Aetna SPECT coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• Non-cardiac SPECT is medically necessary for ANY ONE of the following indications (items below).
• Assessment of osteomyelitis, to distinguish bone from soft tissue infection
• Detection of spondylolysis and stress fractures not visible from x-ray
• Diagnosing and assessing hemangiomas of the liver
• Diagnosing pulmonary embolism (by means of SPECT ventilation/perfusion scintigraphy)
• Differentiation of necrotic tissue from tumor of the brain
• Distinguishing Parkinson's disease from essential tremor (e.g., DaTSCAN [Ioflupane I-123 injection])
• Fever of unknown origin, where initial studies have failed to identify the infection site
• Imaging of parathyroids in parathyroid disease
• Liver metastases or primary liver tumors, before and after hepatic artery chemotherapy infusion or chemoembolization with radioactive spheres
• Localization of abscess, for suspected or known localized infection or inflammatory process
• Lymphoma, to distinguish tumor from necrosis
• Neuroendocrine tumors, diagnosis and staging
• Pre-surgical ictal detection of seizure focus in members with epilepsy (in place of PET)
• Thyroid cancer, iodine imaging for initial and subsequent staging
• SPECT-CT fusion for parathyroid imaging is medically necessary in persons with an enlarged parathyroid gland, parathyroid hyperplasia, OR suspected parathyroid adenoma or carcinoma, AND laboratory evidence of hyperparathyroidism (meet BOTH: parathyroid hormone greater than 55 pg/ml AND serum calcium greater than 10.2 mg/dL)
• Cardiac: SPECT is medically necessary for the diagnosis of coronary artery disease AND for assessment of prognosis in persons with coronary artery disease, EXCEPT as outlined in the exclusion criteria; for specific cardiac medical necessity criteria, refer to eviCore Healthcare Cardiac Imaging Clinical Guidelines
• Repeat cardiac nuclear imaging as frequently as annually may be medically necessary IF there is a history of congestive heart failure AND the member is status post re-vascularization (carve-out from the otherwise-inappropriate repeat-imaging exclusions)

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 78071·PA verdict·Rate
• 78072·PA verdict·Rate
• 78803·PA verdict·Rate
• 78830·PA verdict·Rate
• 78831·PA verdict·Rate
• 78832·PA verdict·Rate
• A9584·PA verdict·Rate

Frequently asked questions

When does Aetna cover SPECT (CPT 78071), and what gets it denied?

