Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single photon emission computed tomography 
(SPECT)-DaTscan. 
 
You asked the Plan to pre-approve a SPECT-DaTscan. You say that a SPECT-DaTscan will help guide in 
correctly diagnosing the enrollee due to unclear symptoms that overlap with other neurological conditions and 
will provide appropriate treatment in a timely fashion. The Plan denied your request. The Plan says there must 
be documentation that shows medication trials or brain imaging, which the medical records do not show. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a SPECT-DaTscan. Our reviewer says 
that the requested SPECT-DaTscan is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided records in this case do not document concern for a stress fracture or 
spondylosis or infection (e.g., discitis) or tumor (e.g., osteoid osteoma) or a need to analyze blood flow to an 
organ, as in the case of myocardial viability or to differentiate ischemic heart disease from dilated 
cardiomyopathy as required by the Medicare NCD. Likewise, the provided medical records and review of the 
current peer-reviewed medical literature do not support the necessity of the SPECT-DaTscan in this clinical 
scenario. As summarized in Up to Date, Diagnosis and differential diagnosis of Parkinson disease (PD): "Based 
upon the data and our clinical experience, we suggest the use of DaTscan for the following scenarios: 
-Patients for whom the diagnosis is unclear after serial clinical evaluations, such as those with long-standing 
ET whose tremor evolves to have characteristics of PD but fails to respond unequivocally to levodopa. 
-Patients suspected of having drug-induced parkinsonism (striatal uptake of the isotope should be normal in this 
setting) (see "Drug-induced parkinsonism"). 
-Patients who are possible candidates for deep brain stimulation but for whom the diagnosis of ET versus PD 
versus some other cause (e.g., dystonia) is unclear and where an accurate diagnosis determines the target of 
deep brain stimulation (e.g., thalamic ventral intermediate nucleus versus subthalamic nucleus/globus pallidus 
interna). 
-To firmly establish the presence of nigrostriatal dopamine deficiency when recruiting for a clinical trial, 
particularly if the focus is neuroprotection. 
The widespread availability of DaTscan outside of specialized medical centers has led to instances of 
misinterpreted results because of inaccurate clinical diagnosis and/or inexperienced nuclear medicine 
practitioners. Therefore, consultation with a movement disorders specialist is recommended to determine the 
utility of ordering a DaTscan." The records in this case do not document any of the clinical features in this case 
which would necessitate the SPECT-DaTscan per Medicare criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a SPECT-DaTscan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a single photon emission computed tomography (SPECT)-DaTscan.