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A.6.01.26
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 to produce images. 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, comprising 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 choline, fluorine 18, gallium 68, fluciclovine 18, and copper 64. Because of their short half-life, some tracers must be made locally using an onsite cyclotron. The radiotracer most commonly used in oncology imaging has been fluorine 18 coupled with fluorodeoxyglucose (FDG), which correlates with glucose metabolism. Fluorodeoxyglucose has been considered useful in cancer imaging because tumor cells show increased metabolism of glucose. The most common malignancies studied have been melanoma, lymphoma, lung, colorectal, and pancreatic cancer.
Fluoroestradiol F18 (FES) is another radiotracer used in oncology imaging. FES specifically targets and binds to the estrogen receptor (ER) and its uptake, measured by PET, in breast cancer tumors is directly proportional to tumor ER expression.
This policy focuses on the use of radiotracers detected with dedicated PET scanners. Radiotracers, such as FDG, may be detected using single-photon emission computerized tomography cameras, a technique that may be referred to as FDG-single-photon emission computerized tomography imaging. The use of single-photon emission computerized tomography cameras for PET radiotracers presents unique issues of diagnostic performance and is not considered in this policy.
This policy focuses on four oncologic applications of PET scanning:
Diagnosis: This refers to the use of PET as part of the testing used in establishing whether a patient has cancer.
Staging / Initial anti-tumor treatment strategy: This refers to the 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 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 after treatment in two situations. Restaging is part of the evaluation of a patient in whom disease recurrence is suspected based on signs and/or symptoms. Restaging also includes determining the extent of malignancy after completion of a full course of treatment.
Surveillance: This refers to the use of imaging in asymptomatic individuals (individuals without objective signs or symptoms of recurrent disease). This imaging is completed 6 months or more (12 months or more for lymphoma) after 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.
A number of radiopharmaceuticals have been granted approval by the FDA to be used with PET for various cancer-related indications, however, none are specific to gastrointestinal cancer, pancreatic cancer, bone cancer, soft tissue sarcoma, hematologic cancer, brain cancer, melanoma, cancer of unknown primary, or single-site metastatic disease. Fluorine-18 fluorodeoxyglucose (FDG) is approved for use in suspected or existing diagnosis of cancer, all types.
As of November 2024, the following radiopharmaceuticals have been granted approval by the FDA to be used with PET for cancer-related indications (see the table below).
Cerianna™ is indicated for use with PET for the detection of estrogen receptor (ER)-positive lesions as an adjunct to biopsy in individuals with recurrent or metastatic breast cancer. It's limitation of use states that "tissue biopsy should be used to confirm recurrence of breast cancer and to verify ER status by pathology."
Radiopharmaceuticals Approved for Use with PET for Oncologic Applications
Radiopharmaceutical | Manufacturer | Name | Carcinoma-Related Indication with PET |
Carbon-11 choline (C-11) | Various | Suspected prostate cancer recurrence based on elevated blood PSA after therapy and noninformative bone scintigraphy, CT, or MRI | |
Copper-64 dotatate | Curium | Detectnet™ | Localization of somatostatin receptor-positive NETs in adult individuals |
Fluorine-18 fluorodeoxyglucose(FDG) | Various | Suspected or existing diagnosis of cancer, all types | |
Fluorine-18 fluoroestradiol (FES) | Zionexa USA | Cerianna™ | Detection of ER-positive lesions as an adjunct to biopsy in individuals with recurrent or metastatic breast cancer |
Fluorine-18 fluciclovine | Blue Earth Diagnostics | Axumin™ | Suspected prostate cancer recurrence based on elevated blood PSA levels after treatment |
Gallium-68 dotatoc | UIHC - P E T Imaging Center | Localization of somatostatin receptor-positive NETs in adult and pediatric individuals | |
Gallium-68 dotatate | Advanced Accelerator Applications | NETSPOT™ | Localization of somatostatin receptor positive NETs in adult and pediatric individuals |
Gallium-68 PSMA-11§ | University of California, Los Angeles and the University of California, San Francisco | PSMA positive lesions in men with prostate cancer with suspected metastasis who are candidates for initial definitive therapy or with suspected recurrence based on elevated serum PSA level | |
Piflufolastat fluorine-18 | Progenics Pharmaceuticals, Inc | Pylarify® | PSMA positive lesions in men with prostate cancer with suspected metastasis who are candidates for initial definitive therapy or with suspected recurrence based on elevated serum PSA level |
Flotufolastat fluorine-18 | Blue Earth Diagnostics | Posluma® | PSMA positive lesions in men with prostate cancer with suspected metastasis who are candidates for initial definitive therapy or with suspected recurrence based on elevated serum PSA level |
§ FDA-approval given to the University of California, Los Angeles and the University of California, San Francisco.CT: computerized tomography; ER: estrogen receptor; MRI: magnetic resonance imaging; NET: neuroendocrine tumors; PET: positron emission tomography; PSA: prostate-specific antigen; PSMA: prostate-specific membrane antigen.
Interim PET Scanning in Oncology to Detect Early Response During Treatment is addressed in a separate policy. Cardiac Applications of PET Scanning are addressed in a separate policy. Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorodeoxyglucose F 18 Positron Emission Tomography are addressed in a separate policy.
