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

∞ Clicking this icon returns you to the hyperlinks menu above.

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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Tumawag sa 800-971-1491 (TTY: 711). УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби

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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