Policy
General Notes:   
ADULT AND PEDIATRIC MALIGNANCIES¹: 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 FOR FDG PET:

The following list applies to biopsy-proven cancers AND lung nodules with no known history of malignancy. This is NOT a comprehensive list. Additional indications for PET are found in the tables following this list. The definitions regarding initial staging and restaging (including time interval following treatment**) apply.

• Solid lung nodule > 8 mm and no prior PET – Indicated
• Mixed lung nodule* with solid component > 6 mm and no prior PET — Indicated
• Basal cell carcinoma of the skin — Not indicated for initial staging or restaging
• Castleman’s Disease — Indicated for initial staging and restaging
• Cervical Cancer (stage IB1 or higher) — Indicated for initial staging and restaging**
• Chondrosarcoma — Not indicated for initial staging or restaging
• Ewing’s Sarcoma* — Indicated for staging (all ages) and restaging age < 30
• Head and Neck Cancer — Indicated for initial staging and restaging**
• Non-Small Cell Lung Cancer — Indicated for initial staging and restaging
• Lymphoma (Hodgkin’s and non-Hodgkins) — Indicated for initial staging and restaging
• Melanoma* — Cutaneous (stage III, IV) — Indicated for initial staging and restaging
• Merkel Cell — Indicated for initial staging and restaging
• Osteosarcoma* — Indicated for initial staging (all ages) and restaging age < 30
• Peritoneal Mesothelioma — Indicated for initial staging and restaging
• Post Transplant Lymphoproliferative Disorder (PTLD) — Indicated for initial staging and restaging
• Renal — Not indicated for initial staging or restaging
• Rhabdomyosarcoma (RMS) — Indicated for initial staging and restaging
• Small bowel carcinoma* — Not indicated for initial staging
• Soft Tissue Sarcoma* (other than RMS) — Indicated for initial staging (age < 30) and restaging (age < 30)
• Testicular Cancer — Seminoma* — Not indicated for initial staging
• Testicular Cancer — Non-Seminoma — Not indicated for initial staging or restaging
• Thymoma/Thymic Cancer — Indicated for initial staging and restaging

*See additional indications in table below
**If radiation or chemoradiation were given, 12 weeks must have elapsed since last radiation treatment. See table below for additional indications if < 12 weeks.

INDICATIONS FOR SPECIAL TRACER PET:
The following list applies to for biopsy-proven cancers for which a non-FDG tracer (special tracer) is indicated in the specific clinical scenarios described. This is NOT a comprehensive list. Additional indications for non-FDG PET are found in the tables following this list. The definitions regarding initial staging and restaging (including time interval following treatment**) apply. Diagnosis needs to be confirmed by biopsy and tracer planned clearly indicated.

• Prostate Cancer* – PSMA PET Indicated for initial staging ONLY of non-metastatic² Gleason 8, 9, 10 disease (or grade group 3, 4 or 5 disease)
• Carcinoid, Well-differentiated Neuroendocrine tumors, pheochromocytoma and paraganglioma* – SSTR PET (such as Ga68-Dotatate, Ga68-Dotattoc and Cu64-Dotatate) Indicated for initial staging ONLY

FDG-PET/CT (fluorodeoxyglucose-positron emission tomography)
LUNG NODULE3 seen on LDCT or CT+ contrast (without known malignancy)

• • Solid Component of Dominant Nodule (either solitary or clearly dominant) ≥ 8mm OR
• • Part solid/mixed nodules with the solid component 6 mm or larger OR
  • Mixed nodule (i.e., ground glass and solid nodule) with solid component of the nodule ≥ 4mm on LDCT when there has been
• • • Interval growth of the solid component of at least 1.5 mm on subsequent LDCT scans OR
    • Interval development of a new mixed nodule on subsequent LDCT with the solid nodule component ≥ 4mm

                                                                        FDG PET

PSMA TRACERS (such as F18 piflufolastat [Pylarify^®], GA 68 PSMA-11, GA 68 gozetotide [Locametz^®], and GA 68 gozetotide [Illuccix^®])

For PROSTATE CANCER^{2, 58}

BACKGROUND  
USEFUL DEFINITIONS: The cancer specific details for adjudication still apply.

