Commerical Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Alabama Blue Cross
Cardiac: Metabolic Myocardial PET for cardiac involvement related to sarcoidosis is covered; metabolic myocardial PET imaging assessment of myocardial viability is covered if patient has document CAD and coronary angiography indicates a correctable lesion and nuclear stress test is discordant with clinical data or indeterminate and patient is revascularization candidate; Perfusion PET is covered when perfusion stress imaging is non-diagnostic or inconsistent with clinical state and patient is being considered for heart catheterization or used in place of SPECT for severely obese patients or patients with implants and individual is high CAD risk or patient has EKG abnormalities with high risk for CAD and one of following EKG abnormalities or drug is present: left ventricular hypertrophy; resting ST segment depression or currently on digoxin; OR when used to assess myocardial ischemia with culprit disease with following are met: stenosis > 50% by angiogram when lesion is amenable to PCI.
Oncologic: Individual consideration will be given for PET for patients with known diagnosis of malignancy when following are met: to determine optimal anatomic site for biopsy or other invasive diagnostic procedure; or staging and restaging when standard imaging is inconclusive or inadequate or for restaging to detect residual or recurrence. Other: PET using 2-fluorine-18-FDG covered for selected patients with epileptic seizures who are candidates for surgery; for patients with chronic granulomatous disease, for assessment of pheochromocytoma when urine and serum catecholamine levels elevated but tumor has not been localized with MRI;
Other: For patients with suspected Huntington's chorea when MRI is nondiagnostic and genetic testing NA or refused; for chronic cerebrovascular disorders when EC-IC is indicated and supported by clinical and lab findings; Individual consideration given for other patients not described above.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Arkansas Blue Cross and Blue Shield
Cardiac: PET for myocardial perfusion is covered if performed in place of SPECT or following inconclusive SPECT.
Oncologic: For Breast, covered as adjunct to other imaging modalities for staging and restaging and to monitor chemo when done after first or second cycle to determine impact. Colorectal for initial staging, to determine recurrence (not to evalutate response to chemo); PET with FDG covered for preop staging of esophageal; PET with FDG covered for initial detection; for restaging following treatment, for monitoring therapy, for prognosis. For suspected head and neck, for initial staging, for detection of residual disease after treatment, for suspected recurrence. PET with FDG covered for evaluation of solitary pulmonary nodule as alternative to surgical biopsy, for staging of newly diagnosed lung cancer if it will impact treatment, for recurrence if other tests inconclusive. For initial staging of lymphoma, for restaging, for suspected recurrence. Covered if primary site not determined in patients with single site of disease outside cervical lymph nodes, patient considering local or regional treatment for single site, conventional testing is negative for occult primary and PET used to rule out or detect other sites that would eliminate local treatment. PET with FDG covered for differentiation of recurrent CNS tumor from scarring associated with treatment. other uses not covered for brain cancer. PET with FDG covered for patients with melanoma to detect extranodal metastases at initial staging or when recurrence is suspected. PET with FDG covered one time for staging of biopsy proven pleural mesothelioma when patient is being evaluated for curative surgery. PET covered for ovarian for restaging is marker is rising and conventional imaging inconclusive and to differentiate between tumor and necrosis after treatment. Pancreas, prostate not covered. PET with FDG covered for testicular germ cell cancer for restaging if marker is elevated and CT inconclusive (other indications not covered). Covered for restaging of recurrent or residual follicular thyroid cancer in specified conditions.
Other: PET with FDG of brain covered for assessment of patients with epilepsy who are candidates for surgery. Not covered for Alzheimers or dementia.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross of California/Wellpoint
Cardiac: PET considered medically necessary for following indications when results can be expected to affect clinical management: Cardiac: 1) to assess myocardial viability in patients with severe left ventricular dysfunction to assess candicacy for surgery;2) to assess myocardial perfusion at rest or with pharmaco stress in diagnosis of CAD when any of following are present: unavailable or inconclusive SPECT; body habitus or other conditions that would result in attenuation problems with SPECT; conditions for which angiography would be technically challenging.
Oncologic: 1) head and neck cancer to identify unknown primary with metastatic to the cervical lymph nodes; to stage or assess resectability; to detect residual or recurrent head and neck after treatment; 2) thyroid for staging or restaging in specific circumstances; 3) staging or restaging or medullary thyroid; 4) to differentiate radiation necrosis from recurrence for brain cancer; 5) for evaluation of suspicious pulmonary nodule where curative treatment is contemplated; 6) for staging in non-small cell and small cell lung cancer; 7) for assessing spread of malignant melanoma beyond lymph nodes; 8) for staging or restaging lymphoma; 9) for localization of recurrent ovarian with rising CA 125 and neg or equivocal CT; 10) for restaging in patients with history of testicular and signs of recurrence; 11) for staging or restaging of confirmed esophageal when conventional radiographic is negative, inconclusive or non-diagnostic; 12) colorectal; 13) to differentiate between benign and malignant pancreatic lesions; 14) cervical; 15) breast; 16) musculoskeletal neoplasms for differentiation or staging; 17) for unknown primary presenting with metastatic outside cervical lymph nodes ; 18) for other malignancies where major surgery or curative high dose local radiation is recommended and PET may identify metastisis that would change treatment; 19) for initial diagnosis and ongoing assessment of response to chemo in pediatric patients with neuroblastoma.
Other: Neurological: identification or localization of seizure foci for epilepsy surgery candidates. Other: PET with or without PET/CT fusion to diagnosis chronic osteomyelitis of central skeleton. All other is considered investigational.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Anthem/Wellpoint
Cardiac: PET considered medically necessary for following indications when results can be expected to affect clinical management: Cardiac: 1) to assess myocardial viability in patients with severe left ventricular dysfunction to assess candicacy for surgery;2) to assess myocardial perfusion at rest or with pharmaco stress in diagnosis of CAD when any of following are present: unavailable or inconclusive SPECT; body habitus or other conditions that would result in attenuation problems with SPECT; conditions for which angiography would be technically challenging.
