Medical Policy


Subject: Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
Document #: RAD.00023 Publish Date:    12/12/2018
Status: Reviewed Last Review Date:    11/08/2018


This document addresses the use of single photon emission computed tomography (SPECT) for non-cardiovascular indications. SPECT provides three-dimensional images of the concentration of a radiopharmaceutical within various tissues and organs, and is an established imaging modality for a number of different indications.

Note: Please see the following related document for additional information:

Position Statement

Medically Necessary:

SPECT scans are considered medically necessary for any of the following:

  1. Bone and joint conditions—to differentiate between infectious, neoplastic, avascular or a traumatic process.
  2. Brain tumors—to differentiate between lymphomas and infections such as toxoplasmosis particularly in the immunosuppressed, or recurrent tumor vs. radiation changes, when PET is not available.
  3. Liver hemangioma—using labeled red blood cells to further define lesions identified by other imaging modalities.
  4. Localization of abscess/infection/inflammation in soft tissues or cases of fever of unknown origin.
  5. Neuroendocrine tumors (for example, adenomas, carcinoid, pheochromocytomas, neuroblastoma, vasoactive intestinal peptide [VIP] secreting tumors, thyroid carcinoma, adrenal gland tumors)—using a monoclonal antibody (OctreoScan [Covidien, Hazelwood, MO]) or I-131 meta-iodobenzyl-guanidine (MIBG).
  6. Parathyroid imaging.
  7. Renal - Dimercaptosuccinic acid (DMSA) scan to assess the status of kidney for scarring and function.

Not Medically Necessary:

SPECT scans are considered not medically necessary for the evaluation or management of cerebrovascular accident (CVA, stroke), subarachnoid hemorrhage, or transient ischemic attack.

Investigational and Not Medically Necessary:

For noncardiovascular indications, SPECT scans are considered investigational and not medically necessary for all other purposes, including, but not limited to:

  1. Attention Deficit and Hyperactivity Disorder.
  2. Chronic fatigue syndrome.
  3. Colorectal carcinoma (for example, used with the monoclonal antibody or IMMU-4 and CEA-Scan® [Immunomedics Inc., Morris Plains, New Jersey]).
  4. Dopamine transporter (DaT) scan for all indications.
  5. Malignancies other than those listed as medically necessary.
  6. Neuropsychiatric disorders without evidence of cerebrovascular disease.
  7. Pervasive development disorders (PDD).
  8. Prostate carcinoma (for example, used with the monoclonal antibody ProstaScint® [EUSA Pharma, Langhorne, PA], with or without fusion imaging with computed tomography or magnetic resonance imaging).
  9. Scintimammography for breast cancer.
  10. SPECT/SISCOM for the preoperative evaluation of individuals with intractable focal epilepsy to identify and localize area(s) of epileptiform activity when other techniques designed to localize a focus are indeterminate.

Currently, there is sufficient evidence in the peer-reviewed medical literature in the form of randomized controlled clinical trials (RCTs) to support the use of SPECT in a variety of disease processes. The literature supports the clinical effectiveness and safety of this imaging for the diagnosis and evaluation of selected oncologic diseases; the evaluation of some specific central nervous system (CNS) disorders (for example, brain tumor, toxoplasmosis); and the investigation of bone, joint and soft tissue disorders for inflammation or infection. SPECT has been shown to be safe and effective for the monitoring of changes in these conditions over time, comparable to the gold standard of positron emission tomography (PET) scanning. In addition, non-randomized controlled clinical trials have established the safety and efficacy of SPECT in identifying infections. Early identification of acute infection, such as in appendicitis, may be critical to early intervention and positive outcome.


A DMSA renal scan using Technetium-99m labeled dimercaptosuccinic acid (DSMA) is a diagnostic imaging exam that evaluates the function, size, shape and position of the kidneys and detects scarring caused by frequent infections. Mohkam and colleagues (2010) evaluated 1476 children with pyelonephritis who had renal ultrasound, voiding cystourethrography (VCUG) and DMSA scanning. A total of 79% of the children with pyelonephritis had evidence of pyelonephritis on DMSA scan. Renal ultrasound results were abnormal in 31.5% of children, VCUG showed vesicoureteral reflux in 25.9% of the children. The National Institute for Health and Clinical Excellence 2007 guideline recommends DMSA scanning when power Doppler ultrasound is not available or if the diagnosis still cannot be confirmed. The American Urological Association 2017 Clinical Practice Guideline recommends a DMSA scan for children with vesicoureteral reflux to detect new renal scarring when renal ultrasound is abnormal.

Cerebrovascular Disease

The use of SPECT for the evaluation and management of cerebrovascular disease, including cerebrovascular accidents (CVA, stroke), subarachnoid hemorrhages, and transient ischemic attacks has been superseded by newer, more accurate imaging modalities. In recent years, the use of magnetic resonance angiography (MRA) and computed tomography angiography (CTA) has become the standard of care for these conditions and the use of SPECT has become obsolete in the presence of superior technologies. Perfusion magnetic resonance imaging (MRI) and computed tomography (CT) perfusion are more akin to SPECT, which measures perfusion, not vessel anatomy. In addition, other advanced imaging modalities, such as PET, have replaced SPECT for evaluating certain types of cancer, including lymphoma.

Pervasive Development Disorder

The diagnosis of pervasive developmental disorder (PDD) can be complex and difficult due to the diversity of the presentation of symptoms and their severity. Due to the multitude of possible causes, and potential confusion with other conditions, many tests exist that may or may not be appropriate. It is vital that parents of children suspected of the disorder seek early diagnosis and care for their child to increase any potential benefits of treatment. 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” (Filipek, 2000).

Diagnosis of Brain Death

Early diagnosis of brain death allows for discontinuation of artificial ventilation and early organ transplants. Brain death is determined by clinical findings, such as no brainstem reflexes and no responses to external stimuli. Diagnostic tests can also be used to assist in the diagnosis of brain death, including electroencephalography (EEG), evoked potentials, Doppler ultrasound, angiography, and SPECT. The typical SPECT finding of brain death is an empty skull appearance. The use of SPECT has been studied in helping to confirm the diagnosis of brain death. However, the current evidence is comprised of published studies with only small sample populations (Bertagna, 2009; Munari, 2005; Okuyaz, 2004).