Two kits used for the preparation of Gallium-68 PSMA-11 have received FDA approval: the Illuccix® (Telix Pharmaceuticals) kit, approved in December 2021; and the Locametz® (Advanced Accelerator Applications/Novartis) kit, approved in March 2022. The preparation kits are for use in individuals with PSMA-positive prostate cancer with suspected metastasis who are candidates for initial definitive therapy, or with suspected recurrence based on elevated serum PSA level. In addition, Locametz is approved for selection of patients with metastatic prostate cancer, for whom lutetium Lu-177 vipivotide tetraxetan (Pluvicto™; Novartis) PSMA-directed therapy is indicated.
Important Note:This policy only addresses the use of radiotracers detected with dedicated PET scanners. Radiotracers, such as FDG, may be detected using single-photon emission computerized tomography (SPECT) cameras, a technique that may be referred to as FDG-SPECT imaging. The use of SPECT cameras for PET radiotracers presents unique issues of diagnostic performance and is not considered in this policy.
All policy statements apply to both positron emission tomography (PET) scans and PET plus computed tomography (CT) scans (ie, PET scans with or without PET/CT fusion).
For the clinical situations indicated that may be considered medically necessary, this assumes 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.
Bladder Cancer | PET scanning may be considered medically necessary in the staging or restaging of muscle-invasive bladder cancer when CT or magnetic resonance imaging are not indicated or remained inconclusive on distant metastasis. PET scanning is considered investigational for bladder tumors that have not invaded the muscle (stage less than cT2). |
Brain Cancer | PET scanning may be considered medically necessary in the staging or restaging of brain cancer. |
Breast Cancer (Male & Female) | PET scanning using 18F-FDG isotope may be considered medically necessary in the staging or restaging of breast cancer for the following application: Detecting locoregional or distant recurrence or metastasis (except axillary lymph nodes) when suspicion of disease is high and other imaging is inconclusive. PET scanning using 18F-FDG isotope is considered investigational in the evaluation of breast cancer for all other applications, including but not limited to the following: Differential diagnosis in individuals with suspicious breast lesions or an indeterminate or low suspicion finding on mammography Staging axillary lymph nodes Predicting pathologic response to neoadjuvant therapy for locally advanced disease. PET scanning using fluoroestradiol F18 (FES) is considered investigational in individuals with breast cancer (see Policy Guidelines for exceptions). |
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 individuals with suspected or biopsy-proven bone metastases. |
Cervical Cancer | PET scanning using 18F-FDG isotope may be considered medically necessary in the initial staging of individuals with locally advanced cervical cancer (conventional imaging is negative for extra-pelvic metastasis). PET scanning using 18F-FDG isotope may be considered medically necessary for restaging to detect residual or recurrent disease in individuals 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 or 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 individuals with previously resected colorectal cancer. A technique contributing to radiotherapy treatment planning. |
Endometrial Cancer | PET scanning using 18F-FDG isotope is considered medically necessary in the: Detection of lymph node metastases, and Assessment of endometrial cancer recurrence. |
Esophageal Cancer | PET scanning may be considered medically necessary in the following situations: Staging and restaging of esophageal cancer. Determining response to preoperative induction therapy. PET scanning is considered investigational in other aspects of the evaluation of esophageal cancer, including but not limited to the following applications: 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. |
Gastric Cancer | PET scanning may be considered medically necessary for the following applications: The initial diagnosis and staging of gastric cancer. Evaluation for recurrent gastric cancer following surgical resection, when other imaging modalities are inconclusive. |
Head and Neck Cancer (excluding central nervous system) | PET scanning may be considered medically necessary in the evaluation of head and neck cancer in the following applications: Initial diagnosis of suspected cancer, Initial staging of disease, and restaging of residual or recurrent disease during follow-up, and Evaluation of response to treatment. |
Lung Cancer | PET scanning may be considered medically necessary for any of the following applications: Individuals with a solitary pulmonary nodule as a single scan technique (not dual-time) to distinguish between benign and malignant disease when prior CT scan and 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 individuals with a presumed solitary metastatic lesion from lung cancer. PET scanning may be considered medically necessary in staging of small-cell lung cancer if limited stage is suspected based on standard imaging. PET scanning is considered investigational in staging of small-cell lung cancer if extensive stage is established and in all other aspects of managing 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 during follow-up treatment for advanced disease (stage III or IV). PET scanning is considered investigational in managing stage 0, I, or II melanoma. PET scanning is considered investigational as a technique to detect regional lymph node metastases in individuals with clinically localized melanoma who are candidates to undergo sentinel node biopsy. |
Multiple Myeloma | PET scanning may be considered medically necessary for staging or restaging, particularly if the skeletal survey is negative. |
Neuroendocrine Tumors | PET scanning with gallium 68 and copper 64 may be considered medically necessary as a technique for staging neuroendocrine tumors either during initial staging or for restaging at follow-up. PET scanning with other radiotracers is considered investigational in all aspects of managing neuroendocrine tumors. |
Ovarian Cancer | PET scanning using 18F-FDG isotope may be considered medically necessary in the evaluation of individuals with signs and/or symptoms of suspected ovarian cancer recurrence (restaging) when standard imaging, including CT scan, is inconclusive. PET scanning using 18F-FDG isotope is considered investigational in the initial evaluation of known or suspected ovarian cancer in all situations. |