• • For restaging or monitoring response during active treatment (including immunotherapy), and/or a single evaluation after completion/cessation of therapy. The interval should ideally^‡ be 6 – 12 weeks after surgery, and 12 weeks after radiation (to avoid false positive findings that can be caused by treatment changes or healing).
    • ‡NOTE: a valid clinical reason explaining why the interval needs to be shorter than ideal must be present
  • 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.

• • Ewing’s Sarcoma and Osteosarcoma in patients specified as high risk: every 3 months for 2 years, then every 4 months up to year 3 post completion of treatment.
  • Small Cell Neuroendocrine Cervical every 3-6 months for the first 2 years post completion of treatment
  • Diffuse Large B Cell Lymphoma when disease was only seen previously on PET: every 6 months for 2 years, then one at 12 months up to year 3 post completion of treatment.
  • Gestational trophoblastic disease when hCG is not a reliable marker every 6 – 12 months for up to 3 years post completion of treatment
  • Histiocytic neoplasms every 3-6 months for the first 2 years post completion of treatment
  • Melanoma (stage 2b-4) specified as high risk every 3 – 12 months for 2 years, then every 6 – 12 months, up to 5 years after initial diagnosis^{33, 61}
  • Solitary plasmacytoma (up to 3 yrs after the diagnosis of plasmacytoma)^{62, 63}

PET with CONTRAINDICATIONS to contrasted CT AND MRI:
When PET is requested for restaging due to the inability to image with contrasted conventional imaging, indeterminate non-contrasted studies must be provided prior to consideration of PET. 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.

PET IN COMBINATION WITH DEDICATED SITE SPECIFIC MR (OR CT): Distinct from PET/MR,
when PET is needed in addition to a dedicated site specific MRI (or CT), two authorizations may be issued: one for the PET scan and one for the site specific MRI (or CT). Clear indications for both must be provided.

STAGING: Staging for cancer is cancer-specific and is typically based on the TNM system of staging. T stage refers to the extent of the main (primary) tumor. N stage refers to the extent of spread to lymph nodes. M stage refers to whether or not the cancer has metastasized to other parts of the body. Clinical stage (such as cT2b) is determined by physical exam, imaging and possibly biopsy. Pathologic stage (such as pT2b) is determined after the tumor has been resected. Certain cancers have additional information that is needed to stage the patient (such as PSA level in prostate cancer).

CANCER SPECIFIC BACKGROUND:
Adrenal Tumors: Features of an adrenal mass on conventional imaging that are suspicious for adrenocortical carcinoma (ACC) include: size > 4 cm, inhomogenous mass with irregular margins and/or has 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.

Anal Cancer: 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.
Brain Tumors: When an oncologic PET is requested for a primary brain malignancy, it typically should be reordered as a Brain PET (CPT 78608 and 78609). This includes requests for recurrent meningioma when dotatate PET is requested.

Breast Cancer: Fluoroestradiol F 18 (Cerianna^® or FES) is a new tracer that is specific for estrogen receptor positive (ER-positive) breast cancer. It is used in recurrent or metastatic breast cancer that was known to be ER-positive at initial diagnosis to determine how much of the current disease has functional estrogen receptors. This can help determine whether endocrine therapy is appropriate. This tracer is NOT indicated for ER-negative disease. An FES PET is NOT done to monitor response to treatment but instead is done ONLY when the receptor status of the recurrent or metastatic sites is in question. FES PET is NOT used for assessing the primary site of disease.

Langerhans Cell Histiocytosis is the most common type of histiocytosis, with variable presentations and sites involvement. Some studies suggest PET/CT may be more effective in detecting bone lesions compared with MRI and bone scans in assessing disease response as healing/treatment changes of bone lesions on conventional imaging may be delayed. However, PET/CT is not the modality of choice in assessing disease response of lung or brain lesions.