Okuyaz and colleagues (2004) reported on 8 deeply comatose and clinically brain dead children who had SPECT and then observation for at least 24 hours following their SPECT. Six of the children showed lack of perfusion in the cerebrum and empty skull appearance. The 2 newborns had two consecutive SPECT scans. The first SPECT showed perfusion not consistent with brain death image. The second SPECT scans showed no perfusion. The authors concluded that while SPECT may confirm the diagnosis of brain death, clinical findings are still the mainstay for the diagnosis. Munari and colleagues (2005) compared SPECT with cerebral angiography in 20 clinically brain dead individuals. In order to avoid time lag, after SPECT, all individuals immediately underwent angiography before data analysis and map reconstruction. The results of the SPECT were interpreted by a specialist in nuclear medicine and the angiography results were interpreted by a neuroradiologist. Both were blinded to the results of the other investigation. Both SPECT and angiography confirmed brain death, showing absence of brain perfusion in 19 of 20 individuals. Further studies with larger groups are necessary to determine if SPECT can accurately diagnose the absence of brain perfusion. Joffe and colleagues (2010) conducted a literature review to determine the usefulness of SPECT testing to confirm the diagnosis of brain death. Using clinically confirmed brain death as the gold standard of comparison, the sensitivity and specificity of SPECT was 90% and 100% respectively. Using cerebral angiography as the gold standard of comparison, the sensitivity of SPECT was 100% and the specificity could not be determined as there were no individuals without clinical brain death undergoing the tests. The authors concluded that since SPECT is being used to diagnose the state of death, specificity of SPECT should be clarified.

Parkinson’s Disease

Dopamine transporter (DaT) scan injection (Ioflupane I 123) is a molecular imaging agent used during a SPECT scan to determine the location and concentration of dopamine transporters in the synapses of striatal dopaminergic neurons. It is becoming increasingly utilized as a tool for detecting the degeneration of the dopaminergic pathway, distinguishing those individuals with essential tremor from those with Parkinsonian syndromes.                                                                      

Kupsch and colleagues (2012) reported on an RCT (non-blinded) that compared DaT scanning in 102 individuals with a control group of 112 individuals. The study authors evaluated the clinical management of Parkinson’s, diagnosis, confidence of diagnosis, quality of life (QOL), health resource use, and the safety in those with uncertain diagnosis. Participants were evaluated at baseline, 4 weeks, 12 weeks, and 1 year. SPECT scans were performed at baseline and then evaluated for changes in clinical management plan and confidence of diagnosis. The most frequent change in clinical management at 12 weeks and 1 year was the initiation of medication not previously considered at baseline (50% in the imaging group compared with 21% in the control group). More participants in the imaging group had a change in their clinical management at 12 weeks and 1 year post-treatment when compared with the control group. Other changes in clinical management included more aggressive dopaminergic therapy and initiation of dopaminergic therapy. At 4 weeks, 45% of the DaT group had a change in diagnosis from baseline compared with 9% of the control group. At 12 weeks, 46% of the DaT group had a change in diagnosis from baseline compared with 12% in the control group. At 1 year, 54% of the DaT group had a change in diagnosis from baseline compared with 23% in the control group. All these reported changes were in the direction of better agreement between clinical diagnosis and imaging results. Confidence of diagnosis for participants suspected of Parkinson’s or non-Parkinson’s was higher at the 4 weeks, 12 weeks and 1 year with DaT imaging when compared with control group. QOL questionnaires and health resource use were similar between the imaging and control groups (no significant differences between the groups were observed). It is noted that changing the medications and initiating medications did not appear to have much of an impact on the participant’s QOL questionnaires as evidenced by the similarities between the two groups and the study didn’t show clinical utility.

In 2017, The American College of Radiology (ACR) in collaboration with the American College of Nuclear Medicine published a practice parameter for the performance of DaT SPECT imaging for movement disorders. The practice parameter stated the following:

  1. Clinical indications for DaT SPECT imaging include, but are not limited to:
    Differentiating Parkinsonian syndrome from essential tremor and drug-induced tremor in patients with:
    1. Worsening essential tremor
    2. Tremor who use neuroleptics
    3. Tremor “who want to know”
    4. Psychogenic features
    5. Dementia, to differentiate between Alzheimer disease and dementia with Lewy bodies (DLB)

These clinical indications are based on low quality evidence including reviews and retrospective studies.

Several other studies have been conducted evaluating the clinical utility of DaT scans in diagnosing and evaluating movement disorders, including Parkinson’s disease. Similar to the study by Kupsch and colleagues (2012), these studies most often sought to determine if the DaT scan changed clinical decision making and none demonstrated a clinically significant improvement in disease management or in in QOL as compared to the gold standard of clinical diagnosis (Bairactaris, 2009; Bajaj, 2014; Bega, 2015; Catafau, 2004; Cerasa, 2016; Gayed, 2015; Marshall, 2009; O’Brien, 2014; Seibyl, 2014; Vlaar, 2008).


DaT imaging using SPECT is increasingly being incorporated into consensus diagnostic criteria for DLB. Accurate recognition of DLB is essential for the development of disease-modifying treatments but the current clinical diagnostic criteria are limited by relatively poor sensitivity. A Cochrane Review (McCleery, 2015) evaluated the accuracy of DaT imaging for the diagnosis of DLB in individuals in secondary care who were suspected to have dementia or already diagnosed by clinical work-up. Systematic review of the literature through 2013 identified only a single study that used a neuropathological reference standard to assess the accuracy of DAT imaging for the diagnosis of DLB. A total of 22 participants in the study met consensus clinical criteria for DLB or National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) criteria for Alzheimer's disease, or both. Although the review concludes that this single study’s results suggest that DaT imaging may be an accurate means of excluding the diagnosis of DLB, it also acknowledges that the small sample size means the sensitivity and specificity estimates are imprecise.

A systematic review of the literature was conducted by Brigo and colleagues (2015) which similarly assessed the utility of DaT imaging in the differential diagnosis between DLB and other dementia syndromes. A total of eight studies were included, and three studies used a neuropathological reference standard which yielded sensitivity and specificity values higher than those adopting a clinical diagnostic reference. The authors pointed out that, “… the clinical utility of these studies lacking neuropathological diagnosis at autopsy as the reference standard is limited by the fact that they are intrinsically unable to demonstrate an accuracy of DAT imaging above that of careful clinical diagnosis alone.” The review concluded that the few studies that provided analysis of the correlation between DaT scans and a neuropathologic reference standard, versus clinical diagnosis, were each small but suggest that SPECT may be a more accurate method. Larger, confirmatory trials are warranted.