Oncologic: 1) head and neck cancer to identify unknown primary with metastatic to the cervical lymph nodes; to stage or assess resectability; to detect residual or recurrent head and neck after treatment; 2) thyroid for staging or restaging in specific circumstances; 3) staging or restaging or medullary thyroid; 4) to differentiate radiation necrosis from recurrence for brain cancer; 5) for evaluation of suspicious pulmonary nodule where curative treatment is contemplated; 6) for staging in non-small cell and small cell lung cancer; 7) for assessing spread of malignant melanoma beyond lymph nodes; 8) for staging or restaging lymphoma; 9) for localization of recurrent ovarian with rising CA 125 and neg or equivocal CT; 10) for restaging in patients with history of testicular and signs of recurrence; 11) for staging or restaging of confirmed esophageal when conventional radiographic is negative, inconclusive or non-diagnostic; 12) colorectal; 13) to differentiate between benign and malignant pancreatic lesions; 14) cervical; 15) breast; 16) musculoskeletal neoplasms for differentiation or staging; 17) for unknown primary presenting with metastatic outside cervical lymph nodes ; 18) for other malignancies where major surgery or curative high dose local radiation is recommended and PET may identify metastisis that would change treatment; 19) for initial diagnosis and ongoing assessment of response to chemo in pediatric patients with neuroblastoma.
Other: Neurological: identification or localization of seizure foci for epilepsy surgery candidates. Other: PET with or without PET/CT fusion to diagnosis chronic osteomyelitis of central skeleton. All other is considered investigational.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Anthem/Wellpoint
Cardiac: PET considered medically necessary for following indications when results can be expected to affect clinical management: Cardiac: 1) to assess myocardial viability in patients with severe left ventricular dysfunction to assess candicacy for surgery;2) to assess myocardial perfusion at rest or with pharmaco stress in diagnosis of CAD when any of following are present: unavailable or inconclusive SPECT; body habitus or other conditions that would result in attenuation problems with SPECT; conditions for which angiography would be technically challenging.
Oncologic: 1) head and neck cancer to identify unknown primary with metastatic to the cervical lymph nodes; to stage or assess resectability; to detect residual or recurrent head and neck after treatment; 2) thyroid for staging or restaging in specific circumstances; 3) staging or restaging or medullary thyroid; 4) to differentiate radiation necrosis from recurrence for brain cancer; 5) for evaluation of suspicious pulmonary nodule where curative treatment is contemplated; 6) for staging in non-small cell and small cell lung cancer; 7) for assessing spread of malignant melanoma beyond lymph nodes; 8) for staging or restaging lymphoma; 9) for localization of recurrent ovarian with rising CA 125 and neg or equivocal CT; 10) for restaging in patients with history of testicular and signs of recurrence; 11) for staging or restaging of confirmed esophageal when conventional radiographic is negative, inconclusive or non-diagnostic; 12) colorectal; 13) to differentiate between benign and malignant pancreatic lesions; 14) cervical; 15) breast; 16) musculoskeletal neoplasms for differentiation or staging; 17) for unknown primary presenting with metastatic outside cervical lymph nodes ; 18) for other malignancies where major surgery or curative high dose local radiation is recommended and PET may identify metastisis that would change treatment; 19) for initial diagnosis and ongoing assessment of response to chemo in pediatric patients with neuroblastoma.
Other: Neurological: identification or localization of seizure foci for epilepsy surgery candidates. Other: PET with or without PET/CT fusion to diagnosis chronic osteomyelitis of central skeleton. All other is considered investigational.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Care First
Cardiac: Covered for assessment of myocardial viability (following inconclusive SPECT prior to revascularization), and evaluation of CAD.
Oncologic: PET covered for classification of solitary pulmonary nodules and diagnosis, staging and restaging of following oncological indications non small cell lung carcinoma, colorectal, lymphoma, melanoma, head and neck, thyroid, esophageal, breast, and cervical in accordance with policy guidelines.
Other: Pre-surgical evaluation of refractory seizures in accordance with policy guidelines.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of Florida
Cardiac: PET covered for assessment of myocardial perfusion for defects; for assessment of myocardial viability in patients with severe left ventricular dysfunction to determine candidacy for revascularization or as primary or initial diagnostic study prior to revascularization or following inconclusive SPECT.
Oncologic: PET medically necessary for diagnosis only when PET results may assist in avoiding invasive diagnostic procedure or when results may assist in determining optimal location to perform invasive procedure. Covered for staging when PET could replace one or more conventional imaging studies when other imaging is insufficient for management of the patient and management would differ based on stage. Covered for restaging after completion of treatment to determine residual disease, or suspected recurrence or extent of known recurrence or if it could replace other imaging studies when other imaging would be insufficient. Indications include brain, breast, cervical, colorectal, esophageal, head and neck, lung, melanoma, ovarian, pancreatic, thyroid, whole body imaging , unknown primary in accordance with specified policies for each type of cancer. PET for multiply myeloma, testicular and vulvar cancer requires Medical Director review.
Other: Other indications: PET with FDG covered for patients with seizures that have not responded to medical therapy and who have been advised to have a resection and conventional techniques for localizations were inconclusive for surgical purposes; PET with FDG covered for work up of brain tumor. all other including evaluation of CNS, pulmonary and musculoskeletal disease considered experimental.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Anthem/Wellpoint
Cardiac: PET considered medically necessary for following indications when results can be expected to affect clinical management: Cardiac: 1) to assess myocardial viability in patients with severe left ventricular dysfunction to assess candicacy for surgery;2) to assess myocardial perfusion at rest or with pharmaco stress in diagnosis of CAD when any of following are present: unavailable or inconclusive SPECT; body habitus or other conditions that would result in attenuation problems with SPECT; conditions for which angiography would be technically challenging.
