MEDICAL POLICY – 6.01.502
Single Photon Emission Computed Tomography (SPECT)
for Non-cardiac Indications
Effective Date: Oct. 1, 2019
Last Revised: Sept. 5, 2019
Replaces: N/A
RELATED MEDICAL POLICIES:
6.01.54 Dopamine Transporter Imaging with Single-photon Emission Computed
Tomography
Select a hyperlink below to be directed to that section.
POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING
RELATED INFORMATION | EVIDENCE REVIEW | REFERENCES | HISTORY
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Introduction
SPECT is a type of nuclear imaging test that uses a radioactive dye, also called a tracer, and a
special camera to create a three-dimensional (3-D) image of the organs in the body. The images
created by tracking the dye in the blood stream can show areas of increased/decreased blood
flow and progressive changes in the body. SPECT is proposed to help diagnose or monitor
certain tumors, bone disorders, and heart problems.
SPECT imaging of the brain for mental health disorders is used as a research tool in clinical trials.
Research has not shown the utility of SPECT brain imaging for differential diagnosis or for
assessing or predicting an individual’s risk of getting a mental health disorder.
Dopamine transporter imaging with single-photon emission computed tomography (DAT-
SPECT) is addressed in another policy (see Related Medical Policies).
Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The
rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for
providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can
be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a
service may be covered.
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Page | 2 of 12 ∞
Policy Coverage Criteria
Procedure Medical Necessity
SPECT scan SPECT scans may be considered medically necessary for any of
the following non-cardiac conditions or symptoms:
• Brain tumor recurrence versus radiation necrosis
• Liver hemangioma versus tumor identification
• Localization of abscess, suspected or known localized infection
vs. inflammation
• Assessment of osteomyelitis (bone vs. soft tissue infection)
• Lymphoma evaluation (tumor vs. necrosis)
• Neuroendocrine tumors (carcinoid, pheocromoctyoma, thyroid
carcinoma, adrenal gland tumors) [OctreoScan™ or MIBG]
• Parathyroid disease
• Renal function and renal scarring evaluation
(Dimercaptosuccinic acid [DMSA] scan)
• Seizure foci localization for patients with intractable epilepsy (in
place of positron emission tomography [PET])
• Vertebral abnormalities evaluation (such as spondylosis,
spondylolisthesis, or stress fractures not visible on x-ray)
SPECT scan SPECT scans are considered not medically necessary for any of
the following conditions or symptoms:
• Cerebrovascular accident (also called CVA, stroke, or brain
attack)
• Subarachnoid hemorrhage
• Transient ischemic attack (TIA)
Procedure Investigational
SPECT scan SPECT scans are considered investigational for all other non-
cardiac conditions, including any of the following:
• Attention deficit hyperactivity disorder (ADHD)
• Autism spectrum disorders
• Colorectal cancer (eg, with CEA-Scan, IMMU-4)
• Head trauma – evaluation of brain morphology
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Procedure Investigational • Mental health disorders (diagnosis, prediction, response to
medication)
• Movement disorder evaluation
• Prostate cancer (eg, with ProstaScint®)
• Unclassified dementia evaluation (eg, Alzheimer disease)
Documentation Requirements
The medical records submitted for review should document that medical necessity
criteria are met. Include history and physical supporting that patient has ANY of the
following symptoms or conditions:
• Brain tumors, to differentiate between recurrent tumor versus radiation changes, infection
• Liver hemangioma, to further define the mass
• Localization of abscess, infection, or inflammation
• Lymphoma evaluation
• Neuroendocrine tumors
• Parathyroid disease
• Renal function and renal scarring evaluation (dimercaptosuccinic acid [DMSA] scan)
• Patients with intractable epilepsy, when seizure focus cannot be localized
• Evaluation of vertebral abnormalities (such as spondylosis, spondylolysis, spondylolisthesis,
degenerative joint disease/arthritis of the facet joints, stress fractures)
Coding
Code Description
HCPCS A9507 Indium in-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries
Note: CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS codes,
descriptions and materials are copyrighted by Centers for Medicare Services (CMS).