Prostate Cancer

ProstaScint, a monoclonal antibody (capromab pendetide) combined with radioactive indium-111, is used to detect prostate cancer. It is injected into the body and a gamma camera (designed to detect radioactivity) is then used to locate prostate cancer cells. ProstaScint may have a clinical benefit; however, there is a paucity of evidence demonstrating improved progression-free survival (PFS) following ProstaScint scans (including fusion with CT or MRI). In a study by Koontz (2008), 40 individuals, who had prostate specific antigen (PSA) recurrence after total prostatectomy, were scanned prior to salvage prostate bed radiotherapy. A total of 20 individuals had negative scans and 20 individuals had locally positive scans. The 2-year PFS rates were 60% for those individuals with a negative scan and 74% for those individuals with a positive scan. The researchers concluded that individuals “with locally positive scans did not have statistically different progression-free survival than those with a negative scan result.”

Pucar and colleagues (2008) concluded that “ProstaScint has no added benefit over other imaging modalities in evaluating post-radical prostatectomy recurrence, due to its low sensitivity for detecting local recurrences and bone metastases.” A prospective trial of 25 hormone-naive men with clinically localized prostate cancer, who received ProstaScint scanning, with blinded correlation by a radiologist and pathologist, found that sensitivity ranged from  37% to 87%, and specificity from 0% to 50%. According to the study authors, the scan seemed to have comparable affinity for both benign and malignant prostate tissue (Mouraviev, 2009).

El-Zawahry (2010) reported on a study using capromab pendetide (ProstaScint) with SPECT images to detect and localize prostate cancer in 69 participants with prostate cancer who had undergone radiation therapy. The goal of this study was to select appropriate individuals with biochemical recurrence of prostate cancer following radiation therapy and then offer cryosurgical ablation of the prostate and avoid premature androgen deprivation therapy. A total of 6 participants had metastatic signal on SPECT scanning and were not considered candidates for cryosurgical ablation. A total of 63 participants had prostate biopsy; of these, 6 had negative biopsy and were excluded from cryosurgical ablation. A total of 59 participants underwent cryosurgical ablation. Use of the SPECT in combination with prostate biopsy spared 2 participants from cryosurgical ablation and spared 44 participants from premature androgen deprivation therapy. While the use of SPECT imaging shows promise, this study is limited by a small group size and per the authors “more patients will be needed to confirm our results” (El-Zawahry, 2010).

Ellis and colleagues (2011) evaluated the use of capromab pendetide imaging with SPECT in primary prostate cancer for pretreatment staging and localization for radiotherapy dose escalation. The authors hypothesized that SPECT with ProstaScint could improve pretreatment prostate cancer staging. A total of 239 participants were evaluated for tumor stage using conventional staging and SPECT. Distant metastatic disease was identified in 22 participants, but this could not be clinically confirmed. A total of 7 participants had uptake in the pelvic lymphatic chain and 15 participants had uptake in other sites suspicious of metastatic disease. In 65 participants, neither conventional imaging, nor any other staging method could confirm the presence of distant metastatic uptake suggested by SPECT. These findings were thought to represent false positive results. While a 10-year follow-up showed overall survival was 85%, this study was characterized by several weaknesses, since it was not randomized and did not have a control group.

Shen and colleagues (2014) conducted a meta-analysis comparing the diagnostic performance of PET/CT, MRI, bone SPECT and bone scintigraphy (BS) in detecting metastases in individuals with prostate cancer. A total of 16 articles were chosen for inclusion, which reported on 27 different studies evaluating 1102 individuals. Four of the studies were retrospective and ten were prospective. Pooled sensitivity, specificity and the diagnostic odds ratio were reported on an individual and per-lesion basis. The authors concluded,

…PET/ CT was a better imaging modality than BS and bone SPECT on either a per-patient basis or a per-lesion basis. Moreover, PET/CT has several additional advantages: evaluation of osteolytic lesions in weight-bearing bones and particularly in the spine and pelvis…

The ACR states the following:  “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 remain unproven.” In the ACR 2017 Appropriateness Criteria for Post-treatment Follow-up of Prostate Cancer they state “ProstaScint shows very limited performance and is challenging to interpret. It is unlikely to provide benefit and is not routinely used in the evaluation of prostate cancer recurrence.” The National Comprehensive Cancer Network (2018) does not address ProstaScint.

Breast Cancer

Scintimammography, also known as breast scintigraphy, involves the use of monoclonal antibodies to target specific tissue types that are then analyzed with planar techniques or SPECT as a diagnostic tool for breast abnormalities. It has not been shown to improve health outcomes in individuals with breast cancer, populations being screened for breast cancer, or as an adjunct for diagnostic or surgical treatment planning. The evidence in the peer-reviewed literature is limited to small, uncontrolled studies that do not document outcome improvement (Ozulker, 2010). Another assessment on scintimammography reported the following conclusions (Sampalis, 2003):

Pan and colleagues (2010) reported on a meta-analysis of five types of non-invasive imaging methods (ultrasound, CT, MRI, scintimammography, and PET) for the evaluation of breast cancer recurrence and metastases. Ultrasound showed a sensitivity of 86% and specificity of 96%. CT sensitivity was 85% with specificity of 75%. MRI sensitivity was 95% and specificity 92%. Scintimammography had a sensitivity of 90%, specificity of 80%. PET was 95% with a specificity of 86%. Ultrasound had the highest specificity and PET had the highest sensitivity. This meta-analysis revealed that scintimammography does not have the highest specificity or sensitivity when compared with other modalities.

A 2012 retrospective study by Weigert and colleagues reported on 1042 individuals who underwent pathological analysis or follow-up imaging after having had at least 1 of the following: equivocal or negative mammogram or sonogram and an unresolved clinical concern; personal history of breast cancer or current cancer diagnosis; palpable masses negative on mammographic and sonographic examination; radiodense breast tissue; or high risk for breast cancer. Pathological analysis or follow-up imaging resulted in 250 positive findings and 792 negative findings. Individuals who had breast-specific gamma imaging were found to have positive results in 408 individuals and negative results in 634 individuals. While the authors concluded that “breast-specific gamma imaging significantly contributed to the detection of malignant or high-risk lesions in patients with negative or indeterminate mammographic findings,” there is no data showing improved clinical outcomes.