Pancreatic Cancer | PET scanning may be considered medically necessary in the initial diagnosis and staging of pancreatic cancer when other imaging and biopsy are inconclusive. PET scanning may be considered medically necessary in the restaging of pancreatic cancer. |
Penile Cancer | PET scanning may be considered medically necessary for staging and restaging in individuals with suspected inguinal lymph node positive disease. PET scanning is considered investigational in all other aspects of managing penile cancer. |
Prostate Cancer | PET scanning with carbon 11 choline and fluorine 18 fluciclovine may be considered medically necessary for evaluating suspected or biochemically recurrent prostate cancer after primary treatment to detect small volume disease in soft tissues. PET scanning with gallium 68-prostate-specific membrane antigen, flotufolastat fluorine-18, and piflufolastat fluorine-18 may be considered medically necessary for any of the following applications: Individuals with diagnosed prostate cancer in need of staging information and: NCCN unfavorable intermediate-, high-, or very-high-risk prostate cancer (see Policy Guidelines); OR NCCN unfavorable intermediate-, high-, or very-high-risk prostate cancer with equivocal results or oligometastatic disease on initial conventional imaging (see Policy Guidelines). Individuals with suspected recurrence of prostate cancer based on serum PSA level who have received: Radical prostatectomy with PSA level persistence or rise from undetectable level (see Policy Guidelines); OR Definitive radiotherapy with PSA rise above nadir (see Policy Guidelines). Individuals with treated prostate cancer (including active surveillance/observation) in need of imaging as part of a workup for progression (see Policy Guidelines). Individuals with metastatic prostate cancer for whom lutetium Lu-177 vipivotide tetraxetan PSMA-directed therapy is indicated. Use of gallium 68-prostate-specific membrane antigen, flotufolastat fluorine-18, and piflufolastat fluorine-18 in known or suspected prostate cancer is considered investigational for all other indications, including diagnosis, primary staging of very-low, low- or favorable intermediate-risk prostate cancer, and evaluation of response to therapy. PET scanning for all other indications in known or suspected prostate cancer is considered investigational. |
Renal Cell Carcinoma | PET scanning is considered investigational in all aspects of managing renal cancer. |
Soft Tissue Sarcoma | PET scanning is considered medically necessary for evaluating response to imatinib and other treatments for gastrointestinal stromal tumors. PET scanning is considered investigational in evaluation of soft tissue sarcoma, including but not limited to the following applications: Distinguishing between benign lesions and malignant soft tissue sarcoma, Distinguishing between low-grade and high-grade soft tissue sarcoma, Detecting locoregional recurrence, and Detecting distant metastasis. |
Testicular Cancer | PET scanning may be considered medically necessary in evaluation of residual mass following chemotherapy of stage IIB and III seminomas (the scan should be completed no sooner than 6 weeks after chemotherapy). Except as noted above for seminoma, PET scanning is considered investigational in evaluation of testicular cancer, including but not limited to the following applications: Initial staging of testicular cancer, Distinguishing between viable tumor and necrosis/fibrosis after treatment of testicular cancer, and Detection of recurrent disease after treatment of testicular cancer. |
Thyroid Cancer | PET scanning may be considered medically necessary in the restaging of individuals with differentiated thyroid cancer when thyroglobulin levels are elevated and whole-body iodine-131 imaging is negative. PET scanning is considered investigational in the evaluation of known or suspected differentiated or poorly differentiated thyroid cancer in all other situations. |
Cancer of Unknown Primary | PET scanning may be considered medically necessary in individuals with a cancer of unknown primary who meet ALL of the following criteria: In individuals with a single site of disease outside the cervical lymph nodes; AND Individual is considering local or regional treatment for a single site of metastatic disease; AND After a negative workup for an 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 individuals with a cancer of unknown primary, including, but not limited to the following: As part of the initial workup of a cancer of unknown primary, and As part of the workup of individuals with multiple sites of disease. |
All Other Solid Tumors (Not listed above) | One PET study may be considered medically necessary for individuals with solid tumors that are biopsy proven or strongly suspected based on other diagnostic testing. The individual'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.
Trustmark 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.
Selection Criteria
As with any imaging technique, the medical necessity of positron emission tomography (PET) scanning depends in part on what imaging techniques are used before or after the PET scanning. Due to its expense, PET scanning is typically considered after other techniques, such as computed tomography (CT), magnetic resonance imaging (MRI), or ultrasonography, provide inconclusive or discordant results. In individuals with melanoma or lymphoma, PET scanning may be considered an initial imaging technique. If so, the medical necessity of subsequent imaging during the same diagnostic evaluation is unclear. Thus, PET should be considered for the medically necessary indications above only when standard imaging (eg, CT, MRI) is inconclusive or not indicated, including situations when an individual has a contraindication to intravenous contrast agents, making initial CT scans unattainable.
Selection criteria for PET scanning may also be complex. For example, it may be difficult to determine from claims data whether a PET scan in an individual with malignant melanoma is being done primarily to evaluate extranodal disease or regional lymph nodes. Similarly, it may be difficult to determine whether a PET scan in an individual with colorectal cancer is being performed to detect hepatic disease or evaluate local recurrence. Due to the complicated hierarchy of imaging options in individuals with malignancy and complex selection criteria, a possible implementation strategy for this policy is its use for retrospective review, possibly focusing on cases with multiple imaging tests, including PET scans.
