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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: