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Date Printed: October 20, 2017: 11:50 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. 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.

04-78000-15

Original Effective Date: 11/15/01

Reviewed: 04/30/09

Revised: 04/15/17

Subject: FDG-SPECT

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

FDG-SPECT, also referred to as metabolic SPECT (single photon emission computed tomography), or PET using a gamma camera, is a general term describing imaging techniques in which a SPECT camera is used to take images of internal organs (e.g., heart). FDG SPECT imaging of the heart shows the live heart muscle and are usually performed on patients who may have had a heart attack. The information from a FDG SPECT may provide information regarding how much live heart muscle in relation to permanently damaged muscle is left to benefit from angioplasty or surgery.

FDG is an abbreviated name for Fluorodeoxyglucose (2-deoxy-2- [18F] fluoro-D-glucose). Radio-labeled 2-fluoro-2-deoxy-D-glucose (FDG) is a radiotracer used in two nuclear medicine imaging modalities: positron emission tomography (PET) and SPECT. FDG is administered intravenously and is used to determine how certain organs and tissues in the body are functioning at the cellular level by measuring glucose metabolism. FDG is widely used for functional studies in neurology, cardiology, and oncology.

Once FDG is injected into the body, FDG emits a positron that interacts with an electron in the body. This interaction creates a gamma ray with a 511keV energy level that exits the body and is detected by the PET or SPECT camera. SPECT cameras are conventionally used to provide anatomic and functional images. When SPECT is used in conjunction with FDG, SPECT cameras can provide images reflecting the anatomy and metabolic activity of tissues, similar to PET scanning.

FDG-SPECT imaging describes two general techniques. In one technique, SPECT cameras are adapted with collimators that screen out the lower energy photons and thus only detect the high-energy 511 ke-V photons. For the purpose of this policy, this technique will be referred to as FDG-collimated-SPECT. In the second technique, a dual-headed rotating SPECT camera can be operated in the “coincidence mode”, meaning that the camera will only count those photons that are simultaneously detected at 180 degrees from one another (referred to as FDG-DHC dual-head coincidence-SPECT).

POSITION STATEMENT:

FDG-SPECT meets the definition of medical necessity when used to evaluate myocardial viability in patients with known coronary artery disease.

FDG-SPECT is considered experimental or investigational, as there is insufficient evidence in the published peer-reviewed scientific literature to support conclusions regarding the effects of FDG-SPECT on health outcomes for all other applications, including, but not limited to evaluation of the following:

BILLING/CODING INFORMATION:

There is no specific CPT code to report FDG-SPECT. The following HCPCS codes may be use to report FDG-SPECT.

HCPCS Coding

S8085

Fluorine-18 fluorodeoxyglucose (F-18 FDG) imaging using dual-head coincidence detection system (non-dedicated PET scan).

ICD-10 Diagnoses Codes That Support Medical Necessity

I25.10

Atherosclerotic heart disease of native coronary artery without angina pectoris

I25.110 – I25.119

Atherosclerotic heart disease of native coronary artery with angina pectoris

I25.700– I25.709

Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris

I25.710 – I25.719

Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris

I25.720 – I25.729

Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris

I25.730 – I25.739

Atherosclerosis of nonautologous artery coronary artery bypass graft(s) with angina pectoris

I25.750 – I25.759

Atherosclerosis of native coronary artery of transplanted heart with angina pectoris

I25.760 – I25.769

Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris

I25.790 – I25.799

Atherosclerosis of other coronary artery bypass graft(s) with

I25.810 – I25.812

Atherosclerosis of coronary vessels without angina pectoris

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report FDG-SPECT:

Camera-based imaging

REFERENCES:

  1. Blue Cross Blue Association Medical Policy-FDG-SPECT (6.01.27), 12/14/05.
  2. Delbeke D, Martin WH, Patton JA et al. Value of Iterative Reconstruction, attenuation Correction, and Image Fusion in the Interpretation of FDG PET Images with an Integrated Dual-Head Coincidence Camera and X-Ray-based Attenuation Maps. Radiology 2001; 218:163-171.
  3. Mastin ST, Drane WE, Harman EM et al. FDG SPECT in Patients with Lung Masses. Chest 1999; 115:1012-1017.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/30/09.

GUIDELINE UPDATE INFORMATION:

11/15/01

New Medical Coverage Guideline.

11/15/02

Guideline revised to include reimbursement statement for codes 78890 and 78891.

12/15/02

Annual review, no change in guideline.

03/15/04

Annual review. Amended the description section. Revised the investigational statement. Added rationale for the investigational statements for: cardiac and oncologic applications and neurologic disorders. Also removed "(Metabolic SPECT)" from title.

01/01/05

HCPCS update. Deleted code 78990.

03/15/05

Scheduled review. No change in coverage statement. Updated references.

04/15/06

Annual review, no change in coverage statement. Added code A9552.

04/15/07

Scheduled review. No change in coverage statement.

06/15/07

Reformatted guideline.

04/15/08

Scheduled review. Expanded ICD-9 diagnoses code range for coronary atherosclerosis, to include 414.06 and 414.07. Updated references.

05/15/09

Annual review. No change in position statements. Updated references.

01/15/11

Revision; related ICD-10 codes added.

05/11/14

Revision: Program Exceptions section updated.

10/15/15

Revision; updated ICD9 and ICD10 coding section. Updated references.

11/01/15

Revision: ICD-9 Codes deleted.

04/15/17

Code update; deleted A9552.

Date Printed: October 20, 2017: 11:50 AM