Single Photon Emission Computer Tomography (SPECT/CT) Imaging for the Evaluation of the Spine Form

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Medical Policy Number: 6.01.VT204

Single Photon Emission Computed Tomography (SPECT/CT) Imaging for the Evaluation of the Spine Corporate Medical Policy

File Name: Single Photon Emission Computed Tomography (SPECT) Imaging for the Evaluation of Back Pain File Code: 6.01.VT204 Origination: 12/2021
Last Review: 03/2025 Next Review: 03/2026
Effective Date: 07/01/2025

Description/Summary

Single photon emission tomography with concurrent CT imaging (SPECT/CT) is a nuclear medicine modality consisting of SPECT acquisition combined with CT using an integrated CT scanner. Such multimodality imaging offers the opportunity to correlate scintigraphic findings with anatomical images and introduces novel algorithms to further enhance SPECT image quality based on the CT data. The indications for SPECT-CT imaging, including for the evaluation of back pain, are broad. Policy Coding Information Click the links below for attachments, coding tables & instructions. Attachment I – CPT® Coding Table

When a service may be considered medically necessary

SPECT Imaging for evaluation of the Spine may be considered medically necessary for any of the following indications: • Diagnosis of infection, to distinguish bone from soft tissue infection, including osteomyelitis, epidural abscess, spondylodiscitis and discitis; OR • Diagnosis of avascular necrosis when both:

• prior plain film x-ray imaging or CT of the suspicious area is nondiagnostic; AND
• MRI cannot be performed or is nondiagnostic • Evaluation of bony lesion, indeterminant on prior imaging; OR
  • Evaluation of pain and/or associated symptoms of the spine, or clinical or radiographic signs in patients with primary bone tumor or tumors known to metastasize frequently to bone; OR • Evaluation of osseous tumor; OR • Evaluation of osteoid osteoma; OR

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Medical Policy Number: 6.01.VT204 • Diagnosis of suspected stress or occult fracture, not visible or indeterminant on prior imaging; OR
• Evaluation of surgical bed in patients with residual pain and/or associated symptoms with prior surgical procedure/fixation/fusion, where there is clinically suspected periprosthetic infection, aseptic loosening or delayed hardware failure; OR • Assessment of the spine and sacroiliac joints for rheumatologic disorders, including spondyloarthropathy, when MRI cannot be performed or is nondiagnostic; OR • Further evaluation of spondylolysis/spondylolisthesis when prior imaging provides insufficient information to direct management

When a service is considered not medically necessary

• Simultaneous ordering of SPECT imaging with other advanced imaging, such as MRI, may be considered not medically necessary unless there is clear, documented rationale to support the medical necessity of all imaging being performed at that the same time. Request must show that simultaneous imaging is medically necessary and is more likely to change patient management and/or outcome over single imaging modality or staged imaging approach. • For all other indications that are not listed as medically necessary

When a service is considered Investigational:

• The use of SPECT/CT imaging to guide surgical planning in individuals with axial neck and/or back pain from disc degeneration (spondylosis,) not otherwise meeting medical necessity criteria above. Policy Guidelines

(Physician documentation information, Instructions for PA submissions, clinical requirements, etc.

The medical records submitted for review should document that medical necessity criteria above are met. Clinical documentation to include history and physical exam information to support that the member has symptoms and/or findings of a condition above. Documentation to include what condition is being evaluated or ruled out.

Rationale/Scientific Background

Bone scintigraphy is a highly sensitive diagnostic nuclear medicine imaging technique that uses a radiotracer to evaluate the distribution of active bone formation in the skeleton related to malignant and benign diseases, as well as physiological processes. Diagnostic sensitivity and specificity of bone scanning can be significantly increased by using SPECT or, if available, SPECT/CT. Tomographic images may thus be acquired to assist in localizing anomalies seen on the whole-body images and to improve lesion contrast. [2]

Concomitant use of single-photon emission computed tomography, able to confine the uptake area to the sacroiliac joint, can significantly improve the diagnostic performance of bone scintigraphy for sacroiliitis. In counterpoint, the use of radionuclide tools for the diagnosis of sacroiliitis with its radiation exposure for the diagnosis in young patients may be unjustified

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Medical Policy Number: 6.01.VT204 or even unethical, when MRI, a modality with no radiation exposure and higher sensitivity and specificity is available, and thus its use is not advisable in daily clinical practice. In general, it seems that patients with suspected acute, particularly infectious sacroiliitis can benefit most from the diagnostic abilities of bone scintigraphy for disease localization, while patients with a more indolent course should probably be referred to alternative means of imaging. [6]

MRI has become commonly used to characterize sacroiliac joint disease severity and activity.

Bone scintigraphy may not be the preferred investigation for symptomatic degenerative joint disease well-characterized on radiographical imaging, properly diagnosed based on the pain syndrome and a well-performed clinical exam. [2]

Brusko, Brusko and colleagues (2019) carried out a retrospective medical and imaging record review of the role of pre-operative hybrid SPECT with CT imaging for surgical planning. The authors concluded that this was the largest series to date describing patients with axial neck and back pain who underwent preoperative SPECT imaging and subsequent surgical intervention on the affected spinal levels. The results demonstrated that SPECT imaging may be a useful adjunct to guide surgical planning, resulting in substantial clinical improvement following surgery. The authors showed started there are several important limitations to this study. First, this series was small, with just 23 patients included. However, traditional management of axial neck or back pain is nonsurgical and thus, this series was the largest one to date examining surgical outcomes. Second, a subset of patients had involvement of multiple spinal levels. Therefore, the inability to treat all degenerated levels and the progressive nature of the osteoarthritic disease may be responsible for a lack of clinical improvement in these select patients over time. Third, biases related to retrospective reviews must be taken into account, and the results of this single-surgeon, single-institution series may not be generalizable to other patient populations. [18]

Traditionally, facet joint injections have been used to aid in the diagnosis of axial pain generators. SPECT imaging has been shown to decrease the required number of facet injections for axial back pain. [19] However, a large discrepancy has been reported between hypermetabolic findings on SPECT/CT and facet joints treated with injections based on clinical symptoms; 53% of injected facets did not demonstrate any increased radiotracer uptake on SPECT imaging. [20] The clinical impact of facet joint bone scan activity is not fully understood. Further prospective double-blinded investigations of the clinical significance of facet joint activity by use of technetium Tc99m methylene diphosphonate SPECT/CT and comparative medial branch blocks are needed. Per Cohen and colleagues, there is moderate evidence supporting the use of SPECT for identifying painful lumbar facet joints prior to medial branch blocks (grade C recommendation, moderate level of certainty that the net benefit is small). Weak evidence exists supporting the use of SPECT for identifying painful lumbar facet joints prior to IA facet joint injections (grade D recommendation, low level of certainty). Regarding the cost-effectiveness of SPECT, further study is required. [21] Reference Resources

1. UptoDate: Evaluation of low back pain in adults. Review Current through 02/2025. Accessed 03/2025.
2. Van den Wyngaert T, Strobel K, Kampen WU, et al. The EANM practice guidelines for bone scintigraphy. Eur J Nucl Med Mol Imaging. 2016;43(9):1723-1738. doi:10.1007/s00259-016-3415-4

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Medical Policy Number: 6.01.VT204

3. Patel ND, Broderick DF, Burns J, Deshmukh TK, Fries IB, Harvey HB, Holly L, Hunt CH, Jagadeesan BD, Kennedy TA, O'Toole JE, Perlmutter JS, Policeni B, Rosenow JM, Schroeder JW, Whitehead MT, Cornelius RS, Corey AS. ACR Appropriateness Criteria Low Back Pain. J Am Coll Radiol. 2016 Sep;13(9):1069-78. doi: 10.1016/j.jacr.2016.06.008. Epub 2016 Aug 3. PMID: 27496288.
4. Israel O, Pellet O, Biassoni L, et al. Two decades of SPECT/CT - the coming of age of a technology: An updated review of literature evidence. Eur J Nucl Med Mol Imaging. 2019;46(10):1990-2012. doi:10.1007/s00259-019-04404-6
5. Slobodin G, Hussein H, Rosner I, Eshed I. Sacroiliitis - early diagnosis is key. J Inflamm Res. 2018;11:339-344. Published 2018 Sep 10. doi:10.2147/JIR.S149494
6. Tsoi C, Griffith JF, Lee RKL, Wong PCH, Tam LS. Imaging of sacroiliitis: Current status, limitations and pitfalls. Quant Imaging Med Surg. 2019;9(2):318-335. doi:10.21037/qims.2018.11.10
7. Matesan M, Behnia F, Bermo M, Vesselle H. SPECT/CT bone scintigraphy to evaluate low back pain in young athletes: common and uncommon etiologies. J Orthop Surg Res. 2016;11(1):76. Published 2016 Jul 7. doi:10.1186/s13018-016-0402-1
8. Perolat R, Kastler A, Nicot B, et al. Facet joint syndrome: from diagnosis to interventional management. Insights Imaging. 2018;9(5):773-789. doi:10.1007/s13244- 018-0638-x
9. Tofte JN, CarlLee TL, Holte AJ, Sitton SE, Weinstein SL. Imaging Pediatric Spondylolysis: A Systematic Review. Spine (Phila Pa 1976). 2017 May 15;42(10):777-
10. doi: 10.1097/BRS.0000000000001912. PMID: 27669047.
11. Booth TN, Iyer RS, Falcone RA Jr, Hayes LL, Jones JY, Kadom N, Kulkarni AV, Myseros JS, Partap S, Reitman C, Robertson RL, Ryan ME, Saigal G, Soares BP, Tekes-Brady A, Trout AT, Zumberge NA, Coley BD, Palasis S. ACR Appropriateness Criteria® Back Pain- Child. J Am Coll Radiol. 2017 May;14(5S):S13-S24. doi: 10.1016/j.jacr.2017.01.039. PMID: 28473069.
12. Patel ND, Broderick DF, Burns J, Deshmukh TK, Fries IB, Harvey HB, Holly L, Hunt CH, Jagadeesan BD, Kennedy TA, O'Toole JE, Perlmutter JS, Policeni B, Rosenow JM, Schroeder JW, Whitehead MT, Cornelius RS, Corey AS. ACR Appropriateness Criteria Low Back Pain. J Am Coll Radiol. 2016 Sep;13(9):1069-78. doi: 10.1016/j.jacr.2016.06.008. Epub 2016 Aug 3. PMID: 27496288.
13. Campbell RS, Grainger AJ, Hide IG, Papastefanou S, Greenough CG. Juvenile spondylolysis: a comparative analysis of CT, SPECT and MRI. Skeletal Radiol. 2005 Feb;34(2):63-73. doi: 10.1007/s00256-004-0878-3. Epub 2004 Nov 25. PMID: 15668821.
14. Dutton JA, Hughes SP, Peters AM. SPECT in the management of patients with back pain and spondylolysis. Clin Nucl Med. 2000 Feb;25(2):93-6. doi: 10.1097/00003072- 200002000-00001. PMID: 10656640.
15. AIM Specialty Health: Clinical Appropriateness Guidelines. Radiology. Appropriate Use Criteria: Nuclear Medicine Imaging. 2020. Reviewed 11/2020.
16. AIM Specialty Health: Clinical Appropriateness Guidelines. Advanced Imaging. Appropriate Use Criteria: Imaging of the Spine. 2020. Reviewed 11/2020.
17. Brusko GD, Perez-Roman RJ, Tapamo H, Burks SS, Serafini AN, Wang MY. Preoperative SPECT imaging as a tool for surgical planning in patients with axial neck and back pain. Neurosurg Focus. 2019 Dec 1;47(6):E19. doi: 10.3171/2019.9.FOCUS19648. PMID:
19. Pneumaticos SG, Chatziioannou SN, Hipp JA, Moore WH, Esses SI. Low back pain: prediction of short-term outcome of facet joint injection with bone scintigraphy. Radiology. 2006 Feb;238(2):693-8. doi: 10.1148/radiol.2382041930. PMID: 16436824.

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Medical Policy Number: 6.01.VT204

18. Lehman VT, Murphy RC, Kaufmann TJ, Diehn FE, Murthy NS, Wald JT, Thielen KR, Amrami KK, Morris JM, Maus TP. Frequency of discordance between facet joint activity on technetium Tc99m methylene diphosphonate SPECT/CT and selection for percutaneous treatment at a large multispecialty institution. AJNR Am J Neuroradiol. 2014 Mar;35(3):609-14. doi: 10.3174/ajnr.A3731. Epub 2013 Sep 12. PMID: 24029387.
19. Cohen SP, Bhaskar A, Bhatia A, Buvanendran A, Deer T, Garg S, Hooten WM, Hurley RW, Kennedy DJ, McLean BC, Moon JY, Narouze S, Pangarkar S, Provenzano DA, Rauck R, Sitzman BT, Smuck M, van Zundert J, Vorenkamp K, Wallace MS, Zhao Z. Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Reg Anesth Pain Med. 2020 Jun;45(6):424-467. doi: 10.1136/rapm-2019-101243. Epub 2020 Apr 3. PMID: 32245841; PMCID: PMC7362874.
20. Expert Panel on Musculoskeletal Imaging:, Bernard SA, Kransdorf MJ, Beaman FD, Adler RS, Amini B, Appel M, Arnold E, Cassidy RC, Greenspan BS, Lee KS, Tuite MJ, Walker EA, Ward RJ, Wessell DE, Weissman BN. ACR Appropriateness Criteria® Chronic Back Pain Suspected Sacroiliitis-Spondyloarthropathy. J Am Coll Radiol. 2017 May;14(5S):S62-S70. doi: 10.1016/j.jacr.2017.01.048. PMID: 28473095.

21. Carelon (Formerly AIM Specialty Health): Clinical Appropriateness Guidelines. Radiology. Appropriate Use Criteria: SPECT Imaging. Effective 01/30/202. Reviewed 03/20245. Document Precedence

    Blue Cross and Blue Shield of Vermont (Blue Cross VT) Medical Policies are developed to provide clinical guidance and are based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. The applicable group/individual contract and member certificate language, or employer’s benefit plan if an ASO group, determines benefits that are in effect at the time of service. Since medical practices and knowledge are constantly evolving, Blue Cross VT reserves the right to review and revise its medical policies periodically. To the extent that there may be any conflict between medical policy and contract/employer benefit plan language, the member’s contract/employer benefit plan language takes precedence. Audit Information

    Blue Cross VT reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in the medical policy. If an audit identifies instances of non-compliance with this medical policy, Blue Cross VT reserves the right to recoup all non-compliant payments. Administrative and Contractual Guidance Benefit Determination Guidance

    Prior approval is required and benefits are subject to all terms, limitations and conditions of the subscriber contract.

    Incomplete authorization requests may result in a delay of decision pending submission of missing information. To be considered compete, see policy guidelines above.

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Medical Policy Number: 6.01.VT204 NEHP/ABNE members may have different benefits for services listed in this policy. To confirm benefits, please contact the customer service department at the member’s health plan.

Federal Employee Program (FEP): Members may have different benefits that apply. For further information please contact FEP customer service or refer to the FEP Service Benefit Plan Brochure. It is important to verify the member’s benefits prior to providing the service to determine if benefits are available or if there is a specific exclusion in the member’s benefit. Coverage varies according to the member’s group or individual contract. Not all groups are required to follow the Vermont legislative mandates. Member Contract language takes precedence over medical policy when there is a conflict. If the member receives benefits through an Administrative Services Only (ASO) group, benefits may vary or not apply. To verify benefit information, please refer to the member’s employer benefit plan documents or contact the customer service department. Language in the employer benefit plan documents takes precedence over medical policy when there is a conflict. Policy Implementation/Update information

02/2021 New Policy. Codes 78803, 78830, 78831, 78832 removed from corporate investigational medical policy and will require prior approval. 04/2022 Policy reviewed. References updated. No changes to Policy Statement. 05/2023 Policy reviewed. References updated. No changes to Policy Statement. 03/2024 Policy reviewed. References updated. No changes to Policy Statement. 03/2025 Policy reviewed. References updated. No changes to Policy Statement. Eligible providers

Qualified healthcare professionals practicing within the scope of their license(s).

Approved by Blue Cross VT Medical Directors

Tom Weigel, MD, MBA
Vice President and Chief Medical Officer

Tammaji P. Kulkarni, MD Senior Medical Director

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Medical Policy Number: 6.01.VT204 Attachment I CPT® Coding Table

Code Type Number Description Policy Instructions The following codes will be considered as medically necessary when applicable criteria have been met. CPT® 78803 Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT), single area (eg, head, neck, chest, pelvis), single day imaging Prior Approval Required CPT® 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 Prior Approval Required CPT® 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 Prior Approval Required CPT® 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 Prior Approval Required