Oncologic: 1) head and neck cancer to identify unknown primary with metastatic to the cervical lymph nodes; to stage or assess resectability; to detect residual or recurrent head and neck after treatment; 2) thyroid for staging or restaging in specific circumstances; 3) staging or restaging or medullary thyroid; 4) to differentiate radiation necrosis from recurrence for brain cancer; 5) for evaluation of suspicious pulmonary nodule where curative treatment is contemplated; 6) for staging in non-small cell and small cell lung cancer; 7) for assessing spread of malignant melanoma beyond lymph nodes; 8) for staging or restaging lymphoma; 9) for localization of recurrent ovarian with rising CA 125 and neg or equivocal CT; 10) for restaging in patients with history of testicular and signs of recurrence; 11) for staging or restaging of confirmed esophageal when conventional radiographic is negative, inconclusive or non-diagnostic; 12) colorectal; 13) to differentiate between benign and malignant pancreatic lesions; 14) cervical; 15) breast; 16) musculoskeletal neoplasms for differentiation or staging; 17) for unknown primary presenting with metastatic outside cervical lymph nodes ; 18) for other malignancies where major surgery or curative high dose local radiation is recommended and PET may identify metastisis that would change treatment; 19) for initial diagnosis and ongoing assessment of response to chemo in pediatric patients with neuroblastoma.
Other: Neurological: identification or localization of seizure foci for epilepsy surgery candidates. Other: PET with or without PET/CT fusion to diagnosis chronic osteomyelitis of central skeleton. All other is considered investigational.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
Regency Blue Cross
Cardiac: May be medically necessary to assess myocardial perfusion to diagnose CAD when patients are at least intermediate risk and the PET scan is in place of but not in addition to SPECT or previous SPECT was inconclusive; myocardial viability in patients with severe left ventricular dysfunction who are candidates for revascularization.
Oncologic: May be necessary for diagnosis in cases where PET may avoid invasive diagnostic. May be necessary for staging when stage is in doubt after completion of standard workup including conventional imaging or when PET could replace an imaging study that is expected to be insufficient for clinical management and when clinical management would differ depending on the stage; Restaging: may be necessary for restaging after completion of treatment for detecting residual disease or suspected recurrence or to determine extent of known recurrence; or if it could replace one or more conventional imaging studies when it is expected that the study information will be insufficient for management of patient. Monitoring: May be necessary to monitor tumor response when change in therapy is contemplated.
Other: PET FDG may be necessary in assessment of patients with epilepsy who are candidates for surgery, when conventional techniques for seizure location are insufficient for surgery and to minimize extended pre-op EEG with implanted eletrodes; or for chronic osteomyelitis. All other investigational.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
Illinois Blue Cross and Blue Shield
Cardiac: May be medically necessary to assess myocardial perfusion defects and thus diagnose CAD when patient has at least intermediate risk and it is used in place of but not in addition to SPECT or previous SPECT was inconclusive. May be considered medically necessary to assess myocardial viability in patients with severe left ventricular dysfunction to determine candidacy for revascularization.
Oncologic: PET may be considered medically necessary for known or suspected malignancies (except screening, surveillance) when the findings on other imaging modalities are inconclusive or discordant and results of the PET or PET/CT will be deciding factor in determining treatment.Once PET is approved subsequent use for monitoring or staging will be considered medically necessary without requirement for retesting with traditional modalities providing it otherwise meets criteria. Not covered for ovarian, pancreatic, small cell or soft tissue sarcoma.
Other: May be necessary fo diagnosis of chronic osteomyelitis; assessment of selected patients with epileptic seizures who are candidates for surgery.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Anthem/Wellpoint
Cardiac: PET considered medically necessary for following indications when results can be expected to affect clinical management: Cardiac: 1) to assess myocardial viability in patients with severe left ventricular dysfunction to assess candicacy for surgery;2) to assess myocardial perfusion at rest or with pharmaco stress in diagnosis of CAD when any of following are present: unavailable or inconclusive SPECT; body habitus or other conditions that would result in attenuation problems with SPECT; conditions for which angiography would be technically challenging.
Oncologic: 1) head and neck cancer to identify unknown primary with metastatic to the cervical lymph nodes; to stage or assess resectability; to detect residual or recurrent head and neck after treatment; 2) thyroid for staging or restaging in specific circumstances; 3) staging or restaging or medullary thyroid; 4) to differentiate radiation necrosis from recurrence for brain cancer; 5) for evaluation of suspicious pulmonary nodule where curative treatment is contemplated; 6) for staging in non-small cell and small cell lung cancer; 7) for assessing spread of malignant melanoma beyond lymph nodes; 8) for staging or restaging lymphoma; 9) for localization of recurrent ovarian with rising CA 125 and neg or equivocal CT; 10) for restaging in patients with history of testicular and signs of recurrence; 11) for staging or restaging of confirmed esophageal when conventional radiographic is negative, inconclusive or non-diagnostic; 12) colorectal; 13) to differentiate between benign and malignant pancreatic lesions; 14) cervical; 15) breast; 16) musculoskeletal neoplasms for differentiation or staging; 17) for unknown primary presenting with metastatic outside cervical lymph nodes ; 18) for other malignancies where major surgery or curative high dose local radiation is recommended and PET may identify metastisis that would change treatment; 19) for initial diagnosis and ongoing assessment of response to chemo in pediatric patients with neuroblastoma.
Other: Neurological: identification or localization of seizure foci for epilepsy surgery candidates. Other: PET with or without PET/CT fusion to diagnosis chronic osteomyelitis of central skeleton. All other is considered investigational.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
Wellmark Blue Cross
Cardiac: May be considered medically necessary to assess myocardial perfusion to diagnose CAD; to assess myocardial viability in patients with severe left ventricular dysfunction to determine candidacy for revascularization.
