic Parkinson's disease, assessment of eating disorders, use for ADHD or autism diagnosis, schizophrenia, many neurologic and psychiatric indications, routine dementia diagnosis/differential use, evaluation of prosthetic graft infection screening, and other uses specified in the policy.

See policy sections listing experimental/investigational indications (chunks 6–9).

inv-05: Indications with supporting evidence

SPECT is considered medically useful in the following clinical contexts based on available evidence and guidelines:

Myocardial perfusion imaging: Effective noninvasive diagnostic test to evaluate clinically significant coronary artery disease (e.g., patients with abnormal resting ECG and limited exercise tolerance) and to assess myocardial viability prior to revascularization; pooled exercise SPECT sensitivity ~90%.

See myocardial perfusion background evidence (chunk 21).

Ictal SPECT for epilepsy localization: Ictal SPECT can localize epileptogenic foci with reported sensitivity 81–93% and is useful for pre-surgical evaluation; requires hospital setting and coordination with EEG/video monitoring.

Interictal SPECT is less sensitive (40–75%) (chunk 22).

SPECT for acute ischemia/stroke assessment: SPECT is more sensitive than CT for detecting acute ischemia within early intervals (eg, up to ~8 hours) but cannot detect hemorrhage and therefore does not replace CT when hemorrhage exclusion is required for thrombolysis decision-making.

Timing and limitations described in chunk 23.

inv-06: Pulmonary embolism (V/P SPECT)

Covered/appropriate uses when supported by guideline statements and evidence summarized in this section:

SPECT V/P for suspected pulmonary embolism: When pre-imaging clinical probability has been assessed and imaging is required, V/P SPECT is recommended as a preferred first-line procedure in many patients (particularly young patients, females, and pregnant patients) and when CTPA is contraindicated; use ventilation agent (Kr, 99mTc‑DTPA aerosol/Technegas) and 99mTc‑MAA for perfusion, and report PE when mismatch of more than 1 subsegment is found.mismatch >1 subsegment

EANM practice guidelines and comparative studies support SPECT V/P (chunks 34–37).

inv-07: Other indications (oncology, parathyroid, neurologic, lung lesion characterization)

Uses supported by some evidence but often investigational or require further research; consider only when results will affect management:

Oncology SPECT-CT and tumor localization: SPECT-CT is being evaluated for lymph node assessment, sentinel node mapping, detection of bone metastases and other oncologic uses; evidence and cost‑effectiveness remain evolving and further assessment is required to define clinical utility.

See chunks 41, 78, 81 for SPECT-CT oncology evidence and limitations.

Parathyroid localization and freehand SPECT/US: SPECT (and SPECT/CT or freehand SPECT/US fusion) increases sensitivity and anatomic localization for primary and recurrent hyperparathyroidism and ectopic adenomas; routine pre-target surgery use of SPECT/CT is still investigational.

See chunks 38 and 46.

Neurologic indications (dementia, movement disorders, FTD): Evidence is mixed: SPECT may help differentiate FTD from other dementias in select research settings but routine use is not recommended due to heterogeneity and limited standardized thresholds; SPECT utility for parkinsonian syndromes and other neurologic disorders is variable and may be investigational for many specific indications.

inv-08: Evidence-supported clinical applications (excerpt)

Evidence-supported uses discussed in this document segment (not formal coverage rules):

Quantitative SPECT MBF/MFR: Dynamic SPECT methods to quantify myocardial blood flow (MBF) and myocardial flow reserve (MFR) using 99mTc tracers may correlate with PET reference standards when advanced detectors and spline‑fitted reconstruction are used; accuracy and reproducibility depend on detector technology and reconstruction method.use of advanced detectors and spline reconstruction

Correlation values (r up to 0.81) and reproducibility data reported (chunks 71–73, 76).

SPECT-CT for indeterminate bone lesions: Targeted SPECT/CT following equivocal whole‑body bone scintigraphy or SPECT can characterize indeterminate bone lesions and detect metastatic bone disease, with meta-analytic pooled sensitivity ~93% and specificity ~96%, and can alter patient management.indeterminate lesion on WBS/SPECT

See chunks 78 and 81.