Aetna CPB 0376 covers SPECT (and SPECT-CT) imaging as medically necessary for a defined list of non-cardiac indications (e.g., osteomyelitis, spondylolysis/stress fractures, liver hemangiomas, pulmonary embolism, distinguishing Parkinson's from essential tremor, parathyroid imaging, neuroendocrine and thyroid cancer staging, seizure-focus localization) and for the diagnosis and prognosis of coronary artery disease per eviCore cardiac imaging guidelines. Coverage is gated to those specific indications: a long list of cardiac scenarios (deemed "inappropriate" per ACC) and essentially all other non-cardiac uses are considered experimental/investigational and not covered, and SPECT-CT parathyroid imaging additionally requires lab evidence of hyperparathyroidism (PTH greater than 55 pg/ml and serum calcium greater than 10.2 mg/dL). Precertification "may be required" for select procedures, checked via Aetna's CPT code search tool. Coverage criteria include: Non-cardiac SPECT is medically necessary for ANY ONE of the following indications (items below).; Assessment of osteomyelitis, to distinguish bone from soft tissue infection; Detection of spondylolysis and stress fractures not visible from x-ray; Diagnosing and assessing hemangiomas of the liver; Diagnosing pulmonary embolism (by means of SPECT ventilation/perfusion scintigraphy); Differentiation of necrotic tissue from tumor of the brain; Distinguishing Parkinson's disease from essential tremor (e.g., DaTSCAN [Ioflupane I-123 injection]); Fever of unknown origin, where initial studies have failed to identify the infection site; Imaging of parathyroids in parathyroid disease; Liver metastases or primary liver tumors, before and after hepatic artery chemotherapy infusion or chemoembolization with radioactive spheres; Localization of abscess, for suspected or known localized infection or inflammatory process; Lymphoma, to distinguish tumor from necrosis; Neuroendocrine tumors, diagnosis and staging; Pre-surgical ictal detection of seizure focus in members with epilepsy (in place of PET); Thyroid cancer, iodine imaging for initial and subsequent staging; SPECT-CT fusion for parathyroid imaging is medically necessary in persons with an enlarged parathyroid gland, parathyroid hyperplasia, OR suspected parathyroid adenoma or carcinoma, AND laboratory evidence of hyperparathyroidism (meet BOTH: parathyroid hormone greater than 55 pg/ml AND serum calcium greater than 10.2 mg/dL); Cardiac: SPECT is medically necessary for the diagnosis of coronary artery disease AND for assessment of prognosis in persons with coronary artery disease, EXCEPT as outlined in the exclusion criteria; for specific cardiac medical necessity criteria, refer to eviCore Healthcare Cardiac Imaging Clinical Guidelines; Repeat cardiac nuclear imaging as frequently as annually may be medically necessary IF there is a history of congestive heart failure AND the member is status post re-vascularization (carve-out from the otherwise-inappropriate repeat-imaging exclusions). Applies to 7 codes: 78071, 78072, 78803, 78830, 78831, 78832, A9584. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. The bulletin states: "Precertification may be required for select procedures and interventions." It directs providers to use the CPT code search tool on Aetna's precertification lists webpage to determine whether precertification is required for a given code. No automatic precertification mandate is stated for all SPECT procedures, and no further submission process is detailed in the bulletin text. Policy exclusions and limitations: Cardiac SPECT myocardial perfusion imaging is considered inappropriate (experimental/investigational): As routine screening after PTCA with or without stenting, or after CABG, prior to discharge from the acute care setting; Cardiac SPECT MPI inappropriate: As routine screening after a re-vascularization procedure at an interval of LESS THAN 2 years if there are no worsening symptoms and no history of congestive heart failure (EXCEPTION/WAIVED: if a CHF history exists and member is status post re-vascularization, repeat nuclear imaging as frequently as annually may be medically necessary); Cardiac SPECT MPI inappropriate: Assessment of vulnerable plaque; Cardiac SPECT MPI inappropriate: Detection of transplant rejection; Cardiac SPECT MPI inappropriate: Evaluation of a member with an acute coronary event AND hemodynamic instability, shock, or mechanical complications; Cardiac SPECT MPI inappropriate: In acute chest pain / equivalent symptoms with high likelihood of acute coronary syndrome when acute MI is diagnosed, in the immediate post-thrombolytic period, OR with high pre-test likelihood of significant coronary disease shown by marked ST elevation; Cardiac SPECT MPI inappropriate: Prediction of treatment resistance in late-onset depression in individuals with Lewy body disease; Cardiac SPECT MPI inappropriate: Prior to high-risk surgery when the member is asymptomatic with a normal cardiac catheterization, intervention, OR a normal nuclear stress test less than 1 year before surgery; Cardiac