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Date Printed: August 23, 2017: 06:08 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

04-78000-18

Original Effective Date: 09/15/01

Reviewed: 05/28/15

Revised: 04/15/17

Subject: Positron Emission Tomography (PET) Miscellaneous Applications

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Positron emission tomography (PET) is an imaging technique that uses radioactive substances injected into individuals to provide images of the body using specialized scanners. These PET images provide information about the function and metabolism of the body’s organs, in contrast to computed tomography (CT) or magnetic resonance imaging (MRI), which show the body’s anatomy and structure.

POSITION STATEMENT:

NOTE: PET imaging addressed in this guideline requires medical review. The physician history and physical, and physician plan of treatment are required documentation for medical review.

Epileptic Seizures

Positron emission tomography (PET) using 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) meets the definition of medical necessity in the assessment of individuals with epileptic seizures who are candidates for surgery and who meet ALL of the following criteria:

Brain Tumor or Cancer

Positron emission tomography (PET) using 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) meets the definition of medical necessity for the following:

• Evaluation of known brain tumor or cancer with new signs or symptoms indicative of a reoccurrence of cancer

• Follow-up of brain tumor after surgery

Follow-up of brain tumor after treatment (radiation or chemotherapy)

• When used to differentiate between treatment induced (radiation) tumor necrosis and brain tumor recurrence

Post-operative/procedureal evaluation (brain PET imaging)

A follow-up study may be needed for evaluation of a member’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that indicates why additional imaging is needed for the type and area(s) of requested imaging.

Dementia

Positron emission tomography (PET) using 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) meets the definition of medical necessity in the evaluation of dementia when ALL of the following criteria have been met (medical records, including the date of onset of symptoms may be required to be submitted to the health plan for review);:

• The member has a recent diagnosis of dementia or frontotemporal dementia (FTD) and documented cognitive decline of at least six months AND

• The member has a change in mental status and has had more than one assessment of mental status, documented by neuro-diagnostic testing, such as:

- Mini-mental status exam (MMSE) or Montreal Cognitive Assessment (MoCA, Mini-Cog) score of less than 26 or similar mental status exam showing at least mild cognitive impairment;

- Electroencephalogram (EEG) and long-term EEG monitoring;

- Transcranial Doppler studies;

- Evoked potentials;

- Intraoperative neurophysiological monitoring

AND

- Metabolic workup (e.g., thyroid function testing, liver function testing, complete blood count) for treatable causes; AND

- Appropriate medication restriction or reduction to test for reversibility

Chronic Osteomyelitis

Positron emission tomography (PET) using 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) meets the definition of medical necessity in the diagnosis of chronic osteomyelitis if the diagnosis cannot be determined by a bone scan.

Other Indications

The use of PET imaging for ALL other miscellaneous indications is considered experimental or investigational, including, but not limited to the following. There is insufficient evidence to determine the role of PET imaging for all other indications including screening.

Central Nervous System (CNS) Diseases

• Alzheimer’s disease

• Autoimmune disorders with CNS manifestations, including:

- Behcet's syndrome

- Lupus erythematosus

• Cerebrovascular diseases, including:

- Arterial occlusive disease (arteriosclerosis, atherosclerosis)

- Carotid artery disease

- Cerebral aneurysm

- Cerebrovascular malformations (AVM and Moya Moya disease)

- Hemorrhage

- Infarct

- Ischemia

• Degenerative motor neuron diseases, including:

- Amyotrophic lateral sclerosis

- Friedreich's ataxia

- Olivopontocerebellar atrophy

- Parkinson's disease

- Progressive supranuclear palsy

- Shy-Drager syndrome

- Spinocerebellar degeneration

- Steele-Richardson-Olszewski disease

- Tourette's syndrome

• Demyelinating diseases, such as multiple sclerosis

• Developmental, congenital, or inherited disorders, including:

- Adrenoleukodystrophy

- Down's syndrome

- Huntington’s chorea

- Kinky-hair disease (Menkes’ syndrome)

- Sturge-Weber syndrome (encephalofacial angiomatosis) and the phakomatoses

• Nutritional or metabolic diseases and disorders, including:

- Acanthocytes

- Hepatic encephalopathy

- Hepatolenticular degeneration

- Metachromatic leukodystrophy

- Mitochondrial disease

- Subacute necrotizing encephalomyelopathy

• Psychiatric diseases and disorders, including:

- Affective disorders

- Depression

- Obsessive-compulsive disorder

- Psychomotor disorders

- Schizophrenia.

