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04-78000-17

Original Effective Date: 06/15/01

Reviewed: 05/28/15

Revised: 02/20/17

Subject: Positron Emission Tomography (PET) for Oncologic 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), also known as PET imaging, PET scan, positron emission transverse tomography (PETT), or positron emission coincident imaging (PECI), is a noninvasive diagnostic imaging procedure that assesses the level of metabolic activity and perfusion in various organ systems of the human body. Images are obtained from positron emitting radioactive tracer substances (radiopharmaceuticals). A variety of radiotracers are used for PET imaging, including oxygen-15, nitrogen-13, carbon-11, and fluorine-18. Because of their short half-life, some tracers must be made locally using an onsite cyclotron. The radiotracer most commonly used in oncology imaging has been fluorine-18 coupled with fluorodeoxyglucose (FDG), which has a metabolism related to glucose metabolism. FDG has been considered useful in cancer imaging, since tumor cells show increased metabolism of glucose.

The efficacy, sensitivity and specificity of PET vary with the type of cancer. The medical indication of PET imaging for oncologic applications depends in part on what imaging techniques are used either before or after PET imaging. PET imaging is typically considered after other techniques provide inconclusive or discordant results, such as computed tomography (CT), magnetic resonance imaging (MRI), or ultrasonography.

Combined positron emission tomography (PET) computed tomography (CT) systems merge PET and CT imaging technology into one system to produce an image that provides both functional and anatomic information. CT uses x-rays to produce cross-sectional anatomic views of the area of interest.

The following applications in oncology apply for PET imaging:

Diagnosis: Diagnosis refers to use of PET imaging as part of the testing used in establishing whether or not an individual has cancer.

Staging: Staging refers to use of PET imaging to determine the stage (extent) of the cancer at the time of diagnosis, before any treatment is given. Imaging at this time is generally to determine whether or not the cancer is localized. This may also be referred to as initial staging.

Restaging: Restaging refers to PET imaging following treatment; evaluation of an individual in which a disease recurrence is suspected based on signs and/or symptoms and in determining the extent of malignancy following completion of a full course of treatment.

Surveillance: Surveillance refers to use of PET imaging in asymptomatic individuals (individuals without objective signs or symptoms of recurrent disease). PET imaging is completed 6 months or more following completion of treatment for cancer and 12 months or more for lymphoma following completion of treatment.

POSITION STATEMENT:

For all uses of positron emission tomography (PET) imaging relating to oncology, the following general criteria applies for the following indications:

Initial Treatment Management

Diagnosis: PET meets the definition of medical necessity only in clinical situations in which the PET results may assist in avoiding an invasive diagnostic procedure, or in which the PET results may assist in determining the optimal anatomic location to perform an invasive diagnostic procedure. In general, for most solid tumors, a tissue diagnosis is made prior to the performance of PET imaging. PET scans following a tissue diagnosis are performed for the purpose of staging, rather than diagnosis.

Staging: PET meets the definition of medical necessity for staging in clinical situations in which the stage of the cancer remains in doubt after completion of a standard diagnostic workup, including conventional imaging (computed tomography (CT), magnetic resonance imaging (MRI), or ultrasound), or the PET could potentially replace one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical management of the patient, and clinical management of the patient would differ depending on the stage of the cancer identified.

Subsequent Treatment Management

Restaging: PET meets the definition of medical necessity for restaging after completion of treatment for the purpose of detecting residual disease, for detecting suspected recurrence or metastasis, to determine the extent of a known recurrence, or if it could potentially replace one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical management of the patient. Restaging apples to testing after a course of treatment is completed.

Monitoring: Refers to the use of PET to monitor tumor response to treatment during the planned course of therapy (e.g., when a change in therapy is anticipated).

Positron emission tomography (PET) imaging with or without combined positron emission tomography/computed tomography (PET/CT) with an FDA approved radiopharmaceutical and radiotracer meets the definition of medical necessity for the following indications.

Bone Cancer

PET imaging of the bone meets the definition of medical necessity in the staging of Ewing sarcoma and osteosarcoma.

