This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions

Medical Policy Search
Printer Friendly Version Oncologic Applications of PET Scanning

Oncologic Applications of PET Scanning

 

DESCRIPTION

 Positron emission tomography (PET) scans are based on the use of positron emitting radionuclide tracers coupled to organic molecules, such as glucose, ammonia, or water. The radionuclide tracers simultaneously emit 2 high-energy photons in opposite directions that can be simultaneously detected (referred to as coincidence detection) by a PET scanner, consisting of multiple stationary detectors that encircle the area of interest.

A variety of tracers are used for PET scanning, including oxygen-15, nitrogen-13, carbon-11, and fluorine-18. Because of their short half-life, tracers must be made locally, the majority requiring an onsite cyclotron. The radiotracer most commonly used in oncology imaging has been fluorine-18 coupled with fluorodeoxyglucose (FDG), which has a metabolism related to glucose metabolism. FDG has been considered potentially useful in cancer imaging, since tumor cells show increased metabolism of glucose. The most common malignancies studied have been melanoma, lymphoma, lung, colorectal, and pancreatic cancer.

This policy focuses on four oncologic applications of PET scanning:

Diagnosis: This refers to use of PET as part of the testing used in establishing whether or not a patient has cancer.

Staging / Initial anti-tumor treatment strategy: This refers to use of PET to determine the stage (extent) of the cancer at the time of diagnosis, before any treatment is given. Imaging at this time is generally to determine whether or not the cancer is localized. This may also be referred to as initial staging. PET imaging enhances the physician’s decision about and planning for an initial anti-tumor treatment strategy and promotes improved health outcomes.

Restaging / Subsequent anti-tumor treatment strategy: This refers to imaging following treatment in two situations. Restaging is part of the evaluation of a patient in whom a disease recurrence is suspected based on signs and/or symptoms. Restaging also includes determining the extent of malignancy following completion of a full course of treatment.

Surveillance: This refers to use of imaging in asymptomatic patients (patients without objective signs or symptoms of recurrent disease). This imaging is completed 6 months or more (12 months or more for lymphoma) following completion of treatment. Surveillance has also been called “tertiary prevention.” Tertiary preventive services are those that are provided to persons who have or have had a disease in order to prevent further complications. PET scanning performed for surveillance purposes is considered not medically necessary as outlined in the Policy section below.

PET Scanning in Oncology to Detect Early Treatment Response is addressed in a separate policy.
Cardiac Applications of PET Scanning are addressed in a separate policy.
Miscellaneous Applications of PET are addressed in a separate policy.

Important Note:
This policy only addresses the use of radiotracers detected with the use of dedicated PET scanners. Radiotracers such as FDG may be detected using SPECT cameras, a technique that may be referred to as FDG-SPECT imaging. 

 

POLICY

  

Brain Cancer

PET scanning may be considered medically necessary for staging and restaging.

Breast Cancer (Male & Female)

           

PET scanning may be considered medically necessary for staging and restaging.

PET scanning is considered investigational in the evaluation of breast cancer, including but not limited to the following applications:

  • Differential diagnosis in patients with suspicious breast lesions or an indeterminate/low suspicion finding on mammography
  • Staging axillary lymph nodes

Bone Metastases

 

PET imaging performed using the radiopharmaceutical diagnostic imaging agent sodium fluouride-18 (NaF-18) may be considered medically necessary in evaluating areas of altered osteogenic activity in bone, for patients with suspected or biopsy-proven bone metastases.

Cervical Cancer

           

PET scanning may be considered medically necessary in the initial staging of patients with locally advanced cervical cancer (conventional imaging is negative for extra-pelvic metastasis).

PET scanning may be considered medically necessary for restaging to detect residual or recurrent disease in patients being followed up after treatment of locally advanced cervical cancer.

Colorectal Cancer

           

PET scanning may be considered medically necessary as a technique for the following situations:

  • Staging and restaging to detect and assess resectability of hepatic or extrahepatic metastases of colorectal cancer.
  • To evaluate a rising and persistently elevated carcinoembryonic antigen (CEA) level when standard imaging, including CT scan, is negative. 

PET scanning is considered investigational as a technique to assess the presence of scarring versus local bowel recurrence in patients with previously resected colorectal cancer.

Esophageal Cancer

PET scanning may be considered medically necessary in the following situations:

  • Staging and restaging 
  • Determining response to preoperative induction therapy 

PET scanning is considered investigational in the evaluation of esophageal cancer, including but not limited to the following application:  Detection of primary esophageal cancer.