SPECT/CT for aseptic prosthetic loosening:

Specific procedure and diagnosis codes are identified in this policy as not covered when used for the listed non‑covered indications. CPT codes explicitly noted as not covered or experimental include 0331T (myocardial sympathetic innervation imaging, planar), 0332T (myocardial sympathetic innervation imaging with SPECT), and +0742T (absolute quantitation of myocardial blood flow SPECT add‑on). Several ICD‑10 code ranges are associated with exclusions for indications listed in the Clinical Policy Bulletin (for example, C34.00‑C34.92 for malignant neoplasm of bronchus and lung and C56.1‑C56.9 for malignant neoplasm of ovary are listed as not covered for those indications when used per the CPB).

When submitting requests for SPECT procedures, providers should map the performed CPT/HCPCS codes to the applicable ICD‑10 selection criteria in the policy and recognize that use of the not‑covered CPT codes for the listed indications may trigger denial under the plan.

SPECT has not been established for routine diagnosis or monitoring in many neurologic and other conditions. The policy specifically notes that SPECT is not established for routine interictal or post‑ictal epilepsy assessments, and clinical studies have not established efficacy for seizure subtype determination or monitoring drug therapy. As a result, routine SPECT for these epilepsy indications is considered investigational/ not medically necessary.

The policy further states that functional neuroimaging (including SPECT) should not be used as a screening or diagnostic tool for attention‑deficit/hyperactivity disorder or for autism spectrum disorder because group differences do not reliably distinguish affected from unaffected individuals; professional guidelines do not recommend neuroimaging for these diagnoses.

Routine use of SPECT for the initial or differential diagnosis of suspected dementia is not supported. The Institute and American Academy of Neurology practice parameters concluded that SPECT has not clearly demonstrated usefulness for routine diagnosis, evaluation of prognosis, or monitoring response to treatment in dementia, and the AAN does not recommend SPECT for routine initial or differential diagnosis of dementia.

Guideline summaries and reviews cited in the policy indicate SPECT has lower diagnostic accuracy than PET for many dementia applications and that SPECT should not replace clinical and neuropsychological assessment for routine diagnostic decisions.

WBC/BM SPECT‑CT is not recommended as a routine screening procedure for evaluating failed shoulder arthroplasties for possible infection. In a referral series cited in the policy, WBC/BM SPECT‑CT demonstrated very low sensitivity (0.18) though specificity was high (1.00), and scans were frequently false‑negative; the investigators concluded the scan added little to pre‑operative diagnosis for shoulder PJI.

Routine myocardial perfusion SPECT as part of pre‑operative evaluation for non‑cardiac surgery is inappropriate outside clearly defined appropriate‑use criteria. The policy cites analyses showing low positive predictive value of SPECT in this context and states SPECT should be restricted to patients who meet established appropriate‑use criteria rather than used routinely for asymptomatic surgical patients.

Cardiac SPECT appropriateness and frequency decisions are further governed by referenced cardiac imaging guidelines (see eviCore guidance).

The policy lists multiple routine or screening uses of myocardial perfusion SPECT that are considered inappropriate per appropriateness criteria (for example, routine screening within <2 years after revascularization when symptoms are stable and no CHF). These scenarios and other routine screening situations for myocardial perfusion imaging are identified as not medically necessary unless specific guideline criteria are met.

Providers performing or ordering myocardial perfusion SPECT should follow the eviCore Cardiac Imaging Clinical Guidelines and prior‑authorization rules referenced in the policy to avoid noncoverage for routine or inappropriate screening uses.

The policy indicates that available studies of SPECT in eating disorders are heterogeneous and methodologically limited. Systematic review authors concluded that study heterogeneity prevents robust conclusions, and UpToDate does not list SPECT as a management tool for eating disorders. Therefore routine use of SPECT for diagnosis or management of eating disorders is not supported by the current evidence base.

Several routine screening scenarios and other uses of SPECT myocardial perfusion imaging are identified as inappropriate per professional appropriateness criteria and this policy (for example, routine early post‑revascularization screening and other ACC‑deemed inappropriate indications). These situations are considered not medically necessary unless the specific appropriateness criteria are met.

The policy also designates certain cardiac SPECT and advanced quantitation approaches as experimental (see the not‑covered codes and investigational sections).

The policy states that SPECT should not be used as a screening or diagnostic tool for attention‑deficit/hyperactivity disorder or autism because existing studies do not provide reliable diagnostic discrimination and major specialty society guidance does not recommend neuroimaging for these conditions.

Consequently, SPECT for ADHD or autism is considered not medically necessary and is not covered for those indications.

Routine resting cerebral blood flow (rCBF) SPECT to differentiate frontotemporal dementia from other dementias is not recommended. A systematic review concluded there is insufficient evidence to support routine clinical use; protocols, thresholds and analysis methods are not standardized and additional prospective studies are needed before routine implementation.

