Download Positron Emission Tomography

JOHNS HOPKINS HEALTHCARE
Medical Policy: Positron Emission Tomography
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
ACTION:
☐ New Policy
☒ Revising Policy Number: CMS16.07
☐ Superseding Policy Number
☐ Archiving Policy Number
☐ Retiring Policy Number
Policy Number
CMS16.07
Page 1 of 14
Effective Date: 06/2003
Review Dates: 10/22/03, 10/22/04,
10/21/05, 05/30/06, 10/13/06, 3/3/08,
3/2/09, 6/4/10, 8/23/11, 3/7/14, 9/4/15,
Johns Hopkins HealthCare (JHHC) provides a full spectrum of health care products and services
for Employer Health Programs, Priority Partners, and US Family Health Plan. Each line of
business possesses its own unique contract and guidelines which, for benefit and payment
purposes, should be consulted to know what benefits are available for reimbursement. Specific
contract benefits, guidelines or policies supersede the information outlined in this policy.
POLICY:
For US Family Health Plan see TRICARE Policy Manual 6010.57-M, February 1, 2008, Nuclear
Medicine: Chapter 5, Section 4.1.
I.
When benefits are provided under the member’s contract, JHHC considers positron
emission tomography (PET) medically necessary for the following Cardiac
Indications:
A. Evaluation of Coronary Artery Disease:
1.
PET scans using rubidium-82 (Rb-82) or N-13 ammonia done at rest or with
pharmacological stress are considered medically necessary for noninvasive imaging of the perfusion of the heart for the diagnosis and
management of members with known or suspected coronary artery disease,
provided such scans meet EITHER one of the two following criteria:
a. The PET scan is used in place of, but not in addition to, a single photon
emission computed tomography (SPECT), in persons with conditions that
may cause attenuation problems with SPECT (obesity (BMI greater than
40), large breasts, breast implants, mastectomy, chest wall deformity,
pleural or pericardial effusion); OR
b. The PET scan is used following an inconclusive SPECT scan (i.e., the
results of the SPECT are equivocal, technically uninterpretable, or
discordant with a member’s other clinical data).
B. Assessment of Myocardial Viability:
Fluorodeoxy-D-glucose (FDG)-PET scans are considered medically necessary
1.
for the determination of myocardial viability prior to re-vascularization, either
as a primary or initial diagnostic study or following an inconclusive SPECT.
The greater specificity of PET makes a SPECT following an inconclusive PET
not medically necessary.
JOHNS HOPKINS HEALTHCARE
Medical Policy: Positron Emission Tomography
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
2.
3.
II.
Policy Number
CMS16.07
Page 2 of 14
The identification of members with partial loss of heart muscle movement or
hibernating myocardium is important in selecting candidates with
compromised ventricular function to determine appropriateness for revascularization. Diagnostic tests such as FDG-PET distinguish between
dysfunctional but viable myocardial tissue and scar tissue in order to affect the
management decisions in members with ischemic cardiomyopathy and left
ventricular dysfunction.
PET-CT fusion is considered experimental and investigational for cardiac and
neurologic indications; a PET scan without CT is adequate to evaluate the
brain and myocardium.
When benefits are provided under the member’s contract, JHHC considers FDG-PET
medically necessary for the following Oncologic Indications, when the following
general and disease-specific criteria for diagnosis, staging, restaging and monitoring are
met, and the FDG-PET scan is necessary to guide management:
A. General Criteria
1.
Diagnosis: The PET results may assist in avoiding an invasive diagnostic
procedure, or the PET results may assist in determining the optimal anatomic
location to perform an invasive diagnostic procedure. In general, for most
solid tumors, a tissue diagnosis is made prior to the performance of PET
scanning. PET scans following a tissue diagnosis are performed for the
purpose of staging, not diagnosis. Therefore, the use of PET in the diagnosis
of lymphoma, esophageal carcinoma, colorectal cancers, and melanoma is
rarely considered medically necessary.
2.
Staging: PET is considered medically necessary in situations in which clinical
management of the member would differ depending on the stage of the cancer
identified and Either:
a. the stage of the cancer remains in doubt after completion of a standard
diagnostic work-up, including conventional imaging (computed
tomography, magnetic resonance imaging, or ultrasound); OR
b. the use of PET would potentially replace one or more conventional
imaging studies when it is expected that conventional study information is
insufficient for the clinical management of the member.
