AcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis
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AcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis - M... Page 1 of 11
AcuTect Scintigraphic Imaging for
Detection of Lower Limb Deep
Vein Thrombosis
Number: 0414
Policy History
Policy
*Please see amendment for Pennsylvania Last Review: 05/18/2021
Medicaid at the end of this CPB. Effective: 05/04/2000
Next Review: 04/21/2022
Aetna considers AcuTect scintigraphic imaging for detection
and localization of deep vein thrombosis (DVT) in the lower
extremity experimental and investigational because the clinical
value of this test in the management of persons with
suspected DVT has not been clearly established by the peer-
reviewed medical literature.
Background
Contrast venography (also known as contrast phlebography) is
the gold standard for the diagnosis of DVT, although it is rarely
used anymore because it is invasive, painful, time-consuming,
and entails exposure to significant amounts of radiation. For
patients with symptoms suggestive of DVT, compression
ultrasonography is the most frequently used test. Pooled
analyses showed that ultrasonography has a sensitivity of 96
% and a specificity of 98 % for proximal vein thrombosis. ItAcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis- M... Page 2 of 11 has been reported that venous thromboembolic complications occur in less than 1 % of untreated patients in whom the presence of DVT is rejected on the basis of serial ultrasonography or ultrasonography plus either an assay for D- dimer (a fragment that is specific for the degradation of fibrin) or clinical score. AcuTect (Diatide, Inc., Londenderry, NH) is a complex of a small-molecule synthetic peptide, apcitide, and the radionuclide, technetium (Tc) 99m (a gamma ray emitter). Apcitide binds preferentially to glycoprotein IIb/IIIa receptors, which are expressed on the surface of activated platelets, a major component of active thrombus formation. Thus, it may localize at sites where blood clots are present or forming. AcuTect is approved for use in the scintigraphic imaging of acute (not chronic) venous thrombosis in the lower extremities of patients who have signs and symptoms of acute venous thrombosis. It allows for early (10 to 60 minutes post-injection, administered by injection into the antecubital vein) imaging of DVT of the entire lower extremities, including the calf. Information provided in the product labeling of AcuTect stated that the agreement rates between AcuTect and contrast venography are between 56 and 73 %. Furthermore, clinical follow-up studies of patients with negative AcuTect scans have not been carried out to determine if negative image findings represent the absence of acute venous thrombosis, and the rate of venous thromboembolic complications in untreated patients after a negative AcuTect scan has not been determined. Thus, the value of AcuTect in the management of patients with suspected DVT has not been clearly established. Dunzinger et al (2008) studied the detection of acute DVT in patients presenting with clinical symptoms suggesting DVT and pulmonary embolism (PE) with (99m)Tc-apcitide. A total of 19 patients (11 males, 8 females) received within 24 hrs after admission to the hospital a mean of 841 MBq (range of 667 to 1,080) (99m)Tc-apcitide i.v. followed by planar
AcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis- M... Page 3 of 11 recordings 10, 60, and 120 mins after injection. Images were compared to the results of compression ultrasonography and/or phlebography. Patients with clinically suspected PE underwent spiral computed tomography or lung perfusion scans. (99m)Tc-apcitide scintigraphy showed acute clot formation in 14 out of 16 patients where the other imaging modalities suggested DVT. Positive scintigraphic results were seen up to 17 days after the onset of clinical symptoms. In 3 out of 3 patients without any proof of DVT, (99m)Tc-apcitide scintigraphy was truly negative. Glycoprotein receptor imaging showed only one segmental PE in 6 patients with imaging- proven sub-segmental (n = 3) or segmental PE (n = 3). The authors concluded that (99m)Tc-apcitide scintigraphy may be an easy and promising tool for the detection of acute clot formation in patients with DVT up to 17 days after the onset of clinical symptoms with a sensitivity of 87 % and a specificity of 100 %. However, it failed to demonstrate PE in 83 % of examined patients with proven PE. Tan et al (2009) noted that currently the combination of a clinical decision rule, D-dimer testing and compression ultrasonography has proved to be safe and effective for the diagnosis of DVT in the lower extremities. Computed tomography (CT) and magnetic resonance imaging (MRI) can be useful as additional or secondary imaging modalities. Somarouthu and colleagues (2010) discussed the approach for diagnosing DVT in different patient populations. Clinical features and probability assessment guide further diagnostic tests. D-dimer testing is used as screening test; however, duplex ultrasound remains the primary confirmatory test. Furthermore, CT and MRI are used only in select patient populations (e.g., when ultrasound results are equivocal, in patients suspected of central venous DVT, or as a part of combined protocol for diagnosis of PE). The authors stated that contrast phlebography and plethysmography do not have much of a role during routine diagnosis of DVT.
AcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis- M... Page 4 of 11 Contrast venography (phlebography) is the "gold-standard" examination (Polak et al, 2005) for suspected deep venous thromboses of the lower extremity. An iodine-containing contrast agent is injected into a foot vein. DVT is present if a distinct filling defect is present in a deep vein of the calf or thigh. Other findings, such as an abrupt cutoff, absence of filling or presence of collaterals, are less specific and may be related to technical factors or to chronic venous thrombosis. American College of Radiology Appropriateness Criteria (Polak et al, 2005) on suspected lower extremity deep venous thrombosis state that invasive contrast phlebography may be necessary where other studies are equivocal or an intervention is planned. Contrast phlebography is assigned an appropriateness rating of 5 of 10. The authors note that, although this examination serves as the "gold standard", it may not give reliable results in 5 to 10 % of patients. It also carries some risks: contrast reaction, local irritation or skin loss due to extravasation, renal failure, and chemically induced thrombophlebitis. Guidelines on venous thromboembolism from the University of Michigan (2009) state that phlebography "is seldom indicated any longer". The guidelines state that phlebography carries appreciable local morbidity, the risk of contrast administration, and is technically inadequate in 7 to 20 % of studies. Ultrasound is recommended for patients with intermediate to high pretest probability of DVT in the lower extremities. Use of ultrasound in diagnosing symptomatic thrombosis in the proximal veins of the lower limb is recommended for patients whose pretest probability of disease falls in the category of intermediate to high risk of DVT under the Wells prediction rule. Ultrasound is less sensitive in patients who have DVT limited to the calf; therefore, a negative ultrasound does not rule out DVT in these patients. Repeat ultrasound or venography may be required for patients who have suspected calf-vein DVT and a negative ultrasound and for patients who have suspected proximal DVT and an ultrasound that is
AcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis- M... Page 5 of 11
technically inadequate or equivocal. Contrast venography is
still considered the definitive test to rule out the diagnosis of
DVT.
CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for
clarification purposes. Codes requiring a 7th character are
represented by "+":
Code Code Description
CPT codes not covered for indications listed in the CPB:
78456 Acute venous thrombosis imaging, peptide
Other CPT codes related to the CPB:
75820 Venography, extremity, unilateral, radiological
supervision and interpretation
75822 Venography, extremity, bilateral, radiological
supervision and interpretation
78457 Venous thrombosis imaging, venogram;
unilateral
78458 bilateral
ICD-10 codes not covered for indications listed in the CPB:
I80.10 - Phlebitis and thrombophlebitis of femoral vein
I80.13
I80.201 - Phlebitis and thrombophlebitis of other and
I80.9 unspecified deep vessels of lower extremities
I82.0 - Other venous embolism and thrombosis
I82.91
O22.00 - Venous complications in pregnancy
O22.93AcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis- M... Page 6 of 11
Code Code Description
O87.0 - Venous complications in the puerperium
O87.9
Other HCPCS code related to the CPB:
A9504 Technetium Tc-99m apcitide, diagnostic, per
study dose, up to 20 millicuries
The above policy is based on the following
references:
1. Birdwell B. Recent clinical trials in the diagnosis of
deep-vein thrombosis. Curr Opin Hematol. 1999;6
(5):275-279.
2. Kraaijenhagen RA, Lensing AW, Wallis JW, et al.
Diagnostic management of venous thromboembolism.
Baillieres Clin Hematol. 1998;11(3):541-586.
3. Lensing AW, Prandoni P, Prins MH, Buller HR. Deep-
vein thrombosis. Lancet. 1999;353(9151):479-485.
4. Kearon C, Julian JA, Newman TE, Ginsberg JS.
Noninvasive diagnosis of deep vein thrombosis.
McMaster Diagnostic Imaging Practice Guidelines
Initiative. Ann Intern Med. 1998;128(8):663-677.
