CLINICAL APPROPRIATENESS GUIDELINES
radiology
Appropriate Use Criteria: SPECT Imaging
EFFECTIVE SEPTEMBER 12, 2021
This document has been archived because it has outdated information. It is for historical information only and should not be consulted for clinical use. Current versions of guidelines are available on the AIM Specialty Health website at http://www.aimspecialtyhealth.com/
Proprietary
© 2021 AIM Specialty Health®. All rights reserved.
RBM10-0921.2
Approval and implementation dates for specific health plans may vary. Please consult the applicable health plan for more details.
AIM Specialty Health disclaims any responsibility for the completeness or accuracy of the information contained herein.
Table of Contents
CLINICAL APPROPRIATENESS GUIDELINES
Appropriate Use Criteria: SPECT Imaging
Description and Application of the Guidelines
Clinical Appropriateness Framework
Simultaneous Ordering of Multiple Diagnostic or Therapeutic Interventions
Repeat Diagnostic Intervention
Repeat Therapeutic Intervention
SPECT Imaging (including SPECT/CT)
SPECT Imaging – General (SPECT or SPECT/CT)
SPECT Bone Imaging (SPECT or SPECT/CT)
SPECT Gallium Scintigraphy (SPECT only)
SPECT Hepatic Scintigraphy (SPECT only)
SPECT Lymphoscintigraphy (SPECT or SPECT/CT)
SPECT Metaiodobenzylguanidine (MIBG) Scintigraphy (SPECT or SPECT/CT)
SPECT Parathyroid Imaging (SPECT or SPECT/CT)
SPECT Renal Scintigraphy (Pediatric only) (SPECT only)
SPECT Somatostatin Receptor Imaging (SPECT or SPECT/CT)
SPECT Thyroid Scintigraphy (SPECT or SPECT/CT)
SPECT VQ Scintigraphy (SPECT only)
Description and Application of the Guidelines
The AIM Clinical Appropriateness Guidelines (hereinafter “the AIM Clinical Appropriateness Guidelines” or the “Guidelines”) are designed to assist providers in making the most appropriate treatment decision for a specific clinical condition for an individual. As used by AIM, the Guidelines establish objective and evidence-based criteria for medical necessity determinations where possible. In the process, multiple functions are accomplished:
- To establish criteria for when services are medically necessary
- To assist the practitioner as an educational tool
- To encourage standardization of medical practice patterns
- To curtail the performance of inappropriate and/or duplicate services
- To advocate for patient safety concerns
- To enhance the quality of health care
- To promote the most efficient and cost-effective use of services
The AIM guideline development process complies with applicable accreditation standards, including the requirement that the Guidelines be developed with involvement from appropriate providers with current clinical expertise relevant to the Guidelines under review and be based on the most up-to-date clinical principles and best practices. Relevant citations are included in the References section attached to each Guideline. AIM reviews all of its Guidelines at least annually.
AIM makes its Guidelines publicly available on its website twenty-four hours a day, seven days a week. Copies of the AIM Clinical Appropriateness Guidelines are also available upon oral or written request. Although the Guidelines are publicly-available, AIM considers the Guidelines to be important, proprietary information of AIM, which cannot be sold, assigned, leased, licensed, reproduced or distributed without the written consent of AIM.
AIM applies objective and evidence-based criteria, and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. The AIM Guidelines are just guidelines for the provision of specialty health services. These criteria are designed to guide both providers and reviewers to the most appropriate services based on a patient’s unique circumstances. In all cases, clinical judgment consistent with the standards of good medical practice should be used when applying the Guidelines. Guideline determinations are made based on the information provided at the time of the request. It is expected that medical necessity decisions may change as new information is provided or based on unique aspects of the patient’s condition. The treating clinician has final authority and responsibility for treatment decisions regarding the care of the patient and for justifying and demonstrating the existence of medical necessity for the requested service. The Guidelines are not a substitute for the experience and judgment of a physician or other health care professionals. Any clinician seeking to apply or consult the Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment.
The Guidelines do not address coverage, benefit or other plan specific issues. Applicable federal and state coverage mandates take precedence over these clinical guidelines. If requested by a health plan, AIM will review requests based on health plan medical policy/guidelines in lieu of the AIM Guidelines.
The Guidelines may also be used by the health plan or by AIM for purposes of provider education, or to review the medical necessity of services by any provider who has been notified of the need for medical necessity review, due to billing practices or claims that are not consistent with other providers in terms of frequency or some other manner.
General Clinical Guideline
Clinical Appropriateness Framework
Critical to any finding of clinical appropriateness under the guidelines for a specific diagnostic or therapeutic intervention are the following elements:
- Prior to any intervention, it is essential that the clinician confirm the diagnosis or establish its pretest likelihood based on a complete evaluation of the patient. This includes a history and physical examination and, where applicable, a review of relevant laboratory studies, diagnostic testing, and response to prior therapeutic intervention.
- The anticipated benefit of the recommended intervention should outweigh any potential harms that may result (net benefit).
- Current literature and/or standards of medical practice should support that the recommended intervention offers the greatest net benefit among competing alternatives.
- Based on the clinical evaluation, current literature, and standards of medical practice, there exists a reasonable likelihood that the intervention will change management and/or lead to an improved outcome for the patient.
If these elements are not established with respect to a given request, the determination of appropriateness will most likely require a peer-to-peer conversation to understand the individual and unique facts that would supersede the requirements set forth above. During the peer-to-peer conversation, factors such as patient acuity and setting of service may also be taken into account.
Simultaneous Ordering of Multiple Diagnostic or Therapeutic Interventions
Requests for multiple diagnostic or therapeutic interventions at the same time will often require a peer-to-peer conversation to understand the individual circumstances that support the medical necessity of performing all interventions simultaneously. This is based on the fact that appropriateness of additional intervention is often dependent on the outcome of the initial intervention.
Additionally, either of the following may apply:
- Current literature and/or standards of medical practice support that one of the requested diagnostic or therapeutic interventions is more appropriate in the clinical situation presented; or
- One of the diagnostic or therapeutic interventions requested is more likely to improve patient outcomes based on current literature and/or standards of medical practice.
Repeat Diagnostic Intervention
In general, repeated testing of the same anatomic location for the same indication should be limited to evaluation following an intervention, or when there is a change in clinical status such that additional testing is required to determine next steps in management. At times, it may be necessary to repeat a test using different techniques or protocols to clarify a finding or result of the original study.