SPECT MPI inappropriate: Prior to intermediate-risk non-cardiac surgery if the member is capable of and has no contraindication to standard stress testing; Cardiac SPECT MPI inappropriate: Prior to low-risk non-cardiac surgery for risk assessment; Cardiac SPECT MPI inappropriate: Re-evaluation of members without chest pain / equivalent symptoms, without known coronary disease, at high-risk (Framingham score greater than 10), with an initial negative radionuclear imaging, when less than 2 years since the last study; Cardiac SPECT MPI inappropriate: Re-evaluation of members without chest pain / equivalent or with stable symptoms, with known coronary disease (prior abnormal catheterization or SPECT study but without prior infarction), when less than 1 year since the last radionuclear study (NOTE: if worsening symptoms or silent ischemia, more frequent imaging/intervention may be medically necessary); Cardiac SPECT MPI inappropriate: Screening of members with chest pain / equivalent when there is low probability of coronary disease (Framingham score less than 10), no history of diabetes, AND no impediments/contraindications to non-nuclear stress testing; Cardiac SPECT MPI inappropriate: Screening of members without chest pain / equivalent when there is low probability of coronary disease (Framingham score less than 10) AND no history of diabetes; Experimental/investigational: Myocardial sympathetic innervation imaging, with or without SPECT; Experimental/investigational: SPECT for absolute quantitation of myocardial blood flow (AQMBF); Experimental/investigational: SPECT for all other cardiac indications; Experimental/investigational: Freehand SPECT/ultrasonography fusion imaging in persons with thyroid disease; Experimental/investigational: SPECT-CT fusion imaging for other indications (e.g., detection of metastatic bone disease in malignancies, quantification of neutrophil uptake in lung cancer); Experimental/investigational: SPECT for all other non-cardiac indications (the items below are listed examples); Experimental/investigational non-cardiac: As an imaging marker of pre-diagnostic Parkinson's disease; Experimental/investigational non-cardiac: Assessment of eating disorders; Experimental/investigational non-cardiac: Detection of air leak / pneumothorax; Experimental/investigational non-cardiac: Diagnosis or assessment of members with attention deficit/hyperactivity disorder (ADHD); Experimental/investigational non-cardiac: Diagnosis or assessment of members with autism; Experimental/investigational non-cardiac: Diagnosis or assessment of members with personality disorders (aggressive/violent behaviors, anti-social personality disorder including psychopathy, schizotypal personality disorder, borderline personality disorder); Experimental/investigational non-cardiac: Diagnosis or assessment of members with schizophrenia; Experimental/investigational non-cardiac: Diagnosis or assessment of stroke members; Experimental/investigational non-cardiac: Diagnosis of lung cancers; Experimental/investigational non-cardiac: Diagnosis of ovarian cancer; Experimental/investigational non-cardiac: Diagnosis of painful legs and moving toes (PLMT) syndrome; Experimental/investigational non-cardiac: Differential diagnosis of Parkinson's disease from other Parkinsonian syndromes; Experimental/investigational non-cardiac: Differentiating malignant from benign lung lesions; Experimental/investigational non-cardiac: Evaluation of carotid stenosis; Experimental/investigational non-cardiac: Evaluation of members with endoleak; Experimental/investigational non-cardiac: Evaluation of members with generalized pain or insomnia; Experimental/investigational non-cardiac: Evaluation of members with head trauma; Experimental/investigational non-cardiac: Evaluation of Merkel cell carcinoma; Experimental/investigational non-cardiac: Evaluation of salivary gland dysfunction; Experimental/investigational non-cardiac: Initial or differential diagnosis of members with suspected dementia (Alzheimer's disease, dementia with Lewy bodies, frontotemporal dementia, vascular dementia); Experimental/investigational non-cardiac: Management of cortico-basal syndrome; Experimental/investigational non-cardiac: Management of progressive supranuclear palsy; Experimental/investigational non-cardiac: Management of systemic lupus erythematosus; Experimental/investigational non-cardiac: Multiple sclerosis; Experimental/investigational non-cardiac: Pre-surgical evaluation of members undergoing lung volume reduction surgery; Experimental/investigational non-cardiac: Prosthetic graft infection; Experimental/investigational non-cardiac: Scanning of the internal carotid artery during temporary balloon occlusion; Experimental/investigational non-cardiac: Surgical planning in individuals with axial neck and back pain from disc degeneration (spondylosis); Experimental/investigational non-cardiac: Vasculitis; Experimental/investigational non-cardiac: Work-up of individuals undergoing non-cardiac surgery. Claims may be denied when the requested service falls under these.

