Mountain State Medical Policy Bulletin |
Section: | Radiation Therapy & Nuclear Medicine |
Number: | R-9 |
Topic: | Oncologic Applications of PET Scanning |
Effective Date: | September 10, 2007 |
Issued Date: | October 1, 2007 |
Date Last Reviewed: | 05/2006 |
Indications and Limitations of Coverage
Positron emission tomography (PET) can be used to diagnose and stage malignancies. It is covered in the following clinical situations:
PET imaging is also covered when used for restaging. Restaging occurs after a course of treatment has been completed. As such, it is covered when:
Surveillance is periodic follow-up imaging of patients with a confirmed history of cancer, who have completed a course of treatment and require periodic evaluation for potential re-occurrence. To be eligible, PET scans performed for surveillance must meet these qualifications. Once the diagnosis has been established, PET is not eligible when performed to monitor tumor response to treatment, when no change in treatment is being considered. The use of PET in this circumstance is considered not medically necessary and as such, is not eligible for reimbursement. When PET is denied as not medically necessary, a participating, preferred, or network provider cannot bill the member for the denied service. PET imaging is not covered when performed as a screening procedure to evaluate asymptomatic patients (patients without signs and/or symptoms of disease or illness). In this case, a participating, preferred, or network provider can bill the member for the denied service. PET imaging is considered medically necessary for the following oncological applications. In all cases, clinical documentation must be maintained in the patient’s medical records to support the medical necessity of the PET study: Brain Breast
PET breast imaging is considered not medically indicated for the initial diagnosis of breast cancer and staging of axillary lymph nodes (code G0252). This service is not eligible for payment. A participating, preferred, or network provider cannot bill the member for the denied service in this instance. Colorectal Colorectal PET imaging for conditions other than those described above is considered not medically indicated and not eligible for payment. Esophageal In most cases, CT and/or endoscopic ultrasound studies are the standard imaging methods to assess patients with esophageal cancer. When CT and/or endoscopic ultrasound are indeterminate or inconclusive, PET imaging may be used to obtain the necessary information to determine treatment management. Esophageal PET imaging for conditions other than those described above is considered not medically indicated and not eligible for payment. Gynecological PET imaging for gynecological conditions other than those specified above is considered not medically indicated and ineligible for payment. Head and Neck, Excluding Central Nervous System PET imaging for the diagnosis, staging and restaging of cancers of the head and neck) is eligible for reimbursement. (140.0-140.9, 141.0-141.9, 142.0-142.9, 143.0-143.9, 144.0-144.9, 145.0-145.9, 146.0-146.9, 147.0-147.9, 148.0-148.9, 149.0-149.9, 160.0-160.9, 161.0-161.9, 162.0, 162.2, 170.0-170.1, 171.0, 173.0-173.4, 176.2, 190.0-190.9, 194.1, 194.3, 195.0, 196.0, 210.0-210.9, 212.0-212.1, 213.0-213.1, 215.0, 216.0-216.4, 224.0-224.9, 228.03, 230.0, 231.0, 231.1, 231.8, 232.0-232.4, 234.0, 235.0-235.1, 235.6, 237.0, 238.0, 238.2, 238.8, 239.0, 239.1, 239.2, 239.8) PET imaging of the head and neck for conditions other than those described above is considered not medically indicated and not eligible for payment. PET studies of the central nervous system are considered investigational. As such, PET scans of the head and neck for central nervous system (CNS) cancers are not covered. Lung PET imaging of the lung is eligible for the diagnosis, staging and restaging of lung cancers (162.0-162.9, 163.0-163.9, 164.8, 164.9, 196.1, 197.0, 197.1, 231.2, 235.7, 235.8, 239.1, 518.89). PET imaging of the lung for conditions other than those described above is considered not medically indicated and not eligible for payment. Lymphoma PET imaging of lymphoma for conditions other than those described above is considered not medically indicated and not eligible for payment. Melanoma PET studies performed to evaluate regional nodes in melanoma patients (code G0219) is considered not medically indicated and, as such, is not eligible for reimbursement. PET imaging of melanoma for conditions other than those described above is considered not medically indicated and not eligible for payment. Pancreas Pancreatic PET imaging for other diagnoses or conditions is not medically indicated and not eligible for payment. Thyroid Other applications for PET imaging of the thyroid are considered not medically indicated. There is insufficient scientific evidence documenting the efficacy of PET thyroid imaging in the clinical setting for any other application including, but not limited to:
PET Imaging for Malignancies in Other Anatomic Areas All eligibility criteria and coverage guidelines that apply to PET studies also apply to codes 78811 through 78813 based on the anatomic area imaged. All eligible diagnosis codes for covered PET studies also apply to codes 78811 through 78813. PET tumor imaging reported with a diagnosis code other than those listed as eligible will be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service. PET Scans Using a Coincidence Detection System A non-dedicated PET scanner, also called a coincidence detection system, uses a modified SPECT gamma camera that has been adapted to produce PET-like images. Radiopharmaceutical Diagnostic Imaging Agents Description PET is a nuclear imaging technology that uses positron emitting radiotracers coupled to organic molecules (e.g., glucose) to obtain both metabolic and physiologic information pertaining to a specific anatomic area. These radiotracers are produced by a nuclear generator or cyclotron and administered intravenously as a radiopharmaceutical diagnostic imaging agent prior to imaging. PET provides cross-sectional images of an anatomic area to identify metabolic, biochemical, hemodynamic, pharmacologic, and physiologic processes for the diagnosis and treatment management of diseases. This policy focuses on the oncologic applications of PET in diagnosing and treating various malignancies. For information on PET imaging for nonmalignant applications see Medical Policy Bulletin R-8. For information on PET/CT fusion imaging (codes 78814-78816) see Medical Policy Bulletin R-16. |