3.
Re-staging: PET is considered medically necessary for re-staging after
completion of treatment for the purpose of detecting residual disease, for
detecting suspected recurrence in persons with signs or symptoms of
recurrence, or to determine the extent of recurrence. Use of PET is also
considered medically necessary if it could potentially replace one or more
conventional imaging studies when it is expected that conventional study
information is insufficient for the clinical management of the
member. PET for post- treatment surveillance is considered experimental and
investigational, where surveillance is defined as use of PET beyond the
JOHNS HOPKINS HEALTHCARE
Medical Policy: Positron Emission Tomography
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
Policy Number
CMS16.07
Page 3 of 14
completion of treatment, in the absence of signs or symptoms of cancer
recurrence or progression, for the purpose of detecting recurrence or
progression or predicting outcome.
4.
Monitoring: PET for monitoring tumor response during the planned course of
therapy is not considered medically necessary except for breast cancer. Restaging occurs only after a course of treatment is completed.
5.
The fusion of PET and CT imaging into a single system (PET/CT fusion) is
considered medically necessary for any oncologic indication where PET
scanning is considered medically necessary.
B. Disease-Specific Criteria
1.
Characterization of Solitary Pulmonary Nodules (SPNs):
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET medically necessary for the characterization of newly
discovered SPNs in persons without known malignancy when the general
medical necessity criteria for oncologic indications (above) are met AND
the following conditions are met:
• A concurrent thoracic CT has been performed, which is necessary to
ensure that the PET scan is properly coordinated with other diagnostic
modalities; AND
• A single indeterminate or possibly malignant lesion, more than 0.8 cm
and not exceeding 4 cm in diameter, has been detected (usually by
CT).
b. The primary purpose of the PET scan of SPN should be to determine the
likelihood of malignancy in order to plan the management of the member.
c. A biopsy is not considered medically necessary in the case of a negative
PET scan for SPNs, because the member is presumed not to have a
malignant lesion, based upon the PET scan results.
d. In cases of serial evaluation of SPNs using both CT and regional PET
chest scanning, such PET scans are not considered medically necessary if
repeated within 90 days following a previous negative PET scan.
2.
Non-Small Cell Lung Carcinoma (NSCLC):
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for the diagnosis, staging and restaging of non-small cell lung carcinoma (NSLC) when the general
medical necessity criteria for oncologic indications (II. A. listed above)
are met.
3.
Small Cell Lung Carcinoma (SCLC):
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for staging of persons with SCLC
that has been determined to be of limited-stage after standard staging
evaluation (including CT of the chest and upper abdomen, bone scan, and
brain imaging).
JOHNS HOPKINS HEALTHCARE
Medical Policy: Positron Emission Tomography
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
4.
5.
6.
7.
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Policy Number
CMS16.07
Page 4 of 14
Mesothelioma:
a. When benefits are provided under the member’s contract, JHHC
considers FDG-PET scans medically necessary for diagnosis and staging
of malignant pleural mesothelioma when the general medical necessity
criteria for oncologic indications (II. A. listed above) are met. According
to National Comprehensive Cancer Network (NCCN) guidelines (2010),
PET-CT scans may be useful in the pre-treatment evaluation of
mesothelioma
Colorectal Cancer and Small Bowel Adenocarcinoma:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for diagnosis*, staging, and restaging of colorectal cancer and small bowel adenocarcinoma when the
general medical necessity criteria for oncologic indications (II. A. listed
above) are met.
b. According to the Centers for Medicare & Medicaid Services (CMS),
medical evidence supports the use of FDG-PET as a useful tool in
determining the presence of hepatic/extra-hepatic metastases in the
primary staging of colorectal carcinoma, prior to selecting the treatment
regimen. Use of FDG-PET is also supported in evaluating recurrent
colorectal cancer or small bowel adenocarcinoma where the member
presents with clinical signs or symptoms of recurrence.
c. A diagnostic tissue sample is usually obtainable without PET localization.
Therefore, PET for diagnosis of colorectal cancer is rarely considered
medically necessary.
Anal Cancer:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for the diagnosis of anal canal
carcinomas when medical necessity criteria for oncologic indications
(II.A. listed above) are met. According to NCCN guidelines (2013), the
routine use of a PET-CT scan for staging or treatment planning for anal
cancer has not been validated
Hodgkins Lymphoma:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for the diagnosis*, staging and restaging of Hodgkins lymphoma when the general medical necessity
criteria for oncologic indications (II. A. listed above) are met.
b. A diagnostic tissue sample is usually obtainable without PET
localization. Therefore, PET for diagnosis of Hodgkins lymphoma is
rarely considered medically necessary.
Non-Hodgkins lymphoma (including post-transplant lymphoproliferative
disorder and Castleman’s disease):
JOHNS HOPKINS HEALTHCARE
Medical Policy: Positron Emission Tomography
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
9.
10.
11.
12.
Policy Number
CMS16.07
Page 5 of 14
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for the diagnosis*, staging and restaging of non-Hodgkins lymphoma when the general medical necessity
criteria for oncologic indications (II. A. listed above) are met.
b. A diagnostic tissue sample is usually obtainable without PET
localization. Therefore, PET for diagnosis of non-Hodgkins lymphoma is
rarely considered medically necessary.
Melanoma:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for the diagnosis*, staging, and restaging of melanoma when the general medical necessity criteria for
oncologic indications (II. A. listed above) are met. FDG-PET is considered
experimental and investigational and not medically necessary for use in
evaluating regional nodes in persons with melanoma.
b. A diagnostic tissue sample is usually obtainable without PET
localization. Therefore, PET for diagnosis of melanoma is rarely
considered medically necessary.
Esophageal Cancer:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET medically necessary for the diagnosis*, staging and re-staging of
esophageal carcinoma when general medical necessity criteria for
oncologic indications (II. A. listed above) are met. Medical evidence is
present to support the use of FDG-PET in pre-surgical staging of
esophageal cancer.
b. A diagnostic tissue sample is usually obtainable without PET
localization. Therefore, PET for diagnosis of esophageal cancer is rarely
considered medically necessary.
Gastric Cancer:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET is considered medically necessary for diagnosis,* staging and
re-staging of gastric carcinoma when general medical necessity criteria for
oncologic indications (II. A. listed above) are met. Consensus guidelines
support the use of FDG-PET in the pre-surgical staging of gastric cancer.
b. A diagnostic tissue sample is usually obtainable without PET
localization. Therefore, PET for diagnosis of gastric cancer is rarely
considered medically necessary.
Gastrointestinal Stromal Tumors:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET is considered medically necessary for diagnosis*, staging and
re-staging of gastrointestinal stromal tumors (GIST) when general medical
necessity criteria for oncologic indications (II. A. listed above) are
met. Consensus guidelines support the use of FDG-PET in the pre-surgical
JOHNS HOPKINS HEALTHCARE
Medical Policy: Positron Emission Tomography
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
13.
14.
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Policy Number
CMS16.07
Page 6 of 14
staging of GIST.
b. A diagnostic tissue sample is usually obtainable without PET
localization. Therefore, PET for diagnosis of GIST is rarely considered
medically necessary.
Head and Neck Cancers:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for the diagnosis, staging, and restaging of head and neck cancers when general medical necessity criteria
for oncologic indications (II.A. listed above) are met. The head and neck
cancers encompass a diverse set of malignancies of which the majority is
squamous cell carcinomas. Persons with head and neck cancers may
present with metastases to cervical lymph nodes but conventional forms of
diagnostic imaging fail to identify the primary tumor. Persons with cancer
of the head and neck are left with 2 options, either to have a neck
dissection or to have radiation of both sides of the neck with random
biopsies. PET scanning attempts to reveal the site of primary tumor to
prevent adverse effects of random biopsies or unneeded radiation.
Thyroid Cancer:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary when general medical necessity
criteria for oncologic indications (II. A. listed above) are met, for staging of
thyroid cancer of follicular cell origin previously treated by thyroidectomy
and radioiodine ablation with an elevated or rising serum thyroglobulin
(Tg) greater than 10 ng/ml and negative I-131 whole body scintigraphy.
b. FDG-PET is considered not medically necessary for determining which
members with metastatic thyroid cancer are at highest risk for death,
because this information is for informational purposes only and has not
been demonstrated to alter member management.
c. FDG-PET scans are considered experimental and investigational for other
thyroid cancer indications, including:
• Use for the initial staging of post-surgical thyroid cancer of cell types
that concentrate I-131 poorly; OR
• Use of FDG-PET for re-staging of previously treated thyroid cancer of
medullary cell origin in persons with an elevated serum calcitonin and
negative standard imaging tests.
Thymic Malignancies:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for the diagnosis, staging, and restaging of thymic malignancies (thymomas and thymic carcinomas) when
the general medical necessity criteria for oncologic indications (II. A. listed
above) are met.
JOHNS HOPKINS HEALTHCARE
Medical Policy: Positron Emission Tomography
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
16.
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Policy Number
CMS16.07
Page 7 of 14
Breast Cancer:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for members with breast cancer for
the following indications, where general medical necessity criteria for
oncologic indications (II. A. listed above) are met:
• Initial staging of members with stage III or higher when conventional
imaging is equivocal; OR
• Monitoring tumor response to treatment for persons with locally
advanced and metastatic breast cancer when a change in therapy is
contemplated; OR
• Restaging of members with known metastases; OR
• Evaluating suspected recurrence (new palpable lesions in axilla or
adjacent area, rising tumor markers, changes in other imaging which
are equivocal or suspicious).
b. FDG-PET is considered experimental and investigational for the initial
diagnosis of breast cancer and for the staging of axillary lymph nodes.
c. Positron emission mammography is considered experimental and
investigational.
Cervical Cancer:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for the diagnostic workup of cervical
cancer, for detection of pre-treatment metastases (staging) in women who
are newly diagnosed with cervical cancer and have negative conventional
imaging (CT or MRI), and for restaging of cervical cancer when general
medical necessity criteria for oncologic indications (II. A. listed above) are
met.
Ovarian Cancer, Fallopian Tube Cancer and Primary Peritoneal Cancer:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for re-staging (detecting recurrence)
of previously treated women with a rising CA-125 level who have negative
or equivocal conventional imaging (CT or MRI) when general medical
necessity criteria for oncologic indications (II.A listed above) are met.
b. FDG-PET scans are considered experimental and investigational for
diagnosis, staging, and monitoring of ovarian cancer, fallopian tube cancer
and primary peritoneal cancer.
Testicular Cancer:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for re-staging (detecting recurrence)
of testicular cancer in men with previously treated disease who have a
residual mass with normal or persistently elevated serum markers (e.g.,
alpha fetoprotein or serum chorionic gonadotropin) when general medical
necessity criteria for oncologic indications (II.A. listed above) are met.
JOHNS HOPKINS HEALTHCARE
Medical Policy: Positron Emission Tomography
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
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Policy Number
CMS16.07
Page 8 of 14
b. FDG-PET scans are considered experimental and investigational for
diagnosis, staging and monitoring of testicular cancer.
Multiple Myeloma and Plasmacytomas:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for evaluating suspected
plasmacytomas (staging) in persons with multiple myeloma and for restaging of persons with solitary plasmacytomas.
Ewing Sarcoma, Chordoma and Osteosarcoma:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for the diagnosis, staging and restaging of osteosarcoma, chordoma, and Ewing sarcoma family of tumors.
Soft Tissue Sarcoma:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for soft tissue sarcomas. FDG-PET
scans are considered medically necessary for staging prior to resection of
an apparently solitary metastasis, or for grading unresectable lesions when
the grade of the histopathological specimen is in doubt.
b. FDG-PET scans are considered experimental and investigational for restaging of Soft tissue sarcomas.
Neuroendocrine Tumors:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for the diagnosis, staging and restaging of persons with pheochromocytoma/ paragangliomas and other
neuroendocrine tumors when general medical necessity criteria for
oncologic indications (II.A. listed above) are met.
Pancreatic Tumors:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans medically necessary for diagnosis and staging of
pancreatic tumors where imaging tests (CT or MRI) are equivocal. FDGPET scans are considered experimental and investigational for restaging of
pancreatic cancer
Brain Cancer:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET scans are considered medically necessary for diagnosis and
staging, where lesions metastatic from the brain are identified but no
primary is found, and for restaging, to distinguish recurrent tumor from
radiation necrosis.
Occult Primary:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET is considered medically necessary for staging in carcinomas of
unknown primary site in tumors of indeterminate histology where the
primary site cannot be identified by endoscopy or other imaging studies
JOHNS HOPKINS HEALTHCARE
Medical Policy: Positron Emission Tomography
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
27.
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III.
Policy Number
CMS16.07
Page 9 of 14
(CT, MRI) and where loco-regional therapy for a single site of disease is
being considered. FDG-PET scans are considered experimental and
investigational for diagnosis or re-staging of carcinomas of unknown
primary.
Paraneoplastic Syndromes:
a. When benefits are provided under the member’s contract, JHHC considers
FDG- PET medically necessary for diagnosis and staging of persons
suspected of having a paraneoplastic syndrome.
Merkel Cell Carcinoma:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET medically necessary for evaluating (i) the possibility of a skin
metastasis from a non-cutaneous carcinoma (e.g., small cell carcinoma of
the lung), especially in cases where CK20 is negative, (ii) to evaluate
regional and distant metastases, and (iii) the extent of lymph node and/or
visceral organ involvement.
Penile Cancer:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET medically necessary for evaluation of persons with penile cancer
who have positive lymph nodes (PLNs) and an abnormal CT or MRI.
Uterine Sarcoma:
a. When benefits are provided under the member’s contract, JHHC considers
FDG-PET medically necessary for diagnosis, staging and restaging of
persons with uterine sarcoma in persons with known or suspected
extrauterine disease.
FDG-PET in Place of 99mTc Skeletal Scintigraphy
a. Due to an interruption in production, there is a temporary shortage of
technetium 99-m (99mTc), which is used in nuclear medicine for skeletal
scintigraphy (bone scans). During this shortage, JHHC will consider FDGPET an acceptable alternative to bone scans for detecting skeletal
abnormalities for medically necessary indications.
NaF-18 PET
a. JHHC considers NAF-18 PET experimental and investigational for
identifying bone metastasis of cancer because of insufficient evidence.
Cargon-11 labeled 5-HTP PET
a. JHHC considers carbon-11 labeled 5-HTP PET experimental and
investigational for carcinoid and all other indications because of
insufficient evidence.
Neurologic Indications:
A.
JHHC considers FDG-PET medically necessary only for pre-surgical evaluation
for the purpose of localization of a focus of refractory seizure activity.
JOHNS HOPKINS HEALTHCARE
Medical Policy: Positron Emission Tomography
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
B.
Policy Number
CMS16.07
Page 10 of 14
JHHC considers PET scans experimental and investigational for Alzheimer
disease (including the use of florbetapir-PET and flutemetamol F18-PET for
imaging Beta-amyloid), dementia, Huntington disease, Parkinson’s disease, or
other neurological indications not listed as medically necessary in this policy
because of insufficient evidence of its effectiveness.
IV.
Other Indications:
A.
FDG-PET is considered medically necessary for diagnosis, staging and re-staging
of Langerhans cell histiocytosis.
V.
PET scanning with a gamma camera is considered experimental and investigational for
all indications because of insufficient evidence of its effectiveness.
VI.
PET/MRI is considered experimental and investigational for all indications because of
insufficient evidence of its effectiveness.
VII.
PET scans for routine screening of asymptomatic members are not considered medically
necessary, regardless of the number and severity of risk factors applicable to the member.
VIII.
Unless specific benefits are provided, JHHC considers PET scans experimental and
investigational for all other indications.
BACKGROUND:
Positron Emission Tomography, also known as PET scan, is a type of medical imaging test that
allows providers to evaluate how well a patient’s tissues and organs are functioning. It is often
referred to as a type of nuclear medicine. Tracers, which determine areas in the body that have
elevated levels of chemical activity, are often swallowed, inhaled, or injected into a patient prior
to the procedure. The higher levels of chemical activity in a specific area can help alert providers
of a disease.
PET scans routinely help detect numerous conditions in patients, including certain cancers, brain
disorders such as Alzheimer’s, and heart disease. In addition to detecting diseases, a PET scan
can also be beneficial for measuring other important body functions, such as blood flow
regulation, oxygen use, and the metabolism of glucose.
