Policy
General Notes:   
ADULT AND PEDIATRIC MALIGNANCIES:¹ ONCOLOGICAL PET IS INDICATED FOR BIOPSY-PROVEN CANCER OR STRONGLY SUSPECTED CANCER BASED ON OTHER DIAGNOSTIC TESTING. The appropriateness of an ordered PET/CT study is dependent on which radiopharmaceutical will be used for the PET/CT.

INDICATIONS
Bone Tumors & Sarcomas
Angiosarcoma¹

• Initial Staging
  • Indicated
    • Chest CT, CT or MRI of the primary site, Brain MRI AND whole spine MRI are indicated in addition to PET
• Restaging
  • Indicated
    • Chest CT, CT or MRI of the primary site, Brain MRI AND whole spine MRI are indicated in addition to PET

Chondrosarcoma²

• Initial Staging
  • NOT Indicated
• Restaging
  • NOT Indicated

Chordoma (2)

• Initial Staging
  • NOT Indicated
• Restaging
  • NOT Indicated

Clear Cell Sarcoma¹

• Initial Staging
  • Indicated
    • Chest CT AND CT or MRI of the primary site are indicated in addition to PET
• Restaging
  • Indicated
    • Chest CT AND CT or MRI of the primary site are indicated in addition to PET
       

Epithelioid Sarcoma¹

• Initial Staging
  • Indicated
    • Chest CT AND CT or MRI of the primary site are indicated in addition to PET
• Restaging
  • Indicated
    • Chest CT AND CT or MRI of the primary site are indicated in addition to PET

Ewing Sarcoma²

• Initial Staging
  • Indicated
    • Chest CT AND CT or MRI of the primary site are indicated in addition to PET
• Restaging
  • Indicated
    • Chest CT AND CT or MRI of the primary site are indicated in addition to PET
• Surveillance
  • For patients with a history of metastatic disease, indicated every 3 months for 2 years, then every 4 months up to year 3 post completion of treatment
    • CT or MRI of the primary site are indicated in addition to PET

Giant Cell Tumor of Bone²

• Initial Staging
  • Not Indicated
• Restaging
  • Not Indicated

Malignant Peripheral Nerve Sheath Tumor (MPNST)¹

• Restaging (for confirmed MPNST, regardless of NF1 status)
  • Indicated if being treated with chemotherapy OR
  • With prior indeterminate imaging
    • Chest CT AND CT or MRI of the primary site are indicated in addition to PET for either restaging indication

Myxoid/Round Cell Liposarcoma¹

• Initial Staging
  • Indicated
    • Chest CT, CT or MRI of the primary site, Brain MRI AND whole spine MRI are indicated in addition to PET
• Restaging
  • Indicated
    • Chest CT, CT or MRI of the primary site, Brain MRI AND whole spine MRI are indicated in addition to PET
       

Osteosarcoma²

• Initial Staging
  • Indicated
    • Chest CT AND CT or MRI of the primary site are indicated in addition to PET
• Restaging
  • Indicated
    • Chest CT AND CT or MRI of the primary site are indicated in addition to PET

Rhabdomyosarcoma¹

• Initial Staging
  • Indicated
    • Chest CT AND CT or MRI of the primary site are indicated in addition to PET
• Restaging
  • Indicated
    • Chest CT AND CT or MRI of the primary site are indicated in addition to PET
       

Soft Tissue Sarcoma — All Other Histologies¹

• Initial Staging
  • Indicated if considering neoadjuvant therapy OR
  • With prior indeterminate imaging
    • Chest CT AND CT or MRI of the primary site are indicated in addition to PET
• Restaging
  • Indicated if being treated with chemotherapy OR
  • With prior indeterminate imaging
    • Chest CT AND CT or MRI of the primary site are indicated in addition to PET

Breast Cancer³
FDG PET

• Initial Staging
  • With prior indeterminate imaging
• Restaging
  • With prior indeterminate imaging

Special Tracer PET (FES/Cerianna)

• Initial Staging
  • Not Indicated
• Restaging
  • FES (Fluoroestradiol F 18 or Cerianna®) is indicated for recurrent or metastatic breast cancer when all of the following are present:
    • Biopsy of recurrent or metastatic site is inconclusive or unable to be performed AND
    • ER status is needed to make a treatment decision

CNS Cancers⁴
All Histologies
When an oncologic PET using FDG (using CPT codes 78811 and 78814) is requested for a primary brain malignancy, it should be reordered as a Brain PET (CPT 78608).
 

When a tracer other than FDG is used (such as SSTR (dotatate) for meningioma), the CPT codes covered by this guideline (78811 and 78814) apply when medical necessity is met (see indications below) rather than the Brain PET code (CPT code 78608).