PET imaging of the bone is considered experimental or investigational for all other applications, including but not limited to staging of chondrosarcoma. There is limited evidence in the published peer-reviewed medical literature to support PET imaging in all other applications, including but not limited to staging of chondrosarcoma

Breast Cancer

PET imaging of the breast meets the definition of medical necessity for any one of the following:

• As an adjunct to standard imaging modalities for staging distant metastasis

• Restaging locoregional recurrence (local recurrence) or metastasis

• As an adjunct to standard imaging modalities for monitoring locally advanced and metastatic breast cancer when a change in therapy is contemplated

• Staging and restaging for detection of locoregional or distant recurrence or metastasis (except axillary lymph nodes) when suspicion of disease is high and other imaging is inconclusive.

PET imaging of the breast is considered experimental or investigational in the diagnostic evaluation of breast cancer for all other applications, including but not limited to any of the following. There is limited evidence in the published peer-reviewed medical literature to support PET imaging for the following:

• Initial diagnosis of breast cancer

• Differential diagnosis in members with suspicious breast lesions or an indeterminate/low suspicion finding on mammography

• Staging of axillary lymph nodes

• Predicting pathologic response to neoadjuvant therapy for locally advanced disease.

Cervical Cancer

PET imaging for cervical cancer meets the definition of medical necessity for any one of the following:

• For initial diagnostic evaluation of cervical cancer as an adjunct to conventional imaging in members with a negative CT or MRI for extra-pelvic metastatic disease

• For initial staging of locally advanced cervical cancer

• For detection and diagnostic evaluation of residual or recurrent disease after treatment or restaging (post cancer surgery, chemotherapy, or radiation therapy).

Chronic Lymphocytic Leukemia (CLL)

PET imaging for chronic lymphocytic leukemia (CLL) meets the definition of medical necessity as the initial study with biopsy proven cancer or for detecting suspected cancer based on diagnostic testing (e.g., bone marrow aspiration, biopsy, CBC).

Colorectal Cancer

PET imaging for colorectal cancer meets the definition of medical necessity for any one of the following:

• Staging and restaging to detect and assess resectability of hepatic or extrahepatic metastases of colorectal cancer;

• To determine the location of recurrent colorectal tumors (indicated by rising levels of carcinoembryonic antigen (CEA) (the primary purpose for determining the location of colorectal tumors is for making a decision as to whether surgical intervention is warrant

• Diagnostic evaluation of rising and persistently elevated carcinoembryonic antigen (CEA) level when imaging (e.g., CT scan) is negative

• Tumor staging and re-staging

• For detection and diagnostic evaluation of residual or recurrent disease after treatment (post cancer surgery, chemotherapy, or radiation therapy).

PET imaging is considered experimental or investigational for the following. There is limited evidence in the published peer-reviewed medical literature to support PET imaging for the following:

Assessment of the presence of scarring versus local bowel recurrence in patients with previously resected colorectal cancer

Radiotherapy treatment planning.

Esophageal Cancer

PET imaging for esophagus cancer meets the definition of medical necessity for any one of the following:

• Tumor staging and restaging

• For detection and diagnostic evaluation of residual or recurrent disease after treatment (post cancer surgery, chemotherapy, or radiation therapy)

• Determining response to preoperative induction therapy.

PET imaging is considered experimental or investigational in the detection of primary esophageal cancer. There is limited evidence in the published peer-reviewed medical literature to support PET imaging in the evaluation of esophageal cancer.

Head and Neck Cancer

PET imaging of head and neck cancer meets the definition of medical necessity for any one of the following:

• Diagnosis, staging, and restaging of head and neck cancer

• Diagnosis of suspected head and neck cancer

• Initial staging of head and neck cancer

• Identification of a head or neck tumor as a suspected but unknown “primary”

• Staging of known head or neck tumor and assessing resectability of the tumor

• Restaging of residual or recurrent disease after treatment (post cancer surgery, chemotherapy, or radiation therapy).

Lung

PET imaging of the lung meets the definition of medical necessity for any one of the following:

• Diagnosis, staging and restaging of known non-small cell lung cancer

• Characterization of solitary pulmonary nodule or single pulmonary nodules (SPN’s) to determine the likelihood of malignancy in order to plan future management and treatment

• As a technique to distinguish between benign and malignant disease when prior CT scan and chest x-ray are inconclusive or discordant

• For detection and diagnostic evaluation of residual or recurrent disease after treatment or restaging (post cancer surgery, chemotherapy, or radiation therapy)

• To determine resectability for presumed solitary metastatic lesion from non-small cell lung cancer

• Restaging and monitoring lung cancer (small cell) if other imaging modalities (ultrasound, CT, MRI) are inconclusive in determining a treatment plan or if unable to perform imaging modalities (ultrasound, CT, MRI).