SPECT functional imaging cannot reliably distinguish corticobasal degeneration from other atypical parkinsonian syndromes and therefore is not an established diagnostic biomarker for corticobasal degeneration or for definitively differentiating among atypical parkinsonian syndromes such as CBD and PSP.

The policy notes that DaTscan (I‑123 FP‑CIT SPECT) is abnormal in these disorders but lacks specificity to confidently differentiate among them.

Covered Indications (Selected)

inv-69: Non-cardiac SPECT medically necessary indications

Summary top-level: Non-cardiac SPECT medically necessary indications include:

noncardiac_summary: Non-cardiac SPECT is medically necessary for multiple specific indications including osteomyelitis assessment; spondylolysis/stress fracture detection; liver hemangioma characterization; V/P SPECT for pulmonary embolism; brain tumor vs radiation necrosis differentiation; DaTSCAN I-123 imaging for Parkinsonian syndromes vs essential tremor; fever of unknown origin after initial work-up; parathyroid imaging; liver tumor evaluation pre/post hepatic artery treatments; abscess localization; lymphoma staging/necrosis assessment; neuroendocrine tumor imaging; pre-surgical ictal seizure localization; and thyroid cancer iodine imaging.

See chunks 4, 12, 13 for coding and indication mappings.

inv-70: Cardiac SPECT — consult eviCore guidelines

Cardiac myocardial perfusion SPECT: follow eviCore Cardiac Imaging Clinical Guidelines for specific medical necessity and prior authorization requirements.

cardiac_top: Refer to eviCore Healthcare Cardiac Imaging Clinical Guidelines for indications, frequency, and prior authorization for myocardial perfusion SPECT; adherence to eviCore criteria determines coverage for cardiac SPECT studies.See eviCore guidelines

Chunk 5 references eviCore; prior authorization expectations summarized in chunk 31.

inv-71: Ventilation/Perfusion SPECT for Pulmonary Embolism

Ventilation/perfusion SPECT for suspected pulmonary embolism — top-level summary:

vpspect_top: V/P SPECT is appropriate for diagnosis of pulmonary embolism when pre-imaging clinical probability has been assessed; SPECT V/P has higher sensitivity and specificity than planar V/P, is feasible in ~99% of patients, and PE should be reported when mismatch of more than 1 subsegment is found; consider SPECT V/P particularly when CTPA is contraindicated or to reduce radiation exposure in younger or pregnant patients.mismatch >1 subsegment

See comparative studies and EANM guidelines (chunks 34–37).

inv-72: Myocardial Perfusion Imaging (MPI) SPECT

Myocardial perfusion SPECT (MPI) — top-level statement:

mpi_top: MPI SPECT is an effective noninvasive diagnostic test for evaluating suspected clinically significant coronary artery disease (eg, patients with abnormal resting ECG and limited exercise tolerance) and for assessing myocardial viability prior to revascularization; reported pooled exercise SPECT sensitivity ~90%.

See chunk 21 for pooled sensitivity and clinical contexts.

inv-73: Brain SPECT for Epilepsy (ictal)

Ictal brain SPECT — top-level statement:

ictal_spect: Ictal SPECT can localize epileptogenic foci with reported sensitivities of 81–93% and is useful for pre-surgical localization when noninvasive methods are insufficient; requires hospital setting and coordination with EEG/video monitoring.

Interictal SPECT shows lower sensitivity (40–75%) (chunks 22–23).

inv-74: Liver SPECT

Liver SPECT — top-level statement:

liver_spect: SPECT with labeled red blood cells is appropriate to differentiate hepatic hemangiomas from other masses when biopsy is risky; SPECT markedly improves resolution over planar RBC scanning.

See chunk 28.

inv-75: Bone SPECT (spine)

Bone SPECT (spine) — top-level statement:

bone_spine: Bone SPECT is highly sensitive for detecting incipient spondylolysis and stress/insufficiency fractures (abnormalities detectable 24–72 hours post-injury) and is useful in children/adolescents, though specificity is limited and supplemental imaging may be needed.