The ACR Appropriateness Criteria® for breast cancer (2017) concludes that there is insufficient evidence to support the use of scintimammography breast cancer screening, citing that radiation dose from scintimammography is higher than the dose of a digital mammogram, and it is not indicated for screening in its present form.


SPECT has also been studied for its application in the preoperative evaluation for those individuals with focal intractable epilepsy. A specialized type of SPECT scan, subtraction peri-ictal SPECT coregistered to MRI (SISCOM), is a recently developed neuroimaging modality that has been proposed to guide localization of seizure foci prior to epileptic surgery by measuring the differences in cerebral blood flow caused by changes in neuronal activity across the interictal, ictal and postictal states.

Tan (2008) reported on 50 individuals with focal epilepsy who had SPECT/SISCOM imaging prior to surgery. The authors evaluated if the results of SPECT/SISCOM alter surgery decisions. A consensus decision was made after presentation of data from a noninvasive evaluation (SPECT/SISCOM data was not provided initially). Consensus decisions were documented again following the presentation of SPECT/SISCOM data. For those individuals with localizing SPECT/SISCOM results, consensus decisions changed in 10 of 32 individuals. For those individuals with nonlocalizing SPECT/SISCOM results, consensus decisions changed in 1 of 18 individuals.

Seo and colleagues (2011) conducted a retrospective review of 14 children with intractable focal epilepsy, who all subsequently underwent respective epilepsy surgery. The authors studied individual medical records for clinical characteristics, surgical outcome, and localizing features on three preoperative diagnostic tests:  SPECT/SISCOM; PET; and magnetoencephalography (MEG). Each test was localized by comparing the concordance with intracranial electroencephalogram (iEEG). MEG and SPECT/SISCOM showed the most concordance with iEEG at 79% (11 of 14 children). PET showed a 13% concordance with iEEG (3 of 14 children). While using a multiple modality approach may enhance the ability to localize the epileptogenic zone in focal epilepsy, the use of iEEG cannot be completely excluded because the extent of curative resection may not be accurately determined without proper iEEG monitoring. The authors concluded that larger prospective trials are necessary to clearly define the role of multiple imaging modalities.

An observational study (von Oertzen, 2011) reported on the use of SISCOM in the presurgical evaluation of epilepsy in 175 individuals with drug-resistant epilepsy. The individuals had either nonlesional MRI or discordant results with the standard set of presurgical tests. The authors concluded that while the study had large numbers, it may have been insufficiently powered and “logistic regression analysis did not show any influencing factors with regard to the gold standard comparison.”

Other Indications

The efficacy of SPECT for other applications has not been firmly established due to the lack of published clinical studies for each application. Specifically, there is a lack of evidence regarding the use of SPECT in attention deficit and hyperactivity disorder (ADHD), autism spectrum disorders (ASDs), chronic fatigue syndrome, thyroid cancer, other malignant carcinomas, neuropsychiatric disorders, and radioembolization/selective internal radiation therapy (SIRT) (ACR-SIR, 2014; Castillo, 2014; Ilhan, 2015; Kan, 2015; Kashyup, 2011; Kucuk, 2013; Wei, 2016).


SPECT is an imaging method designed to provide information about the functional level of a specific part of the body. SPECT involves the injection of a low-level radioactive chemical, called a radiotracer, into the bloodstream. The images reflect the manner in which the tracer is processed by the body and thus this technology provides functional information, in contrast to the structural information provided by CT, MRI and ultrasound. Using various imaging protocols, scans are made with a device that can detect radioactivity in the body. Detailed information is generated by a SPECT camera, gamma camera, or tomograph. Each radiotracer used with SPECT is a radiation emitting substance that is used alone or attached to an element appropriate for obtaining specific information. For example, certain types of proteins called antibodies attach to specific types of tumors. The radiotracer can be attached to the antibodies so that they bind to the tumors, and thus can be identified and located.

SPECT can provide information about the level of chemical or cellular activity within an organ or system as well as provide structural information. This process may show areas of increased activity, such as the inflammation in an abscess. Patterns of distribution of the radiotracer can be correlated with various diseases. SPECT has been useful in early detection in brain and bone disorders, as well as some types of malignancies. The selection of a radiotracer and imaging protocol is specific to the disease process being investigated. SPECT scans may be repeated to follow the course of a disease.

SPECT is typically performed without the need of a hospital stay. The individual is given a dose of a radiotracer, which circulates in the bloodstream and binds to specific target cells. The emitted radiation from the radiotracer travels through body with little interference and is imaged. SPECT cameras can image large areas of the body, or the entire body.

Information acquired by SPECT frequently augments or confirms observations obtained by other testing. SPECT may also provide information not obtainable by means other than PET, which is a newer technology and may provide additional information in some settings. The images obtained through PET are generally of higher quality than those provided by SPECT; however, the availability, sensitivity, specificity, and impact on clinical outcomes when using PET varies by clinical condition. For many conditions, SPECT has been found to be as useful as PET and it is generally more available.

Both PET and SPECT may diagnose disease before any clinical symptoms or structural expressions of disease, by providing information about the level of functioning within a body system. CT, MRI, and planar scintigraphy are alternatives for providing structural information.


Abscess: A collection of pus often caused by the body’s response to an infection.

Adenoma: A benign tumor that arises in or resembles glandular tissue.

Carcinoid syndrome: A syndrome due to carcinoid tumors that secrete large amounts of the hormone serotonin. Carcinoid tumors usually arise in the gastrointestinal tract, anywhere between the stomach and the rectum and may metastasize (spread) to the liver.

Colorectal carcinoma: A cancer of the colon and rectum which is a malignant tumor arising from the inner wall of the large intestine.

Liver hemangioma: The most common benign tumor of the liver. It is made up of small blood vessels and is 4-6 times more common in women than men.

Neuroendocrine tumors: A diverse group of tumors, such as carcinoid, islet cell tumors, neuroblastoma, and small cell carcinomas of the lung. All have dense granules and produce polypeptides that can be identified by immunochemical methods.

Parkinsonian syndromes: A group of diseases that share similar cardinal signs of Parkinsonism characterized by bradykinesia, rigidity, tremor at rest, and postural instability.

Pervasive developmental disorders: Refers to a group of disorders characterized by delays in the development of socialization and communication skills which are often accompanied by cognitive and language delays.

Pyelonephritis: A type of urinary tract infection that can affect one or both kidneys.

Subarachnoid hemorrhage: Bleeding in the space between the two membranes that surround the brain.

