Single Photon Emission Computed Tomography (SPECT) — CPB 0376 | AETNA Coverage Update

Aetna modified CPB 0376 covering SPECT imaging, effective February 25, 2026. Here's what billing teams need to know.

Aetna, a CVS Health company, updated its SPECT coverage policy under CPB 0376 Aetna system, affecting CPT codes 78071, 78072, 78451, 78452, 78803, 78830, 78831, and 78832, along with HCPCS code A9584 for Ioflupane I-123. The policy governs both cardiac and non-cardiac SPECT indications and routes cardiac imaging criteria through eviCore Healthcare — a detail that has real teeth for reimbursement if your team misses it.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna
Policy	Single Photon Emission Computed Tomography (SPECT)
Policy Code	CPB 0376
Change Type	Modified
Effective Date	February 25, 2026
Impact Level	High
Specialties Affected	Nuclear medicine, cardiology, neurology, oncology, endocrinology, orthopedics, pulmonology
Key Action	Audit precertification requirements by CPT code and confirm cardiac SPECT claims align with eviCore cardiac imaging guidelines before submitting

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Aetna SPECT Coverage Criteria and Medical Necessity Requirements 2026

The Aetna SPECT coverage policy under CPB 0376 splits into two tracks: non-cardiac and cardiac. Each track has different criteria and different gatekeepers. Treating them the same is how you generate a claim denial.

Non-Cardiac SPECT

Aetna considers SPECT medically necessary for 14 specific non-cardiac indications. These are not suggestions — they're the criteria list. If the patient's diagnosis doesn't map to one of these, you don't have medical necessity under this policy.

The covered non-cardiac indications include: osteomyelitis assessment to distinguish bone from soft tissue infection; spondylolysis and stress fractures not visible on x-ray; liver hemangioma diagnosis; pulmonary embolism diagnosis via SPECT ventilation/perfusion scintigraphy; brain tumor differentiation from necrotic tissue; Parkinson's disease versus essential tremor distinction using DaTSCAN (Ioflupane I-123, billed as HCPCS A9584); fever of unknown origin after initial workup fails; parathyroid imaging in parathyroid disease; liver metastases or primary liver tumors before and after hepatic artery chemotherapy or chemoembolization; abscess localization for suspected infection or inflammatory process; lymphoma (tumor vs. necrosis distinction); neuroendocrine tumor diagnosis and staging; pre-surgical ictal seizure focus detection in epilepsy (as a PET substitute); and thyroid cancer iodine imaging for initial and subsequent staging.

SPECT-CT fusion — billed under CPT 78072 — carries its own, narrower criteria. Aetna covers it only for parathyroid imaging when the patient has an enlarged parathyroid gland, parathyroid hyperplasia, or suspected parathyroid adenoma or carcinoma, AND laboratory evidence of hyperparathyroidism: parathyroid hormone greater than 55 pg/mL and serum calcium greater than 10.2 mg/dL. Both lab thresholds must be met. One without the other won't clear medical necessity for CPT 78072.

Cardiac SPECT

Cardiac SPECT — CPT 78451, 78452, 78453, and 78454 — is covered for diagnosis and prognosis in coronary artery disease, but Aetna delegates the specific criteria to eviCore Healthcare's Cardiac Imaging Clinical Guidelines. This is where billing teams often get tripped up.

You can't apply the same documentation standards you'd use for non-cardiac indications. Pull up the eviCore guidelines directly at evicore.com, select "Aetna" (or Aetna NJ, Aetna NY, or the appropriate Aetna Better Health Medicaid option), and find the Cardiac Imaging Guidelines PDF. No login is required. Search by CPT code for your specific situation.

Prior Authorization

Precertification — the Aetna term for prior authorization — may be required for select SPECT procedures. Use Aetna's CPT code search tool on their precertification lists page to check by code before you schedule. Don't assume your procedure doesn't require prior auth just because it's covered under CPB 0376. That assumption generates denials.

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Aetna SPECT Exclusions and Non-Covered Indications

Three codes are explicitly excluded under CPB 0376. These aren't borderline — Aetna considers the indications experimental, investigational, or unproven.

CPT 0331T (myocardial sympathetic innervation imaging, planar) and CPT 0332T (same with tomographic SPECT) are not covered. These are Category III codes, and Aetna is aligned with the general market here — there's limited clinical evidence supporting routine reimbursement.

CPT +0742T (absolute quantitation of myocardial blood flow, SPECT) is also not covered. This add-on code for AQMBF is increasingly discussed in cardiology circles, but Aetna hasn't moved it to covered status under this policy.

Aetna also considers SPECT myocardial perfusion imaging inappropriate — and therefore not covered — when the American College of Cardiology's appropriateness criteria classify the study as "inappropriate." The policy references ACC criteria directly. If you're billing cardiac SPECT for an indication the ACC flags as inappropriate, Aetna will treat that as a non-covered service.

The real issue here: if your cardiologists are ordering SPECT for post-PTCA routine screening without symptoms, that's a high-risk scenario under this policy. Check the ACC criteria and the eviCore guidelines before you bill.

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Coverage Indications at a Glance

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Aetna SPECT Billing Guidelines and Action Items 2026

These are the steps your billing team needs to take now — not after you see your first denial.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for SPECT Under CPB 0376

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered / Experimental Codes

Code	Type	Description	Reason Copy
0331T	CPT	Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment	Experimental, investigational, or unproven
0332T	CPT	Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic (SPECT)	Experimental, investigational, or unproven
+0742T	CPT	Absolute quantitation of myocardial blood flow (AQMBF), single-photon emission computed tomography (SPECT)	Experimental, investigational, or unproven

Covered HCPCS Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
A9584	HCPCS	Iodine I-123 Ioflupane, diagnostic, per study dose, up to 5 millicuries

Key ICD-10-CM Diagnosis Codes

The full ICD-10 list under CPB 0376 spans 725 codes across oncology, neurology, cardiology, endocrinology, orthopedics, and infectious disease. Below are representative codes from the actual policy data:

Code	Description Copy
C22.0–C22.9	Malignant neoplasm of liver and intrahepatic bile ducts
C25.0–C25.9	Malignant neoplasm of pancreas (VIPoma, islet cell tumors)
C34.0–C34.9x	Malignant neoplasm of bronchus and lung

The full ICD-10 list is available in the CPB 0376 Aetna policy document. Review it against your patient population to confirm diagnosis code alignment before billing.

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