Use of fluoroestradiol F18 (FES)-PET may be considered in individuals with recurrent or metastatic breast cancer in certain clinical scenarios, such as when a biopsy is inconclusive. Current NCCN guidelines on breast cancer (v.5.2024) state that FES-PET may be considered for estrogen receptor-positive disease.
Prostate-Specific Membrane Antigen Positron Emission Tomography
Appropriate selection of patients for prostate-specific membrane antigen (PSMA) PET imaging may be guided according to National Comprehensive Cancer Network (NCCN) and Society of Nuclear Medicine and Molecular Imaging (SNMMI) criteria (see Policy section 68Ga-PSMA PET, 68Ga-PSMA PET/CT, Piflufolastat-F18 PET, and Piflufolastat-F18 PET/CT Guidelines). NCCN and SNMMI recommendations for use of PSMA PET in individuals with newly diagnosed prostate cancer in need of staging are based on the following NCCN risk criteria:
Risk Group | Clinical/Pathological Features |
Very Low | Has all of the following: cT1c Grade Group 1 PSA <10 ng/mL Fewer than 3 prostate biopsy fragments/cores positive, ≤50% cancer in each fragment/core PSA density <0.15 ng/mL/g |
Low | Has all of the following but does not qualify for very low risk: cT1–cT2a Grade Group 1 PSA <10 ng/mL |
Intermediate | Has all of the following: No high-risk group features No very-high-risk group features Has one or more intermediate risk factor: cT2b–cT2c Grade Group 2 or 3 PSA 10–20 ng/mL |
Favorable Intermediate | Intermediate risk criteria, AND all of the following: 1 intermediate risk factor Grade Group 1 or 2 <50% biopsy cores positive (e.g., <6 of 12 cores) |
Unfavorable Intermediate | Intermediate risk criteria AND one or more of the following: 2 or 3 intermediate risk factors Grade Group 3 ≥50% biopsy cores positive (e.g., ≥6 of 12 cores) |
High | Has no very-high-risk features and has exactly one high-risk feature: cT3a OR Grade Group 4 or Grade Group 5 OR PSA >20 ng/mL |
Very High | Has at least one of the following: cT3b– cT4 Primary Gleason pattern 5 2 or 3 high-risk features >4 cores with Grade Group 4 or 5 |
Individuals who meet unfavorable intermediate-, high- and very-high risk criteria are suitable candidates for PSMA PET bone and/or soft tissue imaging, either following equivocal results on initial conventional imaging (e.g., MRI) or as alternative to conventional imaging.
PSMA PET imaging is not recommended for staging newly diagnosed individuals in very low, low, or favorable intermediate NCCN risk groups, or for individuals with suspected prostate cancer based on elevated PSA, increasing PSA on serial measurements, and/or clinical signs (e.g., abnormal digital rectal exam).
Use of PSMA PET imaging is appropriate for individuals who have undergone radical prostatectomy or radiation therapy for prostate cancer with subsequent suspected persistence or recurrence. Specific considerations for use of PSMA PET are:
Following radical prostatectomy AND:
Failure of PSA to fall to undetectable levels; OR
Previously undetectable PSA with a subsequent detectable PSA that increases on ≥2 measurements
Following definitive radiation therapy AND:
A PSA rise ≥2 ng/mL above the nadir; OR
A positive digital rectal exam.
PSMA PET may also be considered when PSA has been confirmed to be increasing after radiation therapy even if the increase above nadir is not yet 2 ng/mL, particularly in candidates with a favorable prognosis for salvage local therapy.
PSMA PET use is appropriate in individuals who have previously been treated for prostate cancer (including those under active surveillance/observation) who require imaging as part of a workup for progression. NCCN guidelines include recommended workup protocols, which vary according to prior treatment and cancer stage. The guidelines recommend use of PSMA PET bone and soft tissue imaging when conventional imaging results are equivocal, but also state that PSMA PET imaging is more accurate than conventional imaging at detecting micrometastatic disease, and as such, the guidelines note that conventional imaging is not a necessary prerequisite to PSMA PET imaging.
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 Mental Health Disorders, 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 medical necessity, “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.
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.
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 A.6.01.26 added. Policy Guidelines updated to add medically necessary and investigative definitions.
12/30/2016: Code Reference section updated to add new 2017 HCPCS code A9597.
04/09/2018: Policy description updated regarding FDA-approved radiopharmaceuticals. For breast cancer, added statement that PET scanning is considered investigational for "predicting pathologic response to neoadjuvant therapy for locally advanced disease." Added statement that PET scanning is considered medically necessary in the detection of lymph node metastases, and assessment of endometrial cancer recurrence. For head and neck cancer, policy statement changed from medically necessary for "staging and restaging" to medically necessary in the "evaluation of head and neck cancer" meeting certain criteria. Added the following for prostate cancer: 1) PET scanning with Carbon-11 chloline may be medically necessary for evaluating response to primary treatment in prostate cancer. 2) PET scanning with Gallium-68 is considered investigational in all aspects of managing prostate cancer. PET scanning for all other indications in known or suspected prostate cancer is considered investigational. Added statement that PET scanning is considered investigational in all aspects of managing renal cancer. Code Reference section updated to add HCPCS code A9515 and ICD-10 diagnosis codes C54.1, C61, D07.0, and D07.5 to the Covered Codes table. Added HCPCS code A9587 to the Not Medically Necessary Codes table.