Repeated testing for the same indication using the same or similar technology may be subject to additional review or require peer-to-peer conversation in the following scenarios:
- Repeated diagnostic testing at the same facility due to technical issues
- Repeated diagnostic testing requested at a different facility due to provider preference or quality concerns
- Repeated diagnostic testing of the same anatomic area based on persistent symptoms with no clinical change, treatment, or intervention since the previous study
- Repeated diagnostic testing of the same anatomic area by different providers for the same member over a short period of time
Repeat Therapeutic Intervention
In general, repeated therapeutic intervention in the same anatomic area is considered appropriate when the prior intervention proved effective or beneficial and the expected duration of relief has lapsed. A repeat intervention requested prior to the expected duration of relief is not appropriate unless it can be confirmed that the prior intervention was never administered.
SPECT Imaging (including SPECT/CT)
General Information
Scope
These guidelines address nuclear medicine imaging in both adult and pediatric populations. For interpretation of the Guidelines, and where not otherwise noted, “adult” refers to persons age 19 and older, and “pediatric” refers to persons age 18 and younger. Where separate indications exist, they are specified as Adult or Pediatric. Where not specified, indications and prerequisite information apply to persons of all ages.
See the Code section for a list of modalities included in these guidelines.
Technology Considerations
Bone marrow scintigraphy is a nuclear medicine study which may be done in conjunction with other studies such as Gallium or leukocyte scintigraphy for evaluation of marrow involvement. This study is done using technetium 99m-labeled sulfur colloid, the normal biodistribution of which is the reticuloendothelial system (liver, spleen, bone marrow).
Bone scintigraphy is a nuclear medicine exam that uses a radiopharmaceutical (typically technetium 99m labeled methylene diphosphonate [MDP] or hydroxydiphosphonate [HDP]) to measure osteoblastic activity throughout the axial and appendicular skeleton. Bone scintigraphy can be limited or whole body and can be performed with planar scintigraphy or with SPECT.
Dacyroscintigraphy is a nuclear medicine exam in which a radiopharmaceutical (typically, technetium 99m pertechnetate) is administered via eye dropper or syringe to the surface of the eye. This test is used to evaluate the patency of the nasolacrimal duct.
Gallium scintigraphy is a nuclear medicine exam that uses a radiopharmaceutical (typically Gallium-67 citrate) to measure neoplastic, infectious and inflammatory activity involving osseus and soft tissue structures.
A Gastric emptying study is a nuclear medicine exam that uses a radiopharmaceutical (typically technetium 99m sulfur colloid) which is mixed into a standardized solid meal or liquid for oral administration. Multiple images are obtained of the abdomen, and the percentage of activity remaining in the stomach is calculated over time. For measurement of gastric emptying only, imaging is typically performed at hourly intervals until 4 hours after solid meal ingestion and for one hour after liquid administration. Small bowel and whole-gut transit studies may be performed in conjunction with a gastric emptying study, and typically involve administration of a second radiopharmaeutical, 111In-DTPA, followed by additional delayed imaging.
Gastrointestinal blood loss scintigraphy refers to nuclear medicine evaluation for the source of an active site of gastrointestinal bleeding. This is generally used to evaluate a site of lower GI bleeding, though more proximal sites can also be detected. This test is done using the patient’s red blood cells, which are radiolabeled using technetium 99m either in vitro or in vivo. GERD scintigraphy is also known as a “reflux scan” or a “milk scan.” It is a nuclear medicine exam in which a radiopharmaceutical (typically technetium 99m labeled DTPA or sulfur colloid) is administered orally (or by nasogastric or gastrostomy tube) in a liquid meal such as water, juice, or milk. Dynamic imaging is then carried out, typically at 10 seconds per frame for one hour. The number of reflux episodes is determined, as well as the proximal extent of the reflux.
Hepatic scintigraphy refers to nuclear medicine imaging of the liver. Depending on the reason for imaging, there are several radiotracers which may be used. Radiolabeled autologous red blood cells may be used for characterization of a liver lesion when it is suspected to be a hemangioma. Radiolabeled sulfur colloid may be used for characterization of a liver lesion when it is suspected to represent focal nodular hyperplasia.
Hepatobiliary scintigraphy is a nuclear medicine exam that uses a radiopharmaceutical [a technetium 99m-labeled iminodiacetic acid (IDA) such as DISIDA, BrIDA, or PIPIDA] to evaluate the hepatobiliary system including bile formation and transit through the biliary system into the intestine. Gallbladder ejection fraction (GBEF) can be calculated through the administration of a cholecystokinin analog. Also called HIDA scans after an early form of the primary radiopharmaceutical used in them, these studies are most commonly used in the evaluation of suspected acute cholecystitis, but may also be useful in evaluation of suspected biliary atresia or bile leak.
Leukocyte scintigraphy is a nuclear medicine exam that uses a radiopharmaceutical (typically technetium 99m or Indium-111 labeled autologous white blood cells [WBC]) to measure infectious and inflammatory activity involving osseous and soft tissue structures.
Lymphoscintigraphy is a nuclear medicine procedure in which a radiopharmaceutical (typically technetium 99m sulfur colloid, filtered to ensure a small particle size) is used to evaluate lymphatic flow and nodal drainage pathways. This test may be used for lymphedema, but is primarily used for sentinel lymph node detection in malignancies such as breast cancer or melanoma.
A Meckel’s scan is a nuclear medicine examination in which technetium 99m pertechnetate is used to detect a Meckel’s diverticulum. These often become clinically apparent because of gastrointestinal bleeding, which in the setting of Meckel’s diverticulum almost always indicates the presence of ectopic gastric mucosa. Uptake of pertechnetate is dependent on the presence of gastric mucosa, so this radiopharmaceutical is generally useful in Meckel’s diverticula that present with bleeding, but the test may be of less value in other presentations, where the presence of gastric mucosa in the diverticulum may be less likely.
Perfusion scintigraphy is a nuclear medicine examination performed with a gamma camera that measures cerebral blood flow using lipophilic radiopharmaceutical agents (typically technicium-99 labeled hexamethylpropylene amine oxide [HMPAO] or ethyl cysteinate dimer [ECD]) with high cerebral retention.
Peritoneal venous shunt scintigraphy is a nuclear medicine study in which a radiopharmaceutical (such as technetium 99m macroaggregated albumin [MAA]) is injected into the peritoneal cavity in order to evaluate the patency of a LeVeen or Denver shunt. In the presence of a patent shunt, macroaggregated albumin will travel to the lungs, generally within one hour of injection.
Planar scintigraphy refers to static, two-dimensional nuclear medicine imaging. While planar imaging may provide sufficient information in regions where the anatomy is less complex, it is often supplemented by SPECT imaging for improved anatomic localization.