NOTE: See non-malignant disease section for amyloid/dementia

Meningioma

• Special Tracer PET: SSTR (Dotatate) PET
  • Initial Staging:
    • Indicated after Brain MRI is insufficient or indeterminant for diagnosis
  • Restaging
    • Indicated after Brain MRI is insufficient or indeterminant for detection of residual or recurrent disease

NOTE: See above all histologies section regarding FDG

Primary CNS Lymphoma

• Initial Staging:
  • Indicated
    • Brain MRI AND whole spine MRI are indicated in addition to PET
• Restaging:
  • Indicated
    • Brain MRI AND whole spine MRI are indicated in addition to PET

Gastrointestinal Tract Cancers
Anal Carcinoma⁵

• Initial Staging
  • With prior indeterminate imaging OR
  • For radiation planning (to define radiation field)
• Restaging
  • With prior indeterminate imaging OR
  • For radiation planning (to define radiation field) OR
  • Following radiation if PET was used prior to radiation

NOTE: Normal pelvic lymph nodes are often not seen on imaging. When pelvic lymph nodes are visualized on imaging, even if normal in size, that finding raises concern for disease spread and can be considered indeterminate.

Colon Cancer⁶

• Initial Staging
  • With prior indeterminate imaging OR
  • For potentially surgically curable metastatic disease OR
  • When image-guided liver-directed therapies are being considered

NOTE: When there are known or suspected liver metastases, Abdomen MRI is indicated in addition to PET

• Restaging
  • With prior indeterminate imaging (including discordance between tumor markers (CEA) and imaging) OR
  • For potentially surgically curable metastatic disease OR
  • When image-guided liver-directed therapies are being considered

NOTE: When there are known or suspected liver metastases, Abdomen MRI is indicated in addition to PET.

Esophageal & EJ Junction Cancers⁷

• Initial Staging
  • Indicated after initial workup with CT/MRI if no evidence of metastatic disease on imaging
• Restaging
  • Stages I – III: Indicated
    • NOTE: Following chemoradiation PET is indicated 5 – 8 weeks after completion of therapy
  • Stage IV: With prior indeterminate imaging

Gastric Cancer⁸

• • Localized Disease:
    • Indicated when PET was used for initial staging OR
    • With prior indeterminate imaging
  • Metastatic Disease:
    • With prior indeterminate imaging

Gastrointestinal Stromal Tumors⁹

• Initial Staging
  • With prior indeterminate imaging
• Restaging
  • With prior indeterminate imaging OR
  • 2 – 4 weeks after initiation of TKI (tyrosine kinase inhibitor) therapy

Rectal Cancer¹⁰

• Initial Staging
  • With prior indeterminate imaging OR
  • For potentially surgically curable metastatic disease OR
  • When image-guided liver-directed therapies are being considered

NOTE: When there are known or suspected liver metastases, Abdomen MRI is indicated in addition to PET

• Restaging
  • With prior indeterminate imaging (including discordance between tumor markers (CEA) and imaging) OR
  • For potentially surgically curable metastatic disease OR
  • When image-guided liver-directed therapies are being considered

NOTE: When there are known or suspected liver metastases, Abdomen MRI is indicated in addition to PET

Small Bowel Adenocarcinoma¹¹

• Initial Staging
  • With prior indeterminate imaging
• Restaging
  • With prior indeterminate imaging

Genitourinary Cancers
Bladder Cancer¹²

• Initial Staging
  • Non-muscle invasive bladder cancer (NMIBC):
    • NOT indicated
  • Muscle-invasive bladder cancer (MIBC):
    • Indicated when prior imaging is suggestive of disease outside of the urinary tract (imaging does not need to be inconclusive)
• Restaging
  • Non-muscle invasive bladder cancer (NMIBC):
    • NOT indicated
  • Muscle-invasive bladder cancer (MIBC):
    • With prior indeterminate imaging OR
    • Prior to surgical intervention (including cystectomy and potentially surgically curable metastatic disease)

Kidney Cancer¹³

• Initial Staging
  • NOT indicated
• Restaging
  • NOT Indicated

Prostate Cancer¹⁴

• • • Known Metastatic Disease
      • With prior indeterminate imaging OR
      • Discordance between imaging and PSA (i.e., rising PSA with stable imaging or stable PSA with progression on imaging)
    • Radioligand therapy (Lu-177/Pluvicto)
      • Indicated for ANY of the following:
        • When under consideration for radioligand therapy OR
        • Following completion of treatment with radioligand therapy OR
        • Discordance between imaging and PSA
• Special Tracer (Axumin or Choline) PET
  • Initial Staging
    • Not indicated
  • Restaging
    • When the restaging criteria above are met (depending on the clinical scenario/prior treatment) AND
    • Prior indeterminate imaging is provided

NOTE: PET with Axumin or Choline can be considered on a case-by-case basis when a medical reason is given why that tracer would be used instead of PSMA