Transient ischemic attack (TIA): A neurological event with the signs and symptoms of a stroke, but which go away within a short period of time. Also called a mini-stroke, a TIA is due to a temporary lack of adequate blood and oxygen (ischemia) to the brain.


The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Parathyroid; bone and joint; renal; inflammatory processes
When services are Medically Necessary:




Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT)


Bone and/or joint imaging; tomographic (SPECT)


Kidney imaging morphology; tomographic (SPECT)


Radiopharmaceutical localization of inflammatory process; tomographic (SPECT)



ICD-10 Diagnosis



All diagnoses

When Services may be Medically Necessary when criteria are met:




Brain imaging, tomographic (SPECT) [when not specified as DaT scan]



ICD-10 Diagnosis



Malignant neoplasm of cerebral meninges


Malignant neoplasm of brain


Malignant neoplasm of cranial nerves


Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck


Secondary malignant neoplasm of brain and cerebral meninges




Benign neoplasm of cerebral meninges


Benign neoplasm of brain


Benign neoplasm of cranial nerves


Neoplasm of uncertain behavior of cerebral meninges


Neoplasm of uncertain behavior of brain


Neoplasm of uncertain behavior of cranial nerves


Neoplasm of unspecified behavior of brain




Other headache syndromes


Narcolepsy and cataplexy


Other disorders of brain


Localized swelling, mass and lump, head


Fever of other and unknown origin




Convulsions, not elsewhere classified

When services are Not Medically Necessary:
For the procedure code listed above, for the following diagnoses

ICD-10 Diagnosis



Transient cerebral ischemic attacks and related syndromes


Vascular syndromes of brain in cerebrovascular disease


Nontraumatic subarachnoid hemorrhage


Nontraumatic intracerebral hemorrhage


Other and unspecified nontraumatic intracranial hemorrhage


Cerebral infarction


Occlusion and stenosis of precerebral arteries, not resulting in cerebral infarction


Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction


Other cerebrovascular diseases


Somnolence, stupor, coma


Transient alteration of awareness


Syncope and collapse


Traumatic hemorrhage of cerebrum, unspecified


Traumatic hemorrhage of cerebrum, unspecified


Traumatic subdural hemorrhage


Traumatic subdural hemorrhage


Traumatic subarachnoid hemorrhage


Traumatic subarachnoid hemorrhage


Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits

When services are Investigational and Not Medically Necessary:
For the procedure code listed above when criteria are not met or for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

When Services are also Investigational and Not Medically Necessary:




Brain imaging, tomographic (SPECT) [when specified as DaT scan]






Iodine I-123 ioflupane, diagnostic, per study dose, up to 5 millicuries [DaT scan]



ICD-10 Diagnosis



All diagnoses

When Services are Medically Necessary:




Liver imaging (SPECT)


Liver imaging (SPECT); with vascular flow



ICD-10 Diagnosis



Benign neoplasm of liver


Hemangioma of intra-abdominal structures


Hemangioma of other sites


Neoplasm of uncertain behavior of liver, gallbladder and bile ducts


Abdominal and pelvic pain


Hepatomegaly, not elsewhere classified


Hepatomegaly with splenomegaly, not elsewhere classified


Unspecified jaundice




Intra-abdominal and pelvic swelling, mass and lump


Abnormal findings on diagnostic imaging of liver and biliary tract

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above, for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

When Services are Medically Necessary:




Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT)



ICD-10 Diagnosis



Malignant neoplasm of thyroid gland


Malignant neoplasm of adrenal gland


Malignant neoplasm of parathyroid gland


Malignant neuroendocrine tumors


Secondary neuroendocrine tumors


Secondary malignant neoplasm of adrenal gland


Disseminated malignant neoplasm, unspecified


Benign neoplasm of adrenal gland


Benign neoplasm of parathyroid gland


Benign neuroendocrine tumors


Neoplasm of uncertain behavior of thyroid gland


Neoplasm of uncertain behavior of adrenal gland


Neoplasm of uncertain behavior of parathyroid gland




Hyperparathyroidism and other disorders of parathyroid gland


Carcinoid syndrome


Abdominal and pelvic pain


Nausea and vomiting


Flatulence and related conditions


Other symptoms and signs involving the digestive system and abdomen


Fever of other and unknown origin


Abnormal findings on diagnostic imaging of other parts of digestive tract


Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above, for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

When services are also Investigational and Not Medically Necessary:
For the following procedure codes for all diagnoses, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.




Cerebrospinal fluid flow, imaging (not including introduction of material); tomographic (SPECT)


Unlisted nervous system procedure, diagnostic nuclear medicine [when specified as SPECT/SISCOM for the preoperative evaluation of individuals with intractable focal epilepsy]






Indium In-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries [Prostascint]


Scintimammography (radioimmunoscintigraphy of the breast), unilateral, including supply of radiopharmaceutical



ICD-10 Diagnosis



All diagnoses


Peer Reviewed Publications:

  1. Alexiou GA, Zikou A, Tsiouris S, et al.  Comparison of diffusion tensor, dynamic susceptibility contrast MRI and (99m) Tc-Tetrofosmin brain SPECT for the detection of recurrent high-grade glioma. Magn Reson Imaging. 2014; 32(7):854-859.
  2. Bairactaris C, Demakopoulos N, Tripsianis G, et al. Impact of dopamine transporter single photon emission computed tomography imaging using I-123 ioflupane on diagnoses of patients with parkinsonian syndromes. J Clin Neurosci. 2009; 16(2):246-252.
  3. Bajaj N, Hauser RA, Seibyl J, et al. Association between Hoehn and Yahr, Mini-Mental State Examination, age, and clinical syndrome predominance and diagnostic effectiveness of ioflupane I 123 injection (DaTSCAN) in subjects with clinically uncertain parkinsonian syndromes. Alzheimers Res Ther. 2014; 6(5-8):67.
  4. Bega D, Gonzalez-Latapi P, Zadikoff C, et al. Is There a Role for DAT-SPECT Imaging in a Specialty Movement Disorders Practice? Neurodegener Dis. 2015; 15(2):81-86.
  5. Bertagna F, Barozzi O, Puta E, et al. Residual brain viability, evaluated by (99m)Tc-ECD SPECT, in patients with suspected brain death and with confounding clinical factors. Nucl Med Commun. 2009; 30(10):815-821.
  6. Brem RF, Fishman M, Rapeiyea JA. Detection of ductal carcinoma in situ with mammography, breast specific gamma imaging, and magnetic resonance imaging: a comparative study. Acad Radiol. 2007; 14(8):945-950.
  7. Brigo F, Turri G, Tinazzi M. 123I-FP-CIT SPECT in the differential diagnosis between dementia with Lewy bodies and other dementias. J Neurol Sci. 2015; 359(1-2):161-171.
  8. Castillo R, Lopez R, Banez I, et al. Utility of single photon emission computed tomography-computed tomography in selective sentinel lymph node biopsy in patients with melanoma. Rev Esp Med Nucl Imagen Mol. 2014; 33(3):129-135.
  9. Catafau AM, Tolosa E; DaTSCAN. Clinically Uncertain Parkinsonian Syndromes Study Group. Impact of dopamine transporter SPECT using 123I-Ioflupane on diagnosis and management of patients with clinically uncertain Parkinsonian syndromes. Mov Disord. 2004; 19(10):1175-1182.
  10. Cerasa A, Quattrone A. Linking Essential Tremor to the Cerebellum-Neuroimaging Evidence. Cerebellum. 2016; 15(3):263-275.
  11. Chiou JF, Lin MC, Chen DR, et al. Usefulness of thallium-201 SPECT Scintimammography to differentiate benign from malignant breast masses in mammographically dense breasts. Cancer Invest. 2003; 21(6):863-868.
  12. Coover LR, Caravaglia G, Kuhn P. Scintimammography with dedicated breast camera detects and localizes occult carcinoma. J Nucl Med. 2004; 45(4):553-558.
  13. Ellis RJ, Kaminsky DA, Zhou EH, et al. Ten-year outcomes: the clinical utility of single photon emission computed tomography/computed tomography capromab pendetide (prostascint) in a cohort diagnosed with localized prostate cancer. Int J Radiat Oncol Biol Phys. 2011; 81(1):29-34.
  14. El-Zawahry AM, Clarke HS, Eskridge MR, et al. Capromab pendetide scanning has a potential role in optimizing patient selection for salvage cryosurgical ablation of the prostate. Urology. 2010; 76(5):1162-1167.
  15. Fondrinier E, Muratet JP, Anglade E, et al. Clinical experience with 99mTc-MIBI Scintimammography in patients with breast microcalcifications. Breast. 2004; 13(4):316-320.
  16. Fouke SJ, Benzinger T, Gibson D, et al. The role of imaging in the management of adults with diffuse low grade glioma: A systematic review and evidence-based clinical practice guideline. J Neurooncol. 2015; 125(3):457-479.
  17. Gadzicki M, Bikiewicz M, Modkowska E, et al. Cortical scintigraphy in the evaluation of renal defects in children with vesico-ureteral reflux--optimization of the procedure and study interpretation. Nucl Med Rev Cent East Eur. 2004; 7(2):157-164.
  18. Gayed I, Joseph U, Fanous M, et al. The impact of DaTscan in the diagnosis of Parkinson disease. Clin Nucl Med. 2015; 40(5):390-393.
  19. Groshar D, Slobodin G, Zuckerman E. Quantitation of liver and spleen uptake of (99m)Tc-phytate colloid using SPECT: detection of liver cirrhosis. J Nucl Med, 2002; 43(3):312-317.
  20. Haseman MK, Rosenthal SA, Kipper SL, et al. Central abdominal uptake of indium-111 capromab pendetide (ProstaScint) predicts for poor prognosis in patients with prostate cancer. Urology. 2007; 70(2):303-308.
  21. Ilhan H, Goritschan A, Paprottka P, et al. Predictive value of 99mTc-labelled MAA scintigraphy for 90Y-microspheres distribution in radioembolization treatment with resin microspheres in primary and secondary hepatic tumors. J Nucl Med. 2015; 56(11):1654-1660.
  22. Joffe AR, Lequier L, Cave D. Specificity of radionuclide brain blood flow testing in brain death: case report and review. J Intensive Care Med. 2010; 25(1):53-64.
  23. Kan Y, Yuan L, Meeks JK, et al. The accuracy of V/Q SPECT in the diagnosis of pulmonary embolism: a meta-analysis. Acta Radiol. 2015; 56(5):565-572.
  24. Kashyap R, Mittal BR, Sunil HV, et al. Tc99m-ECD brain SPECT in patients with Moyamoya disease: A reflection of cerebral perfusion status at tissue level in the disease process. Indian J Nucl Med. 2011; 26(2):82-85.
  25. Khalkhali I, Baum JK, Villanueva-Meyer J, et al. (99m)Tc sestamibi breast imaging for the examination of patients with dense and fatty breasts: multicenter study. Radiology. 2002; 222(1):149-155.
  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. Kucuk ON, Soydal C, Araz M, et al. Evaluation of the response to selective internal radiation therapy in patients with hepatocellular cancer according to pretreatment (99m)Tc-MAA uptake. Clin Nucl Med. 2013; 38(4):252-255.
  28. Kupsch AR, Bajaj N, Weiland F, et al. Impact of DaTscan SPECT imaging on clinical management, diagnosis, confidence of diagnosis, quality of life, health resource use and safety in patients with clinically uncertain parkinsonian syndromes: a prospective 1-year follow-up of an open-label controlled study. J Neurol Neurosurg Psychiatry. 2012; 83(6):620-628.
  29. Li C, Sheng S, Men Y, et al. Emission Computed Tomography for the Diagnosis of Mandibular Invasion by Head and Neck Cancers: A Systematic Review and Meta-Analysis.  J Oral Maxillofac Surg. 2015; 73(9):1875.e1-11.
  30. Marshall VL, Reininger CB, Marquardt M, et al. Parkinson's disease is overdiagnosed clinically at baseline in diagnostically uncertain cases: a 3-year European multicenter study with repeat [123I]FP-CIT SPECT. Mov Disord. 2009; 24(4):500-508.
  31. Matsuda H, Matsuda K, Nakamura F, et al. Contribution of subtraction ictal SPECT coregistered to MRI to epilepsy surgery: a multicenter study. Ann Nucl Med. 2009; 23(3):283-291.
  32. Mohammed AA, Shergill IS, Vandal MT, Gujral SS. ProstaScint and its role in the diagnosis of prostate cancer. Expert Rev Mol Diagn. 2007; 7(4):345-349.
  33. Mohkam M, Maham S, Rahmani A, et al. Technetium Tc 99m dimercaptosuccinic acid renal scintigraphy in children with acute pyelonephritis: correlation with other imaging tests. Iran J Kidney Dis. 2010; 4(4):297-301.
  34. Mouraviev V, Madden JF, Broadwater G, et al. Use of 111in-capromab pendetide immunoscintigraphy to image localized prostate cancer foci within the prostate gland. J Urol. 2009; 182(3):938-947.
  35. Munari M, Zucchetta P, Carollo C, et al. Confirmatory tests in the diagnosis of brain death: comparison between SPECT and contrast angiography. Crit Care Med. 2005; 33(9):2068-2073.
  36. Nagda SN, Mohideen N, Lo SS, et al. Long-term follow-up of 111In-capromab pendetide (ProstaScint) scan as pretreatment assessment in patients who undergo salvage radiotherapy for rising prostate-specific antigen after radical prostatectomy for prostate cancer. Int J Radiat Oncol Biol Phys. 2007; 67(3):834-840.