• Pyogenic infections, including:

- Aspergillosis

- Encephalitis

• Substance abuse, including the CNS effects of alcohol, cocaine, and heroin

• Trauma, including brain injury and carbon monoxide poisoning

• Viral infections, including:

- Acquired immune deficiency syndrome (AIDS)

- AIDS dementia complex

- Creutzfeldt-Jakob syndrome

- Progressive multifocal leukoencephalopathy

- Progressive rubella encephalopathy

- Subacute sclerosing panencephalitis

Pulmonary diseases:

Adult respiratory distress syndrome

Diffuse panbronchiolitis

Emphysema

Obstructive lung disease

Pneumonia

Musculoskeletal diseases:

Spondylodiscitis

• Joint replacement follow-up

Other

• Anorexia nervosa

• Cerebral blood flow in newborns

Chronic fatigue syndrome

Giant cell arteritis

• Inflammatory bowel disease

• Migraine

• Mycobacterium infection

• Post-traumatic stress disorder

Sick building syndrome

• Vegetative versus “locked-in” state

Vasculitis

BILLING/CODING INFORMATION:

CPT Coding

78608

Brain imaging, positron emission tomography (PET); metabolic evaluation

78609

Brain imaging, positron emission tomography (PET); perfusion evaluation

HCPCS Coding

A9599

A9599 Radiopharmaceutical, diagnostic, for beta-amyloid positron emission tomography (pet) imaging, per study dose, not other wise specified Investigational (with the exception of Medicare Advantage products, refer to program exception section of the this guideline)

G0235

PET imaging, any site, not otherwise specified

LOINC Codes

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment and reason for positron emission tomography (PET) imaging.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

REIMBURSEMENT INFORMATION:

PET scans are performed using a camera that has either been approved or cleared for marketing by the Food and Drug Administration (FDA) to image positron annihilation gamma photons in the body.

PET scans are performed using FDA approved radiotracer (e.g., Nitrogen -13 (as ammonia), oxygen-15 as H0, carbon-11) or radiopharmaceutical. The radiopharmaceutical may be manufactured on site, or manufactured at a regional delivery center with delivery to the institution performing the PET scan. When the radiopharmaceutical is provided by an outside distribution center, there may be a separate charge for both the radiopharmaceutical and transportation of the radiopharmaceutical.

PROGRAM EXCEPTIONS:

Coverage for the radiology services referenced in this guideline performed and billed in an outpatient or office location will be handled through the BCBSF Radiology Management program for select products. The National Imaging Associates (NIA) will determine coverage for these services for select products. Refer to member's contract benefits.

Federal Employee Plan (FEP): FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

Medicare Advantage products:

No Local Coverage Determination (LCD) was found at the time of the last guideline reviewed date.

The following National Coverage Determinations (NCDs) were reviewed on the last guideline reviewed date: Positron Emission Tomography (PET) Scans (220.6-220.6.15), PET (FDG) for Refractory Seizures (220.6.9), PET (FDG) for Dementia and Neurodegenerative Diseases (220.6.13) and PET (FDG) for Infection and Inflammation (220.6.16) located at cms.gov.

DEFINITIONS:

Acquired immune deficiency syndrome (AIDS): An epidemic, transmissible retroviral disease due to infection with human immunodeficiency virus (HIV), which attacks the subset of T lymphocytes known as the CD4 cells or CD4+ T lymphocytes.

Adrenoleukodystrophy: An X-linked recessive disease of childhood, closely related to Schilder disease, marked by diffuse abnormality of the cerebral white matter and adrenal atrophy and characterized by mental deterioration progressing to dementia, with aphasia, apraxia, dysarthria, and loss of vision in about a third of the patients. Almost all show abnormal adrenal functioning when tested.

Adult respiratory distress syndrome: Fulminant pulmonary interstitial and alveolar edema; also called acute respiratory distress syndrome.

Affective disorder: Mental disorders whose essential feature is a disturbance of mood manifested as one or more episodes of mania, hypomania, depression, or some combination.

