2.0 DESCRIPTION
Nuclear Medicine uses very small amounts of
radioactive materials or radiopharmaceuticals to diagnose and treat
disease. Radiopharmaceuticals are substances that are attracted
to specific organs, bones, or tissues. The radiopharmaceutical used
in nuclear medicine emit gamma rays that can be detected externally
by gamma or Positron Emission Tomography (PET) cameras. These cameras
work in conjunction with computers used to form images that provide
data and information about the area of body being imaged. The following
techniques are used in the diagnosis, management, treatment, and prevention
of disease:
• Planar, Single Photon
Emission Computed Tomography (SPECT);
• Positron Emission
Tomography (PET);
• Tomography;
• Nuclear Medicine Scan;
• Radiopharmaceutical;
• Gamma Camera;
• In Vitro Fertilization
(IVF) procedures done in test tubes - Radioimmunoassay (RIA) is
a type of in vitro procedure; and
• In vivo procedures
are when trace amounts of radiopharmaceuticals are given directly
to a patient.
3.0 POLICY
3.1 PET is
covered for:
3.1.1 The
diagnosis and management of seizure disorders.
3.1.2 Evaluation
of ischemic heart disease.
3.1.3 The diagnosis, staging, restaging,
and monitoring of treatment of pancreatic cancer.
3.1.4 PET and
PET/CT for the staging and restaging of differentiated (follicular,
papillary, Hürthle cell) thyroid cancer.
3.1.5 PET and PET/CT for ruling
out recurrence of ovarian cancer.
3.1.6 PET and PET/CT for staging,
restaging, and detection of recurrence of colorectal cancer.
3.1.7 PET/CT
for metastatic bladder cancer.
3.1.8 Restaging of gastrointestinal
stromal tumor (a rare disease).
3.1.9 The diagnosis and management
of lung cancer when documented by reliable evidence as safe, effective,
and comparable or superior to standard care (proven).
3.1.10 PET
and PET/CT for the diagnosis, staging, and monitoring of treatment
of lymphoma.
3.1.11 PET
and PET/CT for the initial diagnosis, staging, and monitoring of
treatment of ovarian cancer.
3.1.12 In addition to the specific coverage indications
listed in
paragraphs 3.1.1 through
3.1.10, effective
May 21, 2013, PET and PET/CT are proven diagnostics for the diagnosis,
staging, restaging, and monitoring of oncologic indications, when
supported by National Comprehensive Cancer Network (NCCN) clinical
practice guidelines.
3.2 SPECT is covered for:
3.2.1 Myocardial
perfusion imaging utilizing SPECT.
3.2.2 Brain imaging utilizing SPECT
for the evaluation of seizure disorder.
3.2.3 Prostatic radioimmunoscintigraphy
imaging utilizing SPECT for the following indications:
3.2.3.1 Metastatic
spread of prostate cancer and for use in post-prostatectomy patients
in whom there is a high suspicion of undetected cancer recurrence.
3.2.3.2 Newly diagnosed
patients with biopsy-proven prostate cancer at high risk for spread
of their disease to pelvic lymph nodes.
3.2.4 Indium111 -
for detecting the presence and location of myocardial injury in
patients with suspected myocardial infarction.
3.2.5 Indium111-
labeled anti-TAG72 for tumor recurrence in colorectal and ovarian
cancer.
3.2.6 SPECT for other indications is covered when
documented by reliable evidence as safe, effective, and comparable
or superior to standard care (proven).
3.3 Indium
111 Pentetreotide
(Octreoscan) Scintigraphy is covered for:
3.3.1 The localization and monitoring
of treatment of primary and metastatic neuroendocrine tumors.
3.3.2 Other indications
when documented by reliable evidence as safe, effective, and comparable
or superior to standard care (proven).
3.4 Bone Density
Studies (Current Procedural Terminology (CPT) procedure codes 78350
and 78351) are covered for:
3.4.1 The diagnosis and monitoring
of osteoporosis.
3.4.2 The diagnosis and monitoring
of osteopenia.
3.4.3 Patients must present with
signs and symptoms of bone disease or be considered at high-risk
for developing osteoporosis. High-risk factors for osteoporosis
are those identified as the standard of care by the American College
of Obstetricians and Gynecologists (ACOG).
4.0 Exclusions
4.1 Bone density
studies for the routine screening of osteoporosis.
4.2 PET for
the diagnosis and monitoring of treatment of Alzheimer’s disease,
fronto-temporal dementia or other forms of dementia is unproven.
4.3 PET and
PET/CT are excluded for:
4.3.1 The initial diagnosis of differentiated
thyroid cancer and for medullary cell thyroid cancer.
4.3.2 The diagnosis,
staging, restaging, and monitoring of treatment of gastric cancer
is unproven.
4.3.3 The initial diagnosis and monitoring of treatment
of colorectal cancer is unproven.
4.3.4 The diagnosis of renal mass or possible Renal
Cell Carcinoma (RCC) recurrence.
4.4 Ultrasound ablation (destruction
of uterine fibroids) with Magnetic
Resonance Imaging (MRI) guidance (CPT procedure code 0071T) in the
treatment of uterine leiomyomata is unproven.
4.5 Scintimammography
(HCPCS code S8080), Breast-Specific Gamma Imaging (BSGI) (CPT procedure
codes 78800, 78801), and Molecular Breast Imaging (MBI) are unproven
for all indications.
5.0 EFFECTIVE
DATES
5.1 January 1, 1995, for PET for ischemic heart
disease.
5.2 December 1, 1996, for PET for lung cancer.
5.3 October
14, 1990, for SPECT for myocardial perfusion imaging.
5.4 January
1, 1991, for SPECT for brain imaging.
5.5 October 28, 1996, for 111In-Capromab
Pendetide, CyT 356 (ProstaScint™).
5.6 June 1, 1994, for Octreoscan
Scintigraphy.
5.7 May 26, 1994, for bone density studies.
5.8 January
1, 2006, for PET and PET/CT for pancreatic cancer.
5.9 February
16, 2006, for PET and PET/CT for thyroid cancer.
5.10 December
1, 2008, for PET and PET/CT for ruling out recurrence of ovarian
cancer.
5.11 May 1, 2007, for PET and PET/CT for staging,
restaging, and detection of recurrence of colorectal cancer.
5.12 January
1, 2010, for PET/CT for metastatic bladder cancer.
5.13 January
1, 2007, for PET and PET/CT for lymphoma.
5.14 January 1, 2010, for PET for
gastrointestinal stromal tumor (a rare disease).
5.15 May 21,
2013, for PET and PET/CT are proven diagnostics for the diagnosis,
staging, restaging and monitoring of oncologic indications when
supported by NCCN clinical practice guidelines.
5.16 February 1, 2015, PET and PET/CT
are proven for the initial diagnosis, staging, and monitoring of
treatment of ovarian cancer.