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, comprising multiple stationary detectors that encircle the area of interest.
The utility of PET scanning for the diagnosis, staging and restaging, and surveillance of malignancies varies by type of cancer. In general, PET scanning can distinguish benign from malignant masses in certain circumstances and improve the accuracy of staging by detecting additional disease not detected by other imaging modalities. Therefore, PET scanning for diagnosis and staging of malignancies can be considered medically necessary when specific criteria are met for specific cancers, as outlined in the policy statements. For follow-up, after initial diagnosis and staging have been performed, there are a few situations in which PET can improve detection of recurrence, and lead to changes in management that improve the net health outcome. The use of PET for interim scanning to assess early response is addressed in policy 6.01.51.
For individuals who have suspected non-small-cell lung cancer (NSCLC) and inconclusive results from other imaging techniques who receive FDG-PET or FDG-PET/CT, the evidence includes several meta-analyses. Relevant outcome is test validity. Pooled analyses have shown that PET and PET/CT have better diagnostic performance than conventional imaging techniques. Clinical guidelines include PET/CT to inform management decisions that may offer clinical benefit. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have diagnosed NSCLC and in need of staging or restaging information who receive FDG-PET or FDG-PET/CT, the evidence includes several meta-analyses. Relevant outcome is test validity. Pooled analyses have shown that PET and PET/CT have better diagnostic performance than conventional imaging techniques. Clinical guidelines include PET/CT to inform management decisions that may offer clinical benefit. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have suspected NSCLC or who are asymptomatic after completing NSCLC treatment who receive FDG-PET or FDG-PET/CT, there is no evidence. Relevant outcome is test validity. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
For individuals with diagnosed small-cell lung cancer (SCLC) and in need of staging or restaging information who receive FDG-PET or FDG-PET/CT, the evidence includes systematic reviews and meta-analyses. Relevant outcome is test validity. While the quality of the studies was considered low, PET and PET/CT can be considered for staging or restaging in individuals with SCLC if a limited stage is suspected. Clinical guidelines include PET/CT to inform management decisions that may offer clinical benefit. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have suspected SCLC or who are asymptomatic after completing SCLC treatment who receive FDG-PET or FDG-PET/CT, there is no evidence. Relevant outcome is test validity. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
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 staging or restaging technique in those with known non-small-cell lung cancer, and
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.
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CPT |
78811-78816 |
Positron emission tomography (PET) imaging; with/without CT; specific to body area |
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78608-78609 |
Brain imaging, positron emission tomography (PET); by evaluation method |
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ICD-10-PCS |
ICD-10-PCS is for use only on inpatient services. There are a few specific PET ICD-10-PCS codes such as the following: |
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CB32KZZ, CB32YZZ |
Nuclear medicine, respiratory system, positron emission tomographic (PET) imaging, lungs and bronchi, code by radionuclide |
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CB3YYZZ |
Nuclear medicine, respiratory system, positron emission tomographic (PET) imaging, respiratory system |
| HCPCS | G0235 | PET imaging, any site not otherwise specified |
| A9552 | Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries | |
| A9597 | Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified | |
| A9598 | Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified |
| ICD-10-CM | C34.0-C34.92 | Malignant neoplasm of bronchus and lung code range |
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. Thus, PET should be considered for the medically necessary indications above only when standard imaging (eg, CT, MRI) is inconclusive or not indicated.
Patient 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 a patient 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 a patient 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 patient 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 PET scanning for surveillance as described in the policy statement and policy rationale refers to the use of PET to detect disease in asymptomatic individuals at various intervals. This is not the same as the use of PET for detecting recurrent disease in symptomatic individuals; these applications of PET are considered within tumor-specific categories in the policy statements.
