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DESCRIPTIONUnlike standard anatomic radiologic techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI), positron emission tomography (PET) is able to image biochemical and physiological functions. This process is accomplished by measuring concentrations of radioactive chemicals that are partially metabolized in the body region of interest. Radiopharmaceuticals used for PET are generated in a cyclotron or nuclear generator and introduced into the body by intravenous injection or by respiration.
A variety of PET radiopharmaceuticals have been investigated; however, only a few have received approval by the U.S. Food and Drug Administration (FDA) for clinical use:
The scanners used for PET imaging are somewhat similar to those used for x-ray CT, but PET requires complicated technology and computerized mathematical models of physiologic functions and tracer kinetics for the generation of images.
This policy focuses on the miscellaneous applications of PET scanning.
Important Note: This policy only addresses the use of radiotracers detected with the use of dedicated full-ring PET scanners. Radiotracers such as FDG may be detected using SPECT cameras, a hybrid PET/SPECT procedure that may be referred to as FDG-SPECT or molecular coincidence detection.
POLICYPositron emission tomography (PET) using 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) may be considered medically necessary in:
In addition, the purpose of the positron emission tomography (PET) examination should be to avoid subjecting the patient to extended preoperative electroencephalographic recording with implanted electrodes or to help localize and minimize the number of sites for implanted electrodes to reduce the morbidity of that procedure.
The use of PET for all other miscellaneous indications is investigational, including, but not limited to:
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member’s specific benefit plan language.
POLICY HISTORY11/19/2009: Policy added as a result of the decision to separate the Positron Emission Tomography (PET) medical policy into application specific policies, this one addressing miscellaneous applications only. Upon creation of this separate policy, miscellaneous applications have been revised as outlined: The Policy Description Section revised for a clearer understanding of PET, Policy Statement Section revised to add the diagnosing chronic osteomyelitis as medically necessary, added a guideline for epileptic candidates for surgery, added CNS diseases, Pulmonary diseases, Musculoskeletal diseases and Giant cell arteritis to investigational implications, Policy Coding Section updated to include Covered Codes specific to epilepsy, seizures, and chronic osteomyelitis applications for PET, and added non-Covered Codes Table.
12/28/2010: Policy statement updated to add "Vasculitis" as an investigational indication in the "Other" category.
11/04/2011: Removed the link to the archived medical policy for Single Photon Emission Computed Tomography (SPECT).
04/11/2012: Added mycobacterium infection and inflammatory bowel disease as investigational indications.
05/13/2013: Added sarcoidosis as an investigational indication.
SOURCESBlue Cross Blue Shield Association policy # 6.01.06
CODE REFERENCEThis 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:
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.
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.