General Information
It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Purpose
SPECT: Single-Photon Emission Computed Tomography (SPECT) is a nuclear medicine imaging technique used to localize data from gamma ray emitting injected
radiopharmaceuticals to specific anatomical locations within the patient. The resulting 3D images can be reconstructed in multiple planes much like a CT scan uses XR, SPECT
utilizes nuclear scintigraphy.

SPECT can be used localize a tumor, inflammatory process, or radioactive tracer distribution. Vascular flow and blood pool imaging are included if performed. The 78803
code represents single–day imaging of a single area, such as the head, neck, chest, or pelvis, or a single acquisition on one day.

SPECT/CT: (Single-photon emission computed tomography combined with Computed Tomography) is now available in many places. The CT portion helps correct the attenuation (decrease) of photons from the target as they get absorbed/reflected by the soft tissues before reaching the detector. CT helps with anatomic localization much like the CT of PET/CT.

When SPECT/CT is requested, additional CT approvals are NOT needed/provided (unless approvable for other separate indications per guidelines for that body part). The CT portion of a SPECT/CT is included in the specific CPT (i.e., 78830 — SPECT/CT, single area, single day and 78832 — SPECT/CT, multiple areas).

This guideline includes both to SPECT and SPECT/CT when routine dynamic and planar imaging is, or is projected to be, insufficient for the following indications.

INDICATIONS
Bone/Joint
Malignancy^1,2,3
Note: For known bone metastases, whole body planar bone scan for staging and restaging is typically sufficient. For patients with impaired renal function who cannot receive iodinated or gadolinium-based contrast agents or undergo MRI for other reasons, SPECT imaging can improve the performance of conventional planar nuclear bone imaging.

• Screening evaluation of patients with malignancy presenting with elevated alkaline phosphatase, bone pain, or new pathological fracture
• Staging or Restaging evaluation when recent overlapping whole-body imaging (CT or PET/CT of the neck, chest, abdomen and pelvis) has not been performed, cannot be performed, or is inconclusive in evaluation of bone metastases
• Staging and restaging for radionuclide bone therapy for predominant bone metastases 

Infection^3,4

• Osteomyelitis: confirmed by both a plain X-ray AND an MRI of the area 
  • if MRI is contraindicated/cannot be performed, technically limited or inconclusive, only x-ray is necessary
• Discitis: MRI is contraindicated, technically limited or inconclusive 

Bone Viability⁵

• Detection of early avascular necrosis, bone infarct, or bone graft viability when patient has had a plain x-ray; and MRI is contraindicated/cannot be performed, technically limited or inconclusive

Trauma

• Extremities: Detection of stress fractures and other occult skeletal trauma when there is persistent pain in the suspected area after negative or inconclusive x-ray and MRI⁶
• Spine:
  • For indications such as spondylolysis or determination of age of fracture after CT/MRI is inconclusive⁷
  • Spondylolysis evaluation in a child, with persistent pain after MRI and conservative treatment, in determining further treatment plan⁸

Inconclusive^7,9,10,11

• Inconclusive MRI/CT
• Identification of a primary etiology (via most reactive/ inflammatory changes) when multiple etiologies are identified by MRI/CT, AND intervention planning is needed (includes primary facet joint target localization)

NOTE: Inconclusive includes the scenario when imaging findings do not explain patient clinical symptoms or lack of treatment efficacy.

Post-operative^7,12,13

• Evaluation of persistent symptoms in postoperative spine/joints/bones, after X-ray and/or CT are negative/inconclusive

Extremities^14,15,16

• For evaluation of unexplained extremity pain when clinical criteria and other imaging (X-ray, AND MRI/Ultrasound/CT) evaluation is inconclusive (e.g., differentiating complex regional pain syndrome from other causes of pain)

Follow-Up

• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Non-Bone Infection/Inflammation^17,18,19
When primary standard modality of CT/CTA/MRI/Ultrasound are inconclusive, limited, or cannot be done, including:

• Fever of Unknown Origin when CT/MR are negative/inconclusive/limited
• Non-bone infection/inflammation when primary standard imaging is negative/inconclusive, including infections related to
  • Transplant and vascular grafts when ultrasound/ CTA are negative/inconclusive/limited
  • Prosthetic valves when echocardiography AND Coronary CTA are inconclusive
  • Cardiac implantable devices when echocardiography is inconclusive