  37. Noz ME, Chung G, Lee BY, et al. Enhancing the utility of prostascint SPECT scans for patient management. J Med Syst. 2006; 30(2):123-132.
  38. O'Brien JT, Oertel WH, McKeith IG, et al. Is ioflupane I123 injection diagnostically effective in patients with movement disorders and dementia? Pooled analysis of four clinical trials. BMJ Open. 2014; 4(7).
  39. Okuyaz C, Gücüyener K, Karabacak NI, et al. Tc-99m-HMPAO SPECT in the diagnosis of brain death in children. Pediatr Int. 2004; 46(6):711-714.
  40. Ozülker T, Ozülker F, Ozpaçaci T, et al. The efficacy of (99m)Tc-MIBI scintimammography in the evaluation of breast lesions and axillary involvement: a comparison with X-rays mammography, ultrasonography and magnetic resonance imaging. Hell J Nucl Med. 2010; 13(2):144-149.
  41. Pan L, Han Y, Sun X, et al. FDG-PET and other imaging modalities for the evaluation of breast cancer recurrence and metastases: a meta-analysis. J Cancer Res Clin Oncol. 2010; 136(7):1007-1022.
  42. Proao JM, Sodee DB, Resnick MI, Einstein DB. The impact of a negative (111)indium-capromab pendetide scan before salvage radiotherapy. J Urol. 2006; 175(5):1668-1672.
  43. 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.
  44. Sampalis FS, Denis R, Picard D, et al. International prospective evaluation of Scintimammography with (99m)technetium sestamibi. Am J Surg. 2003; 185(6):544-549.
  45. Schillaci O, Scopinaro F, Spanu A, et al. Detection of axillary lymph node metastases in breast cancer with Tc-99m tetrofosmin scintigraphy. Int J Oncol. 2002; 20(3):483-487.
  46. Seibyl JP, Kupsch A, Booij J, et al. Individual-reader diagnostic performance and between-reader agreement in assessment of subjects with Parkinsonian syndrome or dementia using 123I-ioflupane injection (DaTscan) imaging.J Nucl Med. 2014; 55(8):1288-1296.
  47. Shen G, Deng H, Hu S, Jia Z. Comparison of choline-PET/CT, MRI, SPECT, and bone scintigraphy in the diagnosis of bone metastases in patients with prostate cancer: a meta-analysis. Skeletal Radiol. 2014; 43(11):1503-1513.
  48. Spanu A, Dettori G, Nuvoli S, et al. (99)mTc-tetrofosmin SPET in the detection of both primary breast cancer and axillary lymph node metastasis. Eur J Nucl Med. 2001; 28(12):1781-1794.
  49. Uchida Y, Minoshima S, Okada S, et al. Diagnosis of dementia using perfusion SPECT imaging at the patient's initial visit to a cognitive disorder clinic. Clin Nucl Med. 2006; 31(12):764-773.
  50. Van Binnebeek S, Vanbilloen B, Baete K, et al. Comparison of diagnostic accuracy of (111)In-pentetreotide SPECT and (68)Ga-DOTATOC PET/CT: A lesion-by-lesion analysis in patients with metastatic neuroendocrine tumours. Eur Radiol. 2016; 26(3):900-909.
  51. Vlaar AM, de Nijs T, Kessels AG, et al. Diagnostic value of 123I-ioflupane and 123I-iodobenzamide SPECT scans in 248 patients with parkinsonian syndromes. Eur Neurol. 2008; 59(5):258-266.
  52. 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.
  53. Wei J, Pei S, Zhu X. Comparison of 18F-FDG PET/CT, MRI and SPECT in the diagnosis of local residual/recurrent nasopharyngeal carcinoma: A meta-analysis. Oral Oncol. 2016; 52:11-17.
  54. Weigert JM, Bertrand ML, Lanzkowsky L, et al. Results of a multicenter patient registry to determine the clinical impact of breast-specific gamma imaging, a molecular breast imaging technique. AJR Am J Roentgenol. 2012; 198(1):W69-W75.
  55. Zhou M, Johnson N, Gruner S, et al. Clinical utility of breast-specific gamma imaging for evaluating disease extent in the newly diagnosed breast cancer patient. Am J Surg. 2009; 197(2):159-163.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. ACR–ACNM Practice parameter for the performance of dopamine (DaT) transporter single photon emission computed tomography (SPECT) imaging for movement disorders. (Resolution 25). Adopted 2017. Available at: Accessed on October 10, 2018.
  2. ACR–SPR Practice parameter for the performance of tumor scintigraphy (WITH GAMMA CAMERAS). (Resolution 48). Revised 2015. Available at: Accessed on October 10, 2018. 
  3. ACR–SPR Practice parameter for the performance single photon emission computed tomography (SPECT) brain perfusion imaging, including brain death examinations. (Resolution 26). Revised 2016. Available at: Accessed on October 10, 2018.
  4. ACR–SIR Practice parameter for radioembolization with microsphere brachytherapy device (RMBD) for treatment of liver malignancies. (Resolution 17). Revised 2014. Available at: Accessed on October 10, 2018.
  5. American College of Radiology. ACR Appropriateness Criteria®. Available at: Accessed on October 10, 2018.
    • Breast cancer screening (2017).
    • Post-treatment Follow-up of Prostate Cancer (2017).
    • Prostate Cancer — Pretreatment Detection, Staging, and Surveillance (2016).
    • Dementia and Movement Disorders (2012).
  6. American Urological Association. Clinical Practice Guideline. Management and screening of primary vesicoureteral reflux. Reviewed 2017. Available at: Accessed on October 10, 2018.
  7. Archer H, Smailagic N, John C, et al. Regional Cerebral Blood Flow Single Photon Emission Computed Tomography for detection of Frontotemporal dementia in people with suspected dementia. Cochrane Database Syst Rev. 2015; CD010896(2).
  8. Berardelli, A, Wenning GK, Antonini A, et al. EFNS/MDS-ES recommendations for the diagnosis of Parkinson's disease. Eur J Neurol. 2013; 20(1):16-34.
  9. Bleeker G, Tytgat A, Adam J, et al. 123I-MIBG scintigraphy and 18F-FDG-PET imaging for diagnosing neuroblastoma. Cochrane Database Syst Rev. 2015; CD009263 (2).
  10. Callister ME, Baldwin DR, Akram AR, et al. British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax. 2015; 70 Suppl 2:ii1-ii54.
  11. Centers for Medicare and Medicaid Services. National Coverage Determination: Single Photon Emission Computed Tomography (SPECT). NCD #220.12. Effective October 1, 2002. Available at: Accessed on October 10, 2018.
  12. Djang, DSW, Janssen MJR, Bohnen N, et al. SNM practice guideline for dopamine transporter imaging with 123I-ioflupane SPECT 1.0. J Nucl Med. 2012; 53(1):154-163.
  13. Filipek PS, Accardo PJ, Ashwal S, et al. American Academy of Neurology and the Child Neurology Society. 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.
  14. Greenspan BS, Dillehay G, Intenzo C, et al. SNM practice guideline for parathyroid scintigraphy 4.0. J Nucl Med Technol. 2012 Jun; 40(2):111-118.
  15. McCleery J, Morgan S, Bradley K, et al. Dopamine transporter imaging for the diagnosis of dementia with Lewy bodies. Cochrane Database Syst Rev. 2015; (2):CD010633.
  16. NCCN Clinical Practice Guidelines in Oncology®. © 2018 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website: Accessed on October 10, 2018.
    • Neuroendocrine Tumors (V.3.2018); Revised September 11, 2018.
    • Prostate Cancer (V.4.2018); Revised August 15, 2018.
  17. U.S. Food and Drug Administration New drug application. Adreview (Iobenguane sulfate I-123). Rockville, MD: FDA. September 19, 2008. Available at: Accessed on October 10, 2018.
  18. U.S. Food and Drug Administration Development approval process. Technetium TC-99m. June 2018.  Rockville, MD: FDA. Available at: Accessed on October 10, 2018.
  19. U.S. Food and Drug Administration New drug application. DaTscan (Ioflupane I 123) Injection. NDA 22-454. Rockville, MD: FDA. January 14, 2011. Available at: Accessed on October 10, 2018.

