June 3, 2021
After many complaints from our members about SPECT/CT coverage denials from various commercial payers, SNMMI has put forth a resource members can use to contest these decisions. This medical necessity letter is written as a template our members may use and personalize as they see fit. It combines months of work from both SNMMI's Coding & Reimbursement and Government Relations Committees and our two 2020-2021 Henkin Fellows. The letter was also vetted by various industry partners.
Many commercial payers provide that SPECT/CT is “investigational and not medically necessary for non-hyperparathyroidism indications and subsequently not covered under the terms of the member’s health plan.” The new and revised 2020 CPT® SPECT/CT codes and CMS payments underwent significant scientific scrutiny in order to be adopted and reimbursed. However, some insurance companies continue to label SPECT and SPECT/CT as "experimental" despite extensive clinical research and everyday clinical use across the United States and elsewhere.
We believe there is a fundamental lack of understanding in commercial payers’ medical review panels regarding the everyday clinical value of SPECT/CT to physician clinicians across all geographic regions and at all major hospital systems in the United States. We hope that the reasons stated and literature cited in this letter will emphasis the value of SPECT/CT and its need for commercial payer coverage. A copy of the letter is found here.