Single Photon Emission Computed Tomography (SPECT)
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This policy defines Aetna's medical necessity, experimental/investigational exclusions, and coding guidance for SPECT imaging for cardiac and non-cardiac indications and affects providers ordering or performing SPECT for Aetna members.
No material clinical or coverage changes in this revision.
Coverage Criteria
inv-01: Non-Cardiac Indications (Medically Necessary)
Covered when ANY of the following non-cardiac indications are present:
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:
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:
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:
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:
See myocardial perfusion background evidence (chunk 21).
Interictal SPECT is less sensitive (40–75%) (chunk 22).
Timing and limitations described in chunk 23.
See chunk 24.
Supported by chunk 28.
See chunk 29.
See chunk 30.
See chunk 31.
See chunks 34–36.
inv-06: Pulmonary embolism (V/P SPECT)
Covered/appropriate uses when supported by guideline statements and evidence summarized in this section:
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:
See chunks 41, 78, 81 for SPECT-CT oncology evidence and limitations.
See chunks 38 and 46.
See chunks 48, 51 and 39–40.
See chunks 54–55.
inv-08: Evidence-supported clinical applications (excerpt)
Evidence-supported uses discussed in this document segment (not formal coverage rules):
Correlation values (r up to 0.81) and reproducibility data reported (chunks 71–73, 76).
See chunks 78 and 81.
See chunk 85.
See chunk 84 and related analyses.
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:
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.
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:
See comparative studies and EANM guidelines (chunks 34–37).
inv-72: Myocardial Perfusion Imaging (MPI) SPECT
Myocardial perfusion SPECT (MPI) — top-level statement:
See chunk 21 for pooled sensitivity and clinical contexts.
inv-73: Brain SPECT for Epilepsy (ictal)
Ictal brain SPECT — top-level statement:
Interictal SPECT shows lower sensitivity (40–75%) (chunks 22–23).
inv-74: Liver SPECT
Liver SPECT — top-level statement:
See chunk 28.
inv-75: Bone SPECT (spine)
Bone SPECT (spine) — top-level statement:
See chunk 30.
inv-76: Ventilation/Perfusion SPECT for suspected pulmonary embolism
Ventilation/Perfusion SPECT for suspected pulmonary embolism — top-level:
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:
See meta-analysis summary in chunks 54–55.
inv-78: Parathyroid and thyroid localization
Parathyroid and thyroid localization — top-level:
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:
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:
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:
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:
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:
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:
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:
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:
See chunks 78 and 81.
inv-87: Evaluation of suspected aseptic prosthetic loosening
Evaluation of suspected aseptic prosthetic loosening — top-level:
See chunk 85.
inv-88: Noninvasive imaging for suspected cardiac amyloidosis
Noninvasive imaging for suspected cardiac amyloidosis — top-level:
See chunk 84 for pooled performance data.
Coding and Billing
| 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. |
| 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. |
| 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. |
| 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 |
| 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 |
Provider Actions and Documentation
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 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 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
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 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 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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Tracer and Contrast Rules
Not Covered / Exclusions
The policy summarizes a set of SPECT applications that are explicitly not covered. These include myocardial sympathetic innervation imaging, SPECT approaches intended for absolute quantitation of myocardial blood flow, and SPECT‑CT fusion for certain non‑parathyroid indications; such uses are considered experimental/investigational and not medically necessary.
The policy further lists the specific CPT codes 0331T, 0332T, and +0742T as not covered for the indications listed, and cautions that use of these codes for listed indications may result in denial.
CPT codes identified in the policy as not covered for the indications listed include 0331T, 0332T, and +0742T. These are described in the coding section as myocardial sympathetic innervation imaging (planar and SPECT) and an add‑on code for absolute quantitation of myocardial blood flow by SPECT.
Providers should not bill these codes for the excluded indications listed in the Clinical Policy Bulletin.
SPECT for routine diagnosis of attention‑deficit/hyperactivity disorder or autism is not supported by the evidence and is therefore not covered for these indications. The policy cites specialty guidelines that do not recommend neuroimaging for diagnosis of ADHD or autism and notes high false‑positive and false‑negative rates in published studies.
When these diagnoses are the primary indication, SPECT should not be performed for diagnostic or screening purposes.
Routine use of SPECT for the initial or differential diagnosis of dementia is not supported by current evidence and is effectively not recommended. Policy citations include a technology assessment and professional practice parameters indicating insufficient added diagnostic value compared with clinical assessment and PET, and therefore such routine SPECT use is not covered.
SPECT may have research or limited adjunct roles in select situations but is not recommended as a standard diagnostic test for dementia in routine clinical practice.
Background
Single Photon Emission Computed Tomography (SPECT) is a nuclear medicine tomographic imaging technique that provides three‑dimensional functional imaging using radiopharmaceutical tracers. It is applied across a range of clinical areas including infection localization, tumor characterization, parathyroid localization, ventilation/perfusion imaging for pulmonary embolism, seizure focus localization (ictal SPECT), and myocardial perfusion imaging when consistent with cardiac imaging guidelines.
Because SPECT provides functional information with concurrent or fused anatomic localization (when combined with CT), it is useful for certain indications but several applications remain investigational and the policy distinguishes medically necessary, covered, and not‑covered uses accordingly.
Definitions and Key Terms
Frequency Limits
Revision History
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