Oncologic: May be medically necessary for breast (detection of lesions, bony metastasis, staging of lymph nodes, monitoring, restaging for recurrence, rule out metastasis in early stage when findings are indicative); cervical (staging); colorectal (diagnosis, staging and monitoring, restaging); esophageal (diagnosis, staging, restaging); head and neck (unknown primary, initial staging of cervical lymph nodes, detection of residual or recurrent disease); primary hepatocellular non-resectable (to rule out extrahepatic metastases for patients being considered for selective internal radiation to the liver); non small cell lung (to distinguish between benign and malignant disease in patients with solitary pulmonary nodule when other results inconclusive or discordant, staging, restaging); lymphoma (initial staging, differentiating benign from malignant, restaging); melanoma (diagnosis, staging, restaging, detection of extranodal metastasis); ovarian (localization of recurrent ovarian in women with rising CA 125 levels and negative or equivocal CT); pancreatic (to differentiate between benigh and malignant when other tests are normal or equivocal, when results may alter treatment); testicular (post chemo for patients exhibiting signs of disease); thyroid (staging and restaging of cancer of follicular origin in presence of rising thyroglobulin levels and negative I-131); unknown primary (occult) in patients with single site of disease outside cervical nodes and patient considering localized treatment and negative work up for occult primary and PEt will be used to rule out or detect additional sites that would eliminate rationale for local treatment. Considered investigational for brain, bladder, primary hepatocellular carcinoma, ovarian and parathyroid(except as described above).
Other: PET may be necessary to identify or localize seizure foci in patients undergoing evaluation for neurosurgical treatment of epilepsy.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of Kansas
Cardiac: Covered following inconclusive SPECT for patient who is candidate for revascularization; myocardial viability for primary or initial diagnosis prior to revascularization or following inconclusive SPECT, perfusion of the heart.
Oncologic: PET medically necessary for diagnosis after tissue diagnosis for purpose of staging and determining location of invasive surgery; for staging when stage is in doubt after completion of diag. workup including conventional imaging or if PET can replace other imaging study and clinical management will differ depending on stage. Covered for restaging to determine residual disease or recurrence. USe of PET to monitor tumor response is not covered except for breast cancer. Staging and restaging covered for brain, colorectal, esophageal, head and neck, lymphoma, melanoma (not regional nodes), lung cancer, thryoid(specified conditions), cervical. Breast denied for stage 0, stage 1 must be reviewed by consultant, stage 2 as adjunct to standard imaging. Characterization of solitary pulmonary nodules.
Other: Pre-op evaluation of refractory seizures also covered.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Anthem/Wellpoint
Cardiac: PET considered medically necessary for following indications when results can be expected to affect clinical management: Cardiac: 1) to assess myocardial viability in patients with severe left ventricular dysfunction to assess candicacy for surgery;2) to assess myocardial perfusion at rest or with pharmaco stress in diagnosis of CAD when any of following are present: unavailable or inconclusive SPECT; body habitus or other conditions that would result in attenuation problems with SPECT; conditions for which angiography would be technically challenging.
Oncologic: 1) head and neck cancer to identify unknown primary with metastatic to the cervical lymph nodes; to stage or assess resectability; to detect residual or recurrent head and neck after treatment; 2) thyroid for staging or restaging in specific circumstances; 3) staging or restaging or medullary thyroid; 4) to differentiate radiation necrosis from recurrence for brain cancer; 5) for evaluation of suspicious pulmonary nodule where curative treatment is contemplated; 6) for staging in non-small cell and small cell lung cancer; 7) for assessing spread of malignant melanoma beyond lymph nodes; 8) for staging or restaging lymphoma; 9) for localization of recurrent ovarian with rising CA 125 and neg or equivocal CT; 10) for restaging in patients with history of testicular and signs of recurrence; 11) for staging or restaging of confirmed esophageal when conventional radiographic is negative, inconclusive or non-diagnostic; 12) colorectal; 13) to differentiate between benign and malignant pancreatic lesions; 14) cervical; 15) breast; 16) musculoskeletal neoplasms for differentiation or staging; 17) for unknown primary presenting with metastatic outside cervical lymph nodes ; 18) for other malignancies where major surgery or curative high dose local radiation is recommended and PET may identify metastisis that would change treatment; 19) for initial diagnosis and ongoing assessment of response to chemo in pediatric patients with neuroblastoma.
Other: Neurological: identification or localization of seizure foci for epilepsy surgery candidates. Other: PET with or without PET/CT fusion to diagnosis chronic osteomyelitis of central skeleton. All other is considered investigational.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Anthem/Wellpoint
Cardiac: PET considered medically necessary for following indications when results can be expected to affect clinical management: Cardiac: 1) to assess myocardial viability in patients with severe left ventricular dysfunction to assess candicacy for surgery;2) to assess myocardial perfusion at rest or with pharmaco stress in diagnosis of CAD when any of following are present: unavailable or inconclusive SPECT; body habitus or other conditions that would result in attenuation problems with SPECT; conditions for which angiography would be technically challenging.