01/01/2019: Policy description updated. Policy section updated to add the following as covered indications if the specified criteria are met: Bladder Cancer and Neuroendocrine Tumors. For lung cancer, staging and restaging of small cell lung cancer changed from investigational to medically necessary in staging of small-cell lung cancer if limited stage is suspected. Policy statement for multiple myeloma changed from investigational to medically necessary for staging and restaging. For prostate cancer, fluorine 18 fluciclovine added as medically necessary. Code Reference section updated to add HCPCS code A9588 as covered. HCPCS code A9587 moved to covered codes table. Added the following ICD-10 diagnosis codes: C67.0 - C67.9, C7A.00 - C7A.8, C7B.00 - C7B.8, C90.00, and C90.02.
12/18/2019: Policy description updated. Policy statements unchanged.
05/28/2020: Code Reference section updated to add ICD-10 diagnosis code R97.21.
09/23/2020: Code Reference section updated to add new HCPCS code C9067, effective 10/01/2020.
01/28/2021: Code Reference section updated to add ICD-10 diagnosis codes C37, C79.31, and C79.32.
02/11/2021: Policy description updated regarding radiopharmaceuticals approved for use with PET for oncologic applications. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."
06/29/2021: Code Reference section updated to add new HCPCS codes A9593 and A9594, effective 07/01/2021.
10/01/2021: Code Reference section updated to add new ICD-10 diagnosis code C84.7A effective 10/01/2021.
06/13/2022: Policy title updated to change "Oncologic Applications of PET Scanning" to "Oncologic Applications of Positron Emission Tomography (PET) Scanning." Policy description updated regarding radiopharmaceuticals approved for use with PET for Oncologic Applications. Added investigational indication for colorectal cancer. Medically necessary statement for lung cancer revised to clarify technique and to include prior CT scan. Added copper 64 to medically necessary statement for neuroendocrine tumors. Added statement that PET scanning may be considered medically necessary for staging and restaging in patients with suspected inguinal lymph node positive disease. Policy statement revised to state PET scanning with gallium 68-prostate-specific membrane antigen and piflufolastat fluorine-18 is considered investigational in all aspects of managing prostate cancer. Policy Guidelines updated regarding patient selection. Code Reference section updated to move HCPCS codes A9593 and A9594 from covered to not medically necessary. Added ICD-10 diagnosis code C60.9 to the covered codes table. Added HCPCS code A9595 to the not medically necessary codes table.
06/27/2022: Code Reference section updated to add new HCPCS code A9596, effective 07/01/2022.
09/30/2022: Code Reference section updated to add new HCPCS code A9800, effective 10/01/2022.
02/01/2023: Policy description updated regarding preparation kits. Policy section updated to add coverage criteria for breast cancer, melanoma, ovarian cancer, pancreatic cancer, testicular cancer, and thyroid cancer. Policy statement regarding PET scanning with gallium 68-prostate-specific membrane antigen and piflufolastat fluorine-18 changed from investigational to medically necessary for the indications listed. Added statement that the use of gallium 68-prostate-specific membrane antigen and piflufolastat fluorine-18 in known or suspected prostate cancer is considered investigational for all other indications, including diagnosis, primary staging of very-low, low- or favorable intermediate-risk prostate cancer, and evaluation of response to therapy. For soft tissue sarcoma, added statement that PET scanning is considered medically necessary for evaluating response to imatinib and other treatments for gastrointestinal stromal tumors. Policy Guidelines updated to add information regarding prostate-specific membrane antigen positron emission tomography. Code Reference section updated to change the following HCPCS codes from not medically necessary to covered: A9593, A9594, A9595, A9596, and A9800. Added ICD-10 diagnosis codes C49.0, C49.10 - C49.12, C49.20 - C49.22, C49.3, C49.4, C49.5, C49.6, C49.8, C49.9, and C49.A0 - C49.A9.
09/26/2023: Code Reference section updated to add new HCPCS code C9156, effective 10/01/2023.
12/21/2023: Code Reference section updated to add new 2024 HCPCS codes A9608 and A9609, effective 01/01/2024.
02/08/2024: Policy description updated regarding radiopharmaceuticals granted approval by the FDA. Policy statements updated with minor changes. Sources updated.
10/01/2024: Code Reference section updated to add new ICD-10 diagnosis codes C86.00, C86.10, C86.20, C86.30, C86.40, C86.60, C88.00, C88.20, C88.30, C88.40, and C88.90.
12/10/2024: Policy description updated regarding radiopharmaceuticals approved for use with PET for oncologic applications. Policy statement for prostate cancer updated to add flotufolastat fluorine-18 as medically necessary for the listed applications. Policy Guidelines updated to acknowledge situations when there are contraindications to contrast agents, making initial CT scans unattainable.
03/15/2025: Policy description updated regarding Fluoroestradiol F18 (FES). Added policy statement that PET scanning using fluoroestradiol F18 (FES) is considered investigational in individuals with breast cancer. Revised policy statements regarding breast cancer, cervical cancer, endometrial cancer, and ovarian cancer to include PET scanning with the use of 18F-FDG isotope. Policy Guidelines updated regarding the use of Fluoroestradiol F18 (FES). Code Reference section updated to add HCPCS code A9591 to the Investigational Codes table and remove deleted HCPCS code C9156.