Ewing’s Sarcoma, Osteogenic Sarcoma

           

PET scanning may be considered medically necessary for staging and restaging of Ewing’s sarcoma and osteogenic sarcoma for the following conditions:

  • Prior to resection of an apparently solitary metastasis
  • For grading unresectable lesions when the grade of the histopathological specimen is in doubt
  • When predictive information, for example, tumor recurrence, response to chemotherapy, is needed to determine clinical management

Head and Neck Cancer (excluding central nervous system)

PET Scanning may be considered medically necessary for staging and restaging.

Lung Cancer

           

PET scanning may be considered medically necessary for any of the following applications:

  • Patients with a solitary pulmonary nodule as a technique to distinguish between benign and malignant disease when chest x-ray findings are inconclusive or discordant.
  • As a staging or restaging technique in those with known non-small cell lung cancer.
  • To determine resectability for patients with a presumed solitary metastatic lesion from lung cancer. 

PET scanning is considered investigational in staging and restaging of small cell lung cancer.

Lymphoma, Including Hodgkin’s Disease

PET scanning may be considered medically necessary for staging and restaging.

Melanoma

           

PET scanning may be considered medically necessary as a technique for assessing extranodal spread of malignant melanoma at initial staging or at restaging.

PET scanning is considered investigational as a technique to detect regional lymph node metastases in patients with clinically localized melanoma who are candidates to undergo sentinel node biopsy.

Multiple MyelomaPET scanning is considered investigational for staging or restaging.

Ovarian Cancer

PET scanning may be considered medically necessary for staging or restaging of ovarian cancer.

PET scanning is considered investigational in the evaluation of suspected ovarian cancer, including, but not limited to:

  • Patients with an adnexal mass or other symptoms suggestive of ovarian cancer for whom the need for full exploratory laparotomy must be considered.
  • Patients with likely ovarian cancer diagnosed by conventional methods who require initial staging in preparation for exploratory laparotomy.

 Pancreatic Cancer

           

PET scanning may be considered medically necessary in the initial diagnosis and staging of pancreatic cancer when other imaging modalities (endoscopic retrograde cholangiopancreatography (ERCP), CT, ultrasonography) are in doubt, inconclusive, or equivocal.

PET scanning may be considered medically necessary in the restaging of pancreatic cancer.

Prostate Cancer

PET scanning is considered investigational in the staging or restaging of known or suspected prostate cancer.

Soft Tissue Sarcoma

PET scanning is considered investigational in evaluation of soft tissue sarcoma in all situations.

Testicular Cancer

           

PET scanning is considered investigational in the initial staging of testicular cancer.

PET scanning may be considered medically necessary for advanced testicular germ cell tumors in patients with a CT documented residual mass after chemotherapy treatment and normal or elevated serum markers to assess for viable tumor, or to differentiate between fibrosis or necrosis.

Thyroid Cancer

             

 

PET imaging for differentiated thyroid cancer may be considered medically necessary only for restaging recurrent or residual thyroid cancers of follicular cell origin. The patient must have been previously treated by thyroidectomy and radioiodine ablation and have a serum thyroglobulin greater than 10ng/mL (10 nanograms per milliliter) and a negative whole body nuclear scan.

PET scanning is considered investigational in the evaluation of known or suspected differentiated thyroid cancer in all other situations.

 Unknown Primary

 

           

PET scanning may be considered medically necessary in patients with an unknown primary who meet ALL of the following criteria:

  • In patients with a single site of disease outside the cervical lymph nodes; AND
  • Patient is considering local or regional treatment for a single site of metastatic disease; AND
  • After a negative workup for a occult primary tumor; AND
  • PET scan will be used to rule out or detect additional sites of disease that would eliminate the rationale for local or regional treatment.

PET scanning is considered investigational for other indications in patients with an unknown primary, including, but not limited to the following:

  • As part of the initial workup of an unknown primary
  • As part of the workup of patients with multiple sites of disease

All Other Solid Tumors (Not listed above)

           

One PET study may be considered medically necessary for patients with solid tumors that are biopsy proven or strongly suspected based on other diagnostic testing. The patient's treating physician must determine that a PET study is needed to locate and categorize the extent of the tumor for the therapeutic initial treatment strategy when the method of the anti-tumor treatment chosen depends on the extent of the tumor.