PET imaging is considered experimental or investigational in staging and restaging of small cell lung cancer. There is limited evidence in the published peer-reviewed medical literature to support PET imaging in the staging of small cell lung cancer.

Lymphoma (including Hodgkin’s disease)

PET imaging for lymphoma meets the definition of medical necessity for any one of the following:

• Diagnosis of lymphoma

• Tumor staging and restaging

For detection and diagnostic evaluation of residual or recurrent disease after treatment or restaging (post cancer surgery, chemotherapy, or radiation therapy).

Melanoma

• PET imaging for melanoma meets the definition of medical necessity for any one of the following:

• Diagnosis, staging, and restaging of malignant melanoma

• As a technique for assessing extranodal spread of malignant melanoma at initial staging or during follow-up treatment

• For detection and diagnostic evaluation of residual or recurrent disease after treatment or restaging (post cancer surgery, chemotherapy, or radiation therapy).

PET imaging is considered experimental or investigational as a technique to detect regional lymph node metastases in patients with clinically localized melanoma who are candidates to undergo sentinel node biopsy. There is limited evidence in the published peer-reviewed medical literature to support PET imaging as a technique to detect regional lymph node metastases in patients with clinically localized melanoma who are candidates to undergo sentinel node biopsy.

Multiple Myeloma

PET imaging for multiple myeloma meets the definition of medical necessity for any one of the following:

Diagnosis and initial staging of multiple myeloma

Restaging after completion of therapy

Monitoring response to treatment.

Neuroendocrine Cancer

PET imaging for restaging and monitoring neuroendocrine cancer (e.g., carcinoid, pheochromocytoma) meets the definition of medical necessity if other imaging (ultrasound, CT, MRI) is inconclusive in determining a treatment plan or if unable to perform imaging modalities.

Ovarian Cancer

PET imaging for ovarian cancer meets the definition of medical necessity for the following:

• Diagnostic evaluation of signs and symptoms of suspected ovarian cancer recurrence (restaging) when imaging (e.g., CT scan) is inconclusive.

PET imaging is considered experimental or investigational in the initial diagnostic evaluation of known or suspected ovarian cancer. There is limited evidence in the published peer-reviewed medical literature to support PET imaging in the initial diagnostic evaluation of known or suspected ovarian cancer.

Pancreatic Cancer

PET imaging for pancreatic cancer meets the definition of medical necessity in the initial diagnosis and staging of pancreatic cancer when other imaging (e.g., ultrasound, CT, or MRI) and biopsy are inconclusive.

PET imaging for subsequent (post-treatment) for pancreatic cancer meets the definition of medical necessity only if other imaging (e.g., ultrasound, CT, or MRI) is inconclusive in determining a treatment plan or if unable to perform imaging modalities.

PET imaging is considered experimental or investigational including, but not limited to PET imaging as a technique for evaluation of other aspects of pancreatic cancer. There is limited evidence in the published peer-reviewed medical literature to support PET imaging for other applications, including but not limited to PET imaging as a technique for evaluation of other aspects of pancreatic cancer.

Prostate Cancer

PET imaging of prostate meets the definition of medical necessity for any one of the following:

• To determine the anatomic extent of tumor when the recommended anti-tumor treatment depends on the extent of the tumor

• To determine if member is an appropriate candidate for an invasive diagnostic or therapeutic procedure

• To determine the optimal anatomic location for an invasive procedure.

PET imaging for prostate cancer is considered experimental or investigational for restaging or monitoring response to active treatment.

Soft Tissue Sarcoma

PET imaging for subsequent (post-treatment) for soft tissue sarcoma meets the definition of medical necessity only if other imaging (e.g., ultrasound, CT, or MRI) is inconclusive in determining a treatment plan or if unable to perform imaging modalities.

PET imaging is considered experimental or investigational in the diagnostic evaluation of soft tissue sarcoma, including but not limited to the following applications. There is limited evidence in the published peer-reviewed medical literature to support PET imaging for the following:

• Distinguishing between low grade and high grades of soft tissue sarcoma

• Diagnostic evaluation of response to imatinib and other treatments for gastrointestinal stromal tumors

Testicular Cancer

PET imaging meets the definition of medical necessity in the diagnostic evaluation of residual mass following chemotherapy of stage IIB and III seminomas (the PET imaging should be completed not sooner than 6 weeks following chemotherapy) and initial staging.

PET imaging is considered experimental or investigational in the diagnostic evaluation of testicular cancer, including but not limited to the following. There is limited evidence in the published peer-reviewed medical literature to support PET imaging for the following:

• Distinguishing between viable tumor and necrosis/fibrosis after treatment of testicular cancer

• Detection of recurrent disease after treatment of testicular cancer, except where noted above

Thyroid Cancer

PET imaging for thyroid cancer meets the definition of medical necessity for the following:

• Restaging of recurrent or residual thyroid cancers of follicular cell origin that have been previously treated by thyroidectomy and radioiodine ablation and the member has a serum thyroglobulin greater than 10ng/ml and negative I-131 whole body scan.

• Restaging of differentiated thyroid cancer when thyroglobulin (Tg) levels are elevated (greater than 10ng/ml) and whole-body I-131 imaging is negative

• Medullary thyroid cancer when calcitonin levels are elevated post operatively (greater than 150pg/mL).

PET imaging is considered experimental or investigational in the diagnostic evaluation of known or suspected differentiated or poorly differentiated thyroid cancer. There is limited evidence in the published peer-reviewed medical literature to support PET imaging in the evaluation of known or suspected differentiated or poorly differentiated thyroid cancer.

Unknown Primary (occult primary tumors/cancers of unknown site)

PET imaging of unknown primary meets the definition of medical necessity when ALL of the following criteria are met:

• For a single site of disease outside the cervical lymph nodes; AND

• Local or regional treatment for a single site of metastatic disease is being considered; AND

• After a negative work up for an occult primary tumor; AND

• PET imaging will be used to rule out or detect additional sites of disease that would eliminate the rationale for local or regional treatment.

PET imaging is considered experimental or investigational for other unknown primary including, but not limited to the following indications. There is limited evidence in the published peer-reviewed medical literature to support PET imaging for the following:

• Initial work-up of an unknown primary

• Work-up for multiple sites of diseases

Other

PET imaging for multiple myeloma, and vulvar cancer requires Medical Director review of the general criteria; refer to initial treatment management (diagnosis, staging) and subsequent treatment management (restaging, monitoring).

PET imaging is considered experimental or investigational for all other indications, including, but not limited to the following indications/applications. There is limited evidence in the published peer-reviewed medical literature to support PET imaging for the following:

• PET mammography (PEM)

• PET magnetic resonance imaging (PET/MR, PET/MRI)

• Diagnostic evaluation of neuroendocrine tumors

• Staging inguinal lymph nodes in patients with squamous cell carcinoma of the penis

Cancer Surveillance

PET imaging is considered experimental or investigational when used as a surveillance tool for patients with cancer or with a history of cancer. PET imaging is considered surveillance if performed more than 6 months after completion of cancer therapy (12 months for lymphoma) in patients without objective signs or symptoms suggestive of cancer recurrence. There is limited evidence in the published peer-reviewed medical literature to support PET imaging in surveillance.

BILLING/CODING INFORMATION:

The following codes may be used to describe positron emission tomography (PET Scan) oncologic.

CPT Coding:

78811

Positron emission tomography (PET) imaging; limited area (e.g., chest, head/neck)

78812

Positron emission tomography (PET) imaging; skull base to mid-thigh

78813

Positron emission tomography (PET) imaging; whole body

78814

Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (e.g., chest, head/neck)

78815

Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh

78816

Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body

HCPCS Coding:

G0219

PET imaging whole body; melanoma for non-covered indications (non-covered)

G0235

PET imaging, any site, not otherwise specified (not covered/not recognized by Medicare)

G0252

PET imaging, full and partial-ring PET scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes), (non-covered)

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.

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

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 (FDG) for Oncologic Conditions (220.6.17) and Positron Emission Tomography (NaF-18) to Identify Bone Metastasis of Cancer (220.6.19) located at cms.gov.