AIDS dementia complex: A progressive primary encephalopathy caused by infection with human immunodeficiency virus type 1; it involves principally the subcortical white matter and deep gray nuclei and is manifested by a variety of cognitive, motor, and behavioral abnormalities; called also AIDS dementia complex, AIDS e., HIV encephalitis, HIV encephalopathy, and HIV-related encephalopathy.

Alzheimer’s disease: A progressive central neurodegenerative disorder.

Amyotrophic lateral sclerosis: A motor neuron disease marked by progressive degeneration of the neurons that give rise to the corticospinal tract and of the motor cells of the brain stem and spinal cord, resulting in a deficit of upper and lower motor neurons; it usually ends fatally within two to three years.

Anorexia nervosa: An eating disorder primarily affecting females, usually with onset in adolescence, characterized by refusal to maintain a normal minimal body weight, intense fear of gaining weight or becoming obese, and a disturbance of body image resulting in a feeling of being fat or having fat in certain areas even when extremely emaciated, undue reliance on body weight or shape for self-evaluation, and amenorrhea.

Aspergillosis: Infection of humans or other animals by species of Aspergillus, marked by inflammatory granulomatous lesions in the skin, ear, orbit, nasal sinuses, lungs, and sometimes the bones and meninges.

Behcet syndrome: A variant of neutrophilic dermatosis of unknown etiology, involving the small blood vessels, characterized by recurrent aphthous ulceration of oral and pharyngeal mucous membranes and genitalia, with skin lesions, severe uveitis, retinal vasculitis, optic atrophy, and often involvement of the joints, gastrointestinal system, and central nervous system.

Chronic fatigue syndrome: Persistent debilitating fatigue lasting longer than six months, with other known medical conditions having been ruled out by clinical diagnosis, accompanied by at least four of the following: significantly impaired short-term memory or concentration, muscle weakness, pain in multiple joints without swelling or redness, sore throat, tender lymph nodes, headaches, unrefreshing sleep, and malaise that lasts more than 24 hours following exertion.

Creutzfeldt-Jakob syndrome: A rare, degenerative, invariably fatal brain disorder.

Dementia with Lewy-Bodies: A general loss of cognitive abilities, including impairment of memory as well as one or more of the following: aphasia, apraxia, agnosia, or disturbed planning, organizing, and abstract thinking abilities with concentrically laminated, round bodies found in vacuoles in the cytoplasm of some neurons of the midbrain in Parkinson disease.

Depression: A mental state of depressed mood characterized by feelings of sadness, despair, and discouragement.

Diffuse panbronchiolitis: A chronic type of infectious inflammation of the airways limited to the bronchioles, seen mainly in East Asia and nearby island countries.

Down’s syndrome: A chromosome disorder characterized by a small, anteroposteriorly flattened skull, short, flat-bridge nose, epicanthal fold, short phalanges, widened spaces between the first and second digits of hands and feet, and moderate to severe mental retardation, with Alzheimer disease developing in the fourth or fifth decade.

Emphysema: Pathological accumulation of air in tissues or organs.

Encephalitis: Inflammation of the brain.

Epilepsy: Any of a group of syndromes characterized by paroxysmal transient disturbances of the brain function that may be manifested as episodic impairment or loss of consciousness, abnormal motor phenomena, psychic or sensory disturbances, or perturbation of the autonomic nervous system.

Friedreich’s ataxia: An autosomal recessive disorder, usually beginning before adolescence, with sclerosis of the posterior and lateral columns of the spinal cord. It is attended by ataxia, speech impairment, lateral curvature of the spinal column, and peculiar swaying and irregular movements, with paralysis of the muscles, especially of the lower limbs, and a high-arched foot. It is often associated with hypertrophic cardiomyopathy.

Frontotemporal dementia: Any of several degenerative conditions of the frontal and anterior temporal lobes that cause personality and behavioral changes.

Giant cell arteritis: A chronic vascular disease in the elderly, of unknown origin, often associated with polymyalgia rheumatica, seen usually in the external carotid arteries but sometimes in other arteries. Characteristics include proliferative inflammation, often with giant cells and granulomas; headache, pain with chewing; weight loss; fever; sometimes ocular symptoms; and increased erythrocyte sedimentation rate.

