Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's Disease
Treatment: 78830 - single-photon emission computed tomography/computed tomography (SPECT/CT), a special kind of combined picture done to show growths, inflammation, or movement of the injected agent in the body, of a single area of the body, done in one day.
The insurer denied coverage for 78830 - SPECT/CT, a special kind of combined picture done to show growths, inflammation, or movement of the injected agent in the body, of a single area of the body, done in one day.
The denial is upheld.

The patient is a female with a history of Parkinson's disease (PD), arthritis, dyspepsia, gastroesophageal reflux disease (GERD), glaucoma, and hypothyroidism. The request is SPECT, a special kind of combined picture done to show growths, inflammation, or movement of the injected agent in the body, of a single area of the body, done in one day. 

The Medical Arts Pavilion note states, the patient has decreased facial expressivity, decreased blink, and slow gait/walk. The assessment is gait abnormality with secondary parkinsonism. The plan is for Nuclear Medicine Dopamine Transporter Scan (NM DaTscan). The patient was seen for severe low back pain with radiation into the legs. Tone was mildly increased in right (R) leg. The assessment is gait abnormality suggesting lumbar spinal stenosis. The patient has features of degenerative spine disease. 

The magnetic resonance imaging (MRI) brain shows there are no abnormalities. Another MRI of the cervical spine shows degenerative changes and moderately severe bilateral foraminal compromise. It is noted that the lower extremities are normal. The patient has signs of akinetic rigid syndrome that could represent parkinsonian syndrome versus compressive neurology.

The requested test was not necessary. There is still consideration for compressive myelopathy, and this was not fully assessed. Therefore, the request is denied and not medically necessary for this patient as policy and peer literature states.  

"Parkinsonian syndromes are classified by etiology mainly on clinical grounds, that is, on the basis of the clinical manifestations and with the aid of conventional ancillary studies. In most cases, the clinical diagnosis is clear. In up to 30% (percent) of cases, however, the etiological classification remains uncertain after completion of the basic clinical diagnostic evaluation, and additional investigation with nuclear imaging may be indicated. In particular, cerebral SPECT with DAT ligands may be helpful." (Buchert, et al., 2019)
"Parkinson disease is a neurodegenerative disorder that mostly presents in later life with generalized slowing of movements (bradykinesia) and at least one other symptom of resting tremor or rigidity. Other associated features are a loss of smell, sleep dysfunction, mood disorders, excess salivation, constipation, and excessive periodic limb movements in sleep." (Zafar, et al., 2022)                                                         

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for 78830 - single photon emission computed tomography (SPECT/CT), a special kind of combined picture done to show growths, inflammation, or movement of the injected agent in the body, of a single area of the body, done in one day is upheld. Medical Necessity is not substantiated.