Positron Emission Tomography (PET) Scan, Oncologic Applications

Medical Policy: 06.01.13 
Original Effective Date: June 2004 
Reviewed: October 2011 
Revised: October 2011 

Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

Description: 

Positron Emission Tomography (PET) measures the level of metabolic activity and perfusion of radioactive chemicals in various organs or organ systems in the body. Radiopharmaceuticals are introduced into the body by intravenous injection or inhalation. PET scanners produce computerized mathematical models of physiologic functions and use tracer kinetics for generation of images.

PET scanning may be considered medically necessary for several oncologic indications. PET results may assist in avoiding an invasive diagnostic procedure, or the results may assist in determining the optimal anatomic location to perform a diagnostic procedure. PET results may support clinical management decisions when the stage of cancer remains in doubt after completion of a standard diagnostic workup; or, when it is expected that conventional imaging studies would yield insufficient information. PET may be used for restaging after completion of treatment for the purpose of detecting residual disease, detecting suspected recurrence or to determine the extent of recurrence.

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Prior Approval: 

Not applicable

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Policy: 

Positron Emission Tomography may be considered medically necessary for the following indications:

Brain Cancer

• To differentiate radiation necrosis from recurrent brain tumor in patients with a confirmed brain cancer diagnosis that have been treated with radiation therapy. 

Breast Cancer

• Initial treatment strategy evaluation for one of the following:
  • Axillary nodal metastasis of unknown primary origin
  • Paraneoplastic syndrome potentially caused by an occult breast cancer
  • Detection of distant metastasis in a high risk patient with known breast cancer
• Evaluation of recurrent or metastatic disease when other staging studies are equivocal or suspicious

Cervical Cancer

• Staging in newly diagnosed patients as an adjunct to conventional imaging that is negative for extra-pelvic metastasis.

Colorectal Cancer

• Diagnosis, staging, and monitoring response to treatment
• Staging and restaging to detect and assess resectability of hepatic or extrahepatic metastases of colorectal cancer
• To evaluate a rising or persistently elevated carcinoembryonic antigen (CEA) level when standard imaging, including CT scan is negative 
• To rule out extrahepatic metastases in patients with non-resectable secondary metastatic colorectal cancer who are being considered for selective internal radiation therapy to the liver.  

Esophageal Cancer

• Diagnosis, staging, and restaging

Gastrointestinal Stromal Tumor (GIST)

• Baseline evaluation in documented GIST when CT findings are inconclusive or inconsistent with clinical presentation
• Post-therapy assessment of response to targeted pharmacotherapeutic management with receptor tyrosine kinase inhibitors (such as imatinib mesylate) when CT findings are inconclusive or inconsistent with clinical presentation   

Head and Neck Cancer

• Identifying an unknown primary suspected to be head and neck cancer
• Initial staging of cervical lymph node metastases
• Restaging for detection of residual or recurrent disease

Primary Hepatocellular Carcinoma (non-resectable)

• To rule out extrahepatic metastases in patients with non-resectable primary hepatocellular carcinoma who are being considered for selective internal radiation therapy to the liver. 

Non-Small Cell Lung Cancer

• Diagnosis 
• Staging in known lung cancer
• Restaging 

Lymphoma, including Hodgkin's disease

• Initial staging
• Differentiating benign from malignant disease
• Restaging after treatment

Melanoma

• Diagnosis, staging and restaging
• Detection of extranodal metastasis

Ovarian Cancer

• For localization of recurrent ovarian cancer in women meeting ALL of the following criteria:
  • Rising CA-125 levels AND
  • Negative or equivocal CT imaging.

Pancreatic Cancer

• Evaluation of a suspicious pancreatic mass to distinguish between benign and malignant disease when other diagnostic tests are normal or equivocal
• When results may potentially alter treatment management (e.g., deciding whether surgical intervention is warranted)

Solitary Pulmonary Nodule

• To distinguish between benign and malignant disease when prior CT scan and chest x-ray findings are inconclusive or discordant 

Testicular Cancer (pure seminoma stages IIB, IIC, and III)

• In patients who are status-post chemotherapy and exhibiting signs or symptoms of residual or recurrent disease. (To reduce incidence of false-positives, PET is usually performed approximately 6 weeks after completion of chemotherapy) 

Thyroid Cancer

• Staging and restaging of cancers of follicular cell origin (such as Hurthle cell carcinoma) in the presence of rising thyroglobulin levels and negative I-131 studies

Unknown Primary (Occult Primary Carcinoma) meeting ALL of the following:

• In patients with a single site of disease outside the cervical lymph nodes; AND
• Patient is considering local or regional treatment for a single site of metastatic disease; AND
• After a negative work-up 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.

• Brain Cancer (except as described above) 
• Bladder Cancer 
• Primary Hepatocellular Carcinoma (except as described above) 
• Ovarian Cancer (except as described above)
• Parathyroid Cancer
• PET bone scanning
• PET mammography
• Non-seminoma testicular cancer
• Anal cancer

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
• 78608 Brain imaging, positron emission tomography (PET); metabolic evaluation  
• 78609 Brain imaging, positron emission tomography (PET); perfusion evaluation 
• 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   
• G0219 PET imaging whole body; melanoma for non-covered indications
• A9552 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries
• A9526 Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 millicuries 

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Selected References: 

• Flamen P, Lerut A, Cutsem E, Cabier JP, et al. The utility of positron emission tomography for the diagnosis and staging of recurrent esophageal cancer. Journal of Thoracic and Cardiovascular Surgery 2000 December; 120(6): 1085-1092.
• Buenaventura P, Luketich JD. Surgical staging of esophageal cancer.  Chest Surgery Clinics of North America 2000 August;10(3): 487-497.
• Rankin SC, Taylor H, Cook GJ, Mason R. Computed tomography and positron emission tomography in the preoperative staging of esophageal cancer. Clinical Radiology 1998 September;53(9):659-665.
• Gould MK, Kuscher WG, Rydzak CE, et al. Test performance of positron emission tomography and computed tomography for mediastinal staging in patients with non-small cell lung cancer: a meta-analysis. Ann Intern Med. 2003 Dec 2;139(11):879-92.
• Van Tinteren H, Hoekstra OS, Smit EF, et al. Effectiveness of positron emission tomography in the preoperative assessment of patients with suspected non-small cell lung cancer: the PLUS multicentre randomized trial. Lancet. 2002 Apr 20;359(9315):1388-93.
• Sarlis NJ, Gourgiotis L. Guthrie LC, et al. In-111 DTPA-octreotide scintigraphy for disease detection in metastatic thyroid cancer: comparison with F-18 FDG positron emission tomography and extensive conventional radiographic imaging. Clin Nucl Med. 2003 Mar;28(3):208-17.
• Swetter SM, Carroll LA, Johnson DL, Segall GM. Positron emission tomography is superior to computed tomography for metastatic detection in melanoma patients. Ann Surg Oncol. 2002 Aug;9(7):664-53.
• Ilias I, Yu J, Carrasquillo JA, et al. Superiority of 6_[18F]-fluorodopamine positron emission tomography versus [131I]-metaiodobenzylguanidine scintigraphy in the localization of metastatic pheochromocytoma. J Clin Endocrinol Metab. 2003 Sep;88(9):4080-2.
• Jacobs A, Voges J, Reszka R, et al. Positron-emission tomography of vector-mediated gene expression in gene therapy for gliomas. Lancet. 2001 Sep 1;358(9283):727-9.
• Muros MA, Llamas-Elvira JM, Ramirez-Navarro A, et al. Utility of fluorodeoxyglucose positron emission tomography in differentiated thyroid carcinoma with negative radioiodine scans and elevated serum thyroglobulin levels. Am J Surg. 2000 Jun;179(6):457-61.
• FDG PET to Manage Patients with an Occult Primary Carcinoma and Metastasis outside the Cervical Lymph Nodes. TEC Assessment, Blue Cross Blue Shield Association, Technology Evaluation Center, v.17, n.14, October 2002.
• FDG Positron Emission Tomography for Evaluation of Breast Cancer. TEC Assessment, Blue Cross Blue Shield Association, technology Evaluation Center, v.18, n.14, November 2003.
• FDG Positron Emission Tomography for Evaluating Esophageal Cancer. TEC Assessment, Blue Cross Blue Shield Association, Technology Evaluation Center, v.16, n.21, April 2002.
• Oncologic applications of PET Scanning. Blue Cross and Blue Shield Association. Medical Policy No. 6.01.26; 2003.
• Havrilesky LJ, Kulasingam SL, Matchar DB, Myers ER. FDG-PET for management of cervical and ovarian cancer. Gynecol Oncol. 2005 Apr; 97(1):183-91.
• Grigsby PW, Singh AK, Siegel BA et al. Lymph node control in cervical cancer. Int J Radiat Oncol Biol Phys. 2004 Jul 1; 59(3):706-12.
• Mantaka P, Baum RP, Hertel A et al. PET with 2-[F-18]-fluoro-2-deoxy-D-glucose (FDG) in patients with cancer of unknown primary: influence on patients' diagnostic and therapeutic management. Cancer Biotherapy & Radiopharmaceuticals. 2003; 18:47-58.
• Delgado-Bolton RC, Fernandez-Perez C, Gonzalez-Mate A et al. Meta-analysis of the performance of 18-FFDG PET in primary tumor detection in unknown primary tumors. J Nucl Med. 2003; 44:1301-1314.
• Bohuslavizki KH, Klutmann, Kroger S et al. FDG PET detection of unknown primary tumors. J Nucl Med. 2000; 41(5):816-22.
• Albernini JL, Belhocine T, Hustinx R et al. Whole-body positron emission tomography using fluorodeoxyglucose in patients with metastases of unknown primary tumors (CUP syndrome). Nuclear Medicine Communications. 2003; 24:1081-1086.
• Lewis DA, Tann M, McCool A et al. PET Scan’s Clinical Utility in Detecting Residual Disease in Postchemotherapy Germ Cell Cancer Patients. Abstract No. 4574. 2005 American Society of Clinical Oncology (ASCO) Annual Meeting.
• Becherer A, DeSantis M, Karanikas G et al. FDG PET is superior to CT in the prediction of viable tumour in post-chemotherapy seminoma residuals. Eur J Radiol. 2005 May;54(2):284-8.
• DeSantis M, Pont J. The Role of Positron Emission Tomography in Germ Cell Cancer. World J Urol. 2004 Apr;22(1):41-6.
• National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology-v.1.2006; Testicular Cancer.
• Takekuma M, Maeda M, Ozawa T et al. Positron emission tomography with 18F-fluoro-2-deoxyglucose for the detection of recurrent ovarian cancer. Int J Clin Oncol. 2005 Jun;10(3):177-81.
• Gadducci A, Cosio S, Zola P et al. Surveillance procedures for patients treated for epithelial ovarian cancer: a review of the literature. Int J Gynecol Cancer. 2007 Jan-Feb;17(1):21-31.
• Chung HH, Kang WJ, Kim JW et al. Role of [18F] FDG PET/CT in the assessment of suspected recurrent ovarian cancer: correlation with clinical or histological findings. Eur J Nucl Med Mol Imaging. 2007 Apr;34(4):480-6.
• Avril N, Sassen S, Schmalfedlt B et a. Prediction of Response to Neoadjuvant Chemotherapy by Sequential F-18-Fluorodeoxyglucose Positron Emission Tomography in patients With Advanced-Stage Ovarian Cancer. J Clin Oncol 2005 Oct 20; 23(30):7445-53.
• ANjos DA, Etchebehere EC, Ramos CD et al. 18F-FDG PET/CT delayed images after diuretic for restaging invasive bladder cancer. J Nucl Med. 2007 May; 48(5):764-70.
• Picchio M, Treiber U, Beer AJ et al. Value of 11C-choline PET and contrast-enhanced CT for staging of bladder cancer: correlation with histopathologic findings. J Nucl Med. 2006 Jun;47(6):938-44.
• Schader H, Larson SM. Positron emission tomography for prostate, bladder, and renal cancer. Semin Nucl Med. 2004 Oct;34(4):274-92.
• Jana S, Blaufox MD. Nuclear medicine studies of the prostate, testes, and bladder. Semin Nucl Med. 2006 Jan;36(1):51-72.
• von Falck C, Maecker B, Schirg E et al. Post transplant lymphoproliferative disease in pediatric solid organ transplant patients: a possible role for [18F]-FDG-PET (/CT) in initial staging and therapy monitoring. Eur J Radiol. 2007 Sep;63(3):427-35.
• Bianchi E, Pascual M, Nicod M et al. Clinical usefulness of FDG-PET/CT scan imaging in the management of posttransplant lymphoproliferative disease. Transplantation. 2008 Mar 15;85(5):707-12.
• McCormack L, Hany TI, Huber M et al. How useful is PET/CT imaging in the management of post-transplant lymphoproliferative disease after liver transplantation? Am J Transplant. 2006 Jul;6(7):1731-6.
• National Comprehensive Cancer Network (NCCN). Soft Tissue Sarcoma: Gastrointestinal Stromal Tumors (GIST). Practice Guidelines in Oncology – v.1.2009.
• Chen, W. Clinical Applications of PET in Brain Tumors. J Nucl Med 2007; 48:1468-1481.
• Hustinx R, Pourdehnad M, Kaschten B et al. PET imaging for differentiating recurrent brain tumor from radiation necrosis. Radiol Clin N Am 43 (2005): 35-47.
• Heusner TA, Kuemmel S, Umutlu L et al. Breast Cancer Staging in a Single Session: Whole-Body PET/CT Mammography. J Nucl Med 2008; 49:1215-22.
• Frangioni JV. New Technologies for Human Cancer Imaging. J Clin Oncol. 2008 Aug 20; 26 (24):4012-21.
• Canadian Agency for Drugs and Technologies in Health (CADTH). Positron Emission Tomography (PET) Mammography: A New Diagnostic Tool. Health Technology Assessments. HTA Reports and Publications; Health Technology Update, Issue 7, September 2007.
• Aparicio J, Sastre J, Germa JR et al. SEOM clinical guidelines for diagnosis and treatment of testicular seminoma (2010). Clin Transl Oncol. 2011 Aug; 13(8):560-4.
• Becherer A. PET in testicular cancer. Methods Mol Biol. 2011; 727:225-41.
• Cotter SE, Grigsby PW, Siegel BA et al. FDG-PET/CT in the evaluation of anal carcinoma. Int J Radiat Oncol Biol Phys. 2006 Jul 1; 65(3):720-5. Epub 2006 Apr 19.
• Trautmann TG, Zuger JH. Positron Emission Tomography for pretreatment staging and posttreatment evaluation in cancer of the anal canal. Mol Imaging Biol. 2005 Jul-Aug; 7(4):309-13.   

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Policy History: 

Date                                        Reason                              Action

October 2011                         Annual review                    Policy renewed

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Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

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