CODING INFORMATION:
CPT Copyright 2016 American Medical Association. All rights reserved. CPT is a registered
trademark of the American Medical Association.
JOHNS HOPKINS HEALTHCARE
Medical Policy: Positron Emission Tomography
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
Policy Number
CMS16.07
Page 11 of 14
Note: The following CPT/HCPCS codes are included below for informational
purposes. Inclusion or exclusion of a CPT/HCPCS code(s) below does not signify or imply
member coverage or provider reimbursement. The member's specific benefit plan
determines coverage and referral requirements. All inpatient admissions require preauthorization.
PRE- AUTHORIZATION REQUIRED
Compliance with the provision in this policy may be monitored and addressed through post
payment data analysis and/or medical review audits
Employer Health
Programs (EHP) **See
Specific Summary Plan
Description (SPD)
CPT ®
CODES
78459
78491
78492
78608
78609
78811
78812
78813
78814
78815
78816
HCPCS
CODES
G0219
Priority Partners (PPMCO)
refer to COMAR guidelines
and PPMCO SPD then
apply policy criteria
US Family Health Plan
(USFHP), TRICARE Medical
Policy supersedes JHHC Medical
Policy. If there is no Policy in
TRICARE, apply the Medical
Policy Criteria
DESCRIPTION
Myocardial imaging, positron emission tomography (PET), metabolic evaluation
Myocardial imaging, positron emission tomography (PET), perfusion; single study at
rest or stress
Myocardial imaging, positron emission tomography (PET), perfusion; multiple
studies at rest and/or stress
Brain imaging, positron emission tomography (PET); metabolic evaluation
Brain imaging, positron emission tomography (PET); perfusion evaluation
Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)
Positron emission tomography (PET) imaging; skull base to mid-thigh
Positron emission tomography (PET) imaging; whole body
Positron emission tomography (PET) with concurrently acquired computed
tomography (CT) for attenuation correction and anatomical localization imaging;
limited area (eg, chest, head/neck)
Positron emission tomography (PET) with concurrently acquired computed
tomography (CT) for attenuation correction and anatomical localization imaging;
skull base to mid-thigh
Positron emission tomography (PET) with concurrently acquired computed
tomography (CT) for attenuation correction and anatomical localization imaging;
whole body
PET imaging whole body; melanoma for noncovered indications
JOHNS HOPKINS HEALTHCARE
Medical Policy: Positron Emission Tomography
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
G0235
G0252
Policy Number
CMS16.07
Page 12 of 14
PET imaging, any site, not otherwise specified
PET imaging, full and partial-ring PET scanners only, for initial diagnosis of breast
cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary
lymph nodes)
REFERENCES STATEMENT:
Analyses of the scientific and clinical references cited below were conducted and utilized by the
Johns Hopkins HealthCare (JHHC) Medical Policy Team during the development and
implementation of this medical policy. Per NCQA standards, the Medical Policy Team will
continue to monitor and review any newly published clinical evidence and adjust the references
below accordingly if deemed necessary.
CLINICAL:
1.
2.
3.
4.
5.
6.
7.
8.
Kuruvilla, D., Lipton, R. (2015). Appropriate use of neuroimaging in headache.
Current Pain and Headache Reports, 19(6), p.490.
Cerfolio, R., Bryant, A. (2006). Maximum Standardized Uptake Values on Positron
Emission Tomography of Esophageal Cancer Predicts Stage, Tumor Biology, and
Survival. The Annals of Thoracic Surgery,82, p.391-395.
Blodgett, T, Meltzer, C., et al. (2007). PET/CT: Form and Function [Abstract].
Journal of Radiology, 242(2), p.360-385.
Buck, A., Herrman, K., et al. (2010). Economic Evaluation of PET and PET/CT in
Oncology: Evidence and Methodologic Approaches. Journal of Nuclear Medicine,
51(3), p.401-412.