Lung Cancer – Small Cell: Initial Staging is classified as Limited Stage (LS) and Extensive Stage (ES). In limited stage disease, the disease burden is localized to the chest (Any T, Any N, M0) AND able to be encompassed in a tolerable radiation plan. Patients with disease OUTSIDE of the chest (M1) or T3-4 due to multiple lung nodules that are too extensive or have tumor/nodal volume that is too large to be encompassed in a tolerable radiation plan are classified as extensive stage. When a patient cannot clearly be classified as ES but there are findings on imaging suggestive of disease (typically extra-thoracic findings such as a liver lesion), then PET may be used to help classify the extent of disease as ES or LS. If conventional imaging clearly shows ES disease, then PET is not indicated. Restaging: When radiation is planned (either for LS disease OR for ES disease that has responded to treatment), PET is indicated to determine radiation fields. Otherwise, disease reassessment/response to therapy is with conventional imaging⁶⁴.

Melanoma: Local satellite/in-transit recurrences are in the deep dermis or subcutaneous fat within or adjacent to the melanoma scar. They are recurrences that occur after an initial adequate wide excision, likely represent dermal lymphatic disease and do need imaging at diagnosis. Persistent disease, by contrast, is disease remaining in the melanoma scar after an initial resection (likely due to inadequate resection) and imaging would only be indicated if stage III or IV disease is present³³.
Mesothelioma^36,65: 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.

Multiple Myeloma: Making the diagnosis of myeloma is complex and may include bone marrow biopsy, cytometry, imaging etc. However, once the diagnosis of myeloma (multiple myeloma or plasmacytoma) is confirmed, PET may be considered.

Neuroendocrine Tumors (NET)57: a Somatostatin Receptor (SSTR) analog PET (commonly dotatate) is indicated at initial diagnosis to evaluate for metastatic disease. If a moderately invasive procedure is needed to confirm the diagnosis (i.e., open surgery), PET prior to this open biopsy may be reasonable when the clinical picture, labs and imaging are consistent with a NET. Restaging can be done with conventional imaging (CT/MRI). However, if progression is seen and/or SSTR directed therapy is being considered, then SSTR-PET is indicated. Because liver lesions are often not well imaged on SSTR-PET, a dedicated liver MRI at the time of SSTR-PET may be indicated if there are known or suspected liver metastases.

FDG PET may be more useful when a NET is metabolically active, such as in poorly differentiated NET and well differentiated grade 3 NET with a high Ki67 (≥ 55%). For poorly differentiated NET, indeterminate conventional imaging is needed prior to FDG PET. For well-differentiated grade 3 NET with a high Ki-67 (≥ 55%), a negative dotatate PET is required before an FDG PET can be considered.

Neurofibromatosis type 1 (NF1): Surveillance of lesions is completed with MRI (often whole body MRI.) Approximately 5% of patients with neurofibromatosis are thought to develop soft tissue sarcomas, most commonly malignant peripheral nerve sheath tumors (MPNSTs), a type of sarcoma. Risk factors for MPNST transformation include: whole NF1 gene deletion, family history of MPNST, prior radiation therapy, large plexiform neurofibroma burden or multiple distinct nodular lesions on magnetic resonance imagining (MRI), neurofibromatous neuropathy, and atypical neurofibroma(s). Once a PET has been done and was negative, rapid growth on conventional imaging and plan for biopsy need to be provided prior to consideration of another PET.

Occult Primary: The typical evaluation for a suspected metastatic malignancy includes a thorough physical exam, laboratory evaluation, CT of the Chest, Abdomen and Pelvis AND a biopsy of the site of disease. The biopsy results then indicate either a clear primary for which the relevant guideline is applied or an epithelial cancer (not site specific). Epithelial cancers are further classified as adenocarcinoma, carcinoma not specified, squamous cell carcinoma (SCC) or neuroendocrine carcinoma (see NET in guideline). If the primary is still not identified, further guidance is often complex and based on the site of disease identified.

Pheochromocytoma and Paraganglioma: Hypertension, tachycardia, sweating and syncope are typical symptoms. Biochemical workup includes catecholamines (such as metanephrines, normetanephrine, and/or dopamine). Elevations in catecholamines that are greater than two times above the upper limit of normal are usually present. Biopsy of a pheochromocytoma and paraganglioma that is biochemically active is contraindicated. Thus, when the clinical picture AND labs is consistent with pheochromocytoma/paraganglioma, the SSTR-PET can be approved without biopsy confirmation. However, if the catecholamines are not elevated (as above), in the setting of clinical concern and a mass, biopsy is required.