DEFINITIONS:

Neoadjuvant: treatment given as a first step to shrink a tumor before the main treatment, which is usually surgery, is given. Examples of neoadjuvant therapy include chemotherapy, radiation therapy, and hormone therapy.

RELATED GUIDELINES:

Positron Emission Tomography (PET) Cardiac Applications, 04-78000-16
Positron Emission Tomography (PET) Miscellaneous Applications, 04-78000-18

OTHER:

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

Combined Positron Emission Tomography-Computed Tomography (PET-CT)
Integrated PET/CT
positron emission transverse tomography (PETT)
positron emission coincident imaging (PECI)
PET-CT

REFERENCES:

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  2. ACR-SPR Practice Guideline for Performing FDG-PET/CT in Oncology, 2012.
  3. American College of Radiology (ACR) Guideline for the Performance of FDG-PET Scintigraphy in Oncology, 01/01/01.
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  6. Becherer A, De Santis M, Karanikas G et al. FDG PET is superior to CT in the prediction of viable tumour in post-chemotherapy seminoma residuals. European Journal of Radiology 2005; 54(2): 284-288.
  7. Benz MR, Czerni J, Allen-Auerbach MS et al. FDG-PET/CT imaging predicts histopathologic treatment responses after the initial cycle of neoadjuvant chemotherapy in high-grade soft-tissue sarcomas. Clinical Cancer Research 2009; 15(8): 2856-63.
  8. Binderup T, Knigge U, Loft A, et al. Functional imaging of neuroendocrine tumors: a head-to-head comparison of somatostatin receptor scintigraphy, 123I-MIBG scintigraphy, and 18F-FDG PET. Journal of Nuclear Medicine 2010; 51(5): 704-712.
  9. Blue Cross Blue Shield Association Oncologic Applications of PET Scanning Medical Policy (6.01.26), 02/15.
  10. Blue Cross Blue Shield Association Interim PET Scanning in Oncology to Detect Early Response During Treatment Medical Policy (6.01.51), 08/14.
  11. Blue Cross Blue Shield Association Positron Emission Mammography (PEM) 6.01.52, 06/14.
  12. Bredella MA, Steinbach L, Caputo G et al. Value of FDG PET in the assessment of patients with multiple myeloma. American Journal of Roentgenology 2005; 184: 1199-1204.
  13. Bristow RE del Carmen MG, Pannu HK et al. Positron emission tomography for detecting clinically occult surgically resectable metastatic ovarian cancer. Gynecologic Oncology 2003; 85(1): 196-200.
  14. Bristow RE, Simpkins F, Pannu HK et al. Clinically occult recurrent ovarian cancer: patient selection for secondary cytoreductive surgery using combined PET/CT. Gynecologic Oncology 2003; 90(3): 519-528.
  15. Centers for Medicare & Medicaid Services (CMS) National Coverage Determination (NCD) for Positron Emission Tomography (NaF-18) to Identify Bone Metastasis of Cancer (220.6.19), 02/26/10.
  16. Centers for Medicare & Medicaid Services (CMS) National Coverage Determination (NCD) for Positron Emission Tomography (FDG) for Oncologic Conditions (220.6.17), 08/04/10.
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  25. Heinrich S, Goerres GW, Schafer M et al. Positron emission tomography/computed tomography influences on the management of resectable pancreatic cancer and its cost-effectiveness. Annals of Surgery 2005; 242(2): 235-243.
  26. Hersh MR, Knapp EL, Choi J. Newer Imaging Modalities to Assess Tumor in the Prostate. Cancer Control 2004; 11(6): 353-357.
  27. Hillner BE, Tunuguntla R, Melvin Fratkin. Clinical Decisions Associated with Positron Emission Tomography in a Prospective Cohort of Patients with Suspected or Known Cancer at One United States Center. Journal of Clinical Oncology 2004; 22(20): 4147-4156.
  28. Jadvar H, Kherbache HM, Pinski JK et al. Diagnostic Role of [F-18]-FDG Positron Emission Tomography in Restaging Renal Cell Carcinoma. Clinical Nephrology 2003; 60 (6): 395-400.
  29. Jadvar H, Pinski JK, Conti PS. FDG PET in suspected recurrent and metastatic prostate cancer. Oncology Reports 2003; 10: 1485-1488.
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  37. Safaei A, Figlin R, Hoh CK et al. The Usefulness of F-18 Deoxygulcose Whole-Body Positron Emission Tomography (PET) for Re-staging of Renal Cell Cancer. Clinical Nephrology 2002; 57 (1): 56-62.
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  40. Shvarts O, Han K, Seltzer M et al. Positron Emission Tomography in Urological Oncology. Cancer Control 2002; 9(4): 335-342.
  41. Takahashi N, Inoue T, Lee J et al. The roles of PET and PET/CT in the diagnosis and management of prostate cancer. Oncology 2007; 72 (3-4): 226-233.
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  45. Van den Abbeele AD. The lessons of GIST—PET and PET/CT: a new paradigm for imaging. The Oncologist 2008; 13 Suppl 2:8-13.
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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 Scans Oncologic Applications.