Radionuclide cisternography is a minimally invasive procedure which uses a radiopharmaceutical (typically Indium-111 or Technetium 99m-labeled diethylenetriaminepentaacetic acid [DTPA]) injected into the cerebrospinal fluid (CSF) to measure CSF flow and identify sites of leakage.
Radiopharmaceuticals are drugs used for diagnosis and therapy which include an isotope (element with the same number of protons but a different number of neutrons and prone to measurable radioactive decay) often coupled to a ligand that binds to a molecule of interest. Examples include technecium 99m-methylene diphosphonate (TC-99 MDP) for bone scintigraphy, iodine 123 for thyroid scintigraphy, and 18F-flurodeoyxglucose (FDG) for PET oncologic imaging.
Renal scintigraphy refers to several types of nuclear imaging performed to evaluate the structure and/or function of the kidneys: renal cortical scintigraphy uses the radiopharmaceutical technetium 99m-dimercaptosuccinic acid (DMSA) to assess the amount of functioning cortical tissue; renal perfusion/functional imaging uses radiopharmaceutical agents such as technetium 99m-mercaptoacetyltriglycine (MAG3) to assess blood flow to the kidneys as well as excretory function; diuretic renal scintigraphy, which uses MAG3 imaging before and after a diuretic in order to evaluate for the presence of upper urinary tract obstruction; and ACE-inhibitor renal scintigraphy, in which and ACE inhibitor is used alongside MAG3 to assess for renal artery stenosis.
Single photon emission computed tomography (SPECT) uses gamma decay from radiopharmaceutical agents captured by gamma cameras to create three-dimensional images of the body, in contrast to the two-dimensional images obtained with planar scintigraphy. SPECT has an improved signal-to-noise ratio relative to planar scintigraphy and is especially useful in regions with complex anatomy that makes localization difficult using two-dimensional imaging alone. Dopaminergic SPECT is a brain SPECT exam using a radiopharmacutical that measures presynaptic dopamine to assess nigrostriatal dysfunction. Ioflupane (I-123) is an FDA approved ligand of dopamine transports used with SPECT (DaT scan)1 to diagnose Parkinson’s disease in select clinical scenarios.
Splenic scintigraphy is generally performed as part of a liver-spleen scan, in which a radiopharmaceutical (such as technetium 99m sulfur colloid or technetium 99m-labeled heat-denatured red blood cells) is administered. Splenic scintigraphy is typically used to evaluate for splenosis, accessory splenic tissue, splenic infarction, or wandering spleen.
Thallium scintigraphy has mainly been used in myocardial imaging, both for assessment of perfusion and viability. Thallium is a potassium analog and its intracellular uptake occurs by several pathways, including a co-transport mechanism in tumor cells. It is taken up by Gallium-avid tumors but, unlike Gallium, does not show significant accumulation in inflammatory or necrotic tissue.2
Thyroid scintigraphy is a nuclear medicine study in which a radiopharmaceutical (generally iodine-123 or iodine-131, though technetium 99m pertechnetate can also be used for thyroid evaluation, particularly in pediatric patients) is administered in order to evaluate the thyroid gland. This test can be used in the evaluation of thyrotoxicosis or to assist in characterization of thyroid nodules. When an iodine-based radiopharmaceutical is used, radioactive iodine uptake (RAIU) can be measured in conjunction with imaging.
VQ scintigraphy is a nuclear medicine study used to evaluate the lungs. This study may evaluate ventilation, perfusion, or both. Ventilation-perfusion scans are generally used in the evaluation of suspected pulmonary embolism. Quantitative lung perfusion scintigraphy is used to evaluate how blood flow is distributed within the lungs, and may be used prior to lung surgery or to evaluate congenital vascular anomalies. Perfusion imaging is performed using technetium 99m-labeled macro-aggregated albumin (MAA). There are several radiopharmaceuticals which may be used for ventilation imaging, including aerosols such as technetium 99m-diethylenetriaminepentaacetic acid (DTPA) or technetium 99m-sulfur colloid, or gases such as 133Xe (Xenon).
Definitions
Phases of the care continuum are broadly defined as follows:
- Screening is testing in the absence of signs or symptoms of disease
- Diagnosis is testing based on a reasonable suspicion of a particular condition or disorder, usually due to the presence of signs or symptoms
- Management is testing to direct therapy of an established condition, which may include preoperative or postoperative imaging, or imaging performed to evaluate the response to nonsurgical intervention
- Surveillance is the periodic assessment following completion of therapy, or for monitoring known disease that is stable or asymptomatic
Statistical terminology
- Confidence interval (CI) is a range of values which is likely to contain the cited statistic. For example, 92% sensitivity (95% CI, 89%-95%) means that, while the sensitivity was calculated at 92% on the current study, there is a 95% chance that, if a study were to be repeated, the sensitivity on the repeat study would be in the range of 89%-95%.
- Diagnostic accuracy relates to the ability of a test to discriminate between the target condition and health. Diagnostic accuracy is quantified using sensitivity and specificity, predictive values, and likelihood ratios.
- Hazard ratio is the odds that an individual in the group with the higher hazard reaches the outcome first. Hazard ratio is analogous to odds ratio and is reported most commonly in time-to-event analysis or survival analysis. A hazard ratio of 1 means that the hazard rates of the 2 groups are equivalent. A hazard ratio of greater than 1 or less than 1 means that there are differences in the hazard rates between the 2 groups.
- Likelihood ratio is the ratio of an expected test result (positive or negative) in patients with the disease to an expected test result (positive or negative) in patients without the disease. Positive likelihood ratios, especially those greater than 10, help rule in a disease (i.e., they substantially raise the post-test probability of the disease, and hence make it very likely and the test very useful in identifying the disease). Negative likelihood ratios, especially those less than 0.1, help rule out a disease (i.e., they substantially decrease the post-test probability of disease, and hence make it very unlikely and the test very useful in excluding the disease).
- Odds ratio represents the odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure. An odds ratio of 1 means that the exposure does not affect the odds of the outcome. An odds ratio greater than 1 means that the exposure is associated with higher odds of the outcome. An odds ratio less than 1 means that the exposure is associated with lower odds of the outcome.
- Predictive value is the likelihood that a given test result correlates with the presence or absence of disease. Positive predictive value is defined as the number of true positives divided by the number of test positives. Negative predictive value is defined as the number of true negatives divided by the number of test negative patients. Predictive value is dependent on the prevalence of the condition.
- Pretest probability is the probability that a given patient has a disease prior to testing. May be divided into very low (less than 5%), low (less than 20%), moderate (20%-75%), and high (greater than 75%) although these numbers may vary by condition.