Tumor

• Iodine imaging for subsequent post thyroidectomy staging of differentiated thyroid cancers, in the setting of:²⁰
  • Post thyroidectomy neck CT/MR showing residual unresectable thyroid tissue/disease in the neck
  • Distant metastases as seen on CT/MR
  • Post thyroidectomy unstimulated thyroglobulin > 5 – 10 ng/ml
  • Radioactive iodine therapy is being considered for high risk or recurrent tumor
  • Post radioiodine treatment (post therapy scan)
  • During surveillance, with rising thyroglobulin or stable/rising antithyroglobulin antibodies or abnormal ultrasound neck

Note: Refer to neck for thyroid nodules

• For initial or restaging of Neuroendocrine tumors (typically In111-octreotide and Iodine-123 MIBG), for any part of the body²¹
  • When CT/MRI OR PET imaging is not available, cannot be done, has contraindications, or is inconclusive
  • I-131 MIBG: when I131 MIBG therapy is being considered
  • In111- octreotide: Somatostatin analog therapy is being considered and Ga68 Dotatate PET is not available
• Imaging during / post therapy with radiotherapeutic agents when it can change management
• Lymphoscintigraphy with sentinel node localizations, for preoperative planning in melanoma, breast, head and neck, and gynecological cancers

Cardiac
See Evolent Clinical Guideline 024 for Myocardial Perfusion Imaging and Evolent Clinical Guideline 027 for Multiple Gated Acquisition Scan.

Neck 
Non-Cancer

• Parathyroid adenoma: Clinically or laboratory proven hyperparathyroidism AND ultrasound of the neck has been completed. If CT is already done, it should be inconclusive.²²
• Thyroid: Abnormal thyroid function tests and planar imaging is inconclusive for the location of a focal thyroid lesion

NOTE: Parathyroid adenomas are evaluated typically initially by cervical ultrasound. Thyroid disorders that are diffuse typically do not need SPECT imaging. However, it may be needed in cases of differentiation of a single cold nodule in the background of multinodular goiter to direct biopsy.

Lung

• Quantification of lung function prior to lung resection/radiation
• Evaluation of congenital cardiac, thoracic, or pulmonary disease, or lung transplants or bronchopleural fistulae²³
• Chronic thromboembolic pulmonary hypertension
• Suspected acute pulmonary embolism with comorbidities (such as COPD, left heart failure, pneumonia, tumor) AND chest X-ray has been performed, AND chest CTA cannot be performed or limited
• Calculation of lung shunt fraction prior to hepatic radioembolization

Brain

• For preoperative localization of epileptic foci after EEG, Brain MRI and PET are done and insufficient²⁴
• DAT scan^25,26
  • To differentiate essential tremor and drug-induced parkinsonism from parkinsonian syndromes
  • For early/inconclusive parkinsonian features
  • For dementia: differentiating Dementia with Lewy Bodies (DLB) from other dementia types, if FDG PET was inconclusive.
• To evaluate cerebrovascular reserve in planning appropriate endovascular/vascular intervention or neurovascular surgical approach — can include:
  • Evaluation for vascular diseases such as Moyamoya²⁷
  • Carotid balloon occlusion²⁸
  • Hyperperfusion syndromes²⁹
  • Shunting for idiopathic normal pressure hydrocephalus³⁰
• Brain perfusion study for evaluation of brain death when CT or MRI already done and planar images are inconclusive³¹
• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Radionuclide Cisternography (CSF)³²

• CSF imaging (for evaluation of hydrocephalus, leak, shunt, normal pressure hydrocephalus, spontaneous intracranial hypotension) when
  • Brain/spine or respective site imaging already performed with appropriate CT/MRI/CT myelography, and deemed to be insufficient; AND
  • Planar images projected to be insufficient for localization of abnormality
• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Renal^33,34
Complex clinical scenarios involving the following indications for which cross-sectional imaging and routine dynamic planar imaging alone is, or projected to be, insufficient:

• Evaluation of renal collecting system for trauma, surgery, obstruction in ADULTS, or with signs, symptoms, and laboratory findings supporting the need for such an evaluation in adults; AND
  • CT has been performed and is inconclusive or contraindicated
• For evaluation of renal collecting system for obstruction or vesicoureteral reflux in children and young females:
  • After ultrasound and VCUG (voiding cystourethrography)/VUS (voiding urosonography) are inconclusive or discordant with clinical picture
• For diagnosis of reno-vascular hypertension with signs, symptoms, laboratory findings, or other imaging supporting the need for such a diagnosis when
  • Duplex ultrasound is inconclusive; AND
  • MRA or CTA cannot be performed or is contraindicated; AND
  • The patient has adequate renal function (GFR > 30) mL/min/1.73 m2) to undergo the study
• Further evaluation of renal perfusion and split function after completion of ultrasound, including in the setting of surgery, trauma, infection, congenital and  mass  abnormalities
• Diagnosis of renal transplant complications after ultrasound has been performed
• Evaluation of renal infections and discrimination of pyelonephritis from cortical scarring
• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Abdomen/Pelvis

• Hepatic radioembolization³⁵
  • For evaluation of pulmonary and gastrointestinal shunts or dosimetry calculations prior to procedure (typically utilizing Tc MAA) (78835 – Radiopharmaceutical quantification measurement)
  • Post-procedure imaging in lieu of PET to determine dose effect/dose toxicity (using the Y90 radiation itself)³⁶ (78835 — Radiopharmaceutical quantification measurement)
• For evaluation of the following:^37,38,39
  • Intermittent/occult gastrointestinal bleeding after initial workup is indeterminate/contraindicated (scopes, CTA)
  • Indeterminate or vascular hepatic lesions or bleed when CT/MRI are contraindicated/inconclusive
  • Indeterminate accessory splenic tissue/asplenia when CT/MRI are contraindicated/inconclusive
• Liver transplant (and other hepatic surgery/radiation) preoperative and postoperative function and complications when ultrasound/CT/MR are indeterminate or contraindicated^37,38*
• Localization of:
  • Suspected ectopic/residual gastric tissue (e.g., Meckel’s diverticulum)
  • Abnormalities in hepatobiliary scintigraphy (e.g., biliary abnormalities/leaks) when ultrasound (in infants) or CT is inconclusive/contraindicated
• Peritoneal imaging for evaluation of complications of shunts, dialysis, or peritoneal integrity, when CT is inconclusive/contraindicated³⁷
• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Further Evaluation of Indeterminate Findings on Prior
Imaging
Unless follow up is otherwise specified within the guideline:

• For initial evaluation of an inconclusive finding on a prior imaging report that requires further clarification
• One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred. (No further surveillance unless specified as highly  suspicious or change was found on last follow-up exam.)