Hepatic encephalopathy: A condition usually seen secondary to advanced disease of the liver but also seen with other severe diseases and in patients with portacaval shunts. It is marked by disturbances of consciousness that may progress to deep coma (hepatic coma), psychiatric changes of varying degree, flapping tremor, and fetor hepaticus.

Hepatolenticular degeneration: A rare, progressive, autosomal recessive disease due to a defect in metabolism of copper.

Huntington’s chorea: A disorder characterized by chronic progressive chorea and mental deterioration terminating in dementia; the age of onset is variable but usually in the fourth decade of life, with death within 15 years.

Kinky-hair disease: Hereditary, X-linked recessive abnormality in copper absorption; the resultant copper poisoning causes symptoms such as sparse, brittle, twisted scalp hair, severe cerebral degeneration, and arterial changes with death in infancy.

Lupus erythematosus: A group of connective tissue disorders primarily affecting women aged 20 to 40 years, comprising a spectrum of clinical forms in which cutaneous disease may occur with or without systemic involvement.

Metachromatic leukodystrophy: An autosomal recessive disorder due to deficiency of cerebroside-sulfatase or saposin B, characterized by accumulation of sulfatide in neural and nonneural tissues, with a diffuse loss of myelin in the central nervous system. There are three forms due to deficiency of cerebroside sulfatase, with variable age of onset, all initially presenting as mental regression and motor disturbances (infantile, juvenile, adult). The infantile form usually begins in the second year of life and is additionally characterized by developmental delay, seizures, optic atrophy, ataxia, weakness, loss of speech, and progressive spastic quadriparesis. The juvenile form is clinically similar, but presents between the ages of 4 and 12 years and progresses more slowly; a variant of the juvenile form is caused by deficiency of saposin B. The adult form begins after 16 years of age, generally presenting initially as dementia and disturbances in behavior and progressing more slowly to motor and posture disturbances.

Migraine: A symptom complex of periodic attacks of vascular headache, usually temporal and unilateral in onset, commonly associated with irritability, nausea, vomiting, constipation or diarrhea, and often photophobia.

Multi-infarct dementia: Dementia with a stepwise deteriorating course (a series of small strokes) and a patchy distribution of neurologic deficits (affecting some functions and not others) caused by cerebrovascular disease. It may be classified as uncomplicated or as occurring with delusions, delirium, or depressed mood; called also vascular dementia.

Obsessive-compulsive disorder: An anxiety disorder characterized by recurrent obsessions or compulsions, which are severe enough to interfere significantly with personal or social functioning.

Obstructive lung disease: Is a category of respiratory disease characterized by airway obstruction.

Olivopontocerebellar atrophy: Any of a group of progressive hereditary disorders involving degeneration of the cerebellar cortex, middle peduncles, ventral pontine surface, and olivary nuclei. They occur in the young to middle-aged and are characterized by ataxia, dysarthria, and tremors similar to those of parkinsonism.

Pick’s disease: Rare progressive degenerative disease of the brain, similar in clinical manifestations and course to Alzheimer disease but having a distinctive histopathology; cortical atrophy is confined to the frontal and temporal lobes; degenerating neurons contain globular intracytoplasmic filamentous inclusions (Pick bodies).

Parkinson’s disease: A slowly progressive disease (usually occurring in late life) characterized by masklike facies, resting tremor, slowing of voluntary movements, festinating gait, peculiar posture, and muscle weakness, sometimes with excessive sweating and feelings of heat. Pathologically, there is neurodegeneration within the nuclear masses of the extrapyramidal system and loss of melanin-containing cells from the substantia nigra and a corresponding reduction in dopamine levels in the corpus striatum.

Pneumonia: Inflammation of the lungs with consolidation.

Post-traumatic stress syndrome: An anxiety disorder caused by exposure to an intensely traumatic event; characterized by re-experiencing the traumatic event in recurrent intrusive recollections, nightmares, or flashbacks, by avoidance of trauma-associated stimuli, by generalized numbing of emotional responsiveness, and by hyper-alertness and difficulty in sleeping, remembering, or concentrating.