Oncologic: 1) head and neck cancer to identify unknown primary with metastatic to the cervical lymph nodes; to stage or assess resectability; to detect residual or recurrent head and neck after treatment; 2) thyroid for staging or restaging in specific circumstances; 3) staging or restaging or medullary thyroid; 4) to differentiate radiation necrosis from recurrence for brain cancer; 5) for evaluation of suspicious pulmonary nodule where curative treatment is contemplated; 6) for staging in non-small cell and small cell lung cancer; 7) for assessing spread of malignant melanoma beyond lymph nodes; 8) for staging or restaging lymphoma; 9) for localization of recurrent ovarian with rising CA 125 and neg or equivocal CT; 10) for restaging in patients with history of testicular and signs of recurrence; 11) for staging or restaging of confirmed esophageal when conventional radiographic is negative, inconclusive or non-diagnostic; 12) colorectal; 13) to differentiate between benign and malignant pancreatic lesions; 14) cervical; 15) breast; 16) musculoskeletal neoplasms for differentiation or staging; 17) for unknown primary presenting with metastatic outside cervical lymph nodes ; 18) for other malignancies where major surgery or curative high dose local radiation is recommended and PET may identify metastisis that would change treatment; 19) for initial diagnosis and ongoing assessment of response to chemo in pediatric patients with neuroblastoma.
Other: Neurological: identification or localization of seizure foci for epilepsy surgery candidates. Other: PET with or without PET/CT fusion to diagnosis chronic osteomyelitis of central skeleton. All other is considered investigational.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
CareFirst
Cardiac: Covered for assessment of myocardial viability (following inconclusive SPECT prior to revascularization), and evaluation of CAD.
Oncologic: PET covered for classification of solitary pulmonary nodules and diagnosis, staging and restaging of following oncological indications non small cell lung carcinoma, colorectal, lymphoma, melanoma, head and neck, thyroid, esophageal, breast, and cervical in accordance with policy guidelines.
Other: Pre-surgical evaluation of refractory seizures in accordance with policy guidelines.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of Massachusetts
Cardiac: To assess myocardial perfusion and diagnose CAD, or to assess myocardial viability in patients with severe left ventricular dysfunction to determine candidacy for revascularization.
Oncologic: Covered to diagnose lung cancer if patient has solitary or multiple pulmonary nodule and prior scans inconclusive; to stage and restage lung cancer; to restage thyroid cancer of follicular origin that have been treated and have elevated thyroglobulin (>10ng/ml) and negative I-131; to diagnose, stage and restage esophageal; for colorectal to determine location of recurrence in patients with rising CEA and to assess resectability of extrahepatic metastases; for staging lymphoma; to evaluate recurrence of melanoma prior to surgery or assess extranodal spread at initial stage or during followup treatment; breast caner as adjunct to other imaging modalities for staging and restaging of recurrence or metastasis, or as adjunct to standard imaging to monitor locally advanced cancer when change in therapy is contemplated; for unknown primary in patients with single site of disease outside cervical lymph nodes, and patient considering local treatment and negative workup for occult primary and to rule out additional sites that would elminate rationale for local treatment.
Other: Covered for patients with complex partial seizures who are being evaluated for surgery.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
Harvard Pilgrim
Cardiac: Reviewed by NIA; guidelines include: Cardiac: to assess myocardial perfusion and diagnose CAD, or to assess myocardial viability in patients with severe left ventricular dysfunction to determine candidacy for revascularization.
Oncologic: Reviewed by NIA; guidelines include:for diagnosis, staging and/or restaging for specified cancers as indicated.
Other: For epilepsy patients who are candidates for surgery; for follow-up on known brain tumor.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of Minnesota
Cardiac: FDG-PET for assessment of myocardial viability in chronic CAD following inconclusive SPECT; Rb-82 or N-13 for assessment of myocardial perfusion in diagnosis of CAD folloiwng inconclusive SPECT or assessment of myocardial perfusion to diagnose CAD in obese patients (BMI 35). NOTE: PET is subject to High Technology Diagnostic Imaging Program (HTDI) review (notification and data collection only). Designated providers approved by BCBSMN interact directly with BC. Non-designated providers must submit through AIM.
Oncologic: Covered when the results of testing will guide clinical management and when neoplasm is determined to be highly glucose avid with FDG (eg prostate, pheochromocytoma, basal cell).
Other: Considered acceptable medical practice for neurology (FDG-PET) for localization of epileptic seizure focus in patients who are candidates for surgery who have not responded to treatment and for whom other techniques have not localized seizure focus.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of Minnesota
Cardiac: FDG-PET for assessment of myocardial viability in chronic CAD following inconclusive SPECT; Rb-82 or N-13 for assessment of myocardial perfusion in diagnosis of CAD folloiwng inconclusive SPECT or assessment of myocardial perfusion to diagnose CAD in obese patients (BMI 35). NOTE: PET is subject to High Technology Diagnostic Imaging Program (HTDI) review (notification and data collection only). Designated providers approved by BCBSMN interact directly with BC. Non-designated providers must submit through AIM.
Oncologic: Covered when the results of testing will guide clinical management and when neoplasm is determined to be highly glucose avid with FDG (eg prostate, pheochromocytoma, basal cell).
Other: Considered acceptable medical practice for neurology (FDG-PET) for localization of epileptic seizure focus in patients who are candidates for surgery who have not responded to treatment and for whom other techniques have not localized seizure focus.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of Minnesota
Cardiac: FDG-PET for assessment of myocardial viability in chronic CAD following inconclusive SPECT; Rb-82 or N-13 for assessment of myocardial perfusion in diagnosis of CAD folloiwng inconclusive SPECT or assessment of myocardial perfusion to diagnose CAD in obese patients (BMI 35). NOTE: PET is subject to High Technology Diagnostic Imaging Program (HTDI) review (notification and data collection only). Designated providers approved by BCBSMN interact directly with BC. Non-designated providers must submit through AIM.
Oncologic: Covered when the results of testing will guide clinical management and when neoplasm is determined to be highly glucose avid with FDG (eg prostate, pheochromocytoma, basal cell).