Penile Cancer¹⁵

• Initial Staging
  • With prior indeterminate imaging OR
  • With suspected inguinal lymph node positive disease (based on imaging or exam)
• Restaging
  • With prior indeterminate imaging OR
  • With suspected inguinal lymph node positive disease (based on imaging or exam)

Testicular Cancer¹⁶

• • Non-seminoma:
    • NOT indicated
  • Pure seminoma:
    • With prior indeterminate imaging OR
    • With a residual mass > 3 cm with a normal AFP and b-hcg AND it has been at least 6 weeks since completion of chemotherapy

NOTE: If this PET is equivocal or borderline for residual disease, an additional repeat PET > 6 weeks later is appropriate to identify patients that can be safely observed without additional surgery. If a persistently FDG-avid mass is present on the second PET, resection or biopsy is recommended.

Gynecological Cancers
Cervical Cancer (including small cell neuroendocrine carcinoma of the cervix [NECC])¹⁷

• Initial Staging
  • Indicated
    • Pelvis MRI is indicated in addition to PET
• Restaging
  • Indicated
• Surveillance
  • Indicated for stage III or higher in the first 2 years following treatment

Uterine Sarcoma¹⁸

• Initial Staging
  • With prior indeterminate imaging
• Restaging
  • With prior indeterminate imaging

Endometrial Cancer¹⁸    

• Initial Staging
  • With prior indeterminate imaging
• Restaging
  • With prior indeterminate imaging

Gestational Trophoblastic Neoplasia¹⁹

• Initial Staging
  • With prior indeterminate imaging OR
  • Potentially surgically curable metastatic disease
• Restaging
  • With prior indeterminate imaging OR
  • Potentially surgically curable metastatic disease OR
  • At completion of chemotherapy when hCG is not a reliable marker
• Surveillance
  • Every 6 – 12 months for up to 3 years post completion of treatment when hCG is not a reliable marker

Ovarian, Fallopian Tube, and Primary Peritoneal Cancer²⁰

• Initial Staging
  • With prior indeterminate imaging
• Restaging
  • With prior indeterminate imaging (including discordance between tumor markers and imaging)

Vulvar Cancer²¹

• Initial Staging
  • Prior indeterminate imaging OR
  • If > T2 tumor (extension beyond vulva/perineum) OR
  • When sentinel lymph node biopsy is positive OR
  • When metastases are suspected
• Restaging
  • Prior indeterminate imaging OR
  • Once 3 – 6 months after completion of primary therapy OR
  • When recurrence or metastatic disease is suspected

Head & Neck Cancer²²

• Initial Staging
  • Indicated
    • Neck CT (or MRI) AND CT (or MRI) of the primary site of disease are indicated in addition to PET
• Restaging
  • Indicated
    • Neck CT (or MRI) AND CT (or MRI) of the primary site of disease are indicated in addition to PET
    • If the end of therapy PET demonstrates possible residual disease, one additional PET is appropriate > 6 weeks after end-of-therapy PET as it may help identify those patients who can be safely observed without additional cancer-directed treatment

Leukemias & Lymphomas
Acute Lymphoblastic Leukemia (ALL) (Pediatric and Adult)^23,24

• Initial Staging
  • For lymphomatous extramedullary disease (on exam or prior conventional imaging)
• Restaging
  • For lymphomatous extramedullary disease (on exam or prior conventional imaging)

Acute Myeloid Leukemia (AML) (Pediatric and Adult)²⁵

• Initial Staging
  • If suspected extramedullary involvement (myeloid sarcoma) (on exam or prior conventional imaging)
• Restaging
  • If suspected extramedullary involvement (myeloid sarcoma) (on exam or prior conventional imaging)

B-Lymphoblastic Lymphoma (Adult)²⁶

B-Lymphoblastic Lymphoma (Pediatric)²⁷

• Initial Staging
  • Indicated
    • Neck CT, Chest CT AND Abdomen and Pelvis CT are indicated in addition to PET
• Restaging
  • Indicated
    • Neck CT, Chest CT AND Abdomen and Pelvis CT are indicated in addition to PET

NOTE: This portion of the guideline should be applied to patients treated at a pediatric institution on a pediatric protocol which can include young adults into their 20's.

Burkitt Lymphoma (Adult)²⁶

• Initial Staging
  • Indicated
• Restaging
  • Indicated

Burkitt Lymphoma (Pediatric)²⁷

• Initial Staging
  • Indicated
    • Neck CT, Chest CT AND Abdomen and Pelvis CT are indicated in addition to PET
• Restaging
  • Indicated
    • Neck CT, Chest CT AND Abdomen and Pelvis CT are indicated in addition to PET

NOTE: This portion of the guideline should be applied to patients treated at a pediatric institution on a pediatric protocol which can include young adults into their 20's.
 