04/23/04

Added coverage statement for G0296. Deleted Medicare & More program exception for G0296.

11/15/04

Annual Review. No change in coverage statements. Revised NIA statements under Program Exceptions. Updated references.

01/01/05

HCPCS update. Deleted 78810. Added 78811, 78812, 78813, 78814, and 78815.

02/15/05

HCPCS update. Added G0330 and G0331. Deleted 78814 and 78815, separate MCG to be developed.

05/15/05

Added coverage statement for combined PET-CT (78814, 78815, and 78816). Revised when services are covered and when services are not covered for PET imaging. Added coverage statement for cervical cancer. Added G0235. Revised reimbursement statement. Updated references.

02/15/06

HCPCS update, deleted G0253 and G0254. Updated references.

03/15/06

HCPCS update, deleted G0125, G0210, G0211, G0212, G0213, G0214, G0215, G0216, G0217, G0218, G0220, G0221, G0222, G0223, G0224, G0225, G0226, G0227, G0228, G0231, G0232, G0234, and G0296. Revised G0235 descriptor.

06/15/06

Revised description section. Revised when services are covered; expand coverage to include ovarian cancer and pancreatic cancer. Revised coverage statement for PET-CT. Revised when services are not covered. Added A9552. Revised reimbursement statement. Added CA-125 to definition section. Added program exception for Medicare Advantage products. Updated references.

12/28/06

Added ICD-9 diagnoses codes.

04/01/07

Deleted G0330 and G0331. Deleted monitoring of ovarian cancer for response to treatment from when services are not covered. Added monitoring of ovarian cancer for response to treatment to when services are covered for ovarian cancer.

07/01/07

Reformatted guideline. Maintain coverage statements. Added statement that multiple myeloma, testicular cancer, and vulvar cancer requires Medical Director Review. Revised investigational/experimental statement, added evaluation of soft tissue sarcoma. Revised reimbursement statement. Updated references.

01/01/08

HCPCS update. Revised 78811, 78812, 78813, 78814, 78815, and the descriptor for code 78816.

01/21/08

Updated Program Exceptions.

07/15/08

Scheduled review. No change in position statement. 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.

11/15/09

Annual review. Added renal/kidney cancer to experimental or investigational position statement. Added program exception for Medicare. Updated references.

01/01/10

Revised BCBSF Radiology Management program exception section.

05/15/10

Added coverage criteria for NaF-18 PET imaging for bone metastasis cancer to program exception for Medicare Care Advantage products.

11/15/10

Annual review: expanded indications that meets the definition of medical necessity for breast cancer (added staging and restaging for detection of locoregional or distant recurrence or metastasis), cervical cancer (added initial staging of locally advanced cervical cancer), colorectal cancer (added staging and restaging to hepatic or extrahepatic metastasis and evaluation of rising and persistently elevated CEA level), esophageal cancer (added determining response to preoperative induction therapy, lung cancer (added to determine respectability for presumed solitary metastatic lesion from the lung). Ovarian cancer (Added evaluation of signs and symptoms of suspected ovarian cancer recurrence), pancreatic cancer (revised position statement, PET imaging meets the definition of medical necessity in the initial diagnosis and staging), testicular cancer (added in the evaluation of residual mass following chemotherapy of stage IIB and III seminomas), thyroid cancer (added staging of differentiated thyroid cancer). Added the following to experimental or investigational: differential diagnosis in patients with suspicious breast lesions or an indeterminate/low suspicion finding on mammography, PET bone scanning PET mammography (PEM), detection of primary esophageal cancer, diagnosis and management of known or suspected prostate cancer, evaluation of testicular cancer, evaluation of known or suspected differentiated thyroid cancer, evaluation of known or suspected cervical cancer, and cancer surveillance. Added ICD-10 diagnoses codes, updated Medicare program exception, and updated references.

