December 19, 2019

ACR Affects Insurer’s Decision to Expand DaT SPECT Scan Coverage

The American College of Radiology® (ACR®) Commission on Nuclear Medicine and Molecular Imaging and Economics Committee on Nuclear Medicine played critical roles in the summer of 2019 by informing private insurer Anthem’s decision to modify its reimbursable medical policy for non-cardiovascular indications for Dopamine Transporter (DaT) SPECT imaging.

Anthem’s Office of Medical Policy and Technology Assessment (MPTA) committee decided to include criteria for DaT SPECT scans at its Aug. 22 meeting after receiving a comment letter from the ACR Nuclear Medicine Commission a month earlier. It described clinical and scientific rationale for accepting the procedure’s medical necessity and appropriateness for evaluating various neurological movement disorders.

The ACR helped advance the discussion with comments submitted collectively and individually from its expert members by responding to Anthem’s detailed medical policy questionnaire on the radiopharmaceutical agent and its SPECT imaging applications. Much of the evidence was documented in the 2017 ACR-ACNM Practice Parameter for the Performance of Dopamine Transporter (DaT) SPECT Imaging for Movement Disorders, as well as the published results of recent multi-site efficacy trials.

Based on its medical policy review of RAD.00023 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications, the MPTA committee decided sufficient evidence had been accumulated to no longer consider DaT SPECT to be investigational.

As described in the insurer’s updated medical policy, effective Aug. 2019, Anthem now deems SPECT scans to be medically necessary for any of the following clinical indications:

  • Bone and joint conditions — to differentiate between infectious, neoplastic, avascular or a traumatic process
  • 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
  • DaT scans are reimbursable — when the following two criteria are met:
    a. To differentiate Parkinsonian syndromes associated with nigrostriatal degeneration from other disorders:
    i. To differentiate Parkinsonian syndrome from non-neurodegenerative disorders such as essential tremor or drug-induced tremor; or
    ii. In individuals with dementia, to differentiate between Alzheimer disease and dementia with Lewy bodies; and
    b. The diagnosis is unclear and the results are likely to guide management.
  • Liver hemangioma — using labeled red blood cells to further define lesions identified by other imaging modalities
  • Localization of abscess/infection/inflammation in soft tissues or cases of fever of unknown origin
  • 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)
  • Parathyroid imaging
  • Renal — Dimercaptosuccinic acid (DMSA) scan to assess the status of kidney for scarring and function

Anthem extended thanks to the ACR for the time and effort spent in reviewing this policy and for supporting the principles of evidence-based medicine. The College will continue to engage with commercial payers, such as Anthem, to ensure a proper alignment of coverage policies and clinical practices to improve patient care.