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 PET and PET/CT
for the diagnosis of cardiac sarcoidosis.
3.1.4 The diagnosis, staging, restaging,
and monitoring of treatment of pancreatic cancer.
3.1.5 PET and PET/CT for the staging
and restaging of differentiated (follicular, papillary, Hürthle cell)
thyroid cancer.
3.1.6 PET and PET/CT for ruling out
recurrence of ovarian cancer.
3.1.7 PET and PET/CT for staging,
restaging, and detection of recurrence of colorectal cancer.
3.1.8 PET/CT for metastatic bladder
cancer.
3.1.9 Restaging of gastrointestinal
stromal tumor (a rare disease).
3.1.10 The diagnosis and management
of lung cancer when documented by reliable evidence as safe, effective,
and comparable or superior to standard care (proven).
3.1.11 PET
and PET/CT for the diagnosis, staging, and monitoring of treatment
of lymphoma.
3.1.12 PET and PET/CT for the initial
diagnosis, staging, and monitoring of treatment of ovarian cancer.
3.1.13 In addition to the specific
coverage indications listed in
paragraphs 3.1.1 through
3.1.11, 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.
4.3.5 The diagnosis
of systemic sarcoidosis.
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.