Presenile dementia: Usually occurs in persons age 65 or younger; since most cases are due to Alzheimer disease, the term is sometimes used as a synonym of dementia of the Alzheimer type, early onset, and has also been used to denote Alzheimer’s disease.

Progressive multifocal leukoencephalopathy: An opportunistic infection of the central nervous system by the JC virus, seen in immunocompromised persons and sometimes secondary to neoplastic conditions such as lymphosarcoma, lymphoblastic leukemia, or myelogenous leukemia.

Progressive supranuclear palsy: A progressive neurological disorder, having onset during the sixth decade, characterized by supranuclear ophthalmoplegia, especially paralysis of the downward gaze, pseudobulbar paralysis, dysarthria, dystonic rigidity of the neck and trunk, and dementia; also called Steele-Richardson-Olszewski syndrome.

Psychomotor disorder: Pertaining to motor effects of cerebral or psychic activity.

Schizophrenia: A mental disorder or heterogeneous group of disorders (the schizophrenias or schizophrenic disorders) comprising most major psychotic disorders and characterized by disturbances in form and content of thought (loosening of associations, delusions, and hallucinations), mood (blunted, flattened, or inappropriate affect), sense of self and relationship to the external world (loss of ego boundaries, dereistic thinking, and autistic withdrawal), and behavior (bizarre, apparently purposeless, and stereotyped activity or inactivity).

Shy-Drager syndrome: A progressive disorder of unknown etiology that begins with symptoms of autonomic insufficiency including orthostatic hypotension, impotence in males, constipation, urinary urgency or retention, and anhidrosis; these are followed by signs of generalized neurologic dysfunction such as parkinsonian-like disturbances, cerebellar incoordination, muscle wasting and fasciculations, and coarse tremors of the legs.

Sick building syndrome: This term is used to describe situations in which building occupants experience acute health and comfort effects that appear to be linked to time spent in a building, but no specific illness or cause can be identified. The complaints may be localized in a particular room or zone, or may be widespread throughout the building.

Spinocerebellar degeneration: Pertaining to the spinal cord and the cerebellum.

Spondylodiscitis: An inflammation of the base and upper plates of the vertebra as well as the adjoining intervertebral disc and is frequently accompanied by spondylitis (inflammation of the vertebral body).

Steele-Richardson-Olszewski syndrome: See progressive supranuclear palsy.

Sturge-Weber syndrome: A congenital syndrome of unknown etiology consisting of a port-wine stain distributed over the trigeminal nerve, usually unilaterally, with a similar vascular disorder of underlying meninges and cerebral cortex.

Subacute necrotizing encephalomyelopathy: A type of encephalopathy of unclear clinical and pathological criteria, causing neuro-pathologic damage. It occurs in two forms (infantile, adult). The infantile form is characterized by degeneration of gray matter with necrosis and capillary proliferation in the brain stem; hypotonia, seizures, and dementia; anorexia and vomiting; slow or arrested development; and ocular and respiratory disorders, with death usually before age 3. The adult form usually first manifests as bilateral optic atrophy with central scotoma and colorblindness, followed by a quiescent period of up to 30 years and then late symptoms such as ataxia, spastic paresis, clonic jerks, grand mal seizures, psychic lability, and mild dementia.

Subacute sclerosing panencephalitis: A rare and devastating form of leukoencephalitis usually affecting children and adolescents. Insidious in onset, it characteristically produces progressive cerebral dysfunction over several weeks or months and death within a year.

Tourette’s syndrome: A syndrome comprising both multiple motor and one or more vocal tics, occurring over a period of at least one year, at least intermittently but sometimes as frequently as many times daily. Obsessions, compulsions, hyperactivity, distractibility, and impulsivity are often associated. Onset is in childhood and tics often lessen in severity and frequency and may even remit during adolescence and adulthood.

Vasculitis: Inflammation of a blood or lymph vessel.

Vegetative versus “locked-in” state: A condition of profound non-responsiveness in the wakeful state caused by brain damage. Locked-in state is a condition in which a patient is aware and awake but cannot move or communicate verbally due to complete paralysis of nearly all voluntary muscles in the body except for the eyes.