Other: Considered acceptable medical practice for neurology (FDG-PET) for localization of epileptic seizure focus in patients who are candidates for surgery who have not responded to treatment and for whom other techniques have not localized seizure focus.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of Minnesota
Cardiac: FDG-PET for assessment of myocardial viability in chronic CAD following inconclusive SPECT; Rb-82 or N-13 for assessment of myocardial perfusion in diagnosis of CAD folloiwng inconclusive SPECT or assessment of myocardial perfusion to diagnose CAD in obese patients (BMI 35). NOTE: PET is subject to High Technology Diagnostic Imaging Program (HTDI) review (notification and data collection only). Designated providers approved by BCBSMN interact directly with BC. Non-designated providers must submit through AIM.
Oncologic: Covered when the results of testing will guide clinical management and when neoplasm is determined to be highly glucose avid with FDG (eg prostate, pheochromocytoma, basal cell).
Other: Considered acceptable medical practice for neurology (FDG-PET) for localization of epileptic seizure focus in patients who are candidates for surgery who have not responded to treatment and for whom other techniques have not localized seizure focus.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of Minnesota
Cardiac: FDG-PET for assessment of myocardial viability in chronic CAD following inconclusive SPECT; Rb-82 or N-13 for assessment of myocardial perfusion in diagnosis of CAD folloiwng inconclusive SPECT or assessment of myocardial perfusion to diagnose CAD in obese patients (BMI 35). NOTE: PET is subject to High Technology Diagnostic Imaging Program (HTDI) review (notification and data collection only). Designated providers approved by BCBSMN interact directly with BC. Non-designated providers must submit through AIM.
Oncologic: Covered when the results of testing will guide clinical management and when neoplasm is determined to be highly glucose avid with FDG (eg prostate, pheochromocytoma, basal cell).
Other: Considered acceptable medical practice for neurology (FDG-PET) for localization of epileptic seizure focus in patients who are candidates for surgery who have not responded to treatment and for whom other techniques have not localized seizure focus.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of Minnesota
Cardiac: FDG-PET for assessment of myocardial viability in chronic CAD following inconclusive SPECT; Rb-82 or N-13 for assessment of myocardial perfusion in diagnosis of CAD folloiwng inconclusive SPECT or assessment of myocardial perfusion to diagnose CAD in obese patients (BMI 35). NOTE: PET is subject to High Technology Diagnostic Imaging Program (HTDI) review (notification and data collection only). Designated providers approved by BCBSMN interact directly with BC. Non-designated providers must submit through AIM.
Oncologic: Covered when the results of testing will guide clinical management and when neoplasm is determined to be highly glucose avid with FDG (eg prostate, pheochromocytoma, basal cell).
Other: Considered acceptable medical practice for neurology (FDG-PET) for localization of epileptic seizure focus in patients who are candidates for surgery who have not responded to treatment and for whom other techniques have not localized seizure focus.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of Minnesota
Cardiac: FDG-PET for assessment of myocardial viability in chronic CAD following inconclusive SPECT; Rb-82 or N-13 for assessment of myocardial perfusion in diagnosis of CAD folloiwng inconclusive SPECT or assessment of myocardial perfusion to diagnose CAD in obese patients (BMI 35). NOTE: PET is subject to High Technology Diagnostic Imaging Program (HTDI) review (notification and data collection only). Designated providers approved by BCBSMN interact directly with BC. Non-designated providers must submit through AIM.
Oncologic: Covered when the results of testing will guide clinical management and when neoplasm is determined to be highly glucose avid with FDG (eg prostate, pheochromocytoma, basal cell).
Other: Considered acceptable medical practice for neurology (FDG-PET) for localization of epileptic seizure focus in patients who are candidates for surgery who have not responded to treatment and for whom other techniques have not localized seizure focus.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of Minnesota
Cardiac: FDG-PET for assessment of myocardial viability in chronic CAD following inconclusive SPECT; Rb-82 or N-13 for assessment of myocardial perfusion in diagnosis of CAD folloiwng inconclusive SPECT or assessment of myocardial perfusion to diagnose CAD in obese patients (BMI 35). NOTE: PET is subject to High Technology Diagnostic Imaging Program (HTDI) review (notification and data collection only). Designated providers approved by BCBSMN interact directly with BC. Non-designated providers must submit through AIM.
Oncologic: Covered when the results of testing will guide clinical management and when neoplasm is determined to be highly glucose avid with FDG (eg prostate, pheochromocytoma, basal cell).
Other: Considered acceptable medical practice for neurology (FDG-PET) for localization of epileptic seizure focus in patients who are candidates for surgery who have not responded to treatment and for whom other techniques have not localized seizure focus.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of Minnesota
Cardiac: FDG-PET for assessment of myocardial viability in chronic CAD following inconclusive SPECT; Rb-82 or N-13 for assessment of myocardial perfusion in diagnosis of CAD folloiwng inconclusive SPECT or assessment of myocardial perfusion to diagnose CAD in obese patients (BMI 35). NOTE: PET is subject to High Technology Diagnostic Imaging Program (HTDI) review (notification and data collection only). Designated providers approved by BCBSMN interact directly with BC. Non-designated providers must submit through AIM.
Oncologic: Covered when the results of testing will guide clinical management and when neoplasm is determined to be highly glucose avid with FDG (eg prostate, pheochromocytoma, basal cell).
Other: Considered acceptable medical practice for neurology (FDG-PET) for localization of epileptic seizure focus in patients who are candidates for surgery who have not responded to treatment and for whom other techniques have not localized seizure focus.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
Empire (Downstate)/Wellpoint
Cardiac: PET considered medically necessary for following indications when results can be expected to affect clinical management: Cardiac: 1) to assess myocardial viability in patients with severe left ventricular dysfunction to assess candicacy for surgery;2) to assess myocardial perfusion at rest or with pharmaco stress in diagnosis of CAD when any of following are present: unavailable or inconclusive SPECT; body habitus or other conditions that would result in attenuation problems with SPECT; conditions for which angiography would be technically challenging.