Does Aetna require prior authorization for SPECT?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. The bulletin states: "Precertification may be required for select procedures and interventions." It directs providers to use the CPT code search tool on Aetna's precertification lists webpage to determine whether precertification is required for a given code. No automatic precertification mandate is stated for all SPECT procedures, and no further submission process is detailed in the bulletin text.

What does Aetna exclude for SPECT?

Policy exclusions and limitations: Cardiac SPECT myocardial perfusion imaging is considered inappropriate (experimental/investigational): As routine screening after PTCA with or without stenting, or after CABG, prior to discharge from the acute care setting; Cardiac SPECT MPI inappropriate: As routine screening after a re-vascularization procedure at an interval of LESS THAN 2 years if there are no worsening symptoms and no history of congestive heart failure (EXCEPTION/WAIVED: if a CHF history exists and member is status post re-vascularization, repeat nuclear imaging as frequently as annually may be medically necessary); Cardiac SPECT MPI inappropriate: Assessment of vulnerable plaque; Cardiac SPECT MPI inappropriate: Detection of transplant rejection; Cardiac SPECT MPI inappropriate: Evaluation of a member with an acute coronary event AND hemodynamic instability, shock, or mechanical complications; Cardiac SPECT MPI inappropriate: In acute chest pain / equivalent symptoms with high likelihood of acute coronary syndrome when acute MI is diagnosed, in the immediate post-thrombolytic period, OR with high pre-test likelihood of significant coronary disease shown by marked ST elevation; Cardiac SPECT MPI inappropriate: Prediction of treatment resistance in late-onset depression in individuals with Lewy body disease; Cardiac SPECT MPI inappropriate: Prior to high-risk surgery when the member is asymptomatic with a normal cardiac catheterization, intervention, OR a normal nuclear stress test less than 1 year before surgery; Cardiac SPECT MPI inappropriate: Prior to intermediate-risk non-cardiac surgery if the member is capable of and has no contraindication to standard stress testing; Cardiac SPECT MPI inappropriate: Prior to low-risk non-cardiac surgery for risk assessment; Cardiac SPECT MPI inappropriate: Re-evaluation of members without chest pain / equivalent symptoms, without known coronary disease, at high-risk (Framingham score greater than 10), with an initial negative radionuclear imaging, when less than 2 years since the last study; Cardiac SPECT MPI inappropriate: Re-evaluation of members without chest pain / equivalent or with stable symptoms, with known coronary disease (prior abnormal catheterization or SPECT study but without prior infarction), when less than 1 year since the last radionuclear study (NOTE: if worsening symptoms or silent ischemia, more frequent imaging/intervention may be medically necessary); Cardiac SPECT MPI inappropriate: Screening of members with chest pain / equivalent when there is low probability of coronary disease (Framingham score less than 10), no history of diabetes, AND no impediments/contraindications to non-nuclear stress testing; Cardiac SPECT MPI inappropriate: Screening of members without chest pain / equivalent when there is low probability of coronary disease (Framingham score less than 10) AND no history of diabetes; Experimental/investigational: Myocardial sympathetic innervation imaging, with or without SPECT; Experimental/investigational: SPECT for absolute quantitation of myocardial blood flow (AQMBF); Experimental/investigational: SPECT for all other cardiac indications; Experimental/investigational: Freehand SPECT/ultrasonography fusion imaging in persons with thyroid disease; Experimental/investigational: SPECT-CT fusion imaging for other indications (e.g., detection of metastatic bone disease in malignancies, quantification of neutrophil uptake in lung cancer); Experimental/investigational: SPECT for all other non-cardiac indications (the items below are listed examples); Experimental/investigational non-cardiac: As an imaging marker of pre-diagnostic Parkinson's disease; Experimental/investigational non-cardiac: Assessment of eating disorders; Experimental/investigational non-cardiac: Detection of air leak / pneumothorax; Experimental/investigational non-cardiac: Diagnosis or assessment of members with attention deficit/hyperactivity disorder (ADHD); Experimental/investigational non-cardiac: Diagnosis or assessment of members with autism; Experimental/investigational non-cardiac: Diagnosis or assessment of members with personality disorders (aggressive/violent behaviors, anti-social personality disorder including psychopathy, schizotypal personality disorder, borderline personality disorder); Experimental/investigational non-cardiac: Diagnosis or assessment of members with schizophrenia; Experimental/investigational non-cardiac: Diagnosis or assessment of stroke members; Experimental/investigational non-cardiac: Diagnosis of lung cancers; Experimental/investigational non-cardiac: Diagnosis of ovarian cancer; Experimental/investigational non-cardiac: Diagnosis of painful legs and moving toes (PLMT) syndrome; Experimental/investigational non-cardiac: Differential diagnosis of Parkinson's disease from other Parkinsonian syndromes; Experimental/investigational non-cardiac: Differentiating malignant from benign lung lesions; Experimental/investigational non-cardiac: Evaluation of carotid stenosis; Experimental/investigational non-cardiac: Evaluation of members with endoleak; Experimental/investigational non-cardiac: Evaluation of members with generalized pain or insomnia; Experimental/investigational non-cardiac: Evaluation of members with head trauma; Experimental/investigational non-cardiac: Evaluation of Merkel cell carcinoma; Experimental/investigational non-cardiac: Evaluation of salivary gland dysfunction; Experimental/investigational non-cardiac: Initial or differential diagnosis of members with suspected dementia (Alzheimer's disease, dementia with Lewy bodies, frontotemporal dementia, vascular dementia); Experimental/investigational non-cardiac: Management of cortico-basal syndrome; Experimental/investigational non-cardiac: Management of progressive supranuclear palsy; Experimental/investigational non-cardiac: Management of systemic lupus erythematosus; Experimental/investigational non-cardiac: Multiple sclerosis; Experimental/investigational non-cardiac: Pre-surgical evaluation of members undergoing lung volume reduction surgery; Experimental/investigational non-cardiac: Prosthetic graft infection; Experimental/investigational non-cardiac: Scanning of the internal carotid artery during temporary balloon occlusion; Experimental/investigational non-cardiac: Surgical planning in individuals with axial neck and back pain from disc degeneration (spondylosis); Experimental/investigational non-cardiac: Vasculitis; Experimental/investigational non-cardiac: Work-up of individuals undergoing non-cardiac surgery. Claims may be denied when the requested service falls under these.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT