Dopamine transporter imaging with single-photon emission computed tomography (DaTScan) may be considered for the following indications:

• Individuals for whom the diagnosis of Parkinson's Disease (PD) is unclear after serial clinical evaluations, such as those with long-standing essential tremor whose tremor evolves to have characteristics of PD but fails to respond unequivocally to levodopa
• Individuals suspected of having drug-induced parkinsonism

Definitions:

DaTScan – (123-I-Ioflupane, 123-I-FT-CIT) is an intravenous, neuroimaging, radiopharmaceutical used with single photon emission computed tomography as an objective adjunct to the clinical diagnosis of neurodegeneration in patients with movement disorders. DaTScan stands for Dopamine Transporter Scan. This technology was approved by the FDA in 2009. This diagnostic method investigates if there is a loss of dopaminergic neurons in striatum.

DaT-SPECT - The scanner that measures the single-photon emission computed radiopharmaceutical DaTScan (see above)

PD – Parkinson’s Disease

Description:

A DaTScan involves injection of a small amount of a radioactive drug that is then measured by a single-photon emission computed tomography scanner (SPECT scanner). The SPECT scanner measures the levels and location of the drug in the brain. SPECT scanning with DaTScan, a radiopharmaceutical indicated for striatal dopamine transporter visualization, may be medically necessary to distinguish Parkinson’s Disease from essential tremor.

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HealthFirst Health Plans
Reimbursement Policy and Clinical Criteria:

1. Test request shall be made by a Neurologist along with the following information and documents:
   1. The request shall include complete neurologist office notes and a physical indicating a detailed neuro exam was completed.
   2. Evidence shall be presented that the patient's tremors affect daily activities.

Inclusions:

1. To aid in the diagnosis of a parkinsonian syndrome (e.g., essential tremor v. Parkinson’s Disease)
2. To distinguish drug-induced parkinsonism (DIP) v. degenerative parkinsonism or idiopathic Parkinson’s disease
3. To discriminate psychogenic parkinsonism from neurologically-based parkinsonism
4. To be used prior to DBS surgery for intractable tremor of uncertain etiology to determine the appropriate site of DBS stimulation (e.g., VIM stimulation for essential tremor v. STN or GPi stimulation for Parkinson’s disease)
5. To distinguish between dementia with Lewy bodies and Alzheimer disease
6. DaTScan should only be ordered by a board-certified neurologist who has evaluated the patient

Exclusions/Limitations:

1. As a screening or confirmatory test and for monitoring disease progression or response to therapy
2. No more than one DaTScan study in the member's lifetime.