Related Information
Page | 4 of 12 ∞
Definition of Terms
Abscess: A mass filled with pus (made up of dead white blood cells and dead tissue, bacteria,
and blood serum) that collects anywhere in the body as a result of the body's response to an
infection.
Adenoma: A noncancerous (benign) epithelial tumor that may affect various organs in the body.
The adenoma often comes from or resembles glandular tissue, though some grow in
nonglandular areas.
Autism spectrum disorders : Refers to a group of disorders defined as delays in the
development of socialization and communication skills often accompanied by cognitive and
language delays.
Carcinoid tumors: Carcinoid tumors are slow growing and usually start in the gastrointestinal
tract (anywhere between the stomach and the rectum) or the lung. These tumors make and
release (secrete) large amounts of hormones, including cortisol, histamine, insulin and serotonin.
Carcinoid tumors are a type of neuroendocrine tumor.
Liver hemangioma: A noncancerous tumor (mass) that forms in or on the liver. It is made up of
small blood vessels. Liver hemangiomas are more common in women than men.
Lymphoma: A cancer of the white blood cells (lymphocytes) of the body’s immune system. It
develops in the lymph nodes and lymphatic system.
Movement disorders: A group of diseases that includes abnormally slow movement
(bradykinesia), rigidity, tremor at rest, and postural instability.
Neuroendocrine tumors: A diverse group of tumors that form from cells of the hormone and
nervous systems. They may be found in the intestine and also occur in the thyroid, lung and
other parts of the body.
Transient ischemic attack (TIA): A temporary lack of adequate blood and oxygen (ischemia) to
the brain. The neurological signs and symptoms are similar to a brain attack (stroke), but go
away within a short period of time. This may also be referred to as a mini-stroke.
Evidence Review
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Background
SPECT is an imaging modality that provides information about the functional level of a particular
body part. It requires the injection of a low-level radioactive isotope (chemical tracer) into the
bloodstream. Images then reflect how the tracer is processed by the body. This is in contrast to
structural information provided by CT, MRI or ultrasound. Scans are made with a device that
detects radioactivity in the body. A SPECT tomograph generates detailed information as the
radiotracers used with a SPECT attach to elements appropriate for obtaining specific
information. An example of this is how antibodies attach to specific types of tumors. A
radiotracer can be attached to an antibody that will then bind to a tumor, which is then
identified and located by a SPECT scan.
SPECT provides information about the cellular or level of chemical activity within an organ or
system, including structural information about that system. This process can show areas of
increased activity, such as inflammation seen in an abscess. Patterns of distribution can then be
correlated with particular diseases. The selection of a radiotracer and imaging protocol is
specific to the disease process being investigated. SPECT cameras can image large areas of the
body as the emitted radiation from the radiotracers travel through the body.
Information obtained by SPECT complements or confirms data obtained by other forms of
testing and may provide additional information in some situations. For many conditions, SPECT
has been found to be as useful as PET, even though PET images tend to be of higher quality
than those of SPECT, SPECT tends to be more available. Both PET and SPECT can diagnose
disease prior to the onset of clinical symptoms or structural manifestations of disease as they
provide information regarding the functional level of a body system.