Castleman's Disease²⁶

• Initial Staging
  • Indicated
• Restaging
  • Indicated

Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)²⁸

• Initial Staging
  • For suspected high-grade transformation OR
  • To guide biopsy with prior indeterminate imaging
• Restaging
  • With accelerated CLL OR
  • To guide biopsy with prior indeterminate imaging

Chronic Myeloid Leukemia (CML)²⁹

• Initial Staging
  • NOT Indicated
• Restaging
  • NOT Indicated

Diffuse Large B Cell Lymphoma (Adult)²⁶

• Initial Staging
  • Indicated
• Restaging
  • Indicated
• Surveillance
  • When a site of disease was previously visualized on a PET Scan but not conventional imaging, PET is indicated every 6 months for 2 years
     

Diffuse Large B Cell Lymphoma (Pediatric)²⁷

• Initial Staging
  • Indicated
    • Neck CT, Chest CT AND Abdomen and Pelvis CT are indicated in addition to PET
• Restaging
  • Indicated
    • Neck CT, Chest CT AND Abdomen and Pelvis CT are indicated in addition to PET

NOTE: This portion of the guideline should be applied to patients treated at a pediatric institution on a pediatric protocol which can include young adults into their 20's.

Follicular lymphoma²⁶

• Initial Staging
  • Indicated
• Restaging
  • Indicated
• Surveillance
  • When a site of disease was previously visualized on a PET Scan but not conventional imaging, PET is indicated every 6 months for 2 years

Mantle cell lymphoma²⁶

• Initial Staging
  • Indicated
• Restaging
  • Indicated

Hodgkin Lymphoma (Pediatric and Adult)^30,31

• Initial Staging
  • Indicated
    • Neck CT, Chest CT AND Abdomen and Pelvis CT are indicated in addition to PET
• Restaging
  • Indicated
    • Dedicated CT scans of the original sites of disease are indicated in addition to PET
      • One repeat PET is appropriate if the end of treatment PET was positive (Deauville Score 4 – 5)

Kaposi Sarcoma³²

• Initial Staging
  • If concerns for coexisting Kaposi sarcoma-associated herpesvirus (KSHV) associated inflammatory cytokine syndrome (KICS), multicentric Castleman disease, or KSHV+ lymphoma
• Restaging
  • Not Indicated

Post-Transplant Lymphoproliferative Disease²⁶

• Initial Staging
  • Indicated
    • Brain MRI is indicated in addition to PET
• Restaging
  • Indicated

Primary Mediastinal Large B-Cell Lymphoma (Pediatric)²⁷

• Initial Staging
  • Indicated
    • Neck CT, Chest CT AND Abdomen and Pelvis CT are indicated in addition to PET
• Restaging
  • Indicated
    • Neck CT, Chest CT AND Abdomen and Pelvis CT are indicated in addition to PET

NOTE: This portion of the guideline should be applied to patients treated at a pediatric institution on a pediatric protocol which can include young adults into their 20's.
 

T Cell Lymphomas³³

• Initial Staging
  • Indicated
• Restaging
  • Indicated

NOTE: This includes the following types of T-cell lymphoma: PTCL-NOS, Enteropathy- associated T-cell lymphoma (EATL), monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL), ALCL ALK positive, ACLC ALK negative, Angioimmunoblastic T-cell lymphoma (AITL), follicular helper T-cell lymphoma, angioimmunoblastic type nodal TFH cell lymphoma, Follicular T-cell lymphoma, Breast Implant-Associated ALCL, T Cell Prolymphocytic Leukemia, T-Lymphoblastic lymphoma, Hepatosplenic T cell lymphoma, Extranodal NK/T-cell lymphoma

Waldenstrom Macroglobulinemia/Lymphoplasmacytic Lymphoma³⁴

• Initial Staging
  • NOT Indicated
• Restaging
  • NOT Indicated

Liver & Hepatobiliary Cancers
Ampullary Adenocarcinoma³⁵

• Initial Staging
  • With prior indeterminate imaging OR
  • If high-risk features are present (markedly elevated CA 19-9 or CEA, large primary tumors, large regional lymph nodes, excessive weight loss and/or extreme pain)
• Restaging
  • With prior indeterminate imaging OR
  • For pre-surgical evaluation

Biliary Tract Cancers³⁶

• • With prior indeterminate imaging
• Restaging
  • With prior indeterminate imaging

Hepatocellular Carcinoma³⁷

• Initial Staging
  • With prior indeterminate imaging
• Restaging
  • With prior indeterminate imaging

YTTRIUM-90 (Y90)
Y90 PET SCAN: Indicated when performed immediately after treatment of liver malignancy (primary or metastatic). The Y90 treatment is also the tracer for this and PET is performed within 24 hours of treatment (while Y90 is still detectible) to confirm the final distribution of the Y90. PET.