5. Diatide Inc. AcuTect product insert. Londonderry, NH:
Diatide; September 1998.
6. U.S. Food and Drug Administration (FDA), Center for
Drug Evaluation and Research. Summary minutes for
the Medical Imaging Drug Advisory Committee
Meeting. Silver Spring, MD, February 9, 1998.
7. Taillefer R. Radiolabeled peptides in the detection of
deep venous thrombosis. Semin Nucl Med. 2001;31
(2):102-123.
8. Institute for Clinical Systems Improvement (ICSI).
Venous Thromboembolism. ICSI Health Care
Guidelines. Bloomington, MN: ICSI; January 2002.AcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis- M... Page 7 of 11
9. Bates SM, Lister-James J, Julian JA, et al. Imaging
characteristics of a novel technetium Tc 99m-labeled
platelet glycoprotein IIb/IIIa receptor antagonist in
patients with acute deep vein thrombosis or a history
of deep vein thrombosis. Arch Intern Med. 2003;163
(4):452-456.
10. Bernarducci MP. 'Pathophysiologic mapping' of venous
thromboembolism: Opportunities for radiolabeled
peptides. Q J Nucl Med. 2003;47(4):292-320.
11. McRae SJ, Ginsberg JS. The diagnostic evaluation of
deep vein thrombosis. Am Heart Hosp J. 2004;2(4):205-
210.
12. Kyrle PA, Eichinger S. Deep vein thrombosis. Lancet.
2005;365(9465):1163-1174.
13. Ilahi OA, Reddy J, Ahmad I. Deep venous thrombosis
after knee arthroscopy: A meta-analysis. Arthroscopy.
2005;21(6):727-730.
14. Kearon C, Ginsberg JS, Douketis J, et al. A randomized
trial of diagnostic strategies after normal proximal vein
ultrasonography for suspected deep venous
thrombosis: D-dimer testing compared with repeated
ultrasonography. Ann Intern Med. 2005;142(7):490-
496.
15. Polak JF, Yucel EK, Bettmann MA, et al.; Expert Panel on
Cardiovascular Imaging. Suspected lower extremity
deep vein thrombosis. ACR Appropriateness Criteria.
Reston, VA: American College of Radiology (ACR); 2005.
16. Dunzinger A, Hafner F, Schaffler G, et al. 99mTc-
apcitide scintigraphy in patients with clinically
suspected deep venous thrombosis and pulmonary
embolism. Eur J Nucl Med Mol Imaging. 2008;35
(11):2082-2087.
17. Qaseem A, Snow V, Barry P, Hornbake ER, Rodnick JE,
Tobolic T, Ireland B, Segal J, Bass E, Weiss KB, Green L,
Owens DK, Joint American Academy of Family
Physicians/American College of Physicians. Current
diagnosis of venous thromboembolism in primaryAcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis- M... Page 8 of 11
care: A clinical practice guideline from the American
Academy of Family Physicians and the American
College of Physicians. Ann Fam Med 2007 Jan-Feb;5
(1):57-62.
18. University of Michigan Health System. Venous
thromboembolism (VTE). Guidelines for Clinical Care.
Ann Arbor, MI: University of Michigan Health System;
February 2009.
19. Tan M, van Rooden CJ, Westerbeek RE, Huisman MV.
Diagnostic management of clinically suspected acute
deep vein thrombosis. Br J Haematol. 2009;146(4):347-
360.
20. Somarouthu B, Abbara S, Kalva SP. Diagnosing deep
vein thrombosis. Postgrad Med. 2010;122(2):66-73.
21. Grant B. Diagnosis of suspected deep venous
thrombosis of the lower extremity. UpToDate [online
serial]. Waltham, MA: UpToDate; updated February 8,
2010.
22. Institute for Clinical Systems Improvement (ICSI).
Venous thromboembolism diagnosis and treatment.
Bloomington, MN: Institute for Clinical Systems
Improvement (ICSI); February 2009.AcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis- M... Page 9 of 11 Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna 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 Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change. Copyright © 2001-2021 Aetna Inc.
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AETNA BETTER HEALTH® OF PENNSYLVANIA
Amendment to
Aetna Clinical Policy Bulletin Number: 0414 AcuTect
Scintigraphic Imaging for Detection of Lower Limb Deep
Vein Thrombosis
There are no amendments for Medicaid.
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