Abscess/Infection
Labeled white blood cells are infused prior to SPECT imaging of the suspected clinical site of
infection. This infusion helps with localization of tissue inflammation.1
Autism Spectrum Disorders
Autism spectrum disorders can be difficult to diagnose due to the variety and severity of the
presentation of symptoms. The American Academy of Neurology Practice Guideline states the
following: "There is no evidence to support a role for functional neuroimaging studies in the
clinical diagnosis of autism at the present time"25
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Surgical Repair
SPECT can be useful in distinguishing between tumor regrowth and radiation necrosis in
patients with cerebral metastases.2
Cerebrovascular Disease (CVA, stroke, brain attack, TIA)
The use of SPECT has become outdated for the evaluation and management of cerebrovascular
disease, including cerebrovascular accidents (CVA or stroke), subarachnoid hemorrhages, and
transient ischemic attacks (TIA). Newer imaging techniques are more common such as
computed tomography angiography (CTA) and magnetic resonance angiography (MRA).3-5
Epilepsy Seizure Foci
Ictal SPECT may be applicable for patients being considered for surgery to treat intractable
epilepsy, when seizure focus cannot be localized by EEG, video-EEG, or MRI. Effective surgical
treatment of patients with intractable epilepsy is dependent on accurate localization of the
epileptic focus and precise delineation of the eliptogenic region. Ictal SPECT uses the
physiologic increase in regional cerebral blood flow during seizures to localize the epileptogenic
region. This testing aids in identifying the source or sources of the seizures as well as assess
brain function. SPECT may offer a safe and accurate alternative to quantitative MRI or PET for
the pre-surgical ictal detection of seizure focus. It should be performed in a hospital setting.6,7
Kidney (renal)
Using Technetium-99m labeled dimercaptosuccinic acid (DSMA) for diagnostic imaging may be
useful to evaluate kidney function and identify scarring that may be the result of frequent
infections.8,9 The National Institute for Health and Clinical Excellence 2007 guideline
recommends DMSA scanning when the diagnosis cannot be confirmed by Doppler ultrasound.10
The American Urological Association 2010 Clinical Practice Guideline recommends DMSA scan
when a renal ultrasound is abnormal in children with vesicoureteral reflux to detect the presence
of any renal scarring.11
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Liver Hemangioma versus Primary Hepatoma or Metastases
Technetium-labeled red blood cells are infused prior to SPECT imaging of the liver. There is risk
of hemorrhage in a percutaneous biopsy of liver hemangiomas, so non-invasive methods of
testing are useful for differentiating between the blood pool of an hepatic hemangioma from
other solid hepatic masses. Review articles and published studies support SPECT as an
appropriate diagnostic tool to differentiate between hepatic lesions versus hemangiomas.12
Lymphoma
SPECT scans may be useful to distinguish tumor from radiation necrosis in the chest and
abdomen. An initial study can be compared with a follow-up study after the completion of
treatment. SPECT is not appropriate for initial staging of lymphoma.13
Mental Health Disorders
SPECT imaging of the brain for mental health disorders is used as a research tool in clinical trials.
The National Institute of Mental Health (NIMH) made the following statement in their brochure
titled “Neuroimaging and Mental Illness: A window into the brain”:
No scientific studies to date have shown that a brain scan by itself can be used for
diagnosing a mental illness or to learn about a person’s risk for disease. Brain scans alone
cannot be used to diagnose a mental disorder, such as autism, anxiety, depression,
schizophrenia, or bipolar disorder. Other types of tests are needed for a mental illness to be
properly diagnosed.14,15
Mild Cognitive Impairment (MCI) Conversion to Alzheimer’s Disease (AD)
The utility of SPECT to predict conversion from mild cognitive impairment (MCI) to Alzheimer’s
disease (AD) is limited.16,17 A technology assessment of SPECT for dementia and AD by the
Institute for Clinical Effectiveness and Health Policy concluded: “SPECT has not clearly
demonstrated its usefulness in assessing patients with dementia, and it has no precise
indications for diagnosis, evaluation of prognosis or monitoring response to treatment.”18
Controlled studies of SPECT in AD show the sensitivity of this testing varies from 50 to 95%. The
Page | 8 of 12 ∞