Lung Cancers
Non-Small Cell Lung Cancer³⁸

• Initial Staging
  • Indicated
    • Brain MRI is indicated in addition to PET
• Restaging
  • Indicated for ANY of the following:
    • Pre-surgical evaluation OR
      • Chest CT is indicated in addition to PET
    • Suspected or confirmed recurrence/progression OR
      • Brain MRI is indicated in addition to PET
    • Indeterminate findings on conventional imaging OR
    • End of treatment evaluation

Small Cell Lung Cancer³⁹

• • Indicated if needed to clarify extent of disease
• Restaging
  • With prior indeterminate imaging OR
  • For radiation planning

Lung Nodules
When a lung nodule is seen on low dose CT or standard Chest CT without known malignancy), PET is indicated for ANY of the following:

• If the solid component of the dominant nodule (either solitary or clearly dominant) is ≥

8 mm OR

• If there is a part solid/mixed nodule with the solid component 6 mm or larger OR
• If there is a mixed nodule (i.e., ground glass and solid nodule) with the solid

component of the nodule ≥ 4 mm on LDCT when there has been EITHER

• • Interval growth of the solid component of at least 1.5 mm OR
  • Interval development of a new mixed nodule with the solid nodule component ≥

4 mm

Neuroendocrine & Adrenal Tumors⁴⁰
Adrenocortical Carcinoma

• FDG PET
  • Adrenal (other than pheochromocytoma/paraganglioma)
    • Initial Staging:
      • Indicated when conventional imaging and biochemical evaluation are highly suggestive of adrenocortical carcinoma
    • Restaging:
      • With prior indeterminate imaging

NOTE: Features of an adrenal mass on conventional imaging that are suspicious for adrenocortical carcinoma (ACC) include: size > 4 cm, homogenous mass with irregular margins and/or local invasion. If there is no history of another primary malignancy and these features are present on imaging, then PET is reasonable. If there is a history of another primary tumor and a metastasis is suspected, biopsy should be done first to determine tissue type. A biochemical evaluation is also done to evaluate for other tumor types (such as pheochromocytoma) for which a different tracer (such as dotatate) may be more appropriate.

Paraganglioma and Pheochromocytoma

• Special Tracer SSTR (Dotatate) PET
  • Initial Staging
    • Indicated when there is a high clinical suspicion based on imaging and biochemical evaluation prior to biopsy OR
    • For biopsy proven disease
  • Restaging
    • Indicated when progression or recurrence is known or suspected (based on labs and/or conventional imaging) OR
    • SSRT directed therapy is being considered OR
    • With prior indeterminate imaging
• FDG PET
  • Initial Staging
    • If negative initial staging SSTR PET
  • Restaging
    • Prior indeterminate imaging OR
    • With bone-dominant disease OR
    • If FDG PET positive at diagnosis AND progression or recurrence is known or suspected (based on labs and/or conventional imaging)

Well-Differentiated Neuroendocrine Tumors (NET)
Special Tracer SSTR (Dotatate) PET

• Initial Staging:
  • Indicated
    • Abdomen MRI (liver) is indicated in addition to PET
• Restaging:
  • With prior indeterminate imaging OR
  • With symptoms, laboratory or imaging findings of progression OR
  • When considering SSTR-directed therapy
    • Abdomen MRI (liver) is indicated in addition to PET for all restaging indications

FDG PET

• • Indicated for high-grade well-differentiated NET AND
  • With a high Ki67 (≥ 55%) AND
  • Negative initial staging SSTR PET
    • Abdomen MRI (liver) is indicated in addition to PET
• Restaging:
  • Indicated when there is prior indeterminate imaging OR progression (see above)

AND either of the following:

• • • Recent negative SSTR PET OR
    • Prior positive FDG PET
      • Abdomen MRI (liver) is indicated in addition to PET for all restaging indications

Poorly Differentiated Neuroendocrine Tumors

• FDG PET
  • Initial Staging
    • Indicated
      • Abdomen MRI (liver) is indicated in addition to PET
• Restaging
  • With prior indeterminate imaging OR
  • With symptoms, laboratory or imaging findings of progression
    • Abdomen MRI (liver) is indicated in addition to PET for both restaging indications
• Special Tracer SSTR (Dotatate) PET
  • Initial Staging
    • NOT Indicated
  • Restaging
    • NOT Indicated

NOTE: This includes large cell neuroendocrine carcinoma of the lung, mixed neuroendocrine tumors, extra-pulmonary small cell carcinoma (i.e., primary site of disease is not in the lung). See small cell lung cancer for primary site of disease in the lung. See cervical cancer for primary site of disease in the cervix.
 