10/01/2025: Code Reference section updated to add new HCPCS code A9616 and ICD-10 diagnosis codes C50.A0, C50.A1, and C50.A2. Removed deleted ICD-10 diagnosis codes C86.0, C86.1, C86.2, C86.3, C86.4, C86.5, C86.6, C88.0, C88.2, C88.3, C88.4, C88.8, and C88.9.
Blue Cross Blue Shield Association policy # 6.01.26
Blue Cross Blue Shield Association policy # 6.01.61
Blue Cross Blue Shield Association policy # 6.01.62
Blue Cross Blue Shield Association policy # 6.01.63
Blue Cross Blue Shield Association policy # 6.01.64
Blue Cross Blue Shield Association policy # 6.01.65
Blue Cross Blue Shield Association policy # 6.01.66
Blue Cross Blue Shield Association policy # 6.01.67
This 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:1. Manufacture of the radiopharmaceutical, which may be manufactured on site or manufactured at a regional delivery center with delivery to the institution performing PET2. Actual performance of the PET scan, and3. 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.
Code Number | Description | ||
CPT-4 | |||
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 | ||
HCPCS | |||
A9515 | Choline C-11 injection, diagnostic, per study dose up to 20 millicuries | ||
A9552 | Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries | ||
A9580 | Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries | ||
A9587 | Gallium ga-68, dotatate, diagnostic, 0.1 millicurie | ||
A9588 | Fluciclovine F-18, diagnostic, 1 millicurie | ||
A9593 | Gallium ga-68 psma-11, diagnostic, (ucsf), 1 millicurie | ||
A9594 | Gallium ga-68 psma-11, diagnostic, (ucla), 1 millicurie | ||
A9595 | Piflufolastat f-18, diagnostic, 1 millicurie | ||
A9596 | Gallium ga-68 gozetotide, diagnostic, (illuccix), 1 millicurie | ||
A9597 | Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified | ||
A9608 | Flotufolastat f 18, diagnostic, 1 millicurie | ||
A9609 | Fludeoxyglucose f18 up to 15 millicuries | ||
A9616 | Gallium ga-68 gozetotide (gozellix), diagnostic, 1 millicurie (New 10/01/2025) | ||
A9800 | Gallium ga-68 gozetotide, diagnostic, (locametz), 1 millicurie | ||
C9067 | Gallium ga-68, dotatoc, diagnostic, 0.01 mci | ||
G0235 | PET imaging, any site, not otherwise specified | ||
ICD-9 Procedure | ICD-10 Procedure | ||
92.01, 92.02, 92.03, 92.04, 92.09 | Radioisotope scan and function study (code range) | C030BZZ, C030KZZ, C030MZZ, C030YZZ | Positron emission tomographic (PET) imaging of brain |
CB32KZZ, CB32YZZ | Positron emission tomographic (PET) imaging of lungs and bronchi | ||
CB3YYZZ | Positron emission tomographic (PET) imaging of respiratory system | ||
CW3NYZZ | Positron emission tomographic (PET) imaging of whole body | ||
92.11, 92.12, 92.13, 92.14, 92.15, 92.16, 92.18, 92.19 | Other radioisotope scan (code range) | CW3NYZZ | Positron emission tomographic (PET) imaging of whole body |
ICD-9 Diagnosis | ICD-10 Diagnosis | ||
140.0, 140.1, 140.3, 140.4, 140.5, 140.6, 140.8, 140.9 | Malignant neoplasm of lip (code range) | C00.0 - C00.9 | Malignant neoplasm of lip (code range) |
141.0, 141.1, 141.2, 141.3, 141.4, 141.5, 141.6, 141.8, 141.9 | Malignant neoplasm of tongue (code range) | C01 - C02.9 | Malignant neoplasm of tongue (code range) |
142.0, 142.1, 142.2, 142.8, 142.9 | Malignant neoplasm of major salivary glands (code range) | C07, C08.0 - C08.9 | Malignant neoplasm of major salivary glands (code range) |
143.0, 143.1, 143.8, 143.9 | Malignant neoplasm of gum (code range) | C03.0 - C03.9 | Malignant neoplasm of gum (code range) |
144.0, 144.1, 144.8, 144.9 | Malignant neoplasm of floor of mouth (code range) | C04.0 - C04.9 | 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) | C05.0 - C05.9, C06.0 - C06.9 | Malignant neoplasm of palate and other unspecified parts of mouth (code ranges) |
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) | C09.0 - C09.9, C10.0 - C10.9 | Malignant neoplasm of oropharynx (code range) |
147.0, 147.1, 147.2, 147.3, 147.8, 147.9 | Malignant neoplasm of nasopharynx (code range) | C11.0 - C11.9 | Malignant neoplasm of nasopharynx (code range) |
148.0, 148.1, 148.2, 148.3, 148.8, 148.9 | Malignant neoplasm of hypopharynx (code range) | C12 - C13.9 | 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) | C14.0 - C14.8 | Malignant neoplasm of other and ill-defined sites I the lip, oral cavity and pharynx (code range) |
150.0, 150.1, 150.2, 150.3, 150.4, 150.5, 150.8, 150.9 | Malignant neoplasm of esophagus | C15.3 - C15.9 | Malignant neoplasm of esophagus (code range) |
151.0 - 151.9 | Malignant neoplasm of stomach | C16.0 - C16.9 | Malignant neoplasm of stomach |