Cancer Surveillance

Surveillance PET scanning is a study performed after the 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. The principles of surveillance are similar to those of traditional screening tests used for the early detection of disease. Surveillance has also been called “tertiary prevention.” Tertiary preventive services are those that are provided to persons who have or have had a disease in order to prevent further complications.

PET performed for surveillance is considered not medically necessary for the following reasons:

  • There are no clinical trials evaluating PET as a method of cancer surveillance to improve patient outcomes.
  • The sensitivity and specificity of PET scans in the surveillance setting is questionable given the possibility of false positives in these situations.
  • There is little published literature from clinical trials and studies that address PET for surveillance. As such, PET is not defined with certainty, inadequate direct, or indirect scientific evidence supporting the efficacy of PET scanning for the purpose of surveillance.
  • Because of the lack of outcome studies supporting the use of PET for surveillance in oncology, there are no standardized selection criteria.
  • It is unknown how frequently and for which cancers PET is used for surveillance. Registries of PET utilization and analysis of claims data (such as the National Oncologic PET Registry or NOPR), do not include PET scans used for surveillance.
  • The length of time after the completion of the cancer treatment is not adequately defined to determine with certainty whether or not a PET study is performed for surveillance purposes.

Other oncologic applications of PET scanning not mentioned in this document are considered investigational.

Note: For the clinical situations indicated that may be considered medically necessary, this is with the assumption that the results of the PET scan will influence treatment decisions. If the results will not influence treatment decisions, these situations would be considered not medically necessary.

 

POLICY EXCEPTIONS

 Trustmark Medical Plan: Effective October 1, 2010, PET scanning is covered for surveillance purposes for patients with adrenal cancer.

 

POLICY GUIDELINES

 Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member’s specific benefit plan language.

 

POLICY HISTORY

 11/17/2009: Policy Added as a result of the decision to separate the Positron Emission Tomography (PET) medical policy into application specific policies, this one addressing oncologic applications only. Upon creation of this separate policy, oncologic applications have been revised as outlined: The Policy Description Section revised for a clearer understanding of PET specific to oncologic applications, Policy Statement Section revised with medically necessary and investigational criteria for specific malignancies, Policy Coding Section updated to include Covered Codes specific to oncologic applications for PET, and added non-Covered Codes Table.

04/12/2010: Description section revised to add the four oncologic applications of PET Scanning; Policy section revised to add indications considered medically necessary for Melanoma, Lymphoma, lung; colorectal; pancreatic; head & neck; esophageal; breast; ovarian and testicular cancers.  Added indications considered medically necessary for differentiated thyroid and cervical cancers; added prostate cancer and cancer surveillance as investigational for all indications. Code reference section revised to add the following ICD-9 diagnosis codes to the covered codes table:  140.0 - 140.9; 141.0 - 141.9; 142.0 - 142.9; 143.0 - 143.9; 150.0 -150.9; 151.0 - 151.9, 155.1; 156.0; 156.2; 157.0 -157.9; 158.0 - 158.9; 159.0 - 159.9; 174.0 - 174.5 and 174.8 - 174.9; 175.0; 175.9; 180.0 - 180.9; 180.3 -183.9; 186.0; 186.9; 190.0 - 190.9; 191.0 - 191.9; 193; 194.0 - 194.9; 195.0; 198.3; 198.4; 198.6; 198.7; 198.81; 198.82; 209.00 - 209.03; 209.20 - 209.29; 230.0 - 230.9; 231.0 - 231.0 - 231.9; 233.0; 233.1; 234.0 - 234.9; 236.2; 235.4; 237.5; 239.0; 239.1; 239.3; 239.6; 239.9; 518.89; 784.2; and 795.81.  Moved HCPCS Code A9580 from non-covered to covered table.

10/05/2010: Policy reviewed; policy statement unchanged. Removed the following ICD-9 codes from the Covered Codes table to be consistent with the policy statement: 151.0-151.9, 152.0-152.9, 155.0-155.2, 156.0-156.9, 158.0-158.9, 159.0, 159.1, 159.8, 159.9, 194.0-194.9, 197.4, 197.5, 197.8, 198.3, 198.4, 198.6, 198.7, 198.81, 198.82, 209.00, 209.01, 209.02, 209.03, 209.11, 209.20-209.29, 230.2, 231.9, 234.8, 234.9, 235.2,  235.3, 235.4, 784.2, and 795.81. Corrected typo to change 235.4 to 236.4. Added 199.1, 209.20, 209.72, and 233.6 to the Covered Codes table.

02/07/2011:  Updated policy description regarding staging, restaging, and surveillance. Policy statement revised to add the following as covered indications if specified criteria are met:  Bone Metastases, Ewing’s Sarcoma, Osteogenic Sarcoma, and Other Solid Tumors. Policy statement extensively re-written. Added Brain Cancer to the policy statement as a specific indication for clarity purposes. Revised the coverage criteria for Breast Cancer to remove the following language: "when suspicion of disease is high and other imaging is inconclusive." Updated coverage criteria for thyroid cancer to state that the patient must have been previously treated by thyroidectomy and radioiodine ablation and have a serum thyroglobulin greater than 10ng/mL (10 nanograms per milliliter) and a negative whole body nuclear scan. Restaging added as covered for esophageal, cervical, and pancreatic cancer. Staging and restaging added as covered for ovarian cancer. Added additional coverage criteria for pancreatic and testicular cancer. Re-worded coverage criteria for soft tissue sarcoma; intent unchanged. Multiple myeloma added as investigational. Cancer surveillance changed from investigational to not medically necessary with reasons for this determination. Clarified the statement that other oncologic applications of PET scanning not mentioned in this document are considered investigational. Added ICD-9 codes 170.0-170.9, 198.5, and 233.39 to the Covered Codes table. 

06/13/2011:  Added the following statement to the Policy Exceptions section: Trustmark Medical Plan: Effective October 1, 2010, PET scanning is covered for surveillance purposes for patients with adrenal cancer.

12/08/2011: Annual ICD-9 code update: 793.1 deleted/expanded to the fifth digit. Added 793.11 to the Covered Codes table.

 

SOURCES

 Blue Cross Blue Shield Association policy # 6.01.26

 

CODE REFERENCE

 This is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

A PET scan essentially involves 3 separate activities:
1. Manufacture of the radiopharmaceutical, which may be manufactured on site or manufactured at a regional delivery center with delivery to the institution performing PET
2. Actual performance of the PET scan, and
3. Interpretation of the results

When the radiopharmaceutical is provided by an outside distribution center, there may be an additional separate charge, or this charge may be passed through and included in the hospital bill. In addition, there will likely be an additional transportation charge for radiopharmaceuticals that are not manufactured on site.

Covered Codes        

Code Number

Description

CPT

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

ICD-9 Procedure

88.90

Diagnostic imaging, not elsewhere classified

92.01, 92.02, 92.03, 92.04, 92.09

Radioisotope scan and function study (code range)

92.11, 92.12, 92.13, 92.14, 92.15, 92.16, 92.18, 92.19

Other radioisotope scan (code range)

ICD-9 Diagnosis
Covered only when medically necessary criteria are met

140.0, 140.1, 140.3, 140.4, 140.5, 140.6, 140.8, 140.9Malignant neoplasm of lip (code range) (Added 04/12/2010)
141.0, 141.1, 141.2, 141.3, 141.4, 141.5, 141.6, 141.8, 141.9Malignant neoplasm of tongue (code range) (Added 04/12/2010)
142.0, 142.1, 142.2, 142.8, 142.9Malignant neoplasm of major salivary glands (code range) (Added 04/12/2010)
143.0, 143.1, 143.8, 143.9Malignant neoplasm of gum (code range) (Added 04/12/2010)

144.0, 144.1, 144.8, 144.9

Malignant neoplasm of floor of mouth (code range)

145.0, 145.1, 145.2, 145.3, 145.4, 145.5, 145.6, 145.8, 145.9

Malignant neoplasm of other and unspecified parts of mouth (code range)

146.0, 146.1, 146.2, 146.3, 146.4, 146.5, 146.6, 146.7, 146.8, 146.9

Malignant neoplasm of oropharynx (code range)

147.0, 147.1, 147.2, 147.3, 147.8, 147.9

Malignant neoplasm of nasopharynx (code range)

148.0, 148.1, 148.2, 148.3, 148.8, 148.9

Malignant neoplasm of hypopharynx (code range)

149.0, 149.1, 149.8, 149.9

Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx (code range)

150.0, 150.1, 150.2, 150.3, 150.4, 150.5, 150.8, 150.9Malignant neoplasm of esophagus (Added 04/12/2010)

153.0, 153.1, 153.2, 153.3, 153.4, 153.5, 153.6, 153.7, 153.8, 153.9

Malignant neoplasm of colon (code range)

154.0, 154.1, 154.2, 154.3, 154.8

Malignant neoplasm of rectum, rectosigmoid junction, and anus (code range)

157.0, 157.1, 157.2, 157.3, 157.4, 157.8, 157.9Malignant neoplasm of pancreas (Added 04/12/2010)

160.0, 160.1, 160.2, 160.3, 160.4, 160.5, 160.8, 160.9

Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses (code range)

161.0, 161.1, 161.2, 161.3, 161.8, 161.9

Malignant neoplasm of larynx (code range)

162.2, 162.3, 162.4, 162.5, 162.8, 162.9

Malignant neoplasm of bronchus, and lung (code range)

163.0, 163.1, 163.8, 163.9

Malignant neoplasm of pleura (code range)

165.0, 165.8, 165.9

Malignant neoplasm of other and ill-defined sites within the respiratory system and intrathoracic organs

170.0 - 170.9Malignant neoplasm of bone and articular cartilage (Added 02-07-2011)

172.0, 172.1, 172.2, 172.3, 172.4, 172.5, 172.6, 172.7, 172.8, 172.9

Malignant melanoma of skin (code range)

174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.8, 174.9

Malignant neoplasm of female breast (code range)

Note:  174.6 is not a covered diagnosis code per Policy.

(Added 04/12/2010)

175.0, 175.9Malignant neoplasm of male breast (Added 04/12/2010)
180.0, 180.1, 180.8, 180.9Malignant neoplasm of cervix uteri (Added 04/12/2010)
183.0, 183.2, 183.3, 183.4, 183.5, 183.8, 183.9Malignant neoplasm of ovary and other uterine adnexa (Added 04/12/2010)
186.0, 186.9Malignant neoplasm of testis (Added 04/12/2010)
190.0, 190.1, 190.2, 190.3, 190.4, 190.5, 190.6, 190.7, 190.8, 190.9 Malignant neoplasm of eye (code range) (Added 04/12/2010)
191.0, 191.1, 191.2, 191.3, 191.4, 191.5, 191.6, 191.7, 191.8, 191.9 Malignant neoplasm of brain (Added 04/12/2010)
193Malignant neoplasm of thyroid gland (Added 04/12/2010)
195.0Malignant neoplasm of head, face and neck (Added 04/14/2010)

196.0, 196.1, 196.2, 196.3, 196.5, 196.6, 196.8, 196.9

Secondary and unspecified malignant neoplasm of lymph nodes (code range)

197.0, 197.1, 197.2, 197.3,  197.6, 197.7

Secondary malignant neoplasm of respiratory and digestive systems (code range)

198.5Secondary malignant neoplasm of bone and bone marrow (Added 02-07-2011)
199.1Other malignant neoplasm of unspecified site (Added 10-05-2010)

200.00, 200.01, 200.02, 200.03, 200.04, 200.05, 200.06, 200.07, 200.08

Reticulosarcoma (code range)

200.10, 200.11, 200.12, 200.13, 200.14, 200.15, 200.16, 200.17, 200.18

Lymphosarcoma (code range)

200.20, 200.21, 200.22, 200.23, 200.24, 200.25, 200.26, 20.27, 200.28

Burkitt’s tumor or lymphoma (code range)

200.30, 200.31, 200.32, 200.33, 200.34, 200.35, 200.36, 200.37, 200.38

Marginal zone lymphoma (code range)

200.40, 200.41, 200.42, 200.43, 200.44, 200.45, 200.46, 200.47, 200.48

Mantle cell lymphoma (code range)

200.50, 200.51, 200.52, 200.53, 200.54, 200.55, 200.56, 20057, 200.58

Primary central nervous system lymphoma (code range)

200.60, 200.61, 200.62, 200.63, 200.64, 200.65, 200.66, 200.67, 200.68

Anaplastic large cell lymphoma (code range)

200.70, 200.71, 200.72, 200.73, 200.74, 200.75, 200.76, 200.77, 200.78

Large cell lymphoma (code range)

200.80, 200.81, 200.82, 200.83, 200.84, 200.85, 200.86, 200.87, 200.88

Other named variants (code range), Lymphoma (malignant), Lymphosarcoma mixed cell type (diffuse), lymphoplasmacytoid type, Reticulolymphosarcoma (diffuse), mixed lymphocytic-histiocytic (diffuse)