Oncologic: 1) head and neck cancer to identify unknown primary with metastatic to the cervical lymph nodes; to stage or assess resectability; to detect residual or recurrent head and neck after treatment; 2) thyroid for staging or restaging in specific circumstances; 3) staging or restaging or medullary thyroid; 4) to differentiate radiation necrosis from recurrence for brain cancer; 5) for evaluation of suspicious pulmonary nodule where curative treatment is contemplated; 6) for staging in non-small cell and small cell lung cancer; 7) for assessing spread of malignant melanoma beyond lymph nodes; 8) for staging or restaging lymphoma; 9) for localization of recurrent ovarian with rising CA 125 and neg or equivocal CT; 10) for restaging in patients with history of testicular and signs of recurrence; 11) for staging or restaging of confirmed esophageal when conventional radiographic is negative, inconclusive or non-diagnostic; 12) colorectal; 13) to differentiate between benign and malignant pancreatic lesions; 14) cervical; 15) breast; 16) musculoskeletal neoplasms for differentiation or staging; 17) for unknown primary presenting with metastatic outside cervical lymph nodes ; 18) for other malignancies where major surgery or curative high dose local radiation is recommended and PET may identify metastisis that would change treatment; 19) for initial diagnosis and ongoing assessment of response to chemo in pediatric patients with neuroblastoma.
Other: Neurological: identification or localization of seizure foci for epilepsy surgery candidates. Other: PET with or without PET/CT fusion to diagnosis chronic osteomyelitis of central skeleton. All other is considered investigational.
Excellus Blue Cross (Upstate NY)
Cardiac: After non-diagnostic or inconsistent stress imaging results when cardiac cath is being considered; in place of SPECT for severely obese patients (BMI>40) or with implants who are asymptomatic prior to non cardiac surgery with known CAD or discharged within last 8 weeks aftter hospitalization for cardiac condition without positive or symptom limited stress test and has atrial fib; myocardial ischemia; CHF who are candidates for revascularization or syncope or near syncope; known cardiac disease with new or changed chest pain or chest pain syndrome, or CHF; evaluation for hibernating myocardium or myocardial viability when there is evidence of ischemia or revascularization is contemplated; or clinical suspicion of cardiac sarcoid.
Oncologic: PET is appropriate for known diagnosis of malignancy to determinal optimal site for biopsy or other invasive diagnostic procedure; Staging and restaging: appropriate if conventional imaging is inconclusive; to replace conventional imaging when it will be inadequate and clinical management is dependent on findings; for restaging after completion of therapy to detect recurrence, extent of recurrence or residual disease; not appropriate for routine monitoring of tumor response when no change in treatment is planned. Specific indications apply by type.
Other: Non-oncologic: appropriate for epileptic seizures when being considered for surgery; when conventional techniques for seizure localization suggest seizure focus but are not conclusive; to avoid extended extra-operative EEG recording with implanted electrodes; should be performed and analyzed at a center experienced in advanced epilepsy management. For post treatment determination of viable primary brain tumor vs. radiation necrosis or preop study of tumor resection margins not defined on MRI or CT; for suspected Huntingtons chorea or progressive ataxia of undetermined etiology; for chronic internal carotid artery occlusion prior to surgery, or moyamoya disease.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of North Carolina
Cardiac: Generally follow AIM policies.Cardiac: It is performed in place of but not in addition to SPECT or SPECT is inconclusive.
Oncologic: In specified circumstances for: breast, brain, invasive cervical, colorectal, esophageal, head and neck (excluding CNS and thyroid), lymphoma, melanoma, solitary pulmonary nodule characterization, non-small cell lung, testicular, thyroid, unknown primary presenting with metastatic outside of cervical lymph nodes.
Other: Brain: for pre-surgical evaluation to locate foci of intractable seizures in patients who have failed conventional therapy and are undergoing pre-surgical evaluation; to differentiate between fronto-temporal dementia and alzheimers when other testing has been unable to provide definitive diagnosis (and clinical criteria are met), or when part of a CMS approved clinical trial to diagnose an treat dementing neurodegenerative disease.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Anthem/Wellpoint
Cardiac: PET considered medically necessary for following indications when results can be expected to affect clinical management: Cardiac: 1) to assess myocardial viability in patients with severe left ventricular dysfunction to assess candicacy for surgery;2) to assess myocardial perfusion at rest or with pharmaco stress in diagnosis of CAD when any of following are present: unavailable or inconclusive SPECT; body habitus or other conditions that would result in attenuation problems with SPECT; conditions for which angiography would be technically challenging.
Oncologic: 1) head and neck cancer to identify unknown primary with metastatic to the cervical lymph nodes; to stage or assess resectability; to detect residual or recurrent head and neck after treatment; 2) thyroid for staging or restaging in specific circumstances; 3) staging or restaging or medullary thyroid; 4) to differentiate radiation necrosis from recurrence for brain cancer; 5) for evaluation of suspicious pulmonary nodule where curative treatment is contemplated; 6) for staging in non-small cell and small cell lung cancer; 7) for assessing spread of malignant melanoma beyond lymph nodes; 8) for staging or restaging lymphoma; 9) for localization of recurrent ovarian with rising CA 125 and neg or equivocal CT; 10) for restaging in patients with history of testicular and signs of recurrence; 11) for staging or restaging of confirmed esophageal when conventional radiographic is negative, inconclusive or non-diagnostic; 12) colorectal; 13) to differentiate between benign and malignant pancreatic lesions; 14) cervical; 15) breast; 16) musculoskeletal neoplasms for differentiation or staging; 17) for unknown primary presenting with metastatic outside cervical lymph nodes ; 18) for other malignancies where major surgery or curative high dose local radiation is recommended and PET may identify metastisis that would change treatment; 19) for initial diagnosis and ongoing assessment of response to chemo in pediatric patients with neuroblastoma.