American Academy of Neurology does not recommend SPECT for routine use in the differential
diagnosis of dementia.19
Neuroendocrine Tumors
SPECT for the diagnosis and staging of neuroendocrine tumors may be done using a
monoclonal antibody (OctreoScan™) or I-131 meta-iodobenzyl-guanidine (MIBG) because
carcinoids and other neuroendocrine tumors have somatostatin receptors and can be imaged
with somatostain analogs tagged with an appropriate radioisotope.20, 21
Parathyroid Disease
Guidelines on parathyroid scintigraphy from the Society of Nuclear Medicine22 state that there is
a developing consensus that SPECT and SPECT/CT are most useful for improving the precision of
anatomic localization. The Parathyroid Task Group of the EANM21 state that the use of SPECT/CT
has a major role for obtaining anatomical details on ectopic foci. However, its use as a routine
procedure before target surgery is still investigational. Preliminary data suggest that SPECT/CT
has lower sensitivity in the neck area compared to pinhole imaging.22-24
Prostate Cancer
ProstaScint, a monoclonal antibody combined with radioactive indium-111, is used to detect
prostate cancer. It is injected into the body and then a gamma camera is used to locate prostate
cancer cells. There is little evidence demonstrating improvements in health outcomes following
ProstaScint scans. One study showed 60% progression-free survival (PFS) of 60% for those study
participants with a negative scan and 74% for those with a positive scan. The researchers of the
study concluded that the individuals with positive scans did not have a statistically significant
difference in PFS than those with a negative scan result.26 Pucar concluded that “ProstaScint has
not added benefit over other imaging modalities in evaluating post-radical prostatectomy
recurrence, due to its low sensitivity for detecting local recurrences and bone metastases.”27
The American College of Radiology (ACR) states: “The reliability and usefulness of indium-111
radiolabeled capromab pendetide (a first-generation monoclonal antibody against prostate-
specific membrane antigen [PSMA]) scan as a method to stage prostate cancer remains
Page | 9 of 12 ∞
unproven.”28 They also note that the optimal use of the scan remains to be determined as the
scans are difficult to interpret and are costly to perform.29
Spondylolysis and Stress Fractures
SPECT scans may be useful in evaluating chronic back or neck pain that is atypical, that may be
caused by spondylolysis or stress fractures that are undiagnosed by conventional imaging. Bone
SPECT may provide diagnostic information in cases of low back pain that is not available with
routine imaging. One study of 34 patients with chronic low back pain compared findings from
radiography, computed tomography (CT) and bone scintigraphy with SPECT. The majority of
lesions (89%) seen on SPECT corresponded to identifiable disease on CT.30 SPECT was also
found to be more sensitive than planar bone scintigraphy in identifying patients with painful
defects in the pars interarticularis compared to radiographic evidence of spondolysis and/or
spondylolisthesis in 19 adult patients studied. 31 Bencardino et al (2016) in the Expert Panel on
Musculoskeletal Imaging. American College of Radiology Appropriateness Criteria states: “planar
scintigraphy combined with SPECT is more accurate in diagnosing stress injuries than planar
scintigraphy alone.”32
Vertebral Abnormalities
SPECT scans may be useful in evaluating chronic back or neck pain that is atypical, that may be
caused by spondylolysis or stress fractures that are undiagnosed by conventional imaging
studies.30,31
References
1. Bybel B, Brunken RC, DiFilippo FP, Neumann DR, Wu G, Cerqueira MD. SPECT/CT imaging: clinical utility of an emerging
technology. Radiographics. 2008 Jul-Aug;28(4):1097-113. PMID 18635631
2. Serizawa T, Saeki N, Higuchi Y et al. Diagnostic value of thallium-201 chloride single-photon emission computerized
tomography in differentiating tumor recurrence from radiation injury after gamma knife surgery for metastatic brain tumors. J
Neurosurg 2005; 102 (Suppl):266-271. PMID 15662823
3. Lewis DH. Functional brain imaging with cerebral perfusion SPECT in cerebrovascular disease, epilepsy, and trauma. Neurosurg
Clin N Am. 1997 Jul;8(3):337-344. PMID9188542
Page | 10 of 12 ∞
4. Ueda T et al. Outcome in acute stroke with successful intra-arterial thrombolysis and predictive value of initial single photon
emission-computed tomography. J Cereb Blood Flow Metab. 1999 Jan;19(1):99-108. PMID 9886360
5. Lewis DH et al. Brain SPECT and the effect of cerebral angioplasty in delayed ischemia due to vasospasm. J Nuc Med, Oct.