10/01/11

Revision; related ICD-9 code 793.11 added and formatting changes.

11/15/11

Annual review; maintain position statements. Updated Medicare Advantage program exception. Updated references.

04/01/12

Update; added related ICD-10 codes.

08/15/13

Removed “scan” from guideline subject. Updated description section; revised radiotracer (radiopharmaceutical) statement. Moved indications considered experimental or investigational from the “Other” section to the corresponding indications that meet the definition of medical necessity. Added heading: “Initial Treatment Management” for (diagnosis and staging) and “Subsequent Treatment Management” for (restaging and monitoring). Added indication for bone cancer; PET scanning meets the definition of medical necessity in the staging of Ewing sarcoma and osteosarcoma. Added investigational statement for bone cancer; PET scanning is considered experimental or investigation in the staging of chondrosarcoma. Added investigational statement for breast cancer; predicting pathologic response to neoadjuvant therapy for locally advanced disease. Added indication for cervical cancer: in the evaluation of known or suspected recurrence of cervical cancer. Added indication for multiple myeloma: diagnosis, initial staging, restaging after completion of treatment and monitoring response to treatment. Add indication for pancreatic cancer; subsequent (post-treatment) if imaging (e.g., ultrasound, CT, or MRI) is inconclusive in determining a treatment plan or if unable to perform imaging modalities. Added indication for soft tissue sarcoma; subsequent (post-treatment) if imaging (e.g., ultrasound, CT, or MRI) is inconclusive in determining a treatment plan or if unable to perform imaging modalities. Add indication for testicular cancer; initial staging. Add investigational statement for colorectal cancer; radiotherapy treatment planning. Add indications for head and neck cancer: diagnosis of suspected cancer, initial staging of disease and deleted “For detection and evaluation”; added “Restaging” to residual or recurrent disease after treatment. Added investigational statement for ovarian cancer; PET scanning is considered experimental or investigational in the initial evaluation of known or suspected ovarian cancer. Revised investigational statement for thyroid cancer; added “or poorly differentiated” in the evaluation of known or suspected thyroid cancer. Added investigational applications: determining early response to treatment, diagnosis of brain cancer, restaging of gastric cancer, evaluation of neuroendocrine tumors and staging inguinal lymph nodes in patients with squamous cell carcinoma of the penis. Added PET magnetic resonance imaging (PET/MR, PET/MRI); experimental or investigational. Deleted indication for ovarian cancer: for localization of recurrent ovarian cancer with rising CA-125 levels, and negative, equivocal, or inconclusive CT imaging and monitoring of ovarian cancer for response to treatment. Deleted PET bone scanning. Deleted diagnoses codes. Updated program exception and references.

11/15/13

Revision; brain: added initial study to experimental or investigational statement; esophageal cancer: deleted diagnosis of esophageal cancer, evaluation of esophageal tumor; and added detection of primary to experimental or investigational statement; lung: added non-small cell; ovarian cancer: added diagnostic to experimental or investigational statement; soft tissue sarcoma: deleted distinguishing between benign lesions and malignant soft tissue sarcoma, detecting locoregional recurrence and detecting distant metastasis; deleted whole body tumor imaging; other: deleted renal/kidney cancer (diagnosis, staging, restaging, monitoring), diagnosis and management of known or suspected prostate cancer, determining early response to treatment (PET performed during a planned course of chemotherapy and/or radiation therapy), and gastric cancer (staging).

06/15/15

Revision; added chronic lymphocytic leukemia (CLL), prostate cancer, lung cancer (small cell), neuroendocrine cancer (e.g., carcinoid phenochromocytoma), and medullary thyroid cancer. Deletes the indication (brain and criteria). Updated references.

02/20/17

Update; Deleted code A9552.

Date Printed: August 23, 2017: 01:31 PM