Medical Policy: 06.01.37 

Original Effective Date: May 2018 

Reviewed: May 2019 

Revised: May 2019 

 

Notice:

This policy contains information which is clinical in nature. The policy is not medical advice. The information in this policy is used by Wellmark to make determinations whether medical treatment is covered under the terms of a Wellmark member's health benefit plan. Physicians and other health care providers are responsible for medical advice and treatment. If you have specific health care needs, you should consult an appropriate health care professional. If you would like to request an accessible version of this document, please contact customer service at 800-524-9242.

 

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) is a non-invasive diagnostic imaging procedure that is able to detect biochemical reactions e.g. metabolism and abnormal distribution of cell receptors within body tissues. A radioactive tracer is used during the procedure. Unlike other nuclear medicine examinations, PET can measure metabolic activity of the cells of body tissues, providing information about the functionality and structure of the particular organ or tissue examined. PET may also detect biochemical changes that help to evaluate malignant tumors or lesions. Integrated PET/CT imaging is a technique in which both PET and CT are performed sequentially during a single visit. The CT and PET images are then co-registered using fusion software, enabling the physiologic data obtained on PET to be localized according to the anatomic CT images. Early studies suggest that this additional information from the CT imaging may help alter treatment decisions. There has been movement toward utilizing PET/CT imaging for any oncologic indication where PET scanning would be indicated. There have been several small studies that have suggested that PET/CT has improved diagnostic ability over PET alone.

 

PET and PET/CT are used for diagnosis, staging, restaging and monitoring tumor response to treatment. The efficacy of PET or PET/CT and the sensitivity and specificity of the technology varies with the type of tumor and thus, the use of PET or PET/CT is only supported for specific oncologic indications.

 

PET and PET/CT in Cancer Surveillance

With regard to surveillance of individuals without signs and symptoms suggestive of recurrence after therapy has been completed, a review of the literature and specialty society guidelines has not found evidence that supports routine use of PET or PET/CT for regular follow-up in this clinical setting. In a 2009 NCCN Task Force paper (Podoloff et. al.) examined the current state of clinical utility for PET and PET/CT for a variety of tumor types, it was noted that data supporting a definitive role for PET in disease surveillance is still lacking, and therefore, exploratory use of PET should be restricted to well-designed clinical trials. Additionally, NCCN clinical practice guidelines (Treatment of Cancer by Site), and NCCN Imaging Appropriate Use Criteria for various malignancies often note that PET scans are not recommended in asymptomatic individuals.

 

The American Society of Clinical Oncology (ASCO) issued a Choosing Wisely statement regarding ten things physicians and patients should question, which included the following regarding PET and PET/CT scanning:

  • Don’t perform surveillance testing (biomarkers) or imaging (PET, CT and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent:
    • Surveillance testing with serum tumor markers or imaging has been shown to have clinical value for certain cancers (e.g. colorectal). However, for breast cancer that has been treated with curative intent, several studies have shown there is no benefit from routine imaging or serial measurement of serum tumor markers in asymptomatic patients.
    • False-positive tests can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation exposure, and misdiagnosis.
  • Avoid using PET or PET-CT scanning as part of routine follow-up care to monitor for a cancer recurrence in asymptomatic patients who have finished initial treatment to eliminate the cancer unless there is a high level evidence that such imaging will change the outcome:
    • PET and PET-CT are used to diagnose, stage and monitor how well treatment is working. Available evidence from clinical studies suggests that using these tests to monitor for recurrence does not improve outcomes and therefore generally is not recommended for this purpose.
    • False-positive tests can lead to unnecessary and invasive procedures, over treatment, unnecessary radiation exposure and incorrect diagnosis.
    • Until high level evidence demonstrates that routine surveillance with PET or PET-CT scans helps prolong life or promote well-being after treatment for a specific type of cancer, this practice should not be done.

 

Summary

The clinical utility of PET and PET/CT scanning in surveillance in asymptomatic patients to detect disease recurrence is not well studied. Routine surveillance with PET or other imaging studies in asymptomatic patients has not been shown to improve survival or impact the ability to palliate recurrent disease, and is therefore not recommended. NCCN clinical practice guidelines (Treatment of Cancer by Site) and NCCN Imaging Appropriate Use Criteria for various malignancies often note that PET and PET/CT scans are not recommended in asymptomatic individuals. Also, ASCO Choosing Wisely statement includes “until high level evidence demonstrates that routine surveillance with PET or PET/CT scans helps prolong life or promote well-being after treatment for a specific type of cancer, this practice should not be done”. The evidence is insufficient to determine that the technology results in a meaningful improvement in net health outcomes.

 

Prior Approval:

Pre Authorization is required.

 

Policy:

PET or PET/CT scanning at various intervals when used as a surveillance tool for patients with cancer or with a history of cancer is considered investigational due to the lack of evidence demostrating an impact on improved outcomes when the following is met:

  • In asymptomatic patients, when there are no new or worsening symptoms, physical findings, lab tests, or other imaging tests suggesting recurrence or progression of malignancy; OR 
  • Have chronic stable symptoms; AND
  • Are not receiving active treatment.