RELATED GUIDELINES:

OTHER:

Other names used to report positron emission tomography (PET):

Positron emission transverse tomography (PETT)
Positron emission coincident imaging (PECI)

REFERENCES:

  1. Agency for Healthcare Research and Quality Evidence Report/Technology Assessment Number 57-Diagnosis and Treatment of Parkinson’s Disease: A Systematic Review of the Literature, 06/03.
  2. Agency for Healthcare Research and Quality Technology Assessment Number 7 – Use of Positron Emission Tomography and other Neuro-imaging Techniques in the Diagnosis and Management of Alzheimer’s Disease and Dementia, 12/14/01.
  3. American Medical Association, Current Procedural Terminology (CPT).
  4. Blue Cross Blue Shield Association Miscellaneous (Non-Cardiac, Non-Oncologic) Applications of Positron Emission Tomography (PET) Medical Policy (6.01.06), 02/15.
  5. Canadian Agency for Drugs and Technologies Health Technology Assessment Rapid Review-FDG-PET to Assess Infections: A Review of the Evidence, June 2008.
  6. Center for Medicare and Medicaid Services (CMS) – Medlearn Matters Number: MM3426 Billing Requirements for Positron Emission Tomography (PET) Scans for Dementia and Neurodegenerative Diseases, 10/04/04. Revised 04/22/05.
  7. Center for Medicare and Medicaid Services (CMS) Medicare Coverage Database-Decision Memo for Positron Emission tomography (FDG) and Other Neuroimaging Devices for Suspected Dementia (CAG-00088R), 09/15/04.
  8. Center for Medicare and Medicaid Services (CMS) NCD for PET (FDG) for Dementia and Neurodegenerative Diseases (220.6.13), 04/03/09.
  9. Center for Medicare and Medicaid Services (CMS) NCD for PET (FDG) for Refractory Seizures (220.6.9), 01/28/05.
  10. Center for Medicare and Medicaid Services (CMS) NCD for PET (FDG) for Infection and Inflammation (220.6.16), 03/19/08.
  11. Centers for Medicare & Medicaid Services – Coverage Issues Manual Diagnostic Services-Positron Emission Tomography (PET) Scans 50-36, 04/03.
  12. Centers for Medicare & Medicaid Services (CMS) Coverage Determinations-Positron Emission Tomography (PET) Scans 220.6-220.6.15, 2005.
  13. Centers for Medicare and Medicaid Services Carriers Manual Part 3 Claims Review and Adjudication Procedures – Positron Emission Tomography (PET) Scans (4173). Accessed 11/21/05.
  14. De Winter F, van de Wiele C, Vogelaers D et al. Fluorine-18 fluorodeoxyglucose-positron emission tomography: a highly accurate imaging modality for the diagnosis of chronic skeletal infections. The Journal of Bone and Joint Surgery 2001; 83-A (5): 651-660.
  15. Delbeke D, Coleman RE, Guiberteau MJ et al. Society of Nuclear Medicine-Procedure Guidelines for Tumor Imaging with F-FDG PET/CT 1.0, 03/10/06.
  16. Galvin JE, Sadowsky CH. Practical guidelines for the recognition and diagnosis of dementia. Journal of the American Board of Family Medicine 2012; 25(3): 367-382.
  17. Guhlmann A, Brecht-Krauss D, Suger G et al. Fluorine-18-FDG PET and technetium-99m antigranulocyte antibody scintigraphy in chronic osteomyelitis. Journal of Nuclear Medicine 1998; 39(12): 2145-2152.
  18. Knopman DS, DeKosky ST, Cummings JL et al. Practice parameter: Diagnosis of dementia (an evidence-based review): Report of the quality standards subcommittee of the American Academy of Neurology. Neurology 2001; 6: 1143-1153.
  19. Medicare National Coverage Determinations, Chapter 1, Part 4-FDG PET for Dementia and Neurodegenerative Diseases, 09/15/04.
  20. Medicare National Coverage Determinations, Chapter 1, Part 4-FDG PET for All Other Cancer Indications Not Previously Specified, 01/28/05.
  21. Meller J, Koster G, Liersch T et al. Chronic bacterial osteomyelitis: prospective comparison of (18)F-FDG imaging with a dual-head coincidence camera and (111) ln-labelled autologous leucocyte scintigraphy. European Journal of Nuclear Medicine and Molecular Imaging. 2002; 29(1): 53-60.
  22. Mosconi L, Tsui WH, Herholz K et al. Multicenter standardized 18F-FDG PET diagnosis of mild cognitive impairment, Alzheimer’s disease, and other dementias. The Journal of Nuclear Medicine 2008; 49(3): 390-398.
  23. National Comprehensive Cancer Network Clinical Practice Guideline in Oncology (NCCN GuidelinesĀ®) Central Nervous System Version 1.2015.
  24. National Imaging Associates, Inc. PET Scan Brain Clinical Guideline, 2015.
  25. National Institutes of Health-Positron Emission Tomography (PET), 2009.
  26. Stumpe K, Strobel K. FDG-PET imaging in musculoskeletal infection. The Quarterly Journal of Nuclear Medicine and Molecular Imaging. 2006; 50: 131-142.
  27. Termaat MF, Raijmakers PG, Scholten HJ et al. The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis. The Journal of Bone and Joint Surgery. 2005; 87(11): 2464-2471.
  28. Turlakow A, Yeung H, Pui J et al. Fludeoxyglucose positron emission tomography in the diagnosis of giant cell arteritis. Archives of Internal Medicine 2001; 161(7): 1003-1007.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/28/15.