Non-Malignant Disease
Dementia^41,42,43

• Special Tracer PET
  • Amyloid PET for evaluation for mild cognitive impairment or dementia in the following situations:
    • Detection of early Alzheimer's disease OR
    • Differentiation between Alzheimer's, dementia with Lewy body disease (DLB) and frontotemporal lobal degeneration (FTD) OR
    • Assessment for the presence of beta amyloid plaque in Alzheimer’s disease

when being considered for treatments that target beta-amyloid plaque

AND ALL the following criteria are met (criteria apply to ANY of the above 3 indications):

• • • Brain MRI is insufficient or indeterminant AND
    • Objective measures demonstrate objective impairment (MMSE/MoCA < 26 or mild cognitive impairment on neuropsychological testing) AND
    • Full lab evaluation (thyroid function tests, CBC, CMP including LFTs and B12) has been completed and if abnormal, have been treated and cognitive difficulty persists AND
    • Medication side effects⁴⁴ and medical causes, such as vascular or traumatic or inflammatory etiologies have been excluded

NOTE: Brain CT is an alternative to brain MRI when MRI is contraindicated or cannot be performed for detection and differentiation but NOT for treatment planning as MRI is a prerequisite to beta-amyloid targeted treatment

Sarcoidosis

• Known sarcoidosis:
  • ONLY if conventional testing (CXR, CT and inflammatory serology) are indeterminate for known sarcoid to determine:
    • If treatment might be helpful OR
    • Extent of disease, if it will potentially change management OR
    • Response to treatment
• Suspected sarcoidosis:
  • To determine most suitable site to biopsy

Vasculitis

• In limited circumstances for patients with known vasculitis, PET is indicated after conventional imaging (MRA/CTA/MR/CT) is insufficient to determine treatment

Other Malignancies
Castleman's Disease²⁶

• Initial Staging
  • Indicated
• Restaging
  • Indicated

Histiocytic Neoplasms⁴⁵

• Langerhan's cell histiocytosis, Erdheim Chester disease, Rosai-Dorfman disease
  • Initial Staging
    • Indicated
• Restaging
  • Indicated
• Surveillance
  • Every 3 – 6 months for 2 years then annually

Melanoma: Uveal⁴⁶

• Initial Staging
  • NOT indicated
• Restaging
  • NOT indicated

Merkel Cell Carcinoma⁴⁷

• Initial Staging
  • Indicated
• Restaging
  • Indicated

Mesothelioma: Peritoneal⁴⁸

• Initial Staging
  • Indicated
• Restaging
  • Indicated

Mesothelioma: Pleural⁴⁹

• Initial Staging
  • Indicated
    • Chest CT is indicated in addition to PET
• Restaging
  • Indicated
    • Chest CT is indicated in addition to PET

NOTE: The evaluation of recurrent pleural effusion and/or pleural thickening includes CT chest, thoracentesis and pleural biopsy. The diagnostic sensitivity of this investigation is 70% – 75%. If the first biopsy is non-diagnostic, there is a higher chance that subsequent biopsies will be non-diagnostic, thus a PET to guide subsequent biopsy is reasonable in this situation.

Neuroblastoma⁵⁰

• • • Due to the complexity of these tumors and the young age of patients, multiple overlapping imaging studies and modalities are often necessary in addition to PET.
    • Neuroblastoma tumors often encase vasculature, vascular imaging is appropriate if requested in addition to standard cross-sectional imaging and PET.
• Surveillance
  • If PET is used for functional imaging evaluation in place of MIBG during treatment, surveillance PET is appropriate every 3 – 6 months for 1 year, then every 6 months for 1 year, then annually
    • Due to the complexity of these tumors and the young age of patients, multiple overlapping imaging studies and modalities are often necessary in addition to PET.

NOTE: Functional imaging with Iodine 123 (123I-MIBG) is routinely used as the standard functional imaging modality in this disease given the high specificity and sensitivity to identify metastatic disease.

Occult Primary⁵¹

• Initial Staging
  • With prior indeterminate imaging
• Restaging
  • With prior indeterminate imaging

NOTE: The typical evaluation for a suspected metastatic malignancy with an unknown primary includes CT of the Chest, Abdomen and Pelvis AND a biopsy of the site of disease.

Post Transplant Lymphoproliferative Disorder (PTLD)²⁶

• Initial Staging
  • Indicated when the diagnosis is made OR
  • If suspected based on abnormal physical exam, abnormal imaging or abnormal labs (i.e., significantly elevated or rising viral titers)
• Restaging
  • Indicated

Thymomas & Thymic Carcinomas⁵²

• • Indicated
• Restaging:
  • Indicated

Thyroid Carcinoma⁵³
Papillary, Follicular, Oncocytic and Poorly Differentiated:

• Initial Staging:
  • NOT Indicated
• Restaging Following Total/Completion Thyroidectomy and/or Radioiodine Ablation (RAI) for ANY of the following:
  • With known or suspected metastases (based on laboratory or imaging findings)