See chunk 30.

inv-76: Ventilation/Perfusion SPECT for suspected pulmonary embolism

Ventilation/Perfusion SPECT for suspected pulmonary embolism — top-level:

vpspect_suspected_pe: Pre-imaging clinical probability should be assessed; when imaging is indicated, SPECT V/P is preferred in many patients, especially when MDCT is contraindicated; report PE when mismatch >1 subsegment and document tracer methods used.mismatch >1 subsegment

See EANM guidelines and feasibility data in chunks 36–37.

inv-77: Tc-MIBI SPECT for lung lesion malignancy assessment

Tc‑MIBI SPECT for lung lesion malignancy assessment — top-level:

tc_mibi_lung: Tc‑MIBI SPECT may help differentiate malignant from benign pulmonary lesions with pooled sensitivity ~0.84 and specificity ~0.83; heterogeneity across studies and limited direct PET comparisons constrain definitive conclusions; consider only when PET is unavailable and when results will affect management.

See meta-analysis summary in chunks 54–55.

inv-78: Parathyroid and thyroid localization

Parathyroid and thyroid localization — top-level:

parathyroid_thyroid_localization: SPECT (including SPECT/CT and investigational freehand SPECT/ultrasound fusion) improves localization for parathyroid adenomas and thyroid disease and may assist surgical planning; routine use of SPECT/CT before target surgery remains investigational.

See chunks 38 and 46.

inv-79: Characterization of suspicious lung lesions when PET unavailable

Characterization of suspicious lung lesions when PET unavailable — top-level:

lung_lesion_vs_pet: When PET is unavailable, Tc‑MIBI SPECT can be considered to characterize indeterminate pulmonary lesions recognizing pooled sensitivity ~0.84 and specificity ~0.83 and study heterogeneity limits generalizability.

See chunks 54–55 for evidence and limitations.

inv-80: Experimental imaging for PD-L1 expression in NSCLC

Experimental imaging for PD‑L1 expression in NSCLC — top-level:

pd_l1_investigational: 99mTc‑labeled anti‑PD‑L1 single‑domain antibody (NM‑01) SPECT/CT has been evaluated in first‑in‑human studies showing safety, acceptable dosimetry, and correlation of tumor-to-blood-pool ratios with PD‑L1 immunohistochemistry; this application remains investigational and is appropriate only in research or clinical trial settings.investigational / research use

See chunks 56–57 for study details.

inv-81: Emerging technique for absolute quantitation of myocardial blood flow and flow reserve

Emerging quantitative myocardial blood flow techniques — top-level:

quantitative_mbf_mfr: Dynamic SPECT techniques for absolute quantitation of myocardial blood flow and myocardial flow reserve (MBF/MFR) may provide clinically useful information when performed with advanced detectors and appropriate reconstruction (eg, spline fitting); documentation of methods and validation is recommended when used clinically or for authorization.use of dynamic protocol and spline-fitted reconstruction

See validation and correlation data with PET in chunks 71–73.

inv-82: Assessment of cerebral hemodynamics in carotid stenosis

Cerebral hemodynamics assessment in carotid stenosis — top-level:

cerebral_hemodynamics: Multi‑phase arterial spin labeling (ASL) may detect delayed perfusion not seen on resting SPECT in carotid stenosis, and ASL can be preferred or complementary to SPECT for noninvasive hemodynamic assessment.

See chunk 58 for comparative example.

inv-83: Not recommended as a routine screening for suspected shoulder peri-prosthetic infection

Peri-prosthetic shoulder infection screening — top-level:

shoulder_pji: WBC/BM SPECT-CT demonstrated very low sensitivity for detecting shoulder peri‑prosthetic joint infection in a referral series and is not recommended as a routine screening test; positive scans were seen only in obvious infections.

See chunk 62 (sensitivity 0.18, specificity 1.00).

inv-84: Adjunct imaging for identifying potential pain generators prior to fusion surgery

Adjunct imaging for axial spine surgical planning — top-level:

spine_adjunct: SPECT or SPECT/CT may be used as an adjunct to clinical evaluation to identify potential pain generators prior to fusion surgery in select patients; evidence is limited and use should be considered adjunctive to standard evaluation.

See single‑center series in chunks 69–70.

inv-85: Quantification of myocardial blood flow and myocardial flow reserve

Quantification of myocardial blood flow and reserve — top-level:

mbf_mfr_quantification: Quantitative SPECT MBF and MFR estimation may be performed in patients with known or suspected CAD using dynamic protocols, advanced detectors, and spline‑fitted reconstruction to improve correlation with PET; document methods and reconstruction when used clinically or for authorization.use of dynamic protocol and spline reconstruction

Correlation and performance data reported in chunks 71–76.

inv-86: Characterization of indeterminate bone lesions / detection of metastatic bone disease

