Download 11 C-Acetate Scheduling Checklist - Indiana Institute for Biomedical

11 C-Acetate PET/CT Exam Information
11 C-Acetate Scheduling Checklist
The Food and Drug Administration (FDA) is allowing Indiana University to use this unapproved
11C-Acetate under its “expanded access” program. As required by the FDA, this Expanded
Access IND will have oversight by the local Institutional Review Board which requires that we
obtain consent from each patient. **Please do not contact centralized scheduling when scheduling
the 11 C-Acetate scan but follow the required steps below**
1. Fax or email an 11 C-Acetate Eligibility Form to Dr. James Fletcher at
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[email protected] or 317-944-1806. The clinical indications for use of the 11-C acetate
are listed on the Eligibility Form and the patient must meet one of these indications.
Please provide an email address or phone number for referring office.
Obtain pre-authorization from the patient’s insurance to cover expenses associated with
scan using the Fact Sheet for Pre-approval of 11 C-Acetate. (CPT code for Whole body
PET/CT-78816. This code does not cover the radiopharmaceutical portion of exam)
A Radiology representative ([email protected]) will contact referring physician or
physician’s coordinator to schedule date and time for scan. Radiology Research
Coordinator will schedule scan through the Office of Research Imaging.
The following information will be needed in order to schedule the patient:
 Eligibility Form emailed or faxed to Dr. Fletcher ([email protected])
 Scheduling request/order form (email form to [email protected] )
 Patient’s weight and height.
 Information regarding any allergic reactions to contrast dye
 Copy of BUN and creatinine levels obtained in the past 30 days to support
renal function.
 Pre-authorization number from patient’s insurance.
 A valid phone number for the patient
A confirmation phone call/email of patient’s scheduled scan will be given to physician’s
office by Radiology representative.
Patient will be contacted with instructions (provided below) and location of scan. It is
important we be able to contact your patient. If we are unable to do so, we may need to
reschedule the scan.
04/30/2014
11 C-Acetate PET/CT Exam Information
Exam Procedures
How to prepare for exam:
We ask that patients arrive no less than 30 minutes prior to their exam. If they are late for the
exam it may be necessary to reschedule. We also ask that patients not eat anything for 2 hours
prior to the PET/CT scan. However, they are allowed to drink fluids. We ask that patients wear
comfortable clothing. Sweat pants without zippers and metal buttons are preferable.
Parking Information:
The IU Health Neuroscience Center/Goodman Hall is located at 355 W. 16th Street. When
coming for the appointment, the parking garage is located off of 15th Street and Missouri and is
attached to the building. The map attached shows the location of this garage. There is no
parking attendant on duty so patients’ must take their ticket into the building to pay at the kiosk
on the way out of their appointment. Parking rates are $5 or less depending on the length of stay.
Where to go:
Patients will need to check into the Radiology Department which is located on the Lower Level
of Goodman Hall. Patients should take the main bank of elevators to the Lower Level and check
in with the Radiology Receptionist where they will be registered for the exam.
Patient Preparation:
A representative from the Department of Radiology will explain the entire procedure and will
review the consent. A small intravenous tube will be placed. The process of the 11 C
preparations takes approximately 60 minutes to complete. Once prepared, the 11 C-Acetate will
be injected though the tube. PET/CT Imaging will take place immediately after the injection. It
takes about 60 minutes to complete the PET/CT images. Patients will be asked to lie on their
back on the imaging table and place their arms above their head into an arm holder. Every effort
will be made to assure their comfort during the procedures.
How Long for Total Exam:
The total exam will take up to 90 minutes -30 minutes to review the consent and place
intravenous tube and 60 minutes for the PET/CT scan. They will be allowed to leave once the
scan is completed and the intravenous tube is removed.
How Long for Results:
Results from the PET/CT scan will be provided to the referring physician via Cerner or Synapse.
Fax copy of report can be provided to the referring physician if they do not have access to these
data resources.
04/30/2014