201.00, 201.01, 201.02, 201.03, 201.04, 201.05, 201.06, 201.07, 201.08, 201.10, 201.11, 201.12, 201.13, 201.14,  201.15, 201.16, 201.17, 201.18, 201.20, 201.21, 201.22, 201.23, 201.24, 201.25, 201.26, 201.27, 201.28, 201.40, 201.41, 201.42, 201.43, 201.44, 201.45, 201.46, 201.47, 201.48, 201.50, 201.51, 201.52, 201.53, 201.54, 201.55, 201.56, 201.57, 201.58, 201.60, 201.61, 201.62, 201.63,  201.64, 201.65, 201.66, 201.67, 201.68, 201.70, 201.71, 201.72, 201.73, 201.74, 201.75, 201.76, 201.77, 201.78, 201.90, 201.91, 201.92, 201.93, 201.94, 201.95, 201.96, 201.97, 201.98

Hodgkin’s disease (code range)

202.00, 202.01, 202.02, 202.03, 202.04, 202.05, 202.06, 202.06, 202.07, 202.08,  202.10, 202.11, 202.12, 202.13, 202.14,  202.15, 202.16, 202.17, 202.18, 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26, 202.27, 202.28, 202.30, 202.31, 202.32, 202.33, 202.34, 202.35, 202.36, 202.37, 202.38, 202.40, 202.41, 202.42, 202.43, 202.44, 202.45, 202.46, 202.47, 202.48, 202.50, 202.51, 202.52, 202.53, 202.54, 202.55, 202.56, 202.57, 202.58, 202.60, 202.61, 202.62, 202.63,  202.64, 202.65, 202.66, 202.67, 202.68, 202.70, 202.71, 202.72, 202.73, 202.74, 202.75, 202.76, 202.77, 202.78, 202.80, 202.81, 202.82, 202.83, 202.84, 202.85, 202.86, 202.87, 202.88, 202.90, 202.91, 202.92, 202.93, 202.94, 202.95, 202.96, 202.97, 202.98

Other malignant neoplasms of lymphoid and histiocytic tissue (code range)

209.10, 209.11, 209.12, 209.13, 209.14, 209.15, 209.16, 209.17, 209.20

Malignant carcinoid tumors of the large intestine and rectum (code range) (Added 10-05-2010)

 

209.72Secondary neuroendocrine tumor of liver (Added 10-05-2010) 
230.0, 230.1, 230.3, 230.4, 230.5, 230.6, 230.7, 230.8, 230.9Carcinoma in situ of digestive organs (code range) (Revised 10-05-2010)
231.0, 231.1, 231.2. 231.8Carcinoma in situ of respiratory system (code range) (Revised 10-05-2010)
233.0Carcinoma in situ of breast (Added 04/12/2010)
233.1Carcinoma in situ of cervix uteri (Added 04/12/2010)
233.39Carcinoma in situ, other female genital organ (Added 02-07-2011)
233.6Carcinoma in situ of other and unspecified male genital organs (Added 10-05-2010)
234.0Carcinoma in situ of eye (Revised 10-05-2010)

235.0, 235.1, 235.5, 235.6, 235.7, 235.8, 235.9

Neoplasm of uncertain behavior of digestive and respiratory systems (code range) (Revised 10-05-2010)

236.2Neoplasm of uncertain behavior of ovary (Added 04/12/2010)
236.4Neoplasm of uncertain behavior of testis (Revised 10-05-2010)
237.5 Neoplasm of uncertain behavior of brain and spinal cord (Added 04/12/2010)
239.0, 239.1, 239.3, 239.6, 239.9Neoplasms of unspecified nature (code range) (Added 04/12/2010)
518.89Other diseases of lung, not elsewhere classified (Added 04/12/2010)
793.1

Nonspecific (abnormal) findings on radiological and other examination of lung field  Deleted  (09-30-2011)

793.11

Solitary pulmonary nodule (New 10-01-2011)

HCPCS

A9552

Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries

A9580Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries (Moved to Covered Codes Table 04/12/2010)

G0235

PET imaging, any site, not otherwise specified

 


 

 Non-Covered Codes           

This is not an all-inclusive list of non-covered procedure codes.

The code(s) listed below and ANY code not listed in the previous section are considered non-covered for this procedure. 

Code Number

Description

CPT

 

 

ICD-9 Procedure

 

 

ICD-9 Diagnosis

 

 

HCPCS

G0219

PET imaging whole body; melanoma for noncovered indications

G0252

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)

S8085

Fluorine-18 fluorodeoxyglucose (F-18 FDG) imaging using dual-head coincidence detection system (nondedicated PET scan)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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