Download oncologic pet/ct review tool

ONCOLOGIC PET/CT REVIEW TOOL
Fax to 1.888.329.8471 or 740.695.5297.
Patient/Enrollee Name:
Health Plan ID#:
Physician Name:
Telephone#:
INDICATE TEST REQUESTED:
ü CPT
Description
78608 Brain imaging, positron emission tomography (PET); metabolic evaluation
78609 Brain imaging, positron emission tomography (PET); perfusion evaluation
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
78814 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for
attenuation correction and anatomical localization imaging; limited area (eg, 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
PLEASE COMPLETE THE INFORMATION BELOW:
Type of Cancer:
MRI/CT completed:
Proven by biopsy or
No
Yes
Suspected
Results:
1. PET requested as part of the Initial Treatment Strategy:
To determine if suspicious lesion is cancer
Pulmonary nodule
Other (specify):
To detect an occult primary tumor:
In patient with known/suspected metastatic disease
In patient with suspected paraneoplastic syndrome
Initial Staging of confirmed, newly diagnosed cancer
2. PET requested as part of the Subsequent Treatment Strategy:
Monitoring Response during the following treatment:
Chemotherapy
Radiotherapy
Other (type):
Restaging after completion of the following therapy
Chemotherapy
Radiotherapy
Other (type):
Suspected Recurrence of a previously treated cancer:
Site of suspected recurrence:
Based on the following clinical findings:
Surveillance of a previously treated cancer in a patient with no known residual disease (this is a noncovered indication)
ADDITIONAL HISTORY OR INSTRUCTIONS: