Academy, Anthem revise SPECT/CT fusion imaging policy

October 2016 - Vol. 35, No. 9

Thanks to Academy physician leaders’ comments and clinical recommendations, Anthem revised the Anthem Medical Policy for Single-Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) Fusion Imaging. The key change included adding a statement that considers the use of SPECT/CT fusion imaging medically necessary in the evaluation of parathyroid glands in individuals with hyperparathyroidism when used for anatomic localization prior to parathyroid surgery.

Mark E. Zafereo, MD, Endocrine Committee, led the May 10, 2016, meeting. Members from the Physician Payment Policy Workgroup (3P) and Imaging Committee also attended to provide input on policy language, critiques on the referenced medical literature, and overall clinical recommendations to revise the policy. Due to effective relationships the Academy physician experts held, the Academy also invited external leadership to the meeting, including Past New York State American College of Radiology Chair, Robert Rapoport, MD, and Section Chief of Nuclear Medicine and Radiation Safety Officer of St. Peter’s Hospital, Stewart Hawkins, MD. Anthem was open to discussing the policy and agreed to review the Academy’s comments and suggestions on appropriate medical literature at their next Medical Policy & Technology Assessment Committee (MPTAC) meeting.

“The success in the revision of Anthem’s SPECT/CT Fusion Imaging Policy is an example of how the collaborative efforts of the Academy can serve to benefit all otolaryngologist-head and neck surgeons, said Dr. Zafereo. “Thanks to the efforts of experts from multiple committees and the hard work of Academy staff, our physicians can now spend less time negotiating with insurance companies on the medical necessity of a SPECT/CT, and more time in caring for our patients.”

The lead-up to the successful policy revision began in October 2015, when the Academy’s Imaging and Endocrine Committees provided reviews on Anthem’s SPECT/CT Fusion Imaging Medical Policy. Academy committee members disagreed with the policy position that SPECT/CT fusion imaging was considered “investigational and not medically necessary” for all indications. Physician leaders believed it would be valuable to arrange a conference call before Anthem reviewed the policy to understand the policy rationale and discuss criteria for coverage.

In January 2016, Anthem informed the Academy that it was the decision of the MPTAC to retain the policy position without Academy recommendations. In February, the Health Policy Team inquired on the rationale behind this decision, and requested the recommendations be reconsidered and implemented in the next iteration of the policy. Ultimately, Anthem agreed to meet in May. The clinical expertise provided in May and the additional value referenced in the medical literature led to the successful change in policy.

On the call, the Academy discussed that many otolaryngologists-head and neck surgeons frequently use SPECT-CT to optimize patient outcomes in parathyroid surgery. Furthermore, experts said that based on detailed anatomic localization of abnormal parathyroid glands, SPECT/CT may contribute to improved success of surgery, fewer revision surgeries, less morbidity of surgery, fewer complications, less operative time, and equivalent or reduced overall treatment cost.

This exceptional outcome confirms the positive impact the Academy’s physician leaders contribute to private payer issues. The new policy now reflects medical literature from several studies demonstrating that SPECT/CT may be superior to SPECT alone and planar imaging with single and dual phase sestamibi, and the policy reflects the overall medical necessity of SPECT/CT fusion imaging in the anatomic localization of parathyroid glands. See the revised medical policy, complete with Academy physician efforts, at https://www.anthem.com/medicalpolicies/policies/mp_pw_a050555.htm.