Knopman, D., DeKosky, S., Cummings, J., et al. (2001). Practice Parameter:
Diagnosis of Dementia (An Evidence-Based Review) Report of the Quality
Standards Subcommittee of the American Academy of Neurology. Journal of the
American Academy of Neurology, 56(9), p.1143-1153. Retrieved:
http://www.neurology.org/content/56/9/1143.full.html
Hayes, Inc. (2013). Medical Technology Directory: Positron Emission for Treatment
Planning of Lung Cancer. Retrieved:
https://www.hayesinc.com/subscribers/displaySubscriberArticle.do?articleId=9466
Hayes, Inc. (2014). Medical Technology Directory: Positron Emission Tomography
(PET) and Combined Positron Emission Tomography-Computed Tomography
(PET-CT) for Breast Cancer Staging. Retrieved:
https://www.hayesinc.com/subscribers/displaySubscriberArticle.do?articleId=11247
Hayes, Inc. (2015). Medical Technology Directory: Positron Emission Tomography
(PET) for Alzheimer’s Disease. Retrieved:
https://www.hayesinc.com/subscribers/displaySubscriberArticle.do?articleId=2056
JOHNS HOPKINS HEALTHCARE
Medical Policy: Positron Emission Tomography
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
Policy Number
CMS16.07
Page 13 of 14
HEALTH PLAN:
9.
10.
11.
12.
Empire-Blue Cross/Blue Shield. (2015). Medical Policy: Positron Emission
Tomography (PET) and PET/CT Fusion. Policy Number: RAD.00002. Retrieved:
http://www.empireblue.com/medicalpolicies/policies/mp_pw_a050587.htm
Aetna. (2015). Clinical Policy Bulletin: Positron Emission Tomography (PET).
Policy Number: 0071. Retrieved:
http://www.aetna.com/cpb/medical/data/1_99/0071.html
United Healthcare. (2015). Coverage Summary: Positron Emission Tomography
(PET)/ Combined PET-CT (Computed Tomography). Policy Number: P-003.
Retrieved: https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/enUS/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/
Policies%20and%20Protocols/UnitedHealthcare%20Medicare%20Coverage/Positro
nEmissionTomographyPET_FDG_UHCMA_CS.pdf
CIGNA. (2013). Medical Coverage Policy: Positron Emission Tomography (PET).
Policy Number: 0091. Retrieved:
http://www.cardiogen.com/sites/Bracco/BraccoDocuments/Cardiogen/CardiogenPri
vateCoverage/Cigna2013Positron%20Emission%20Tomography%20(PET)%20Cig
na%20Medical%20Coverage%20Policy.pdf
REGULATORY:
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Centers for Medicare and Medicaid (CMS). Department of Health & Human
Services (DHHS). (2013).Medicare National Coverage Determinations: Chapter 1,
Radiology: 220.6-Positron Emission Tomography (PET). Retrieved:
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R156NCD.pdf
Centers for Medicare and Medicaid (CMS). Department of Health & Human
Services (DHHS). (2010). Medicare National Coverage Determinations: Positron
Emission Tomography (FDG PET) for Initial Treatment Strategy (PI) in Solid
Tumors and Myeloma. Retrieved: http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads/R124NCD.pdf
Centers for Medicare and Medicaid (CMS). (2009). Decision Memo for Positron
Emission Tomography (FDG) for Solid Tumors. Retrieved:
http://www.snm.org/docs/PET_PROS/CMS%20PET%20Decision%20Memo%20A
pril%202009.pdf
TRICARE. (2008). Policy Manual 6010.57-M, February 1, 2008, Radiology,
Chapter 5, Section 4.1. Retrieved from: http://manuals.tricare.osd.mil/
Centers for Medicare and Medicaid (CMS). Department of Health & Human
Services (DHHS). (2010). Medicare National Coverage Determinations: FDG PET
for Solid Tumors and Myeloma. Retrieved: http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads/R120NCD.pdf
JOHNS HOPKINS HEALTHCARE
Medical Policy: Positron Emission Tomography
Department: Medical Management
Lines of Business: EHP, USFHP, PPMCO
18.
19.
20.
21.
Policy Number
CMS16.07
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COMAR. Positron Emission Tomography (PET) Scan 10.34.19.01. and 10.34.19.02.
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3.htm#
Health Quality Ontario (Presented to the Ontario Health Technology Advisory
Committee). (2010). Positron Emission Tomography for the Assessment of
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Machac, J. (2001). PET Myocardial Perfusion Imaging. Argentine Federation of
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