Non-small cell lung cancer (NSCLC) is the most common type of lung cancer and includes adenocarcinoma, squamous cell carcinoma, and large cell neuroendocrine tumors.

General Considerations

Positron emission tomography (PET)/ computed tomography (CT) may be considered medically necessary to confirm solitary focus of metastatic disease (i.e., brain or adrenal) if being considered for an aggressive surgical management.

PET/CT scan is considered not medically necessary for initial staging or restaging of NSCLC with distant metastatic disease, pleural/pericardial effusion, or for multiple sites that are located outside the chest cavity, when found on conventional imaging (i.e., liver, bone and adrenal metastases, etc.).

Suspected/Diagnosis

Imaging studies may be considered medically necessary for ANY of the following indications:

• Abnormal chest x-ray or clinical suspicion remains high despite a normal chest x-ray in symptomatic patient, ONE of the following:
  • CT chest without contrast; or
  • CT chest with contrast.
• Pulmonary nodule less than eight (8) millimeters (mm) in size noted on CT chest:
  • Please refer to Medical Policy X-199, Chest: Solitary Pulmonary Nodule (SPN).
• Pulmonary nodule eight (8) mm (0.8 centimeters (cm)) to 30 mm (3 cm) seen on CT chest or magnetic resonance imaging (MRI) chest:
  • PET/CT:
    • If negative: repeat CT chest with contrast or CT chest without contrast at six (6) months and repeat at 24 months from the first CT chest; or
    • If positive: qualifies as initial staging PET/CT; or
    • If inconclusive: repeat CT scan or biopsy.
• Pulmonary mass 31 mm (3.1 cm) or greater seen on CT or MRI:
  • PET/CT may be considered medically necessary prior to biopsy if ONE or MORE of the following applies:
    • Resection will be performed instead of biopsy if PET confirms limited disease; or
    • Multiple possible biopsy options are present within the chest and PET findings will be used to determine the most favorable biopsy site; or
  • Biopsy is indicated prior to PET imaging for all other indications in pulmonary masses greater than or equal to 31 mm (3.1 cm) in size.
• Mediastinal/hilar mass:
  • Please refer to Medical Policy X-185, Chest: Lymphadenopathy.
• Paraneoplastic syndrome suspected:
  • Please refer to Medical Policy X-357, ONC: Medical Conditions with Cancer in the Differential Diagnosis; Paraneoplastic Syndromes; General Considerations.

Repeat PET/CT for inconclusive PET/CT findings in pulmonary nodules eight (8) mm (0.8 cm) to 30 mm (3 cm) is considered not medically necessary.

Advanced imaging for all other indications not listed above is considered not medically necessary.

Initial Workup/Staging

ANY or ALL of the following imaging studies may be considered medically necessary for ALL individuals:

• CT chest with contrast; or
• CT abdomen with contrast:
  • If the upper abdomen through level of adrenals was not clearly documented on the CT chest report; or
• Bone scan, if PET/CT not being done (please also refer to Medical Policy X-328, ONC: General Guidelines; Nuclear Medicine (NM) Imaging in Oncology).

PET/CT may be considered medically necessary if not already completed prior to histological diagnosis for ANY of the following indications:

• All stage I-IIIB disease; or
• Stage IV disease confined to the chest region (pleura/pericardium or solitary site including lung nodules); or
• Conventional imaging is inconclusive.

MRI brain without and with contrast may be considered medically necessary for ANY of the following:

• All stage II-IV disease; or
• Stage I disease and considering surgical resection as primary therapy.

ANY or ALL of the following imaging studies may be considered medically necessary for suspected superior sulcus (Pancoast) tumor:

• MRI chest without and with contrast; or
• MRI cervical spine without and with contrast; or
• MRI thoracic spine without and with contrast.

PET is considered not medically necessary for metastatic disease outside the chest cavity (e.g. malignant pleural/pericardial effusion or bony metastases) present on CT, MRI or bone scan.

Advanced imaging for all other indications not listed above is considered not medically necessary

Restaging/Recurrence

Individuals with measurable disease undergoing treatment, ANY or ALL of the following imaging studies may be considered medically necessary every two (2) cycles:

• CT chest with or CT chest without contrast; or
• CT abdomen with contrast; or
  • CT abdomen/pelvis with contrast if known pelvic disease or pelvic symptoms; or
• MRI brain without and with contrast for measurable brain metastases being treated with systemic therapy.

Imaging studies may be considered medically necessary for ANY of the following indications:

• Locally advanced (stage III, nonmetastatic, unresectable); or
• Inoperable tumor if chemotherapy or chemoradiation was the initial treatment modality; or
• Inadequately resected disease; or
• Suspected recurrence; and
• ANY or ALL of the following imaging studies:
  • CT chest with or CT chest without contrast; or
  • CT abdomen with contrast; or
    • CT abdomen/pelvis with contrast if known pelvic disease or pelvic symptoms.

To determine resectability following neo-adjuvant therapy, MRI chest without and with contrast may be considered medically necessary.

For newly identified lung nodule(s), please refer to Medical Policy X-358, ONC: Metastatic Cancer, Carcinoma of Unknown Primary Site, and Other Types of Cancer; Lung Metastases for new nodule evaluation.

PET/CT may be considered medically necessary for ANY of the following indications:

• Suspected/biopsy proven recurrence localized to the chest cavity; or
• Inconclusive findings on conventional imaging; or
• To differentiate tumor from radiation scar/fibrosis.

MRI Brain without and with contrast may be considered medically necessary for ANY of the following indications:

• Following a demonstrated adequate response to neoadjuvant therapy if intracranial disease will preclude surgery; or
• Documented recurrence/progression; or
• New or worsening neurological signs or symptoms.

PET is considered not medically necessary for metastatic disease outside the chest cavity (e.g. malignant pleural/pericardial effusion or bony metastases) present on CT, MRI or bone scan.

Restaging imaging is considered not medically necessary for stage I or II patients who undergo definitive local treatment with surgery, radiation, or radiosurgery. Please also refer to the Surveillance/Follow-Up section of this policy.

Advanced imaging for all other indications not listed above is considered not medically necessary

Surveillance/Follow-Up

For individuals with stage I-II NSCLC, CT chest with contrast or CT chest without contrast may be considered medically necessary every six (6) months for two (2) years and then annually.

• Individuals treated with radiation therapy and residual abnormality on imaging may undergo CT chest every three (3) months for the first year after therapy, every six (6) months in year two (2), then annually thereafter.

For individuals with stage III-IV (metastatic sites treated with definitive intent) NSCLC, CT chest with contrast or CT chest without contrast may be considered medically necessary every three (3) months for two (2) years, every six (6) months for three (3) years and then annually. 

Individuals with a new lung nodule, please refer to Medical Policy X-358, ONC: Metastatic Cancer, Carcinoma of Unknown Primary Site, and Other Types of Cancer; Lung Metastases.

Advanced imaging for all other indications not listed above is considered not medically necessary.