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) | C18.0 - C18.9 | 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) | C19 - C21.8 | Malignant neoplasm of rectum, rectosigmoid junction, anus and anal canal (code range) |
157.0, 157.1, 157.2, 157.3, 157.4, 157.8, 157.9 | Malignant neoplasm of pancreas | C25.0 - C25.9 | Malignant neoplasm of pancreas (code range) |
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) | C30.0 - C31.9 | 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) | C32.0 - C32.9 | 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) | C34.00 - C34.92 | Malignant neoplasm of bronchus and lung (code range) |
C37 | Malignant neoplasm of thymus | ||
163.0, 163.1, 163.8, 163.9 | Malignant neoplasm of pleura (code range) | C38.4, C45.0 | Malignant neoplasm of pleura and mesothelioma of pleura |
165.0, 165.8, 165.9 | Malignant neoplasm of other and ill-defined sites within the respiratory system and intrathoracic organs | C39.0, C39.9 | Malignant neoplasm of other and ill-defined sites within the respiratory system and intrathoracic organs |
170.0 - 170.9 | Malignant neoplasm of bone and articular cartilage | C40.00 - C41.9 | Malignant neoplasm of bone and articular cartilage (code range) |
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) | C43.0 - C43.9 | Malignant melanoma of skin (code range) |
D03.0 - D03.9 | Melanoma in situ (skin) (code range) | ||
C49.0 - C49.A9 | Malignant neoplasm of other connective and soft tissue | ||
174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.8, 174.9 | Malignant neoplasm of female breast (code range) | C50.011 - C50.019, C50.111 - C50.119,C50.211 - C50.219,C50.311 - C50.319,C50.411 - C50.419,C50.511 - C50.519,C50.811 - C50.819,C50.911 - C50.919 | Malignant neoplasm of female breast (code ranges) |
175.0, 175.9 | Malignant neoplasm of male breast | C50.021 - C50.029,C50.121 - C50.129, C50.221 - C50.229, C50.321 - C50.329,C50.421 - C50.429,C50.521 - C50.529,C50.621 - C50.629,C50.821 - C50.829,C50.921 - C50.929 | Malignant neoplasm of male breast (code ranges) |
C50.A0, C50.A1, C50.A2 | Malignant inflammatory neoplasm of breast (New 10/01/2025) | ||
180.0, 180.1, 180.8, 180.9 | Malignant neoplasm of cervix uteri | C53.0 - C53.9 | Malignant neoplasm of cervix uteri (code range) |
C54.1 | Malignant neoplasm of endometrium | ||
183.0, 183.2, 183.3, 183.4, 183.5, 183.8, 183.9 | Malignant neoplasm of ovary and other uterine adnexa | C56.1 - C56.9, C57.00 - C57.4 | Malignant neoplasm of ovary and other uterine adnexa (code ranges) |
C60.9 | Malignant neoplasm of penis, unspecified | ||
C61 | Malignant neoplasm of prostate | ||
186.0, 186.9 | Malignant neoplasm of testis | C62.00 - C62.12,C62.90 - C62.92 | Malignant neoplasm of testis (code ranges) |
C67.0 - C67.9 | Malignant neoplasm of bladder | ||
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) | C69.00 - C69.92 | Malignant neoplasm of eye (code range) |
191.0, 191.1, 191.2, 191.3, 191.4, 191.5, 191.6, 191.7, 191.8, 191.9 | Malignant neoplasm of brain | C71.0 - C71.9 | Malignant neoplasm of brain (code range) |
193 | Malignant neoplasm of thyroid gland | C73 | Malignant neoplasm of thyroid gland |
195.0 | Malignant neoplasm of head, face and neck | C76.0 | Malignant neoplasm of head, face and neck (code range) |
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) | C77.0 - C77.9 | 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) | C78.00 - C78.39, C78.7 | Secondary malignant neoplasm of respiratory and digestive systems (code range) |
C79.31 | Secondary malignant neoplasm of brain | ||
C79.32 | Secondary malignant neoplasm of cerebral meninges | ||
198.5 | Secondary malignant neoplasm of bone and bone marrow | C79.51, C79.52 | Secondary malignant neoplasm of bone and bone marrow |
C7A.00 - C7A.8 | Malignant neuroendocrine tumors | ||
199.1 | Other malignant neoplasm of unspecified site | C45.9, C80.1, G73.1 | Other malignant neoplasm of unspecified site |
200.10, 200.11, 200.12, 200.13, 200.14, 200.15, 200.16, 200.17, 200.18 | Lymphosarcoma (code range) | C83.50 - C83.59 | 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) | C83.70 - C83.79 | 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) | C83.10 - C83.19 | Mantle cell lymphoma (code range) |
200.50, 200.51, 200.52, 200.53, 200.54, 200.55, 200.56, 200.57, 200.58 | Primary central nervous system lymphoma (code range) | C83.80 - C83.89 | Other non-follicular lymphoma (code ranges) |
200.60, 200.61, 200.62, 200.63, 200.64, 200.65, 200.66, 200.67, 200.68 | Anaplastic large cell lymphoma (code range) | C84.60 - C84.7A | Anaplastic large cell lymphoma (code range) |