DaT Scan

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History






Medical Policy & Technology Assessment Committee (MPTAC) review.



Hematology/Oncology Subcommittee review. Title changed to Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications. Updated Description, Rationale, and References sections.



MPTAC review.



Hematology/Oncology Subcommittee review. Updated Rationale, References and Websites sections. The document header wording updated from “Current Effective Date” to “Publish Date.”



MPTAC review.



Hematology/Oncology Subcommittee review. Updated Rationale, References and Websites sections.



MPTAC review.



Hematology/Oncology Subcommittee review. Reformatted Criteria. Updated Rationale, Background/Overview and References sections, Removed ICD-9 codes from Coding section.



MPTAC review.



Hematology/Oncology Subcommittee review.  Updated Rationale and References sections.



MPTAC review. Updated Rationale and References sections.



MPTAC review. Updated Rationale and References.



Updated Coding section with 01/01/2013 CPT changes.



MPTAC review. Updated Description/Scope, Rationale, Definitions, Coding, References and Index. Added renal DMSA to Medically Necessary Position Statement. Added Pervasive Development Disorders to Investigational and Not Medically Necessary Position Statement. Added DaT scan to Investigational and Not Medically Necessary Position Statement. Removed Web Sites for Additional Information section.



MPTAC review.



Hematology/Oncology Subcommittee review. Updated Position Statement to include “Preoperative evaluation of individuals with intractable focal epilepsy to identify and localize area(s) of epileptiform activity when other techniques designed to localize a focus are indeterminate” in investigational and not medically necessary statement. Updated Description/Scope, Rationale, Coding, References, and Index.



MPTAC review.



Hematology/Oncology Subcommittee review. Updated Description/Scope, Rationale, and References.



MPTAC review. Title change to Single Photon Emission Computed Tomography (SPECT) Scans for Noncardiovascular Indications. Removal of cardiac indications from Position Statement. Clarification of medically necessary statement for brain tumor to include when PET unavailable. Removal from medically necessary statements epilepsy and lymphoma. Clarification of investigational and not medically necessary statement for prostate carcinoma to include “with or without fusion imaging with computed tomography or magnetic resonance imaging” is also investigational and not medically necessary. Updated Description/Scope, Rationale, Background/Overview, Definitions, Coding and Reference sections.



MPTAC review.



Hematology/Oncology Subcommittee review. Added prostate cancer with the use of ProstaScint to “investigational and not medically necessary” statement. Updated Rationale, References and Web Sites. Updated Coding section to include 01/01/2010 CPT changes.



MPTAC review.



Hematology/Oncology Subcommittee review. Updated References, Web Sites and Rationale sections.



Updated Coding section with 10/01/2008 ICD-9 changes.



MPTAC review. No change to Position Statement. The phrase “investigational/not medically necessary” was clarified to read “investigational and not medically necessary.” Updated Coding section with 01/01/2008 CPT changes.



Updated Coding section with 10/01/2007 ICD-9 changes.



Included note to see CG-RAD-16 Cardiac Radionuclide Imaging for use of radionuclide imaging for cardiac conditions.



MPTAC review. Added “unexplained ventricular arrhythmia” as a medically necessary indication. Updated Rationale and Reference sections.



Updated Coding section with 01/01/2007 CPT/HCPCS changes.



MPTAC review. Added cerebrovascular disease to not medically necessary section; revised Rationale section. 



MPTAC review. Removed Cerebrovascular accident from medically necessary and Rationale sections.



Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).



MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. 



MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review Date

Document Number


Anthem, Inc.




Single Emission Computed Tomography (SPECT) and Scintimammography

WellPoint Health Networks, Inc.


Clinical Guideline









Oncologic Applications of Radioscintigraphy using Targeted Radiotracers