AND I-123/131 is negative OR

• • With rising or new Tg Antibody OR
  • Oncocytic thyroid cancer following thyroidectomy if ANY of the following are present:
    • Tumor > 2 cm
    • ≥ 1 focus of vascular invasion
    • Any positive lymph node (≥ cN1)
    • Gross extension outside thyroid
    • Positive margin
    • Postop Tg ≥ 1 ng/mL
• Recurrence:
  • Indicated when recurrence is suspected based on laboratory or imaging findings AND
• • I-123/131 is negative (or was previously negative in the setting of known disease)

Anaplastic or De-Differentiated:

• Initial Staging:
  • Indicated
• Restaging:
  • Indicated

Medullary:

• • • Indicated
  • Restaging:
    • Indicated when tumor markers (calcitonin and/or CEA) are rising AND

conventional imaging is negative

• • Recurrence:
    • Indicated when tumor markers (calcitonin and/or CEA) are rising AND

conventional imaging is negative

• FDG PET
  • Initial Staging:
    • NOT indicated
  • Restaging:
    • NOT indicated

Wilms Tumor⁵⁴

• Initial Staging:
  • With prior indeterminate imaging
• Restaging:
  • With prior indeterminate imaging

YTTRIUM-90 (Y90)
Y90 PET SCAN: Indicated when performed immediately after treatment of liver malignancy (primary or metastatic). The Y90 treatment is also the tracer for this and PET is performed within 24 hours of treatment (while Y90 is still detectible) to confirm the final distribution of the Y90 PET.

Pancreatic Cancer⁵⁵

• • • Very symptomatic (jaundice, symptomatic gastric outlet obstruction, venous thromboembolism, extreme pain and excessive weight loss)
• Restaging
  • With prior indeterminate imaging OR
  • For pre-surgical evaluation

Plasma Cell Dyscrasias
MGUS (56)

• Initial Staging
  • NOT Indicated
• Restaging
  • NOT Indicated

NOTE: Whole Body Low Dose CT is used rather than PET - see CG_063 (Unlisted Study) under Unlisted CT

Multiple Myeloma56

• Initial Staging:
  • Indicated
• Restaging on Active Treatment (including following Bone Marrow Transplant (BMT) or CAR-T treatment):
  • Indicated

NOTE: For individuals receiving Bone Marrow Transplant (BMT) or CAR-T treatment PET is indicated prior to treatment and at 1 month, 3 months AND 6 months post-treatment

• Surveillance: Indicated annually (indefinitely)

Smoldering Myeloma⁵⁶

• Initial Staging:
  • Indicated
• Restaging:
  • Indicated when there are symptoms and/or laboratory findings to suggest progression

Solitary Plasmacytoma⁵⁶

• Initial Staging:
  • Indicated
• Restaging:
  • Indicated
• Surveillance:
  • When initial staging or restaging on treatment was with PET, PET is indicated during surveillance at the following intervals:
    • 3 months after completion of treatment then
    • Annually up to 5 years

Systemic Light Chain Amyloidosis⁵⁷

• Initial Staging:
  • Indicated
• Restaging:
  • Indicated

Skin Cancers
Basal Cell Skin Cancer⁵⁸

• Initial Staging
  • NOT Indicated
• Restaging
  • NOT Indicated

Melanoma: Cutaneous⁵⁹

• Surveillance
  • For select patients with primary disease in the extremities OR previous disease only able to be seen on PET, surveillance imaging is indicated in place of CT scans every 3 – 12 months for 2 years, then every 6 – 12 months for 3 years

Squamous Cell Skin Cancer⁶⁰

• Initial Staging
  • Indicated when lymph node or metastatic site has been biopsied and shows disease spread
• Restaging
  • Indicated when lymph node or metastatic site has been biopsied and shows disease spread