Prostate Cancer Initial Staging: PSMA is the only approvable tracer for initial staging. Risk groups are determined by the Gleason Score (on pathology report), PSA, clinical stage (by exam (digital rectal exam (DRE) and/or imaging such as pelvis MRI). This information may also be expressed as a grade group. The three risk groups for which PSMA PET is indicated are: very high risk, high risk and unfavorable intermediate risk. Any of the following criteria place the patient into one of these risk groups and PSMA PET may be approved for initial staging:

• Gleason score 8, 9 or 10
• Primary pattern 4 (Gleason 4 + 3 = 7)
• PSA > 20 AND Gleason score 3 + 3 = 6 or higher
• PSA > 10 AND Gleason score 3 + 4 = 7
• PSA > 10 AND Gleason score 3 + 3 = 6 AND clinical stage ≥ T2b
• Clinical stage ≥ T3a AND Gleason score 3 + 3 = 6 or higher
• Clinical stage ≥ T2b AND Gleason score 3 + 4 = 7 or higher
• ≥ 50% of cores positive for cancer in a random, non-targeted prostate biopsy
• Grade group 3, 4 or 5 disease

When active surveillance was selected as the initial plan of care, PSMA PET is indicated when the disease progresses to very high risk, high risk or unfavorable intermediate risk using the most recent Gleason score/biopsy result, clinical stage and PSA level.
 
A biopsy typically needs to be done confirming the diagnosis of prostate cancer prior to PSMA PET. If the PSA is > 50, when there is no clinical concern for infection nor has there been recent instrumentation AND there is an intent to treat the patient for prostate cancer without biopsy confirmation, PSMA PET can be considered. Situations where this may be reasonable are when the biopsy poses significant risk (i.e., anticoagulation or significant comorbidity) OR if treatment is urgently needed (such as spinal cord compromise from metastases)66.

Patients who are metastatic at diagnosis (no prior treatment) are staged with conventional imaging². PSMA PET can be considered if there are indeterminate findings on conventional imaging and specific details regarding how clarification of these findings with PSMA PET would change treatment are provided.

Prostate Cancer Restaging: PSMA is the preferred tracer for restaging of prostate cancer due to the increased sensitivity and specificity for detection of disease. There may be situations where Axumin or Choline are approvable tracers such as for detection of inconclusive findings on bone scan, when prior PET scans have used that tracer and direct comparison is needed or if PSMA is not available. For both Axumin and Choline, inconclusive conventional imaging is required and the reason that tracer is being requested instead of PSMA needs to be provided. When a PSMA PET has failed to detect a site of recurrence (i.e., PSMA PET was negative previously yet PSA continues to rise), a repeat PSMA PET may be approved as early as 6 months if the PSA doubling time is < 12 months.

Thyroid Cancer: Thyroid cancer can be grouped into three main histologic subtypes: Differentiated (including papillary, follicular, and oncocytic), Anaplastic and Medullary.

Differentiated thyroid cancer: As iodine is taken up by differentiated thyroid cancers, an iodine scan (I-123 and/or I-131) is often the first line imaging modality (in addition to ultrasound).

When there is a discordance between the tumor marker (thyroglobulin or thyroglobulin antibody) and imaging (I-123 or I-131 scan) AND the thyroid tissue has been removed (total or completion thyroidectomy) or ablated, this indicates that the tumor may have de-differentiated and FDG PET is indicated. After therapy with I-131 it can take several months for Tg to disappear from the circulation, so an early elevated level does not necessarily indicate a recurrence/persistence of the cancer. For papillary, follicular and oncocytic thyroid cancer, FDG PET can be approved for the following:

• A total (or completion) thyroidectomy OR radioiodine iodine has been completed; AND
• Serum thyroglobulin (Tg) is > 2 ng/ml (unstimulated or stimulated) OR there is a high anti-thyroglobulin antibody (anti-Tg Ab) > 1 year after treatment AND
• A Negative current I-123 (or I-131) scan OR a Negative prior stimulated whole body I- 123 (or I-131) scan done at Tg level similar to the current Tg level (a current scan is needed if on radioiodine sensitizing medications)

Anaplastic thyroid cancers are aggressive and imaging with FDG PET is appropriate.
 