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78811 | 78812 | 78813 | G0219 | G0235 | G0252 |
S8085 |
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program. |
Oncologic Applications of PET: An updated review, Applied Radiology, June 2000 Positron Imaging in Oncology: Present and Future, Nuclear Medicine Annual, 1998 A Meta-Analysis of the Literature for Whole-Body FDG PET Detection of Recurrent Colorectal Cancer, The Journal of Nuclear Medicine, Volume 41, No. 7, July 2000 Utility of Positron Emission Tomography for the Staging of Patients with Potentially Operable Esophageal Carcinoma, Journal of Clinical Oncology, Volume 18, No. 18, September 2000 Positron Emission Tomography: Another Useful Test for Staging Esophageal Cancer, Journal of Clinical Oncology (Editorial), Volume 18, No. 18, September 2000 Whole-Body FDG Positron Emission Tomographic Imaging for Staging Esophageal Cancer Comparison with Computed Tomography, Clinical Nuclear Medicine, Volume 25, No. 11, November 2000 Fluorine-18 Fluorodeoxyglucose Positron Emission Tomography in the Staging and Follow-up of Lymphoma: Is it time to shift gears? (United States study), European Journal of Nuclear Medicine, Volume 27, No. 10, October 2000 Positron Emission Tomography (PET) is Superior to Computerized Tomography (CT) for Metastatic Staging in Melanoma Patients, Clinical Positron Imaging, Volume 3, No. 4, July 2000 Optimal Interpretation of FDG PET in the Diagnosis, Staging and Management of Pancreatic Carcinoma, The Journal of Nuclear Medicine, Volume 40, No. 11, 1999 Preoperative Staging of Non-Small-Cell Lung Cancer with Positron Emission Tomography, The New England Journal of Medicine, Volume 343, No. 4, July 2000 Accuracy of Whole-Body Fluorine-18 FDG PET for the Detection of Recurrent or Metastatic Breast Carcinoma, The Journal of Nuclear Medicine, Volume 39, No. 3, March 1998 Clinical Utility of FDG-PET in Detecting Had and Neck Tumors: A Comparison of Diagnostic Methods and Modalities, Clinical Positron Imaging, Volume 3, No. 1, 2000 PET in Oncology: Will it replace the other modalities?, Seminars in Nuclear Medicine, Volume XXVII, No. 2, 4/87 Decision Tree Sensitivity Analysis for Cost Effectiveness of FDG-PET in the Staging and Management of Non-Small-Cell Lung Carcinoma, The Journal of Nuclear Medicine, Volume 37, No. 9, 9/96 Evaluation of Pulmonary Lesions with FDG-PET, Comparison of Findings in Patients with and without a History of Prior Malignancy, Chest, Volume 109, 4/96 Oncologic Applications of PET Scanning, National Blue Cross Blue Shield Association Medical Policy Reference Manual, Policy No. 6.01.26, Issued April 2000 Medicare Coverage Database Decision Memo CAG-00095N F18-fluorodeoxyglucose positron emission tomography in detecting metastatic papillary thyroid carcinoma with elevated human serum thyroglobulin levels but negative I-131 whole body scan, Endocrine Research, May 2003 Postoperative management of differentiated thyroid cancer, Otolaryngologic Clinics of North America, February 2003 Clinical Relevance of Thyroid Fluorodeoxyglucose-Whole Body Positron Emission Tomography Incidentaloma, Journal of Clinical Endocrinology and Metabolism, April 2002 Positron-Emission Tomography and Assessment of Cancer Therapy, The New England Journal of Medicine, February, 2006 Prediction of Response to Neoadjuvant Chemotherapy by Sequential F-18-Fluorodeoxyglucose Positron Emission Tomography in Patients with Advanced-Stage Ovarian Cancer, Journal of Clinical Oncology, October, 2005 Imaging of Pelvic Malignancies with In-Line FDG PET-CT: Case Examples and Common Pitfalls of FDG PET, Radiographics, July 2005 FDG-PET for Management of Cervical and Ovarian Cancer, Gynecology Oncology, April, 2005 Positron Emission Tomography with 2-deoxy-2-[18F]fluoro-D-glucose for Evaluating Local and Distant Disease in Patients with Cervical Cancer, Molecular Imaging and Biology, January-February, 2004 Why Nearly All PET of Abdominal and Pelvic Cancers Will Be Performed as PET/CT, Journal of Nuclear Medicine, January, 2004 (Supplement) Clinically Occult Recurrent Ovarian Cancer: Patient Selection for Secondary Cytoreductive Surgery Using Combined PET/CT, Gynecology Oncology, September, 2003 Positron Emission Tomography/Computed Tomography Imaging for the Detection of Recurrent Ovarian and Fallopian Tube Carcinoma: A Retrospective Review, Gynecology Oncology, April, 2002 Use of PET/CT Scanning in Cancer Patients: Technical and Practical Considerations, Baylor University Medical Center Proceedings, October, 2005 Imaging and Response in Soft Tissue Sarcomas, Hematology/Oncology Clinics of North America, June, 2005 Oncologic Application of PET Scanning, National Blue Cross Blue Shield Medical Policy 6.01.26, February, 2005 PET: A Revolution in Medical Imaging, Radiology Clinics of North America, November 2004 PET in the Management of Urologic Malignancies, Radiology Clinics of North America, November 2004 |
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