200.00, 200.01, 200.02, 200.03, 200.04, 200.05, 200.06, 200.07, 200.08, 200.70, 200.71, 200.72, 200.73, 200.74, 200.75, 200.76, 200.77, 200.78 | Reticulosarcoma (code range) Large cell lymphoma (code range) | C83.30 - C83.39, C85.20 - C85.29 | 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) | C83.00 - C83.09 | Small cell B-cell lymphoma (code range) |
C83.90 - C83.99 | Non-follicular (diffuse) lymphoma, unspecified (code range) | ||
C86.00 | Extranodal NK/T-cell lymphoma, nasal type not having achieved remission | ||
C86.10 | Hepatosplenic T-cell lymphoma not having achieved remission | ||
C86.20 | Enteropathy-type (intestinal) T-cell lymphoma not having achieved remission | ||
C86.30 | Subcutaneous panniculitis-like T-cell lymphoma not having achieved remission | ||
C86.40 | Blastic NK-cell lymphoma not having achieved remission | ||
C86.60 | Primary cutaneous CD30-positive T-cell proliferations not having achieved remission | ||
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) | C81.00 - C81.99 | Hodgkin lymphoma (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) | C82.00 - C82.99 | Follicular lymphoma (code range) |
C84.00 - C84.99, C84.A0 - C84.A9, C84.Z0 - C84.Z9 | Mature T/NK-cell lymphomas, including anaplastic large cell lymphoma, ALK-positive (code ranges) | ||
C85.10 - C85.19, C85.80 - C85.99 | Other specified and unspecified types of non-Hodgkin lymphoma (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) | C7A.020 - C7A.029 | Malignant carcinoid tumors of appendix, large intestines and rectum (code range) |
209.72 | Secondary neuroendocrine tumor of liver | C7B.00 - C7B.8 | Secondary neuroendocrine tumors |
C88.00 | Waldenstrom macroglobulinemia not having achieved remission | ||
C88.20 | Heavy chain disease not having achieved remission | ||
C88.30 | Immunoproliferative small intestinal disease not having achieved remission | ||
C88.40 | Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma] not having achieved remission | ||
C88.90 | Malignant immunoproliferative disease, unspecified not having achieved remission | ||
C90.00 | Multiple myeloma not having achieved remission | ||
C90.02 | Multiple myeloma in relapse | ||
230.0, 230.1, 230.3, 230.4, 230.5, 230.6, 230.7, 230.8, 230.9 | Carcinoma in situ of digestive organs (code range) | D00.00 - D00.08, D00.1, D00.2, D01.0 - D01.9 | Carcinoma in situ of digestive organs (code ranges) |
230.2 | Carcinoma in situ of stomach | D00.2 | Carcinoma in situ of stomach |
231.0, 231.1, 231.2, 231.8 | Carcinoma in situ of respiratory system (code range) | D02.0 - D02.4 | Carcinoma in situ of respiratory system (code range) |
233.0 | Carcinoma in situ of breast | D05.00 - D05.92 | Carcinoma in situ of breast (code range) |
233.1 | Carcinoma in situ of cervix uteri | D06.0 - D06.9 | Carcinoma in situ of cervix uteri (code range) |
D07.0 | Carcinoma in situ of endometrium | ||
D07.5 | Carcinoma in situ of prostate | ||
233.39 | Carcinoma in situ, other female genital organ | D07.30, D07.39 | Carcinoma in situ, other and unspecified female genital organs |
233.6 | Carcinoma in situ of other and unspecified male genital organs | D07.60, D07.61, D07.69 | Carcinoma in situ, other and unspecified male genital organs |
234.0 | Carcinoma in situ of eye | D09.20, D09.21, D09.22 | Carcinoma in situ of eye |
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) | D37.01 - D37.09 | Neoplasm of uncertain behavior of digestive system (code range) |
D38.1 - D38.6 | Neoplasm of uncertain behavior of respiratory system (code range) | ||
236.2 | Neoplasm of uncertain behavior of ovary | D39.10, D39.11, D39.12 | Neoplasm of uncertain behavior of ovary |
236.4 | Neoplasm of uncertain behavior of testis | D40.10, D40.11, D40.12 | Neoplasm of uncertain behavior of testis |
237.5 | Neoplasm of uncertain behavior of brain and spinal cord | D43.0, D43.1, D43.2, D43.4 | Neoplasm of uncertain behavior of brain and spinal cord |
239.0, 239.1, 239.3, 239.6, 239.9 | Neoplasms of unspecified nature (code range) | D49.0, D49.1, D49.3, D49.6 | Neoplasms of unspecified nature (code range) |
518.89 | Other diseases of lung, not elsewhere classified | J98.4 | Other diseases of lung, not elsewhere classified |
793.11 | Solitary pulmonary nodule | R91.1 | Solitary pulmonary nodule |
R97.21 | Rising PSA following treatment for malignant neoplasm of prostate |
Not Medically Necessary Codes
Code Number | Description |
CPT-4 | |
HCPCS | |
A9591 | Fluoroestradiol F-18, diagnostic, 1 mCi |
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) |
ICD-10 Procedure | |
ICD-10 Diagnosis |
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