Characterization of indeterminate bone lesions — top-level:

sPECTCT_indeterminate_bone: Targeted SPECT/CT is indicated to characterize indeterminate bone lesions identified on whole‑body bone scintigraphy or SPECT and can improve specificity and influence patient management; meta-analyses report pooled sensitivity ~93% and specificity ~96%.indeterminate lesion on WBS/SPECT

See chunks 78 and 81.

inv-87: Evaluation of suspected aseptic prosthetic loosening

Evaluation of suspected aseptic prosthetic loosening — top-level:

aseptic_prosthetic_loosening: SPECT/CT may be used to evaluate suspected aseptic prosthetic loosening given high pooled diagnostic performance (pooled sensitivity ~0.94 and specificity ~0.89, AUC ~0.97) and clinical applicability demonstrated in meta-analysis.clinical suspicion of aseptic loosening

See chunk 85.

inv-88: Noninvasive imaging for suspected cardiac amyloidosis

Noninvasive imaging for suspected cardiac amyloidosis — top-level:

cardiac_amyloidosis: Radionuclide SPECT with bone‑seeking tracers (eg, 99mTc‑PYP, ‑DPD, ‑HMDP) has demonstrated high pooled sensitivity and specificity for diagnosing cardiac amyloidosis in meta-analyses and may be used as a noninvasive diagnostic option in appropriate clinical contexts.use of validated bone-seeking tracers

See chunk 84 for pooled performance data.

Coding and Billing

Covered CPT Codes (when selection criteria are met)CPTCovered

78071	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.
78803	Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT), single area (eg, head, neck, chest, pelvis), single day imaging.
78830	Radiopharmaceutical localization ... tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of pathology, single area (eg, head, neck, chest, pelvis), single day imaging.
78831	Tomographic (SPECT), minimum 2 areas (eg, pelvis and knees, abdomen and pelvis), single day imaging, or single area imaging over 2 or more days.
78832	Tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of pathology, minimum 2 areas (eg, pelvis and knees, abdomen and pelvis), single day imaging, or single area imaging over 2 or more days.
78451	Myocardial perfusion imaging, tomographic (SPECT); single study, at rest or stress.
78452	Myocardial perfusion imaging, tomographic (SPECT); multiple studies, at rest and/or stress and/or redistribution and/or rest reinjection.
78453	Myocardial perfusion imaging, planar; single study, at rest or stress.
78454	Myocardial perfusion imaging, planar; multiple studies, at rest and/or stress and/or redistribution and/or rest reinjection.

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CPT Codes Not Covered / ExperimentalCPTNot Covered

0331T	Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment.
0332T	Myocardial sympathetic innervation imaging; with tomographic SPECT.
+0742T	Absolute quantitation of myocardial blood flow (AQMBF) SPECT.

HCPCS Codes (covered if selection criteria are met)HCPCSCovered

A9584	Iodine I-123 Ioflupane, diagnostic, per study dose, up to 5 millicuries.
A9500	Technetium tc-99m sestamibi, diagnostic, per study dose.

ICD-10 Codes Covered if Selection Criteria MetICD-10Covered

C22.0 - C22.9	Malignant neoplasm of liver and intrahepatic bile ducts.
C73	Malignant neoplasm of thyroid gland.
G20	Parkinson's disease.
I26.01 - I26.99	Pulmonary embolism.
G40.001 - G40.919	Epilepsy and recurrent seizures.
I25.10 - I25.9	Atherosclerotic heart disease of native coronary artery.

ICD-10 Codes Not Covered for Indications ListedICD-10Not Covered

C34.00 - C34.92	Malignant neoplasm of bronchus and lung.
C56.1 - C56.9	Malignant neoplasm of ovary.
G30.0 - G30.9	Alzheimer's disease.

Covered CPT Codes (when selection criteria met)CPTCovered

78451	Myocardial perfusion imaging, tomographic (SPECT); single study, at rest or stress
78452	Myocardial perfusion imaging, tomographic (SPECT); multiple studies, at rest and/or stress
78453	Myocardial perfusion imaging, planar; single study, at rest or stress
78454	Myocardial perfusion imaging, planar; multiple studies, rest and/or stress
78469	Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification

CPT codes not covered for indications listed in the CPBCPTNot Covered

0331T	Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment
0332T	Myocardial sympathetic innervation imaging; with tomographic SPECT
+0742T	Absolute quantitation of myocardial blood flow (AQMBF), SPECT; add-on