- Relative risk is the probability of an outcome when an exposure is present relative to the probability of the outcome occurring when the exposure is absent. Relative risk is analogous to odds ratio; however, relative risk is calculated by using percentages instead of odds. A relative risk of 1 means that there is no difference in risk between the 2 groups. A relative risk of greater than 1 means that the outcome is more likely to happen in the exposed group compared to the control group. A relative risk less than 1 means that the outcome is less likely to happen in the exposed group compared to the control group.
- Sensitivity is the conditional probability that the test is positive, given that the patient has the disease. Defined as the true positive rate (number of true positives divided by the number of patients with disease). Excellent or high sensitivity is usually greater than 90%.
- Specificity is the conditional probability that the test is negative, given that the patient does not have the disease. Defined as the true negative rate (number of true negatives divided by the number of patients without the disease). Excellent or high specificity is usually greater than 90%.
Clinical Indications
The following section includes indications for which SPECT imaging is considered medically necessary, along with prerequisite information and supporting evidence where available. Indications, diagnoses, or imaging modalities not specifically addressed are considered not medically necessary.
It is recognized that imaging often detects abnormalities unrelated to the condition being evaluated. Such findings must be considered within the context of the clinical situation when determining whether additional imaging is required.
SPECT Imaging – General (SPECT or SPECT/CT)
These indications apply only to scenarios not addressed elsewhere in the SPECT imaging guidelines.
Preoperative evaluation
For preoperative evaluation to further localize a lesion identified on planar scintigraphy or SPECT when additional anatomic information is needed to direct surgery and that information has not already been provided by CT or MRI.
Planning of selective internal radiation therapy
- For planning of selective internal radiation therapy (SIRT)
SPECT Bone Imaging (SPECT or SPECT/CT)
Avascular necrosis
Avascular necrosis when MRI cannot be performed or is nondiagnostic, in EITHER of the following scenarios:
- Diagnosis following negative or inconclusive radiographs
- Preoperative planning for osteonecrosis with femoral head collapse
Fracture
Fracture (including occult or stress fractures) in ANY of the following scenarios:
- Suspected spinal fracture when other imaging (radiographs, CT, or MRI) is nondiagnostic
- Suspected skeletal injury in non-accidental trauma when MRI cannot be performed or is nondiagnostic
-
Suspected fracture, when MRI cannot be performed or is nondiagnostic, at the following high-risk/weight bearing sites:
- Femoral neck; proximal femur
- Tibia (anterior/lateral/plateau)
- Great toe sesamoid
- Patella
- Scaphoid
- Lunate
- Talus
- Navicular
- Metatarsal base (second and fifth digits)
Indeterminate bone lesions
For further characterization of indeterminate bone lesions when MRI, CT, or planar scintigraphy is equivocal
Infection, not otherwise specified
Infection, not otherwise specified, in EITHER of the following scenarios:
- Diagnosis and management of osteomyelitis when MRI, CT, or planar scintigraphy is nondiagnostic
- Evaluation of sternal wound infection or dehiscence when CT chest is nondiagnostic
Osseous metastatic disease, not otherwise specified
Osseous metastatic disease, not otherwise specified, in EITHER of the following scenarios:
-
Diagnostic workup and management when BOTH of the following apply:
- Patient has a documented malignancy and signs or symptoms concerning for bony metastatic disease
- Suspicious findings on CT, MRI, or planar bone scintigraphy require further clarification
- To determine bone invasion prior to surgical resection of head and neck malignancies when CT, PET/CT, or MRI is nondiagnostic
Postoperative joint or spine pain
Postoperative joint or spine pain when other imaging (radiographs, CT, or MRI) is nondiagnostic.
Spondylolysis/spondylolisthesis
Spondylolysis/spondylolisthesis, when radiographs provide insufficient information to direct management.
SPECT Brain
Dopaminergic SPECT (SPECT only)
Movement disorders (Adult only)
Dopaminergic SPECT is considered medically necessary to distinguish between Parkinson’s disease and essential tremor when diagnostic uncertainty persists after ALL of the following:
- Independent evaluation by at least one physician experienced in movement disorders
- Structural imaging (CT or MRI)
- Results of the test will determine whether medication is initiated or withdrawn, or whether deep brain stimulation is performed
Rationale
While clinical evaluation is usually sufficient to establish the diagnosis of Parkinson’s disease, functional imaging with dopaminergic SPECT may be useful in select clinical scenarios where diagnostic uncertainty persists following specialist clinical evaluation3 and structural imaging. Dopaminergic SPECT has a high odds ratio (OR 210; 95% CI, 79-562) for distinguishing Parkinson’s disease from essential tremor4, although the vast majority of articles used clinical consensus/follow up rather than histopathology as the criterion standard. Dopaminergic SPECT may impact management by changing prescribed medication including the initation or withdrawal of dopaminergic treatment. This is especially true when the differential includes essential tremor since medical management differs substantially.5
Neurocognitive disorders (Adult only)
Includes mild cognitive impairment, dementia, and variants (e.g., vascular, Alzheimer’s, frontotemporal degeneration spectrum, diffuse Lewy body).
Dopaminergic SPECT is considered medically necessary as a one-time study to differentiate between diffuse Lewy body dementia and Alzheimer’s disease when substantial diagnostic uncertainty remains after ALL of the following:
- Neuropsychological testing
- Independent evaluation by at least one physician experienced in neurodegenerative disease
- Structural imaging (CT or MRI)
- Results of the test will determine whether a sustained course of medication is initiated or withdrawn
Rationale
Diffuse Lewy body dementia is a neurocognitive disorder characterized histopathologically by lewy body desposition, especially in the brainstem and nigrostriatal regions, progressing to the limbic system and cortex. Diffuse Lewy body dementia presents clinically with neurocognitive dysfunction and at least two additional clinical symptoms including delirium, visual hallucinations, REM sleep behavior disorder, or Parkinsonism.6 Clinical features of Lewy body dementia can overlap with Alzheimer’s disease and Parkinson’s in the early stages, and advanced imaging is a biomarker to aid the diagnosis when clinical symptoms are insufficient and symptomatic treatment for the condition may differ. Structural imaging shows relative preservation of the mesial temporal lobe in diffuse Lewy body dementia when compared to Alzheimer’s.7 A positive dopaminergic SPECT has a good positive predictive value for Lewy body dementia in this scenario and may be appropriate, as it is recommended by multiple evidence-based guidelines.7-9
Thallium Scintigraphy (SPECT only)
Intracranial mass
Thallium scintigraphy is considered medically necessary for evaluation of HIV-positive patients with an intracranial mass.
Rationale
In a systematic review comparing the diagnostic accuracy of thallium scintigraphy, FDG-PET, and MR spectroscopy in distinguishing CNS lymphoma from toxoplasmosis in HIV positive patients, Yang et al. found high (> 90%) diagnostic accuracy with moderate samples sizes for scintigraphy and PET. Limited data for MR spectroscopy suggests lower and widely ranging diagnostic accuracy.105
SPECT Gallium Scintigraphy (SPECT only)
Lymphoma
For diagnosis and management of lymphoma when PET imaging cannot be performed and when standard imaging (CT or MRI) does not provide sufficient information to guide management.
Osteomyelitis of the skull base or calvarium, when CT or MRI cannot be performed or is nondiagnostic
Gallium scintigraphy is considered medically necessary for diagnosis.
Perioperative evaluation, not otherwise specified, including delayed hardware failure
Also see Bone Marrow Scintigraphy.
Gallium scintigraphy, with or without bone marrow scintigraphy, is considered medically necessary for diagnosis and management of periprosthetic infection.
Rationale
For periprosthetic infections in the spine, a variety of structural and functional imaging modalities may help define the presence or extent of disease. CT and MRI are commonly performed but evaluation of the surgical bed may be limited by beam hardening/susceptibility artifact. Gallium and bone scintigraphy are functional imaging alternatives that have a higher diagnostic accuracy than leukocyte scintigraphy in the spine.3, 4
Spinal infection, when MRI cannot be performed or is nondiagnostic
Gallium scintigraphy is considered medically necessary for diagnosis and management of spinal infection, including but not limited to epidural abscess, arachnoiditis, discitis, and osteomyelitis.
Rationale
MRI has high diagnostic accuracy for spondylodiscitis, is widely available, nonionizing, and is recommended as the initial modality by multiple clinical guidelines.15-17 When MRI cannot be performed or is nondiagnostic, functional imaging with bone scintigraphy with or without gallium scintigraphy is suggested as a weak recommendation based on low quality evidence from the Infectious Disease Society of America (IDSA). While gallium/bone scintigraphy may have moderate-to-high sensitivitiy for spondylodisciitis18, leukocyte scintigraphy has limited sensitivity in the axial skeleton and is not recommended.15 Functional imaging also offers the advantage of a wider field of view than MRI and can be useful to assess for multifocal or chronic forms of osteomyelitits such as chronic recurrent multifocal osteomyelitis and the Synovitis, Acne, Pustulosis, Hyperostosis and Osteitis (SAPHO) syndrome.
SPECT Hepatic Scintigraphy (SPECT only)
Indeterminate liver lesion
For evaluation of an indeterminate liver lesion > 1 cm in size to evaluate for focal nodular hyperplasia or hemangioma.
Rationale
Cavernous hemangiomas are common; autopsy studies have shown that they occur in up to 7% of the population.10, 11 Hemangiomas appear as a homogenous hyperechoic mass, usually less than 3 cm in diameter with acoustic enhancement and sharp margins and are important to identify because they are benign lesions with a characteristic imaging appearance. Confident diagnosis of hemagioma can therefore avoid further biopsy and intervention. Triphasic CT and MRI are usually sufficient to establish the diagnosis.12 Hemangiomas usually show radiotracer uptake on RBC scintigraphy with high positive likelihood ratios and good interobserver agreement.13, 14 However, this is a historical technique that offers less information about alternative diagnosis and is typically reserved in situations where ultrasound is nondiagnostic and neither triphasic MRI or CT can be performed. Similarly, sulfur colloid scintigraphy has been used to further characterize suspected focal nodular hyperplasia15 but is rarely performed as both MRI and CT are usually diagnostic.
SPECT Leukocyte Scintigraphy
Fever of unknown origin, when contrast-enhanced CT cannot be performed or is nondiagnostic (SPECT only)
Leukocyte scintigraphy is considered medically necessary in EITHER of the following scenarios:
- Fever of duration greater than 3 weeks which is unexplained following a standard diagnostic evaluation to identify the source
- Unexplained fever in immunocompromised patient
Rationale
CT is usually the first line advanced imaging modality performed in the evaluation of fever of unknown origin (FUO).61 When a source remains unidentified following a comprehensive clinical and laboratory evaluation and CT, nuclear medicine imaging may be an option. Leukocyte scintigraphy has historically been used in the work up of FUO. It is specific (83%; 95% CI, 61%-94%) but not sensitive (33%; 95% CI, 24%-44%) for FUO, because it is limited to the identification of infectious sources.62 However, leukocyte scintigraphy may play a role in further characterizing abnormalities on CT, or when CT is negative and an infectious source is suspected.
Inflammatory bowel disease, including Crohn’s disease and ulcerative colitis, when CT or MRI is nondiagnostic (SPECT only)
Leukocyte scintigraphy is considered medically necessary in EITHER of the following scenarios:
-
Diagnosis of suspected Crohn’s disease following nondiagnostic colonoscopy in ANY of the following clinical scenarios when a patient:
- Meets criteria for irritable bowel syndrome with a normal colonoscopy and an elevated fecal calprotectin OR C-reactive protein (CRP) level
- Has concurrent upper gastrointestinal signs or symptoms with a nondiagnostic upper endoscopy
- Does not meet criteria for irritable bowel syndrome and does not have concurrent upper gastrointestinal signs or symptoms
- Management of new or worsening symptoms to confirm exacerbation or evaluate for complications, including stricture, abscess, toxic megacolon, or fistula
Rationale
Leukocyte scintigraphy also has the advantage of full gastrointestinal visualization and can detect sites of inflammatory bowel disease with the small and large bowel.63, 64 Relative to CT/MRI, leukocyte scintigraphy has lower spatial resolution, higher radiation doses, and is less widely available; hence, it is typically reserved as an add-on test when CT or MR enterography are nondiagnostic.
Osteomyelitis and septic arthritis (SPECT or SPECT/CT)
Also see Bone Marrow Scintigraphy.
Leukocyte scintigraphy is considered medically necessary in EITHER of the following scenarios:
- For diagnosis and management of osteomyelitis of the skull base or calvarium when CT, MRI, or planar scintigraphy is equivocal
- For diagnosis and management of osteomyelitis or septic arthritis at other sites (with or without bone marrow scintigraphy) when radiograph, ultrasound, or arthrocentesis is nondiagnostic or not sufficient to guide treatment and when CT, MRI, or planar scintigraphy is equivocal
Rationale
Functional imaging with bone scintigraphy has historically been used to evaluate for osteomyelitis when radiographs are nondiagnostic. Greater accuracy and the lack of ionizing radiation for MRI have largely made scintigraphy an add-on test when MRI cannot be performed or is nondiagnostic9, 19, 20, although bone scintigraphy offers a wider field of view and hence can localize multifocal disease. Similarly, leukocyte scintigraphy is usually not appropriate in the initial evaluation of osteomyelitis19 but may play a complementary role to bone scintigraphy in specific scenarios such as multifocal disease.
Perioperative evaluation, not otherwise specified, including delayed hardware failure (SPECT only)
Also see Bone Marrow Scintigraphy.
Leukocyte scintigraphy (with or without bone marrow scintigraphy) is considered medically necessary for diagnosis and management of periprosthetic infection.
Rationale
EXTREMITY
Leukocyte scintigraphy is an option in patients with suspected periprosthetic infection5 and has a high diagnostic accuracy (greater than 90%) for periprosthetic infections of the hip and knee; bone scintigraphy is highly sensitive for infection but is less specific.6, 7
SPINE
For periprosthetic infections in the spine, a variety of structural and functional imaging modalities may help define the presence or extent of disease. CT and MRI are commonly performed but evaluation of the surgical bed may be limited by beam hardening/susceptibility artifact. Gallium and bone scintigraphy are functional imaging alternatives that have a higher diagnostic accuracy than leukocyte scintigraphy in the spine.3, 4
Infectious and inflammatory conditions, not otherwise referenced (SPECT only)
Leukocyte scintigraphy is considered medically necessary for diagnosis and management in EITHER of the following scenarios:
- To evaluate for sternal wound infection or dehiscence when CT chest is nondiagnostic
- To evaluate sites of intra-abdominal infection suspected by CT or MRI
Rationale
CHEST
CT chest is usually sufficient for evaluating for sternal wound dehiscence or other forms of chest infection and has the advantage of simultaneous visualization of the mediastinum and lung parenchyma.13 Historically and in rare circumstances, bone or leukocyte scintigraphy has been used to differentiate superficial and deep infections, although evidence for diagnostic accuracy is limited.14
ABDOMEN AND PELVIS
CT or MRI is usually sufficient to evaluate for complications of intra-abdominal infection such as abscess and are widely available and commonly performed. However, factors such as distorted anatomy, ileus, ascites, and healing wounds can complicate the structural assessment of infection.64 When diagnostic uncertainty remains following CT and/or MRI, leukocyte scintgraphy may be helpful as an add-on test to further characterize suspected sites of infection such as infected surgical material including vascular grafts, shunts, or abscess.63, 64
SPECT Lymphoscintigraphy (SPECT or SPECT/CT)
For sentinel node localization when clinical evaluation is negative for nodal involvement, in the following scenarios:
- Stage I-III invasive breast cancer
- Cervical cancer that is stage IA1 with lymphovascular invasion (LVI), IA2, IB1, or IIA1
- Head and neck cancer when decisions are being made regarding mandibular resection
- Melanoma that is stage IA with adverse features, IB, stage II, in-transit, or locally recurrent
- Penile cancer
- Uterine cancer confined to the uterus
- Vulvar cancer (T1 or T2)
SPECT Metaiodobenzylguanidine (MIBG) Scintigraphy (SPECT or SPECT/CT)
Neuroendocrine cancer
Diagnostic workup and management of documented neuroendocrine cancer in the following scenarios:
Diagnostic workup
As clinically indicated for neuroblastoma or tumors of the autonomic nervous system (pheochromocytoma, paraganglioma, ganglioneuroma) in ANY of the following scenarios:
- Suspected metastatic disease
- Suspected neuroblastoma or tumors of the autonomic nervous system (pheochromocytoma, paraganglioma, ganglioneuroma) based on CT, MRI or abnormal serum or urine metanephrine levels
- For pheochromocytoma/paraganglioma prior to planned I131 iobenguane treatment
Management
As clinically indicated for pheochromocytoma/paraganglioma prior to planned I131 iobenguane treatment.
SPECT Parathyroid Imaging (SPECT or SPECT/CT)
Parathyroid adenoma
To identify a parathyroid adenoma for surgical planning in patients with primary hyperparathyroidism.
Localization of residual parathyroid tissue in patients with recurrent or persistent disease following parathyroidectomy.
Rationale
Ultrasound and sestamibi scintigraphy are the most common initial imaging tests used to evaluate suspected parathyroid adenoma and have a diagnostic accuracy of above 80%.18 A meta-analysis of 12 diagnostic accuracy studies with over 500 patients found comparable sensitivity for ultrasound (80%, CI 77%-83%) and planar sestamibi scintigraphy (84%, CI 80%-87%) and slightly higher specificity for sesamibi (87%, CI 83%-91%) vs ultrasound (77%, CI 71%-82%).19 When ultrasound and sestamibi exams are not diagnostic, 4-dimensional CT, including dynamic contrast enhancement, has high sensitivity (94%) and specificity (96%).20 This is consistent with clinical practice/consensus-based guidelines on parathyroid scintigraphy.21, 22
SPECT Renal Scintigraphy (Pediatric only) (SPECT only)
Renal scarring
To evaluate for renal scarring at least 4 months following urinary tract infection in EITHER of the following scenarios:
- Age less than 3 years with atypical urinary tract infection
- Recurrent urinary tract infection
Rationale
Renal scintigraphy using dimercaptosuccinic acid (DMSA) is sensitive for the detection of renal scarring following urinary tract infection or pyelonephritis. Renal scintigraphy is not routinely indicated in initial evaluation of a urinary tract infection (UTI), but may be used to help direct management including use of prophylactic antibiotics in children under 3 years of age with atypical UTIs (including features such as septicemia, infection with non Escherichia coli organisms, and other markers of serious illness) or in patients with recurrent UTI.23, 24
SPECT Somatostatin Receptor Imaging (SPECT or SPECT/CT)
Neuroendocrine cancer
Diagnostic workup and management of documented well-differentiated neuroendocrine cancer in EITHER of the following scenarios:
-
Diagnostic workup in EITHER of the following scenarios:
- Biopsy-proven well-differentiated neuroendocrine tumor
- Suspected well-differentiated neuroendocrine tumor based on endoscopy, conventional imaging, or biochemical markers when not amenable to biopsy
-
Management in EITHER of the following scenarios:
- Prior to planned peptide receptor radioligand therapy (PRRT) for well-differentiated neuroendocrine tumor
-
When identification of more extensive disease will change management and ANY of the following criteria are met:
- Equivocal findings of disease progression on conventional imaging
- Clinical or biochemical progression with negative conventional imaging
- When the original disease was only detectable by somatostatin receptor-based imaging
SPECT Thyroid Scintigraphy (SPECT or SPECT/CT)
Thyroid cancer
Diagnostic workup, management, and surveillance of documented thyroid cancer.
Diagnostic workup
As clinically indicated for differentiated thyroid cancer in ANY of the following scenarios:
- Prior to planned definitive radioactive iodine therapy in low risk patients
- Post thyroidectomy when radioactive iodine therapy is planned (except in low risk patients)
- For known or suspected metastatic disease when radioactive iodine therapy is planned
Management
As clinically indicated for differentiated thyroid cancer in ANY of the following scenarios:
- Immediately following radioactive iodine therapy
- Evaluation of persistent disease found on post radioactive iodine therapy imaging
- Evaluation for suspected recurrent thyroid cancer found during surveillance (i.e., elevated Tg, stable or rising antithyroglobulin antibodies, abnormal ultrasound during surveillance)
Surveillance
As clinically indicated for intermediate or high risk differentiated thyroid cancer 6 to 12 months after therapy has been completed.
Note: Low risk papillary thyroid cancer
- Classic papillary thyroid cancer
- Largest primary tumor < 2 cm
- Intrathyroidal
- Unifocal or multifocal (all foci ≤ 1 cm)
- No detectable anti-Tg antibodies
- Postoperative unstimulated Tg < 1 ng/mL
Note: Low risk follicular and Hurthle cell thyroid cancer
- Largest primary tumor < 2 cm
- Intrathyroidal
- No vascular invasion
- Clinical N0
- Postoperative unstimulated Tg < 1 ng/mL
Rationale
DIAGNOSTIC WORKUP
High quality evidence and medical society recommendations support the use of thyroid scintigraphy after thyroidectomy in patients with intermediate to high-risk differentiated thyroid cancer and in whom radioactive iodine treatment is planned. In a large systematic review, no clear improvement in overall survival or disease free survival was seen in low risk patients treated with radioactive iodine.25 In a retrospective review of 1298 patients with low-risk differentiated thyroid cancer, radioactive iodine resulted in a 10-year overall survival of 95.8% while patients not treated with radioactive iodine after surgery had a 10-year overall survival of 94.6%.26 Conversely, a review of the NCI database of 21,870 patients with intermediate-risk differentiated thyroid cancer who underwent total thyroidectomy with or without radioactive iodine showed improved overall survival (P < .001). After a multivariate adjustment for demographic and clinical factors, radioactive idone was associated with a 29% reduction in the risk of death, with a hazard risk 0.71 (95% CI, 0.62-0.82; P < .001).27 In a 2015 NTCTCS Registry analysis of 4941 patients, improved overall survival was seen in stage III patients who received radioactive iodine (risk ratio, 0.66; P = .04) and stage IV patients who received both total/near-total thyroidectomy and radioactive iodine (risk ratio, 0.66 and 0.70; combined P = .049).28
MANAGEMENT
Relatively weak evidence and medical society recommendations support the use of thyroid scintigraphy after radioactive iodine treatment evaluation. Up to 25% of images show lesions that may be clinically important but which were not originally detected on diagnostic imaging. In a retrospective study comparing whole body scans obtained before and after radioactive iodine in patients (N = 93) with thyroid carcinoma, in 27% of treatment cycles, the results of posttreatment and pretreatment scans differed. Only 10% of post-treatment scans detected new locations of metastatic disease.
SCREENING AND SURVEILLANCE
Biochemical monitoring remains the most vital component for surveillance of differentiated thyroid cancer, although conventional imaging may also be considered when clinically indicated. High quality evidence and medical society recommendations do not support the use of thyroid scintigraphy for asymptomatic surveillance of patients without evidence of disease. Both the American Thyroid Association and NCCN give consideration to a single exam after completion of therapy in intermediate-risk and high-risk differentiated thyroid cancer patients. The value of continued monitoring if no evidence of disease is seen is controversial.29, 30
SPECT VQ Scintigraphy (SPECT only)
Pulmonary embolism, in the following scenarios:
Adult: In pregnant patients or when CT/CTA cannot be performed or is nondiagnostic
VQ scintigraphy is considered medically necessary in ANY of the following scenarios:
- Pulmonary embolism likely based on modified Wells criteria31 (> 4 points)
- Pulmonary embolism unlikely based on modified Wells criteria31 (≤ 4 points) with a positive D-dimer
- Suspected pulmonary embolism in pregnancy
Pediatric
VQ scintigraphy is considered medically necessary in EITHER of the following scenarios:
- Moderate or high clinical suspicion of pulmonary embolism
- Concern for recurrent embolism in patients on adequate medical therapy
Rationale
For patients with suspected pulmonary embolism of moderate-to-high pretest probability, the majority of high-quality evidence-based guidelines recommend the use of VQ scintigraphy as an add-on test when CTA is nondiagnostic or cannot be performed due to contrast allergy or nephrotoxicity.6, 32 While systematic reviews of comparative diagnostic accuracy are mixed33, 34, many cited studies used earlier generations of CT technology, limiting the applicability of this literature to contemporary clinical practice. CT has fewer nondiagnostic studies35 and is widely available. Comparative effective radiation dose between VQ scintigraphy and CT is also controversial, but a normal VQ or Q scan may offer a lower radiation dose than CT and confidently exclude pulmonary embolism when negative (negative likelihood ratio 0.05).33 Scintigraphy is also recommended by consensus-based guidelines as an alternative test in pregnant patients.36
References
- 1. Jakobson Mo S, Axelsson J, Jonasson L, et al. Dopamine transporter imaging with [(18)F]FE-PE2I PET and [(123)I]FP-CIT SPECT-a clinical comparison. EJNMMI Res. 2018;8(1):100.
- 2. Schuster DM, Alazraki N. Gallium and other agents in diseases of the lung. Semin Nucl Med. 2002;32(3):193-211.
- 3. National Institute for Health and Care Excellence. Parkinson’s disease in adults: diagnosis and management. London, UK: National Institute for Health and Care Excellence; 2017. p. 243 pgs.
- 4. Vlaar AM, van Kroonenburgh MJ, Kessels AG, et al. Meta-analysis of the literature on diagnostic accuracy of SPECT in parkinsonian syndromes. BMC Neurol. 2007;7:27.
- 5. Subramaniam RM, Frey KA, Hunt CH, et al. ACR-ACNM practice parameter for the performance of dopamine transporter (DaT) single photon emission computed tomography (SPECT) imaging for movement disorders. Clin Nucl Med. 2017;42(11):847-52.
- 6. Lewy Body Dementia Association. New diagnostic criteria published for DLB, Lilburn, GA: Lewy Body Dementia Association; 2018 [cited 2019 February 5]. Available from: https://www.lbda.org/go/new-diagnostic-criteria-published-dlb-0.
- 7. Filippi M, Agosta F, Barkhof F, et al. EFNS task force: the use of neuroimaging in the diagnosis of dementia. Eur J Neurol. 2012;19(12):e131-40, 1487-501.
