CMS Updates SPECT Imaging Coverage Policy (NCD 271) — What Billing Teams Need to Know

The Centers for Medicare & Medicaid Services (CMS) has modified National Coverage Determination (NCD) 271, governing Single Photon Emission Computed Tomography (SPECT) imaging, with a policy effective date of March 12, 2026. This update reinforces critical sequencing rules between SPECT and FDG PET imaging for myocardial viability evaluation—a distinction that directly affects how radiology and cardiology practices bill Medicare claims. If your team orders or bills SPECT studies, understanding what this policy permits and explicitly prohibits could be the difference between a clean claim and a denial.

What CMS NCD 271 Covers: SPECT Indications for Medicare Billing

SPECT imaging works by tracking the concentration of radionuclides introduced into a patient's body, producing three-dimensional images that a standard planar scan cannot provide. Under NCD 271, CMS recognizes SPECT as a covered diagnostic test across a defined set of clinical conditions.

Medicare covers SPECT imaging when it is used to evaluate or diagnose any of the following:

• Stress fracture — particularly useful when plain film radiographs are negative but clinical suspicion remains high
• Spondylosis — degenerative spinal changes that require functional imaging to assess activity level
• Infection — including discitis, where early identification changes antibiotic and surgical management
• Tumor — such as osteoid osteoma, where SPECT localizes the nidus more precisely than CT alone
• Myocardial blood flow analysis — evaluating myocardial viability by analyzing perfusion patterns
• Differentiating ischemic heart disease from dilated cardiomyopathy — a clinically significant distinction that guides treatment decisions

Each of these indications represents a scenario where SPECT provides diagnostic value that supports medical necessity under Medicare's benefit category for Diagnostic Tests (other).

The Critical Sequencing Rule: SPECT and FDG PET for Myocardial Viability

This is the provision that billing teams and ordering physicians need to internalize before the March 2026 effective date.

CMS policy under NCD 271 draws a clear, one-directional sequencing rule for myocardial viability imaging:

• ✅ Allowed: FDG PET may follow an inconclusive SPECT when evaluating myocardial viability
• ❌ Not allowed: SPECT may NOT follow an inconclusive FDG PET performed to evaluate myocardial viability

The logic here reflects CMS's positioning of FDG PET as the definitive study for myocardial viability. When SPECT produces inconclusive results, escalating to FDG PET is clinically appropriate and reimbursable. But if a provider starts with FDG PET and it's inconclusive, ordering a SPECT afterward will not meet Medicare medical necessity criteria—and CMS will not cover it.

This has real claims implications. If a cardiologist orders SPECT after an inconclusive FDG PET study on a Medicare patient, that claim is at risk for denial, and the provider may face medical necessity appeals or, in cases of repeated billing, potential compliance exposure. Document the imaging order sequence clearly in the medical record before submitting any related claims.

Frequency Limitations and MAC Discretion

NCD 271 does not specify a hard frequency limit for SPECT studies. Instead, CMS delegates frequency limitation determinations to the Medicare Administrative Contractor (MAC) with jurisdiction over the provider's geographic region.

This means your billing team cannot rely on a universal rule like "one SPECT per year." Instead, you need to:

1. Know which MAC covers your region (e.g., Novitas Solutions, CGS Administrators, Noridian)
2. Check that MAC's Local Coverage Determinations (LCDs) and billing articles for any SPECT-specific frequency restrictions
3. Document medical necessity thoroughly for each study, especially for repeat imaging within a short period

MAC-discretion policies can catch practices off guard when a claim is denied for frequency reasons that never appeared in the national policy. Proactive LCD review is the safest approach.

Cross-Reference: NCD 211 for PET Scans

CMS explicitly cross-references NCD 211 (Positron Emission Tomography Scans) within NCD 271. For any practice billing both SPECT and FDG PET studies on Medicare patients—particularly in cardiology or nuclear medicine—both policies should be reviewed together.

The sequencing rule in NCD 271 only makes full sense in the context of what NCD 211 allows for FDG PET in myocardial viability cases. Reviewing these two NCDs in parallel is essential for any cardiology or nuclear medicine billing team managing complex imaging workups.

Affected Codes

The policy as published does not list specific CPT or HCPCS codes within NCD 271. CMS has not enumerated covered or non-covered procedure codes in the current version of this policy document.

What this means for billing teams: Code selection for SPECT studies—such as commonly billed nuclear medicine CPT codes—should be validated against your MAC's applicable LCD and billing articles, as well as the CMS Medicare Coverage Database. Do not assume a code is covered solely based on the NCD; MAC-level guidance will provide the procedural code specificity this national policy lacks.

Similarly, no ICD-10-CM diagnosis codes are specified within this NCD. Appropriate diagnosis coding should align with the covered indications listed above and be supported by the clinical documentation in the medical record.

What Your Billing Team Should Do