Other CPT codes related to the CPBCPT

33140	Transmyocardial revascularization
33141	Transmyocardial revascularization (alternate)

ICD-10 CodesICD-10

I25.10 - I25.9	Atherosclerotic heart disease of native coronary artery (range)
I21.01 - I24.1	STEMI and NSTEMI myocardial infarction (range) — listed as not covered for indications in the CPB
R57.0 - R57.9	Shock, not elsewhere classified (range)
Z13.6	Encounter for screening for cardiovascular disorders
Z01.818	Encounter for other preprocedural examination
Z12.2	Encounter for screening for malignant neoplasm of respiratory organs [lung cancer]
Z12.73	Encounter for screening for malignant neoplasm of ovary

Parathyroid hormone and serum calcium — lab thresholds used to justify parathyroid SPECT-CT

PTH thresholdParathyroid hormone (PTH) greater than 55 pg/ml

Serum calcium thresholdSerum calcium greater than 10.2 mg/dL

Indication contextLaboratory evidence required for SPECT-CT fusion when person has enlarged parathyroid gland, parathyroid hyperplasia, or suspected adenoma/carcinoma

V/P scintigraphy mismatch rule — PE reported when mismatch of more than 1 subsegment is found

Mismatch rule for PE diagnosisReport pulmonary embolism when mismatch of more than 1 subsegment is found on V/P scintigraphy

Definition of mismatchLung segments or subsegments without perfusion but preserved ventilation indicate mismatch

Pre-test probabilityPre-imaging clinical probability assessment is recommended to reduce false positives/negatives

Provider Actions and Documentation

Prior Authorization

eviCore guideline requirement for cardiac SPECT

Cardiac SPECT studies must follow eviCore Healthcare Cardiac Imaging Clinical Guidelines. Providers should reference the eviCore Cardiac Imaging Guidelines (select the appropriate Aetna plan option) when ordering or performing myocardial perfusion SPECT to ensure criteria for medical necessity are met.

eviCore Cardiac Imaging Clinical Guidelines: https://www.evicore.com/provider/clinical-guidelines-details?solution=cardiovascular%20and%20radiology

Prior Authorization

Prior authorization for listed SPECT CPT codes

Prior authorization may be required for certain myocardial perfusion and related SPECT CPT codes. Verify plan-specific prior authorization requirements before scheduling studies to avoid claim denials.

Check payer/prior authorization portal for listed CPT codes (e.g., 78451–78454, 78469)
Follow eviCore prior auth pathways for cardiac imaging when applicable

Prior Authorization

Prior authorization for SPECT-CT in oncology

When SPECT-CT is used in oncology, document the clinical indication and how the result is expected to impact patient management. Prior authorization is recommended when using SPECT‑CT for oncologic staging or characterization.

Provide indication, expected management change, and relevant prior imaging
Consider prior authorization for SPECT‑CT in oncology due to variable evidence of clinical utility

Documentation Required

Specialized quantitative SPECT documentation

Advanced quantitative SPECT techniques for absolute myocardial blood flow (MBF) and myocardial flow reserve (MFR) are specialized. Provide validation and methodological details when submitting for coverage or review.

Include reconstruction algorithm, tracer, validation data, and reproducibility evidence for AQMBF/MFR methods
Document device type (e.g., CZT cameras) and supporting literature

Prior Authorization

Prior authorization for SPECT‑CT to resolve indeterminate bone lesions

Prior authorization is recommended when SPECT‑CT is ordered specifically to resolve indeterminate lesions on whole‑body bone scan (WBS). Document why targeted SPECT‑CT is needed and how it will change management.

Indicate prior WBS findings and why SPECT‑CT is preferred over immediate cross-sectional imaging
Explain expected impact on staging or treatment planning

Prior Authorization

Prior authorization and plan review

Some SPECT studies may require plan review or prior authorization per member plan provisions. Follow the member's plan prior‑authorization processes and submit documentation supporting medical necessity.

Check member's plan provisions and prior authorization portal
Attach clinical notes, prior imaging, and rationale for the requested SPECT study

Denial Risk

eviCore‑based cardiac prior authorization/denial risk

Adherence to eviCore cardiac guidelines influences prior authorization decisions and denial risk. Nonconformance with those guidelines may increase the likelihood of prior‑authorization denial.

Ensure orders meet eviCore appropriateness criteria to mitigate denial risk
Retain documentation of guideline-based decision-making

Billing Rule

Non‑covered CPT codes

Certain CPT codes are listed as not covered for indications in this policy. Do not bill these codes for covered indications in the Clinical Policy Bulletin.