1992; Vol. 33, No. 10:1789-1796. PMID 1403146
6. von Oertzen TJ, Mormann F, Urbach H, et al. Prospective use of subtraction ictal SPECT coregistered to MRI (SISCOM) in
presurgical evaluation of epilepsy. Epilepsia. 2011; 52(12):2239-2248. PMID 22136078
7. Kumar A, Chugani HT. The role of radionuclide imaging in epilepsy, Part 1: Sporadic temporal and extratemporal lobe epilepsy.
J Nucl Med. 2013 Oct;54(10):1775-1781. PMID 23970368
8. Even-Sapir E, Gutman M, Lerman H et al. Kidney allografts and remaining contralateral donor kidneys before and after
transplantation: assessment by quantitative (99m) TC-DMSA SPECT. J Nucl Med 2002; 43(5):584-588. PMID 11994518
9. Mullerad M, Kastin A, Issaq E et al. The value of quantitative 99M technetium dimercaptosuccinic acid renal scintigraphy for
predicting postoperative renal insufficiency in patients undergoing nephrectomy. J Urol 2003; 169(1):24-27. PMID 12478094
10. National Institute for Health and Care Excellence. Clinical Guideline[CG54] Urinary tract infection in under 16s: diagnosis and
management. Published date: August 2007. Last updated: October 2018. Available at:
https://www.nice.org.uk/guidance/cg54 Accessed September 2019.
11. American Urological Association. Clinical Practice Guideline. Management and screening of primary vesicoureteral reflux.
Reviewed 2017. Available at: http://www.auanet.org/guidelines/vesicoureteral-reflux-(2010-reviewed-and-validity-
confirmed-2017) Accessed September 2019.
12. Jacobson AF, Teefey SA. Cavernous hemangiomas of the liver. Association of sonographic appearance and results of Tc-99m
labeled red blood cell SPECT. Clin Nucl Med. 1994;19(2):96-99. PMID 8187411
13. Bockisch A, Freudenberg LS, et al. Hybrid imaging by SPECT/CT and PET/CT: proven outcomes in cancer imaging. Semin Nucl
Med. 2009 Jul;39(4):276-289. PMID 19497404
14. American Psychiatric Association. Practice Guideline for the Psychiatric Evaluation of Adults, Third Edition. August 2015.
Available at: https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines Accessed September 2019.
15. Farah MJ, Gillihan SJ. The Puzzle of Neuroimaging and Psychiatric Diagnosis: Technology and Nosology in an Evolving
Discipline. AJOB neuroscience. 2012;3(4):31-41. PMID 23505613
16. Devanand DP, Van Heertum RL, Kegeles LS, et al. (99m)Tc hexamethyl-propylene-aminoxime single-photon emission computed
tomography prediction of conversion from mild cognitive impairment to Alzheimer disease. Am J Geriatr Psychiatry.
2010;18(11):959-972. PMID 20808143
17. McNeill R, Sare GM, Manoharan M, et al. Accuracy of single-photon emission computed tomography in differentiating
frontotemporal dementia from Alzheimer’s disease. J Neurol Neurosurg Psychiatry. 2007;78(4):350-355. PMID 17158559
18. Ferrante, D. SPECT for the diagnosis and assessment of dementia and Alzheimer’s disease (summary). Report ITB No. 14.
Buenos Aires, Argentina: Institute for Clinical Effectiveness and Health Policy (ICES); 2004.