GUIDELINE UPDATE INFORMATION:

10/15/03

Annual review. Developed separate policy for PET Miscellaneous Applications.

12/15/04

Reviewed; added musculoskeletal diseases (investigational) to when services are not covered. Added G0336 to HCPCS coding. Added G0336 to program exception for Medicare and coverage criteria for G0336 (PET imaging; brain imaging for the differential diagnosis of Alzheimer’s disease with aberrant features vs. frontotemporal dementia), and updated references.

03/15/05

Added program exception for Health Options, Blue Care, and Medicare Advantage products.

01/01/06

Scheduled review. No change in coverage and investigational statements, and updated references. HCPCS update; added G0235.

03/15/06

HCPCS update, deleted G0229 and G0336. Revised Medicare Advantage products program exception.

06/15/06

Added A9552. Revised reimbursement information section. Updated references.

10/15/06

Added coverage statement for follow-up of known brain tumor to WHEN SERVICES ARE COVERED section. Revised Medicare Advantage products program exception, and updated references. Added statement regarding radiopharmaceutical.

07/01/07

Reformatted guideline. Maintain coverage statement for epileptic seizures and brain tumor. Maintain investigational statement for all other PET indications (CNS diseases, pulmonary diseases, musculoskeletal diseases), considered investigational. Revised reimbursement statement. Revised Medicare Advantage products program exception, and updated references.

01/21/08

Updated Program Exceptions.

07/15/08

Annual review. Added chronic osteomyelitis (meets the definition of medical necessity) and giant cell arteritis (considered experimental or investigational) to position statements. Added definition for giant cell arteritis to definitions section, and updated references.

05/21/09

Removed Federal Employee Plan (FEP) from BCBSF Radiology Management program exception statement. Added FEP program exception statement: FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

07/01/09

Updated BCBSF Radiology Management program exception; added BlueSelect. Added program exception for Medicare Advantage products for dementia (Alzheimer’s disease and fronto-temporal dementia.

10/15/09

Updated description section. Added, “if the diagnosis cannot be determined by a bone scan” for chronic osteomyelitis, and updated references.

01/01/10

Revised BCBSF Radiology Management program exception section.

10/01/11

Revision; formatting changes.

10/15/11

Revision; formatting changes.

02/15/13

Scheduled review; added inflammatory bowel disease and mycobacterium infection (experimental or investigational). Added coverage statement for Medicare Advantage; FDG PET for: seizures and infection and inflammation. Updated references.

01/01/14

Annual HCPCS coding update; added A9599.

05/11/14

Revision: Program Exceptions section updated.

06/15/15

Revision; added “or Cancer to Brain Tumor, when used to differentiate between treatment induced (radiation) tumor necrosis and brain tumor recurrence, post-operative/procedureal evaluation (brain PET imaging), and dementia.

01/01/17

Annual HCPCS code update. Revised A9599 code descriptor.

04/15/17

Code update; deleted A9552, revised G0235 descriptor.

Date Printed: August 23, 2017: 06:08 AM