Medullary thyroid cancers arise from the neuroendocrine parafollicular C cells of the thyroid and are not iodine-avid. Staging with SSTR PET is indicated for initial staging when indeterminate imaging is provided. For restaging, when calcitonin level is ≥ 150 pg/ml or CEA levels > 5 ng/ml post-surgery AND indeterminate imaging (including negative CT/MRI with elevated calcitonin and/or CEA) is provided, PET is indicated. Typically the tracer for restaging is SSTR (dotatate), however, there may be situations where an FDG PET is reasonable.
 

References

1. NCCN Imaging Appropriate Use Criteria™. National Comprehensive Cancer Network (NCCN). Accessed January 31, 2023. https://www.nccn.org/professionals/imaging/default.aspx
2. W. L, R. D, D.F. J, al. e. Updates to advanced prostate cancer: AUA/SUO guideline (2023). Journal of Urology. 2023;209(6)doi:10.1097/JU.0000000000003452
3. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Non-Small Cell Lung Cancer Version 3.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated April 13, 2023. Accessed April 23, 2023. https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf
4. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Neuroendocrine and Adrenal Tumors Version 2.2022. National Comprehensive Cancer Network®. May 8, 2023. Updated December 21, 2022. Accessed April 12, 2023. https://www.nccn.org/professionals/physician_gls/pdf/neuroendocrine.pdf
5. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Kaposi Sarcoma Version 1.2023. National Comprehensive Cancer Network®. Updated December 20, 2022. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/kaposi.pdf
6. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Pediatric Acute Lymphoblastic Leukemia Version 2.2023. National Comprehensive Cancer Network®. Updated March 10, 2023. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/ped_all.pdf
7. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Acute Lymphoblastic Leukemia Version 1.2022. National Comprehensive Cancer Network®. May 8, 2023. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/all.pdf
8. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Acute Myeloid Leukemia Version 3.2023. National Comprehensive Cancer Network®. May 8, 2023. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/aml.pdf
9. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Anal Carcinoma Version 2.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated April 18, 2023. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/anal.pdf
10. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Basal Cell Skin Cancer Version 1.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated March 10, 2023. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/nmsc.pdf
11. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Biliary Tract Cancers Version 1.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated March 10, 2023. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/btc.pdf
12. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Bladder Cancer Version 2.2023. National Comprehensive Cancer Network®. May 8, 2023. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/bladder.pdf
13. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Bone Cancer Version 3.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated April 4, 2023. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/bone.pdf
14. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Breast Cancer Version 4.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated March 23, 2023. Accessed April 14, 2023 https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf
15. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Cervical Cancer Version 1.2023. National Comprehensive Cancer Network®. May 8, 2023. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/cervical.pdf
16. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Colon Cancer Version 2.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated April 25, 2023. Accessed April 12, 2023. https://www.nccn.org/professionals/physician_gls/pdf/colon.pdf
17. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Rectal Cancer Version 2.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated April 25, 2023. Accessed May 8, 2023. https://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf
18. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Uterine Neoplasms Version 2.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated April 28, 2023. Accessed April 2023, 2023. https://www.nccn.org/professionals/physician_gls/pdf/uterine.pdf
19. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Esophageal and Esophagogastric Junction Cancers Version 2.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated March 10, 2023. Accessed April 12, 2023. https://www.nccn.org/professionals/physician_gls/pdf/esophageal.pdf
20. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Gastric Cancer Version 1.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated March 10, 2023. Accessed April 12, 2023. https://www.nccn.org/professionals/physician_gls/pdf/gastric.pdf
21. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Gestational Trophoblastic Neoplasia Version 1.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated December 20, 2022. Accessed April 18, 2023 https://www.nccn.org/professionals/physician_gls/pdf/gtn.pdf
22. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Gastrointestinal Stromal Tumors Version 1.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated March 13, 2023. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/gist.pdf
23. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Head and Neck Cancers Version 1.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated December 20, 2022. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf
24. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Hepatocellular Carcinoma Version 1.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated March 10, 2023. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/hcc.pdf
25. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Non- Small Cell Lung Cancer Version 3.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated April 13, 2023. Accessed April 11, 2023. https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf
26. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma Version 2.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated January 25, 2023. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/cll.pdf
27. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) T-Cell Lymphomas Version 1.2023. May 8, 2023. Updated January 5, 2023. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/t-cell.pdf
28. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Primary Cutaneous Lymphomas Version 1.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated January 5, 2023. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/primary_cutaneous.pdf
29. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Pediatric Hodgkin Lymphoma Version 2.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated March 9, 2023. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/ped_hodgkin.pdf
30. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Pediatric Aggressive Mature B-Cell Lymphomas Version 1.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated April 4, 2023. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/ped_b-cell.pdf
31. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Hodgkin Lymphoma Version 2.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated November 8, 2022. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/hodgkins.pdf
32. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) B-Cell Lymphomas Version 2.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated February 8, 2023. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/b-cell.pdfNational
33. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Melanoma: Cutaneous Version 2.2023. National Comprehensive Cancer Network®. May 8,2023. Updated March 10, 2023. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/cutaneous_melanoma.pdf
34. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Melanoma: Uveal Version 1.2023. National Comprehensive Cancer Network®. May 10, 2023. Updated May 4, 2023. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/uveal.pdf
35. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Merkel Cell Carcinoma Version 1.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated April 10, 2023. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/mcc.pdf
36. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Mesothelioma: Pleural Version 1.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated December 15, 2022. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/meso_pleural.pdf
37. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Mesothelioma: Peritoneal Version 1.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated December 15, 2023. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/meso_peritoneal.pdf
38. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Multiple Myeloma Version 3.2023. National Comprehensive Cancer Network®. May 8, 2023. Updated December 8, 2022. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/myeloma.pdf
39. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Neuroendocrine and Adrenal Tumors Version 2.2022. National Comprehensive Cancer Network®. May 8, 2023. Updated December 21, 2022. Accessed April 18, 2023 https://www.nccn.org/professionals/physician_gls/pdf/neuroendocrine.pdf
40. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer Version 1.2023. National Comprehensive Cancer Network®. May 9, 2023. Updated December 22, 2022. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/ovarian.pdf
41. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Occult Primary (Cancer of Unknown Primary [CUP]) Version 3.2023. National Comprehensive Cancer Network®. May 9, 2023. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/occult.pdf
42. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Penile Cancer Version 1.2023. National Comprehensive Cancer Network®. May 9, 2023. Updated December 1, 2022. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/penile.pdf
43. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Kidney Cancer Version 4.2023. National Comprehensive Cancer Network®. May 9, 2023. Updated January 18, 2023. Accessed April 11, 2023. https://www.nccn.org/professionals/physician_gls/pdf/kidney.pdf
44. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Squamous Cell Skin Cancer Version 1.2023 National Comprehensive Cancer Network®. May 9, 2023. Updated March 10, 2023. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/squamous.pdf
45. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Small Bowel Adenocarcinoma Version 1.2023. National Comprehensive Cancer Network®. May 9, 2023. Updated January 9, 2023. Accessed Arpil 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/small_bowel.pdf
46. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Soft Tissue Sarcoma Version 2.2023. National Comprehensive Cancer Network®. May 9, 2023. Updated April 25, 2023. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/sarcoma.pdf
47. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Testicular Cancer Version 1.2023. National Comprehensive Cancer Network®. May 9, 2023. Updated January 26, 2023. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/testicular.pdf
48. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Thymomas and Thymic Carcinomas Version 1.2023. National Comprehensive Cancer Network®. May 9, 2023. Updated December 15, 2022. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/thymic.pdf
49. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Thyroid Carcinoma Version 1.2023. National Comprehensive Cancer Network®. May 9, 2023. Updated March 24, 2023. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/thyroid.pdf
50. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Uterine Neoplasms Version 2.2023. National Comprehensive Cancer Network®. May 9, 2023. Updated April 28. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/uterine.pdf
51. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Vulvar Cancer Version 1.2023. National Comprehensive Cancer Network®. May 9, 2023. Updated December 22, 2022. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/vulvar.pdf
52. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Histiocytic Neoplasms Version 1.2022. National Comprehensive Cancer Network®. May 9, 2023. Updated May 20, 2022. Accessed April 13, 2023. https://www.nccn.org/professionals/physician_gls/pdf/histiocytic_neoplasms.pdf
53. Reilly KM, Kim A, Blakely J, et al. Neurofibromatosis Type 1-Associated MPNST State of the Science: Outlining a Research Agenda for the Future. J Natl Cancer Inst. Aug 1 2017;109(8)doi:10.1093/jnci/djx124
54. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Central Nervous System Cancers Version 1.2023. National Comprehensive Cancer Network®. May 9, 2023. Updated March 24, 2023. Accessed April 14, 2023. https://www.nccn.org/professionals/physician_gls/pdf/cns.pdf
55. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Soft Tissue Sarcoma Version 2.2023. National Comprehensive Cancer Network®. May 9, 2023. Updated April 25, 2023. Accessed April 14, 2023. https://www.nccn.org/professionals/physician_gls/pdf/sarcoma.pdf
56. Chinnery PF. Neuroferritinopathy. In: M.P. A, M. MG, R.A. P, al. e, eds. GeneReviews®. University of Washington, Seattle; 2005.
57. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Neuroendocrine and Adrenal Tumors Version 2.2022. National Comprehensive Cancer Network®. May 9, 2023. Updated December 21, 2022. Accessed April 18, 2023. https://www.nccn.org/professionals/physician_gls/pdf/neuroendocrine.pdf
58. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Prostate Cancer Version 1.2023. National Comprehensive Cancer Network®. May 9, 2023. Updated September 16, 2022. Accessed April 11, 2023. https://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf
59. Positron Emission Tomography (PET) scans for lymphoma. Washington State Health Care Authority. Updated January 18, 2019. Accessed January 31, 2023, https://www.hca.wa.gov/assets/program/PET-scans-lymphoma-final-findings-decision- 20190118.pdf
60. About the Health Care Authority (HCA). Washington State Health Care Authority. Accessed January 31, 2023. http://hca.wa.gov/about-hca
61. Lewin J, Sayers L, Kee D, et al. Surveillance imaging with FDG-PET/CT in the post-operative follow-up of stage 3 melanoma. Annals of Oncology. 2018/07/01/ 2018;29(7):1569-1574. doi:https://doi.org/10.1093/annonc/mdy124
62. Kumar S, Paiva B, Anderson KC, et al. International Myeloma Working Group consensus criteria for response and minimal residual disease assessment in multiple myeloma. The Lancet Oncology. 2016;17(8):e328-e346. doi:10.1016/S1470-2045(16)30206-6
63. Foundation IM. What is Relapse in Myeloma? International Myeloma Foundation. May 9, 2023. Accessed April 21, 2023. https://www.myeloma.org/treatment/relapse-definition
64. Network® NCC. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Small Cell Lung Cancer Version 3.2023. National Comprehensive Cancer Network®. May 9, 2023. Updated December 21, 2022. Accessed April 11, 2023. https://www.nccn.org/professionals/physician_gls/pdf/sclc.pdf
65. de Fonseka D, Underwood W, Stadon L, et al. Randomised controlled trial to compare the diagnostic yield of positron emission tomography CT (PET-CT) TARGETed pleural biopsy versus CT-guided pleural biopsy in suspected pleural malignancy (TARGET trial). BMJ Open Respir Res. 2018;5(1):e000270. doi:10.1136/bmjresp-2017-000270
66. Wei JT, Barocas D, Carlsson S, et al. Early Detection of Prostate Cancer: AUA/SUO Guideline Part II: Considerations for a Prostate Biopsy. J Urol. Apr 25 2023:101097ju0000000000003492. doi:10.1097/ju.0000000000003492

Coding Section

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, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated 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 2024 Forward