19. Knopman DS, DeKosky ST, et al. Practice parameter: Diagnosis of dementia (an evidence-based review). Report of the Quality
Standards Subcommitte of the American Academy of Neurology. Neurology. 2001;56 (9): 1143-1153
20. Schillaci O, Scopinaro F, Angeletti S, et al. SPECT improves accuracy of somatostatin receptor scintigraphy in abdominal
carcinoid tumors. J Nuclear Med. 1996;37(9):1452-1456. PMID 8790191
21. Schillaci O, Corleto VD, Annibale B, et al. Single photon emission computed tomography procedure improves accuracy of
somatostatin receptor scintigraphy in gastro-entero pancreatic tumours. Ital J Gastroenterol Hepatol. 1999 Oct; 31 Suppl
2():S186-189. PMID 10604127
22. Greenspan BS, Brown ML, Dillehay GL, et al. The Society of Nuclear Medicine Procedure Guideline for Parathyroid Scintigraphy.
Version 3.0. Reston, VA: Society of Nuclear Medicine; June 2004.
https://www.nice.org.uk/guidance/cg54http://www.auanet.org/guidelines/vesicoureteral-reflux-(2010-reviewed-and-validity-confirmed-2017)http://www.auanet.org/guidelines/vesicoureteral-reflux-(2010-reviewed-and-validity-confirmed-2017)https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines
Page | 11 of 12 ∞
23. Hindié E, Ugar O, Fuster D, et al; Parathyroid Task Group of the EANM. 2009 EANM parathyroid guidelines. Eur J Nucl Med Mol
Imaging. 2009:36(7):1201-1216. PMID 19471928
24. Tunninen V, Varjo P, Schildt J, et al. Comparison of five parathyroid scintigraphic protocols. Int J Mol Imaging.
2013;2013:921260. PMID 23431436
25. Filipek PS, Accardo PJ, Ashwal S, et al. Practice parameter: screening and diagnosis of autism: report of the Quality Standards
Subcommittee of the American Academy of Neurology and the Child Neurology Society. Neurology. 2000; 55(4):468-479.
PMID: 10953176
26. Koontz BF, Mouraviev V, Johnson JL, et al. Use of local (111) in-capromab pendetide scan results to predict outcome after
salvage radiotherapy for prostate cancer. Int J Radiat Oncol Biol Phys. 2008; 71(2):358-361.
27. Pucar D, Sella T, Schöder H. The role of imaging in the detection of prostate cancer local recurrence after radiation therapy and
surgery. Curr Opin Urol. 2008; 18(1):87-97.
28. American College of Radiology. ACR Appropriateness Criteria®. Post-treatment Follow-up of Prostate Cancer (Revised 2017).
Available at: https://acsearch.acr.org/docs/69369/Narrative/ Accessed September 2019.
29. American College of Radiology. ACR Appropriateness Criteria®. Prostate Cancer — Pretreatment Detection, Staging, and
Surveillance (Revised 2016). Available at: https://acsearch.acr.org/docs/69371/Narrative/ Accessed September 2019.
30. Ryan PJ et al. Chronic low back pain: Comparison of bone SPECT with radiography and CT. Radiology 1992, Vol. 182:849-854.
PMID 1531544
31. Collier BD et al. Painful spondylolysis of spondylolisthesis studied by radiography and single photon emission computed
tomography. Radiology 1985, Vol. 154:207-211. PMID 3155479
32. Bencardino, JT, Stone TJ, Roberts CC, et al.Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria Stress
(fatigue/insufficiency) fracture, including sacrum, excluding other vertebrae.. J Am Coll Radiol 2017; 14 (5S): S293-S306. PMID:
28473086. https://acsearch.acr.org/docs/69435/Narrative/ Accessed September 2019.