Rationale
BACKGROUND

Definitions

• • Imaging is typically performed 6 – 12 weeks after surgery
  • Imaging is typically performed 12 weeks after radiation (to avoid false positive findings that can be caused by treatment changes or healing).
    • PET/CT can be performed 1 – 3 weeks after neoadjuvant chemotherapy or neoadjuvant chemoradiation if done for presurgical planning to evaluate for distant metastatic disease or to evaluate known metastatic disease located in areas separate from the site(s) being radiated.
  • When an end of treatment PET scan performed at an appropriate post-treatment interval (see above) shows indeterminate findings, one additional repeat PET in 3 months is indicated.
  • Common exceptions are noted in the guideline. If not noted in the guideline, a valid clinical reason explaining why the interval needs to be shorter is needed.
• TREATMENT includes chemotherapy, immunotherapy, radiation, as well as patients on “maintenance therapy” who have known, or existing, metastatic disease being controlled by this treatment. Allogenic bone marrow transplant and CART T-cell therapy should be considered ‘active’ treatment for at least 6 months after infusion/transplant and as such can be approved at 30 days, 100 days, and 6 months after the most recent infusion.
• INDETERMINATE IMAGING:
  • When indeterminate imaging is required prior to PET, this typically means conventional imaging (CT, MRI, OR Nuclear Medicine Scan (i.e. bone scan)) shows a finding that is indeterminate AND clarification of that finding with PET will potentially change management.
  • The information provided should clearly explain why conventional imaging is insufficient to determine treatment or management.
  • Biopsy guidance:
    • To determine the best location to biopsy either within a tumor that has necrosis on imaging OR
    • To determine the best location to biopsy when there are findings on standard imaging that would require a significantly invasive procedure (such as laparoscopic or open surgical procedures) AND malignancy is highly suspected based on imaging.
  • When previous conventional imaging has been shown to be negative, yet a concurrent PET scan was positive (i.e., conventional imaging was falsely negative/ missed lesions seen on PET), we do not require repeat conventional imaging prior to every subsequent PET because conventional imaging was already shown to be insufficient. Appropriate interval criteria should still be met.

Further Information
PET with CONTRAINDICATIONS to contrasted CT AND MRI: The inability to image with contrasted conventional imaging includes contraindications to both CT (such as chronic renal failure with GFR < 30 OR significant iodinated contrast allergy) AND to MRI (such as gadolinium allergy, implanted device that is not MRI compatible, or GFR < 40). When requested for surveillance due to the above reasons, PET can be considered during the time that the highest risk of recurrence for that cancer (typically the first two years after completion of treatment).

PET/MR: When PET/MR can be considered per the guideline, if the criteria are met for PET for that cancer and the plan is to do a PET/MR rather than a PET/CT, the PET scan can be approved. In the same way a separate approval for total body CT is not needed when a PET/CT is requested, a separate approval for the total body MR is not typically needed.

However, until a PET/MR CPT code is implemented, unlisted MR in addition to PET can be considered on a case-to-case basis.
 

References

59. NCCN. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Melanoma: Cutaneous Version 2.2024. National Comprehensive Cancer Network®. 2024.
60. NCCN. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) —Squamous Cell Skin Cancer Version 1.2024. National Comprehensive Cancer Network®. 2023.
61. Washington State Health Care Authority. Health Technology Clinical Committee Findings and Decision for Positron Emission Tomography (PET) Scans for Lymphoma. Washington State Health Care Authority. 2019 [January 18].
62. State of Arkansas. HB1357 - TO CONTINUE CARE FOR THE PROTECTION OF CANCER SURVIVORS. Arkansas State Legislature 93rd General Assembly. 2021.

Coding Section

Codes	Number	Description
CPT	78811	Positron emission tomography (pet) imaging; limited area (eg, chest, head/neck)
	78812	Positron emission tomography (pet) imaging; skull base to mid-thigh
	78813	Positron emission tomography (pet) imaging; whole body
	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
Type of Service
Place of Service

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.  

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

11/05/2024	Annual review, policy updated for clarity and consistency, grouping similar cancer types together, revised indeterminate imaging and contraindications to conventional imaging, adding the use of Amyloid PET for early Alzheimer’s updating surveillance PET, updating multiple different cancers to be consistent with national guidelines. Also updating rationale and references.
06/03/2024	Corrected formatting issue. No other changes made.
11/07/2023	Annual review, updating title to include PET, PET with CT Attenuation and PET/CT. Multiple updates made throughout the policy related to criteria for different diagnoses. Entire policy updated for clarity and consistency.
11/17/2022	Annual review, adding note for lung nodule and updating surveillance criteria for clarity and specificity.
11/01/2021	Annual review, adding statements regarding CAR-T therapy and medical necessity criteria for PTLD. Also updating description and references.
01/26/2021	Updating annual review date.
11/17/2020	Annual review with major format revision to a table format. Also multiple policy revisions related to NCCN recommendation changes. Updating description and references.
02/13/2020	Annual review, no change to policy intent. Updating rationale and references.
02/07/2019	Major revision of content for clarity without change to policy intent.
04/10/2018	Interim review to add medical necessity verbiage for Axumin (fluciclovine F 18) and a statement directing readers to CAM 512 as it relates to reimbursement for radiopharmaceuticals related to PET scanning.
03/15/2018	Annual review, policy revised to indicate the following: "Additional details added to policy statements. Updated guidelines, rationale and references
02/06/2017	Annual review, no change to policy intent.
02/17/2016	Annual review, no change to policy intent.
03/05/2015	Annual review, added verbiage related to medical necessity related to gastric cancer, added related policies and coding. Updated guidelines, rationale and references.
09/11/2014	Corrected typo error. No change in policy.
02/24/2014	Annual review.  Updated rationale and references. Changing policy verbiage to indicate initial treatment strategy for breast cancer & melanoma is investigational.