Not covered CPT codes for listed indications: 0331T, 0332T, +0742T

Documentation Required

Modality selection documentation

When choosing SPECT over alternative modalities (e.g., MDCT for PE evaluation or PET where indicated), document the clinical rationale and any contraindications to the alternative modality.

Document contraindications to MDCT (e.g., contrast allergy, renal insufficiency) or rationale for SPECT preference
Record pre-test probability and modality selection reasoning in the medical record

Documentation Required

Use of myocardial perfusion SPECT in pre‑operative work‑up

Myocardial perfusion SPECT should be limited to defined appropriate-use indications. Routine pre-operative SPECT for low- or intermediate-risk non‑cardiac surgery is generally inappropriate unless clear indications exist.

Do not use SPECT routinely for pre-operative evaluation unless patient meets established appropriate‑use criteria
Document specific risk factors (e.g., ischemic heart disease, symptoms) that justify testing

Documentation Required

WBC/BM SPECT‑CT scanning for prosthetic joint infection screening

WBC/BM SPECT‑CT has limited utility as a screening test for prosthetic shoulder infection. Use targeted diagnostic pathways and reserve WBC/BM SPECT‑CT for situations where it will meaningfully influence management.

Avoid WBC/BM SPECT‑CT as routine screening for shoulder PJI
Document clinical suspicion and how imaging results will change management

Documentation Required

Equivocal planar bone scan follow‑up

After an equivocal planar whole‑body bone scan, consider targeted SPECT or SPECT‑CT rather than immediate advanced cross‑sectional imaging. Document why SPECT‑CT is the next appropriate step and how results will alter care.

Document prior planar WBS findings and rationale for targeted SPECT/SPECT‑CT
Explain expected diagnostic yield and downstream management changes

Note

No authorization or denial criteria specified in additional‑information

The additional‑information sections do not specify automatic authorization or denial criteria; follow plan provisions and prior authorization processes to determine coverage decisions.

No blanket authorization/denial rules provided — verify with plan prior authorization requirements
Submit complete clinical documentation to support medical necessity

Documentation Required

Laboratory evidence required for parathyroid SPECT‑CT

Parathyroid SPECT‑CT for parathyroid disease requires laboratory evidence of hyperparathyroidism. Provide PTH and serum calcium values when requesting imaging.

Laboratory thresholds: PTH > 55 pg/mL and serum calcium > 10.2 mg/dL
Document prior imaging and clinical exam supporting localization study

Billing Rule

Coding and documentation

Code and document SPECT procedures accurately. Map CPT codes to the clinical indication and include supporting ICD‑10 codes and clinical notes with prior authorization requests.

Covered CPT examples when criteria met: 78451–78454, 78469
Include relevant ICD‑10 codes and clinical justification with claims and prior authorization submissions

Documentation Required

V/Q SPECT reporting and pre‑test probability

For ventilation/perfusion (V/Q) SPECT, document the pre‑imaging clinical probability assessment and the method used. Reporting should convey whether mismatch of >1 subsegment is present.

Record Wells score or other clinical probability assessment and who performed it
Report findings using mismatch >1 subsegment threshold and correlate with clinical probability

Documentation Required

Required imaging justification and correlation

Provide justification that includes the clinical indication, correlation with prior imaging or laboratory data, and the expected impact on patient management when requesting SPECT or SPECT‑CT.

State how the imaging result will change diagnosis, staging, or treatment plan
Attach prior imaging, labs, and consult notes as applicable

Note

Links to Aetna resources

See Aetna resources for glossary, member information, plan provisions, and prior‑authorization portals. Use these links to locate plan disclosures, program provisions, and other administrative resources.

Aetna Glossary: https://www.aetna.com/glossary.html
Plan Provisions: https://www.aetna.com/legal-notices/program-provisions.html
Member resources and prior authorization portals available via Aetna website

Documentation Required

Preferred first‑line modality for PE in select patients

SPECT V/Q is often the preferred first‑line modality for many patients with suspected pulmonary embolism — particularly when MDCT is contraindicated (e.g., pregnancy, contrast allergy, renal insufficiency). Document this rationale when selecting V/Q SPECT.

Prefer SPECT V/Q in young patients, pregnant females, or when MDCT contraindicated
Document contraindications to MDCT and pre-test probability assessment

Step Therapy

No step therapy rules stated in this excerpt

This excerpt does not state any step‑therapy rules. Follow plan‑specific utilization management policies if applicable.