33. Centers for Medicare & Medicaid Services. National Coverage Decision (NCD) for Single Photon Emission Computed
Tomography (SPECT) (220.12). 2002. https://www.cms.gov/medicare-coverage-database/details/ncd-
details.aspx?NCDId=271&ncdver=1&DocID=220.12&bc=gAAAAAgAAAAAAA%3d%3d& Accessed September 2019.
History
Date Comments 09/01/16 New policy, approved August 9, 2016. Add to Medicine section. SPECT may be
considered medically necessary when criteria are met for select non-cardiac
indications. SPECT is not medically necessary for cerebrovascular indications. SPECT is
investigational when criteria are not met.
06/01/17 Annual review, approved May 23, 2017. Policy reorganized for clarity; no change in
policy statements.
07/01/18 Annual Review, approved June 12, 2018. Policy updated with literature search through
April 2018, References 10, 11,18, 19, 26-29 added. Added assessment of osteomyelitis
to medical necessity criteria. Deleted degenerative joint disease/arthritis of the facet
joints from the vertebral abnormalities medical necessity criteria.
https://acsearch.acr.org/docs/69369/Narrative/https://acsearch.acr.org/docs/69371/Narrative/https://acsearch.acr.org/docs/69435/Narrative/https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=271&ncdver=1&DocID=220.12&bc=gAAAAAgAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=271&ncdver=1&DocID=220.12&bc=gAAAAAgAAAAAAA%3d%3d&
Page | 12 of 12 ∞
Date Comments 10/01/19 Annual Review, approved September 5, 2019. Policy updated with literature search
through August 2019. References 32 and 33 added. Minor edits made for clarity.
Otherwise, policy statements unchanged. Added HCPCS code A9507, removed CPT
code 78607.
Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The
Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and
local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review
and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit
booklet or contact a member service representative to determine coverage for a specific medical service or supply.
CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). ©2019 Premera
All Rights Reserved.
Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when
determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to
the limits and conditions of the member benefit plan. Members and their providers should consult the member
benefit booklet or contact a customer service representative to determine whether there are any benefit limitations
applicable to this service or supply. This medical policy does not apply to Medicare Advantage.
037404 (11-06-2019)
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мовної підтримки. Телефонуйте за номером 800-971-1491 (телетайп: 711). ្របយ័ត�៖ េបើសិន�អ�កនិ�យ ��ែខ�រ, េស�ជំនួយែផ�ក�� េ�យមិនគិតឈ� �ល
គឺ�ច�នសំ�ប់បំេរ �អ�ក។ ចូរ ទូរស័ព� 800-971-1491 (TTY: 711)។ 注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。800-971-1491(TTY:711)
まで、お電話にてご連絡ください。 ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ
800-971-1491 (መስማት ለተሳናቸው: 711). XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 800-971-1491 (TTY: 711).
.)711: والبكم الصم ھاتف رقم ( 800-971-1491 برقم اتصل. بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة، اذكر تتحدث كنت إذا: ملحوظةਿਧਆਨ ਿਦਓ: ਜੇ ਤੁਸ� ਪੰਜਾਬੀ ਬੋਲਦੇ ਹੋ, ਤ� ਭਾਸ਼ਾ ਿਵੱਚ ਸਹਾਇਤਾ ਸਵੇਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਧ ਹੈ। 800-971-1491
(TTY: 711) 'ਤੇ ਕਾਲ ਕਰੋ। ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.
Rufnummer: 800-971-1491 (TTY: 711). ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ,
ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 800-971-1491 (TTY: 711). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 800-971-1491 (TTY: 711). ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 800-971-1491 (ATS : 711). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 800-971-1491 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 800-971-1491 (TTY: 711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero
800-971-1491 (TTY: 711). .دیریبگ تماس TTY: 711) 1491-971-800) با. باشد یم فراھم شما یبرا گانیرا بصورت یزبان التیتسھ د،یکن یم گفتگو فارسی زبان بھ اگر: توجھ
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