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Medical Policy: 06.01.14
Original Effective Date: January 2003
Reviewed: January 2012
Revised: August 2009
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Tumor scintigraphy involves the intravenous administration of a radiopharmaceutical that localizes in specific tumor tissues. Subsequent computer-generated images will allow the interpreting physician to detect and evaluate primary, residual, metastatic, or recurrent tumor tissue.
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Prior Approval:
Not applicable
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Policy:
The following applications of tumor scintigraphy may be considered medically necessary:
- Indium-111 pentetreotide (OctreoScan®) for the localization of primary and metastatic neuroendocrine tumors bearing somatostatin receptors
- I-131 meta-iodobenzylguanidine (MIBG) for the localization of primary or metastatic neuroblastoma and pheochromocytoma.
- Iobenguane I-123 (AdreView™) for detection of primary or metastatic pheochromocytoma or neuroblastoma as an adjunct to other diagnostic tests.
Because the current medical literature is not sufficient to support conclusions concerning efficacy and impact on clinical management, the use of tumor scintigraphy is considered investigational with regard to treatment of the following conditions:
- Malignant melanoma
- Breast cancer
- Lung cancer
- Prostate cancer
See also policy 05.01.18 Radioimmunotherapy for Non-Hodgkin's Lymphoma
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- The following CPT codes may be used to report radioimmunoscintigraphy:
- 78800 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); limited area
- 78801 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); multiple areas
- 78802 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, single day imaging
- 78803 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT)
- 78804 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, requiring two or more days imaging
- The following HCPCS codes may be used to report the radiopharmaceutical agent:
- A4641 Supply of radiopharmaceutical diagnostic imaging agent, not otherwise classified
- A9582 Iodine I-123 iobenguane, diagnostic, per study dose, up to 15 millicuries
- A9572 Indium In-111 pentetreotide, diagnostic, per study dose, up to 6 millicuries
- A9508 Iodine I-131 iobenguane sulfate, diagnostic, per 0.5 millicurie
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Selected References:
- Lieberman G et al. Preoperative diagnosis of ovarian carcinoma with a novel monoclonal antibody. American Journal of Obstetrics and Gynecology 2000 83(1): 534-540.
- Saunders TH, Ribeiro Mendes HK, Gleeson FV. New techniques for imaging colorectal caner: the use of MRI, PET and radioimmunoscintigraphy for primary staging and follow-up. British Medical Bulletin 2002;64:81-99.
- Wegener WA, Petrelli N, Serafini A, Goldenberg DM. Safety and efficacy of arcitumomab imaging in colorectal cancer after repeated administration. J Nucl Med. 2000 Jun;41(6):1016-20.
- Artiko V, Obradovic V, Davidovic B, et al. Radioimmunodetection of colorectal carcinoma. Hepatogastroenterology 2003 Jul-Aug; 50(52):1029-31.
- Su WT, Brachman M, O'Connell TX. Use of OncoScint scan to assess resectability of hepatic metastases from colorectal cancer. Am Surg. 2001 Dec;67(12):1200-3.
- Lechner P, Lind P, Goldenberg DM. Can postoperative surveillance with serial CEA immunoscintigraphy detect resectable rectal cancer recurrence and potentially improve tumor-free survival? J Am Coll Surg 2000 Nov;191(5):511-18.
- Raj GV, Partin AW, Polascik TJ. Clinical utility of indium 111-capromab pendetide immunoscintigraphy in the detection of early, recurrent prostate carcinoma after radical prostatectomy. Cancer 2002 Feb 15;94(4):987-96.
- Kahn D, Williams RD, Manyak MJ, et al. 111 indium-capromab pendetide in the evaluation of patients with residual or recurrent prostate cancer after radical prostatectomy. The ProstaScint Study Group. J Urol 1998 Jun;159(6): 2041-6; discussion 2046-7.
- Surwit EA, Childers JM, Krag DN, et al. Clinical assessment of 111In-CYT-103 immunoscintigraphy in ovarian cancer. Gynecol Oncol. 1993 Mar;48(3): 285-92.
- Breitz HB, Tyler A, Bjorn MJ, Lesley T, Weiden PL. Clinical experience with Tc-99m nofetumomab merpentan (Verluma) radioimmunoscintigraphy. Clin Nucl Med 1997 Sep; 22(9): 615-20.
- Granberg D, Sundin A, Janson ET, et al. Octreoscan in patients with bronchial carcinoid tumours. Clin Endocrinol (Oxf) 2003 Dec; 59(6): 793-9.
- Lau SK, Johnson DS, Coel MN. Imaging of non-small cell lung cancer with indium-111 pentetreotide. Clin Nucl Med. 2000 Jan;25(1): 24-8.
- Krausz Y, Keidar Z, Kogan I, et al. SPECT/CT hybrid imaging with 111In-pentetreotide in assessment of neuroendocrine tumours. Clin Endocrinol (Oxf) 2003 Nov;59(5):565-73.
- Chiti A, Briganti V, Fanti S, et al. Results and potential of somatostatin receptor imaging in gastroenteropancreatic tract tumors. J Nucl Med. 2000 Mar;44(1): 42-9.
- Le Duc-Pennec A, Thol C, Cavarec M, et al. Octreotide imaging plus bone scintigrams to optimally localize gastroenteropancreatic neuroendocrine tumors. Clin Nucl Med. 2003 Jan;28(1): 5-8.
- Blue Cross and Blue Shield Association. Medical Policy No. 6.01.05; Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging) Using Technetium-99m Nofetumomab Merpentan (Verluma). 2004.
- Blue Cross and Blue Shield Association. Medical Policy No. 6.01.36; Radioimmunoscinitigraphy imaging (monoclonal antibody imaging) using In-111 Satumomab Pendetide (OncoScint) or Tc-99m Arcitumomab (IMMU-4, CEA-Scan). 2004.
- Blue Cross and Blue Shield Association. Medical Policy No. 6.01.37; Radioimmunoscinigraphy Imaging (Monoclonal Antibody Imaging) With Indium-111 Capromab Pendetide (Prostascint® for Prostate Cancer. 2004.
- Jani AB, Blend MJ, Hamilton R et al. Influence of radioimmunoscintigraphy on postprostatectomy radiotherapy treatment decision making. J Nucl Med 2004; 45(4):571-8.
- American College of Radiology (ACR), Society for Pediatric Radiology (SPR). ACR-SPR practice guideline for the performance of tumor scintigraphy (with gamma cameras). [online publication]. Reston (VA): American College of Radiology; 2010.
- Kayano D, Taki J, Fukuoka M et al. Low-dose (123) I-metaiodobenzylguanidine diagnostic scan is inferior to (131) I-metaiodobenzylguanidine posttreatment scan in detection of malignant pheochromocytoma and paraganglioma. Nucl Med Comm. 2011 Oct; 32(10):941-6.
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Policy History:
Date Reason Action
January 2011 Annual review Policy renewed
January 2012 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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