References

1. Donohoe K, Cohen E, Giammarile F, Grady E, Greenspan B et al. Appropriate Use Criteria for Bone Scintigraphy in Prostate and Breast Cancer: Summary and Excerpts. J Nucl Med. Apr 2017; 58: 14n-17n.
2. O'Sullivan G, Carty F, Cronin C. Imaging of bone metastasis: An update. World J Radiol. Aug 28, 2015; 7: 202-11. 10.4329/wjr.v7.i8.202.
3. Walker E, Beaman F, Wessell D, Cassidy R, Czuczman G et al. ACR Appropriateness Criteria® Suspected Osteomyelitis of the Foot in Patients with Diabetes Mellitus. J Am Coll Radiol. Nov 2019; 16: S440-s450. 10.1016/j.jacr.2019.05.027.
4. Pierce J, Perry M, Wessell D, Lenchik L, Ahlawat S et al. ACR Appropriateness Criteria® Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue Infection (Excluding Spine and Diabetic Foot): 2022 Update. Journal of the American College of Radiology. 2022; 19: S473 - S487. 10.1016/j.jacr.2022.09.013.
5. Ha A, Chang E, Bartolotta R, Bucknor M, Chen K et al. ACR Appropriateness Criteria® Osteonecrosis: 2022 Update. Journal of the American College of Radiology. 2022; 19: S409 - S416. 10.1016/j.jacr.2022.09.009.
6. Bencardino J, Stone T, Roberts C, Appel M, Baccei S et al. ACR Appropriateness Criteria (®) Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other  Vertebrae. J Am Coll Radiol. May 2017; 14: S293-s306. 10.1016/j.jacr.2017.02.035.
7. American College of Radiology. ACR Appropriateness Criteria® Low Back Pain. 2021; 2023:
8. Goetzinger S, Courtney S, Yee K, Welz M, Kalani M. Spondylolysis in Young Athletes: An Overview Emphasizing Nonoperative Management. J Sports Med (Hindawi Publ Corp). 2020; 2020: 9235958. 10.1155/2020/9235958.
9. Brusko G, Perez-Roman R, Tapamo H, Burks S, Serafini A. Preoperative SPECT imaging as a tool for surgical planning in patients with axial neck and back pain. Neurosurg Focus. Dec 1, 2019; 47: E19. 10.3171/2019.9.Focus19648.
10. Cohen S, Bhaskar A, Bhatia A, Buvanendran A, Deer T et al. Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Reg Anesth Pain Med. Jun 2020; 45: 424-467. 10.1136/rapm-2019-101243.
11. Tender G, Davidson C, Shields J, Robichaux J, Park J et al. Primary pain generator identification by CT-SPECT in patients with degenerative spinal disease. Neurosurg Focus. Dec 1, 2019; 47: E18. 10.3171/2019.9.Focus19608.
12. Bäcker H, Steurer-Dober I, Beck M, Agten C, Decking J et al. Magnetic resonance imaging (MRI) versus single photon emission computed tomography (SPECT/CT) in painful total hip arthroplasty: a comparative multi-institutional analysis. Br J Radiol. Jan 2020; 93: 20190738. 10.1259/bjr.20190738.
13. Peters M, Bastiaenen C, Brans B, Weijers R, Willems P. The diagnostic accuracy of imaging modalities to detect pseudarthrosis after spinal fusion-a systematic review and meta-analysis of the literature. Skeletal Radiol. Oct 2019; 48: 1499-1510. 10.1007/s00256-019-03181-5.
14. Ha S, Hong S, Paeng J, Lee D, Cheon G et al. Comparison of SPECT/CT and MRI in diagnosing symptomatic lesions in ankle and foot pain patients: diagnostic performance and relation to lesion type. PLoS One. 2015; 10: e0117583. 10.1371/journal.pone.0117583.
15. Israel O, Pellet O, Biassoni L, De Palma D, Estrada-Lobato E et al. Two decades of SPECT/CT - the coming of age of a technology: An updated review of literature evidence. Eur J Nucl Med Mol Imaging. Sep 2019; 46: 1990-2012. 10.1007/s00259-019-04404-6.
16. Shin S, Kim S. Bone scintigraphy in patients with pain. Korean J Pain. Jul 2017; 30: 165-175. 10.3344/kjp.2017.30.3.165.
17. Sethi I, Baum Y, Grady E. Current Status of Molecular Imaging of Infection: A Primer. AJR Am J Roentgenol. Aug 2019; 213: 300-308. 10.2214/ajr.19.21094.
18. Lauri C, Iezzi R, Rossi M, Tinelli G, Sica S et al. Imaging Modalities for the Diagnosis of Vascular Graft Infections: A Consensus Paper amongst Different Specialists. J Clin Med. May 17, 2020; 9: 10.3390/jcm9051510.
19. Galea N, Bandera F, Lauri C, Autore C, Laghi A. Multimodality Imaging in the Diagnostic Work-Up of Endocarditis and Cardiac Implantable Electronic Device (CIED)  Infection. J Clin Med. Jul 14, 2020; 9: 10.3390/jcm9072237.
20. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Thyroid Carcinoma Version 1.2024. 2024.
21. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Neuroendocrine and Adrenal Tumors Version 1.2023. 2023.
22. Itani M, Middleton W. Parathyroid Imaging. Radiol Clin North Am. Nov 2020; 58: 1071-1083. 10.1016/j.rcl.2020.07.006.
23. American College of Radiology (ACR), Society for Pediatric Radiology (SPR) , Society of Thoracic Radiology (STR). ACR-SPR-STR practice parameter for the performance of pulmonary scintigraphy. 2018; 2022:
24. von Oertzen T. PET and ictal SPECT can be helpful for localizing epileptic foci. Curr Opin Neurol. Apr 2018; 31: 184-191. 10.1097/wco.0000000000000527.
25. Buchert R, Buhmann C, Apostolova I, Meyer P, Gallinat J. Nuclear Imaging in the Diagnosis of Clinically Uncertain Parkinsonian Syndromes. Dtsch Arztebl Int. Nov 1, 2019; 116: 747-754. 10.3238/arztebl.2019.0747.
26. Hustad E, Aasly J. Clinical and Imaging Markers of Prodromal Parkinson’s Disease. Front Neurol. 2020; 11: 395. 10.3389/fneur.2020.00395.
27. White T, Gandhi S, Langer D, Katz J, Dehdashti A. Does Advanced Imaging Aid in the Preoperative Evaluation of Patients With. Cureus. 2022; 14: e29816.
28. Tansavatdi K, Dublin A, Donald P, Dahlin B. Combined Balloon Test Occlusion and SPECT Analysis for Carotid Sacrifice. Journal of neurological surgery. Part B, Skull base. 2015; 76: 249-51.
29. Richardson T, Beech P, Cloud G. Limb-shaking TIA: a case of cerebral hypoperfusion in severe cerebrovascular disease in a young adult. BMC Neurology. 2021; 21: true. 10.1186/s12883-021-02296-4.
30. Thavarajasingam S, El-Khatib M, Vemulapalli K, Iradukunda H, K S et al. Radiological predictors of shunt response in the diagnosis and treatment of. Acta neurochirurgica. 2023; 165: 369-419.
31. Donohoe K, Agrawal G, Frey K, Gerbaudo V, Mariani G et al. SNM practice guideline for brain death scintigraphy 2.0. J Nucl Med Technol. Sep 2012; 40: 198-203. 10.2967/jnmt.112.105130.
32. Moonis G, Subramaniam R, Trofimova A, Burns J, Bykowski J et al. ACR Appropriateness Criteria® Dementia. J Am Coll Radiol. May 2020; 17: S100-s112. 10.1016/j.jacr.2020.01.040.
33. American College of Radiology (ACR), American College of Nuclear Medicine (ACNM) , Society of Nuclear Medicine and Molecular Imaging (SNMMI) , Society for Pediatric Radiology (SPR). ACRACNM-SNMMI-SPR practice parameter for the performance of radionuclide cystography. 2020; 2022:
34. American College of Radiology (ACR), Society for Pediatric Radiology (SPR). ACR-SPR practice parameter for the performance of renal scintigraphy. 2022; 2023:
35. Hong K, Akinwande O, Bodei L, Chamarthy M, Devlin P et al. ACR-ABS-ACNM-ASTRO-SIRSNMMI practice parameter for selective internal radiation therapy or radioembolization for treatment of liver malignancies. Brachytherapy. May-Jun 2021; 20: 497-511. 10.1016/j.brachy.2021.01.006.
36. Kim S, Cohalan C, Kopek N, Enger S. A guide to (90)Y radioembolization and its dosimetry. Phys Med. Dec 2019; 68: 132-145. 10.1016/j.ejmp.2019.09.236.
37. American College of Radiology (ACR), American College of Nuclear Medicine (ACNM) , Society of Nuclear Medicine and Molecular Imaging (SNMMI) , Society for Pediatric Radiology (SPR). ACRACNM-SNMMI-SPR practice parameter for the performance of gastrointestinal tract, hepatic, and splenic scintigraphy. 2020; 2022:
38. American College of Radiology (ACR), American College of Nuclear Medicine (ACNM) , Society of Nuclear Medicine and Molecular Imaging (SNMMI) , Society for Pediatric Radiology (SPR). ACRACNM-SNMMI-SPR practice parameter for the performance of hepatobiliary scintigraphy. 2021; 2023:
39. American College of Radiology. ACR Appropriateness Criteria® Liver Lesion-Initial Characterization. 2020; 2023:

Coding Section

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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