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DESCRIPTIONPositron 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.
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:
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 EXCEPTIONSTrustmark Medical Plan: Effective October 1, 2010, PET scanning is covered for surveillance purposes for patients with adrenal cancer.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member’s specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
POLICY HISTORY11/17/2009: 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.
05/13/2013: Policy reviewed; no changes to policy statement. Removed deleted ICD-9 code 793.1 from the Code Reference section.
09/15/2014: Policy statement revised to state that PET scanning may be considered medically necessary for the following applications: 1) The initial diagnosis and staging of gastric cancer and 2) Evaluation for recurrent gastric cancer following surgical resection, when other imaging modalities are inconclusive. Added the following ICD-9 diagnosis codes to the Covered Codes table: 151.0 - 151.9 and 230.2.
08/31/2015: Code Reference section updated for ICD-10. Removed ICD-9 procedure code 88.90.
05/31/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
SOURCESBlue Cross Blue Shield Association policy # 6.01.26
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary 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.
Not Medically Necessary Codes