 

Note: see Policy Guideline below.

 

Policy Guidelines

Surveillance: Refers to use of imaging performed in patients with cancer or with a history of cancer who are asymptomatic (e.g. patients without new or worsening symptoms, physical findings, lab tests, or other imaging tests suggesting recurrence or progression of disease) or have chronic stable symptoms, and are not receiving active treatment.

  • A PET or PET/CT scan is considered surveillance if performed more than 6 months after completion of cancer therapy in patients without objective signs or symptoms suggesting of cancer recurrence, except for individuals with lymphoma a scan is considered surveillance if performed more than 12 months after completion of cancer therapy in patients without objective signs or symptoms suggesting of cancer recurrence.

 

Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes and / or diagnosis codes.

  • 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 (e.g. 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

 

Selected References:

  • Podloff A, Ball D, Ben-Josef E, et. al. NCCN Task Force Report: Clinical Utility of PET in a Variety of Tumor Types. Journal of the National Comprehensive Cancer Network Volume 7 Supplement 2, Jun 2009. PMID 19555588
  • Fletcher J, Djulbegovic B, Soares H, et. al. Recommendations on the use of F-FDG PET in Oncology. The Journal of Nuclear Medicine Vol. 49 No. 3 March 2008. PMID 18287273
  • American Society of Clinical Oncology (ASCO) Choosing Wisely Ten Things Physicains and Patients Should Question. October 29, 2013. 
  • Siva S, Herschtal A, Thomas J, et. al. Impact of post-therapy positron emission tomography on prognostic stratification and surveillance after chemoradiotherapy for cervical cancer. Cancer 2011; Sept 1;117:3981-88. PMID 21365626
  • Wang S. Surveillance radiologic imaging after treatment of oropharyngeal cancer: a review. World Journal of Surgical Oncology 2015 13:94
  • Baxi S, Dunn L, Pfister D, et.al. Evaluating the potential role of PET/CT in the post treatment surveillance of head and neck cancer. J Natl Compr Canc Netw 2015 March;13(3):252-254
  • UpToDate. Post Treatment Surveillance of Squamous Cell Carcinoma of the Head and Neck. Nabil F. Saba M.D., FACP, Topic last updated September 7, 2017. 
  • UpToDate. Surveillance after Colorectal Cancer Resection. Beverly Moy M.D., MPH, Brian C. Jacobson M.D., MPH. Topic last updated March 9, 2018. 
  • UpToDate. Radiation Therapy, Chemoradiotheray, Neoadjuvant Approaches, and Postoperative Adjuvant Therapy for Localized Cancers of the Esophagus. Noah C. Choie M.D., Michael K. Gibson M.D., PhD, FACP. Topic last updated February 12, 2018
  • UpToDate. Thymic Neuroendocrine (Carcinoid) Tumors. Jonathan R. Strosberg M.D., Mark F. Berry M.D., Henry D. Tazelaar M.D., Topic last updated February 10, 2018. 
  • UpToDate. Clinical Manifestations and Diagnosis of Cholangiocarcinoma. Robert C. Lowe M.D., Christopher D. Anderson M.D., FACS, Kris V. Kowdley M.D., FACP, FACG, FASGE, AGAF. Topic last updated November 30, 2016. 
  • UpToDate: Follow-up Surveillance During and After Treatment for Prostate Cancer. David F. Penson M.D., MPH, Topic last updated January 15, 2018. 
  • UpToDate. Invasive Cervical Cancer: Patterns of Recurrence and Post-Treatment Surveillance. J. Michael Straughn Jr, M.D., Topic last updated August 3, 2017. 
  • UpToDate. Monitoring of the Patient with Classical Hodgkin Lymphoma Durign and After Treatment. Jonathan W. Friedberg M.D., Topic last updated June 22, 2016. 
  • UpToDate. Imaging Studies in Melanoma. Keven Donohoe M.D., Topic last updated May 23, 2017. 
  • UpToDate. Overview of the Diagnosis and Staging of Head and Neck Cancer. Colon S. Poon M.D., PhD, FRCPC, Kerstin M. Stenson M.D., FACS. Topic last updated November 14, 2017. 
  • National Comprehensive Cancer Network (NCCN) Acute Lymphoblastic Leukemia Version 2.2019. 
  • National Comprehensive Cancer Network (NCCN) Acute Myeloid Leukemia Version 3.2019. 
  • National Comprehensive Cancer Network (NCCN) Aids-Related Koposi Sarcoma Version 2.2019. 
  • National Comprehensive Cancer Network (NCCN) Anal Carcinoma Version 1.2019. 
  • National Comprehensive Cancer Network (NCCN) Bladder Cancer Version 3.2019. 
  • National Comprehensive Cancer Network (NCCN) Bone Cancer Version 2.2019.     