- 8. National Guideline Alliance, Dementia: assessment, management and support for people living with dementia and their carers, (2018) London, UK, National Institute for Health and Care Excellence, 419 pgs.
- 9. Wippold FJ, 2nd, Brown DC, Broderick DF, et al. ACR Appropriateness Criteria dementia and movement disorders. J Am Coll Radiol. 2015;12(1):19-28.
- 10. Garrett R. Solid liver masses: approach to management from the standpoint of a radiologist. Curr Gastroenterol Rep. 2013;15(12):359.
- 11. Venkatesh SK, Chandan V, Roberts LR. Liver masses: a clinical, radiologic, and pathologic perspective. Clin Gastroenterol Hepatol. 2014;12(9):1414-29.
- 12. Internal Clinical Guidelines Team, Gallstone disease: diagnosis and management, (2014) London, UK, National Institute for Health and Care Excellence, 102 pgs.
- 13. Farlow DC, Chapman PR, Gruenewald SM, et al. Investigation of focal hepatic lesions: is tomographic red blood cell imaging useful? World J Surg. 1990;14(4):463-7.
- 14. Bradley M, Stewart I, Metreweli C. Diagnosis of the peripheral cavernous haemangioma: comparison of ultrasound, CT and RBC scintigraphy. Clin Radiol. 1991;44(1):34-7.
- 15. Bhoil A, Gayana S, Sood A, et al. Hybrid single photon emission computed tomography/computed tomography sulphur colloid scintigraphy in focal nodular hyperplasia. World J Nucl Med. 2013;12(3):124-5.
- 16. Panes J, Bouhnik Y, Reinisch W, et al. Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines. J Crohns Colitis. 2013;7(7):556-85.
- 17. Society of Nuclear Medicine, Society of Nuclear Medicine procedure guideline for 111In-leukocyte scintigraphy for suspected infection/inflammation, version 3.0, (2004) Reston, VA, Society of Nuclear Medicine, 6 pgs.
- 18. Smith RB, Evasovich M, Girod DA, et al. Ultrasound for localization in primary hyperparathyroidism. Otolaryngol Head Neck Surg. 2013;149(3):366-71.
- 19. Nafisi Moghadam R, Amlelshahbaz AP, Namiranian N, et al. Comparative diagnostic performance of ultrasonography and 99mTc-Sestamibi scintigraphy for parathyroid adenoma in primary hyperparathyroidism; systematic review and meta-analysis. Asian Pac J Cancer Prev. 2017;18(12):3195-200.
- 20. Kutler DI, Moquete R, Kazam E, et al. Parathyroid localization with modified 4D-computed tomography and ultrasonography for patients with primary hyperparathyroidism. Laryngoscope. 2011;121(6):1219-24.
- 21. Greenspan BS, Dillehay G, Intenzo C, et al. SNM practice guideline for parathyroid scintigraphy 4.0. J Nucl Med Technol. 2012;40(2):111-8.
- 22. American College of Radiology, Society for Pediatric Radiology, ACR-SPR practice parameter for the performance of parathyroid scintigraphy, (2014) Reston VA, American College of Radiology, 7 pgs.
- 23. Karmazyn BK, Alazraki AL, Anupindi SA, et al. ACR Appropriateness Criteria urinary tract infection-child. J Am Coll Radiol. 2017;14(5s):S362-s71.
- 24. National Collaborating Centre for Women’s and Children’s Health, Urinary tract infection in children: diagnosis, treatment and long-term management, (2017) London, UK, National Institute for Health and Clinical Excellence, 178 pgs.
- 25. Sawka AM, Brierley JD, Tsang RW, et al. An updated systematic review and commentary examining the effectiveness of radioactive iodine remnant ablation in well-differentiated thyroid cancer. Endocrinol Metab Clin North Am. 2008;37(2):457-80, x.
- 26. Schvartz C, Bonnetain F, Dabakuyo S, et al. Impact on overall survival of radioactive iodine in low-risk differentiated thyroid cancer patients. J Clin Endocrinol Metab. 2012;97(5):1526-35.
- 27. Ruel E, Thomas S, Dinan M, et al. Adjuvant radioactive iodine therapy is associated with improved survival for patients with intermediate-risk papillary thyroid cancer. J Clin Endocrinol Metab. 2015;100(4):1529-36.
- 28. Carhill AA, Litofsky DR, Ross DS, et al. Long-term outcomes following therapy in differentiated thyroid carcinoma: NTCTCS Registry analysis 1987-2012. J Clin Endocrinol Metab. 2015;100(9):3270-9.
- 29. Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association guidelines task force on thyroid nodules and differentiated thyroid cancer. Thyroid. 2016;26(1):1-133.
- 30. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Thyroid Carcinoma (Version 2.2019). Available at http://www.nccn.org. ©National Comprehensive Cancer Network, 2019.
- 31. Wells PS, Anderson DR, Rodger M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000;83(3):416-20.
- 32. Kapucu OL, Nobili F, Varrone A, et al. EANM procedure guideline for brain perfusion SPECT using 99mTc-labelled radiopharmaceuticals, version 2. Eur J Nucl Med Mol Imaging. 2009;36(12):2093-102.
- 33. Roy PM, Colombet I, Durieux P, et al. Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism. BMJ. 2005;331(7511):259.
- 34. Cochon L, McIntyre K, Nicolas JM, et al. Incremental diagnostic quality gain of CTA over V/Q scan in the assessment of pulmonary embolism by means of a Wells score Bayesian model: results from the ACDC collaboration. Emergency Radiology. 2017;24(4):355-9.
- 35. Martinez G, Vernooij RW, Fuentes Padilla P, et al. 18F PET with flutemetamol for the early diagnosis of Alzheimer’s disease dementia and other dementias in people with mild cognitive impairment (MCI). Cochrane Database Syst Rev. 2017;11:Cd012884.
- 36. Waxman AD, Bajc M, Brown M, et al. Appropriate use criteria for ventilation-perfusion imaging in pulmonary embolism: summary and excerpts. J Nucl Med. 2017;58(5):13n-5n.
Codes
CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright by the American Medical Association. All Rights Reserved. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.
The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.
Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.
CPT/HCPCS
78071 Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT)
78072 Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization
78803 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT)
78830 Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of pathology, single area (eg, head, neck, chest, pelvis), single day imaging
78831 Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT), minimum 2 areas (eg, pelvis and knees, abdomen and pelvis), single day imaging, or single area imaging over 2 or more days
78832 Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of pathology, minimum 2 areas (eg, pelvis and knees, abdomen and pelvis), single day imaging, or single area imaging over 2 or more days