No step therapy requirements in this policy section
Check member plan for any utilization management or step rules

Step Therapy

Stepwise imaging after equivocal WBS

After an equivocal whole‑body bone scan, consider a stepwise imaging approach: targeted SPECT or SPECT‑CT first to clarify indeterminate lesions before proceeding to more advanced cross‑sectional imaging.

Document prior WBS findings and rationale for targeted SPECT/SPECT‑CT
Only escalate to CT or MRI if SPECT/SPECT‑CT remains inconclusive

Definitions and Key Terms

SPECT-CT fusion for parathyroid imaging — definition and use

DefinitionConjoined SPECT with concurrently acquired CT for anatomical localization used for parathyroid imaging

Clinical useUsed in persons with enlarged parathyroid gland, parathyroid hyperplasia, or suspected parathyroid adenoma or carcinoma

Documentation requirementRequires laboratory evidence of hyperparathyroidism (PTH >55 pg/ml and serum calcium >10.2 mg/dL) to be medically necessary

SPECT — Single Photon Emission Computed Tomography definition

Full nameSingle Photon Emission Computed Tomography (SPECT)

TechniqueNuclear medicine technique using radiopharmaceuticals, rotating camera, and computer to produce tomographic functional images

Image natureProduces functional images (physiologic information) rather than purely anatomical images

V/P mismatch — definition

DefinitionV/P mismatch: lung segments or subsegments without perfusion but preserved ventilation, indicating possible pulmonary embolism

Interpretation implicationMismatch forms the basis for PE diagnosis on ventilation/perfusion scintigraphy

Tracers usedVentilation: Kr-labeled, 99mTc-DTPA aerosol or Technegas; Perfusion: intravenous 99mTc-MAA

SPECT V/P — definition emphasizing higher sensitivity/specificity

DefinitionSPECT V/P: tomographic ventilation/perfusion study providing higher sensitivity and specificity than planar V/P

Clinical advantagesPermits accurate diagnosis of PE even with co-morbid diseases (eg, COPD, pneumonia) and is feasible in ≈99% of patients

Radiation dose advantageEffective dose for SPECT V/P ~1.2–2 mSv; lower breast dose (~35–40% of MDCT breast dose) making it preferred in young/pregnant patients

MBF / MFR — definition for myocardial blood flow and myocardial flow reserve by dynamic SPECT

MBF definitionMyocardial blood flow (MBF) quantified by dynamic SPECT techniques using 99mTc tracers and dynamic acquisition

MFR definitionMyocardial flow reserve (MFR) is the ratio of stress to rest MBF (stress/rest MBF) used to assess coronary perfusion and microvascular function

Methodological noteAdvanced reconstruction (eg, spatiotemporal spline fitting) and cadmium zinc telluride detectors improve correlation with PET and reproducibility

T:BP — tumor-to-blood-pool ratio definition for investigational PD-L1 imaging

DefinitionTumor-to-blood-pool ratio (T:BP): ratio of tumor uptake to blood-pool uptake measured on SPECT imaging (used in 99mTc anti–PD‑L1 sdAb studies)

Clinical correlation2-hour T:BP ratios correlated with PD‑L1 immunohistochemistry (r = 0.68) in first‑in‑human NM‑01 study

Typical values observedObserved T:BP ranged ~1.24–3.53 (mean ~1.79 at 1 hr; ~2.22 at 2 hrs) in the reported study

MBF and MFR — additional definition emphasizing units and clinical meaning

MBF unitsMBF typically reported in mL/min/g when quantified

MFR clinical meaningMFR is the stress/rest MBF ratio reflecting coronary perfusion and microvascular function; lower values indicate impaired coronary reserve

Technical dependenceAccuracy and reproducibility depend on detector technology and reconstruction (spline fitting improves correlation with 13N‑ammonia PET)

Aseptic prosthetic loosening (AL) — definition and clinical relevance

DefinitionAseptic prosthetic loosening (AL): clinical failure of a prosthetic joint in the absence of infection

Diagnostic relevanceSPECT/CT demonstrates high pooled diagnostic accuracy for AL (pooled sensitivity 0.94; specificity 0.89; AUC 0.97) and may be a primary diagnostic choice

Clinical applicationUseful to evaluate suspected prosthetic loosening following joint replacement to guide management decisions

OpenPayer

Single Photon Emission Computed Tomography (SPECT)

Coverage Criteria

Covered Indications (Selected)

Coding and Billing

Provider Actions and Documentation

Prior Authorization Considerations

Tracer and Contrast Rules

Not Covered / Exclusions

Background

Definitions and Key Terms

Frequency Limits

Revision History