  • National Comprehensive Cancer Network (NCCN) Breast Cancer Version 1.2019.  
  • National Comprehensive Cancer Network (NCCN) Central Nervous System Cancers Version 1.2019.      
  • National Comprehensive Cancer Network (NCCN) Cervical Cancer Version 4.2019. 
  • National Comprehensive Cancer Network (NCCN) Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma Version 4.2019.      
  • National Comprehensive Cancer Network (NCCN) Chronic Myeloid Leukemia Version 4.2019.     
  • National Comprehensive Cancer Network (NCCN) Colon Cancer Version 1.2018.   
  • National Comprehensive Cancer Network (NCCN) Rectal Cancer Version 2.2019.    
  • National Comprehensive Cancer Network (NCCN) Esophageal and Esophagogastric Junction Cancers Version 1.2019. 
  • National Comprehensive Cancer Network (NCCN) Gastric Cancer Version 1.2019.   
  • National Comprehensive Cancer Network (NCCN) Gestational Trophoblastic Neoplasia Version 1.2019.
  • National Comprehensive Cancer Network (NCCN) Hairy Cell Leukemia Version 3.2019.       
  • National Comprehensive Cancer Network (NCCN) Head and Neck Cancers Version 1.2019.      
  • National Comprehensive Cancer Network (NCCN) Hepatobiliary Cancers Version 2.2019.     
  • National Comprehensive Cancer Network (NCCN) Hodgkin Lymphoma Version 1.2019.     
  • National Comprehensive Cancer Network (NCCN) Kidney Cancer Version 4.2019.       
  • National Comprehensive Cancer Network (NCCN) Malignant Pleural Mesothelioma Version 2.2019.       
  • National Comprehensive Cancer Network (NCCN) Melanoma Cutaneous Version 2.2019.           
  • National Comprehensive Cancer Network (NCCN) Uveal Melanoma Version 1.2018.      
  • National Comprehensive Cancer Network (NCCN) Multiple Myeloma Version 2.2019.   
  • National Comprehensive Cancer Network (NCCN) Systemic Light Change Amyloidosis Version 1.2019.   
  • National Comprehensive Cancer Network (NCCN) Waldenstrom’s Macroglobulinemia/Lymphoplasmacytic Lymphoma Version 2.2019. 
  • National Comprehensive Cancer Network (NCCN) Myelodysplastic Syndromes Version 2.2019.    
  • National Comprehensive Cancer Network (NCCN) Myeloproliferative Neoplasms Version 2.2019.   
  • National Comprehensive Cancer Network (NCCN) Neuroendocrine and Adrenal Tumors Version 1.2019. 
  • National Comprehensive Cancer Network (NCCN) B-Cell Lymphomas Version 2.2019. 
  • National Comprehensive Cancer Network (NCCN) Primary Cutaneous B-Cell Lymphomas Version 2.2019. 
  • National Comprehensive Cancer Network (NCCN) Gestational Trophoblastic Neoplasia Version 1.2019
  • National Comprehensive Cancer Network (NCCN) Basal Cell Skin Cancer Version 1.2019. 
  • National Comprehensive Cancer Network (NCCN) Dermatofibrosarcoma Protuberans Version 1.2019. 
  • National Comprehensive Cancer Network (NCCN) Merkel Cell Carcinoma Version 2.2019. 
  • National Comprehensive Cancer Network (NCCN) Squamous Cell Skin Cancer Version 2.2019. 
  • National Comprehensive Cancer Network (NCCN) Non-Small Cell Lung Cancer Version 4.2019. 
  • National Comprehensive Cancer Network (NCCN) Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer Version 1.2019. 
  • National Comprehensive Cancer Network (NCCN) Pancreatic Adenocarcinoma Version 2.2019. 
  • National Comprehensive Cancer Network (NCCN) Penile Cancer Version 2.2019. 
  • National Comprehensive Cancer Network (NCCN) Prostate Cancer Version 2.2019. 
  • National Comprehensive Cancer Network (NCCN) Small Cell Lung Cancer Version 1.2019. 
  • National Comprehensive Cancer Network (NCCN) Soft Tissue Sarcoma Version 2.2019. 
  • National Comprehensive Cancer Network (NCCN) Testicular Cancer Version 1.2019. 
  • National Comprehensive Cancer Network (NCCN) Thymomas and Thymic Carcinomas Version 2.2019. 
  • National Comprehensive Cancer Network (NCCN) Thyroid Carcinomas Version 1.2019. 
  • National Comprehensive Cancer Network (NCCN) Uterine Neoplasm Version 3.2019. 
  • National Comprehensive Cancer Network (NCCN) Vulvar Cancer (Squamous Cell Carcinoma) Version 2.2019.
  • NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC).

 

Policy History:

  • May 2019 - Annual Review, Policy Revised
  • May 2018 - New Policy

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.

 

*CPT® is a registered trademark of the American Medical Association.