Other: Neurological: identification or localization of seizure foci for epilepsy surgery candidates. Other: PET with or without PET/CT fusion to diagnosis chronic osteomyelitis of central skeleton. All other is considered investigational.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of Oklahoma
Cardiac: May be medically necessary to assess myocardial perfusion defects and thus diagnose CAD when patient has at least intermediate risk and it is used in place of but not in addition to SPECT or previous SPECT was inconclusive. May be considered medically necessary to assess myocardial viability in patients with severe left ventricular dysfunction to determine candidacy for revascularization.
Oncologic: PET may be considered medically necessary for known or suspected malignancies (except screening, surveillance) when the findings on other imaging modalities are inconclusive or discordant and results of the PET or PET/CT will be deciding factor in determining treatment.Once PET is approved subsequent use for monitoring or staging will be considered medically necessary without requirement for retesting with traditional modalities providing it otherwise meets criteria. Not covered for ovarian, pancreatic, small cell or soft tissue sarcoma.
Other: May be necessary fo diagnosis of chronic osteomyelitis; assessment of selected patients with epileptic seizures who are candidates for surgery.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
Regency Blue Cross
Cardiac: May be medically necessary to assess myocardial perfusion to diagnose CAD when patients are at least intermediate risk and the PET scan is in place of but not in addition to SPECT or previous SPECT was inconclusive; myocardial viability in patients with severe left ventricular dysfunction who are candidates for revascularization.
Oncologic: May be necessary for diagnosis in cases where PET may avoid invasive diagnostic. May be necessary for staging when stage is in doubt after completion of standard workup including conventional imaging or when PET could replace an imaging study that is expected to be insufficient for clinical management and when clinical management would differ depending on the stage; Restaging: may be necessary for restaging after completion of treatment for detecting residual disease or suspected recurrence or to determine extent of known recurrence; or if it could replace one or more conventional imaging studies when it is expected that the study information will be insufficient for management of patient. Monitoring: May be necessary to monitor tumor response when change in therapy is contemplated.
Other: PET FDG may be necessary in assessment of patients with epilepsy who are candidates for surgery, when conventional techniques for seizure location are insufficient for surgery and to minimize extended pre-op EEG with implanted eletrodes; or for chronic osteomyelitis. All other investigational.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
Highmark
Cardiac: Covered when results of a SPECT are inconclusive for myocardial viability and for assessing myocardim perfusion in the diagnosis of CAD and to determine candidacy for revascularization.
Oncologic: PET can be used to diagnose and stage malignancies in place of other conventional imaging studies when it's expected that other studies will be insufficient for clinical management or when stage of cancer is in doubt following a standard workup or when clinical management will differ based on the stage of the cancer. PET is also covered for restaging when the physician suspects residual disease or a recurrence or it is necessary to determine extent of known recurrence or patient develops new or additional symptoms of disease. Surveillance: PET is not eligible when it is used to monitor tumor response when no change in treatment is being considered. Covered in accordance with specified conditions for breast, colorectal, brain, esophageal, gynecologic, head and neck (excluding CNS), lung, lymphoma, melanmoa, pancreas and thyroid.
Other: Covered for presurgical evaluation of refractory seizures; One PET per lifetime covered for patients with recent diagnosis of dementia and documented cognitive decline of at least 6 months who meet diagnostic criteria for Alzheimers and frontotemporal dementia.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of South Carolina
Cardiac: Covered for symptomatic ischemic heart disease, assessment of myocardial viability in patients with severe left ventricular dysfunction to determine candidacy for revascularization; FDG for assessment of myocardial viability should only be used for obese patients where tissue attenuation is of concern, for patients for whom thallium testing has failed, or for patients for whom ECG testing has failed to provide conclusive evidence. Rb PET is appropriate to predict response to revascularization in symptomatic patients with ischemic disease.
Oncologic: Brain - to differentiate between necrosis and tumor recurrence when results may alter treatment; Breast - for detection of primary lesion, bone metastasis, staging of axillary lymph nodes, monitoring of treatment, rule out metastasis for newly diagnosed early stage if tumor >5cm, axillary lymphadenopathy is present; Colorectal - suspected recurrence or hepatic or extrahepatic metastases indicated by rising CEA and other tests normal or equivocal and results may alter management; head and neck - identifying unknown primary, initial staging of cervical lymph node metastases and assessing resectability, detection of recurrent or residual following prior treatment; Liver - same as colorectal; Lung - FDG for evaluation of solitary nodule when conventional non invasive methods failed to distinguish between benign and malignant and results will alter treatment, and staging for patients who are candidates for surgery; Lymphoma - initial staging, differentiating benign from malignant and followup when results may alter treatment; melanoma-FDG for detection of extranodal metastasis at initial staging or detection of extranodal metastasis after treatment if results will impact treatment; pancreatic - FDG to distinguish between benign and malignant when other tests normal or equivocal and results may alter treatment; thyroid - for detection of recurrence or suspected metastasis and or differentiation between benign and malignant when thyroglobulin value and 131 iodine are non-diagnostic and results may alter treatment; esophageal - FDG covered for diagnosis, staging and restaging; ovarian - FDG covered for patients with adnexal masses or other suggestive symptoms that would potentially require exploratory laparotomy, for patient who require initial staging in preparation for exploratory laparotomy, for patients being monitored for recurrence or progression or being monitored for response to treatment; unknown primary - in patients with single site disease outside cervical lymph nodes, patients considering local treatment for single site and and after negative workup for occult primary tumor.
Other: PET FDG is appropriate for assessment of epilepsy patients who are candidates for surgery when conventional location techniques have failed; purpose is to avoid extended extraoperative EEG recording with implanted electrodes.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
Wellmark Blue Cross
Cardiac: May be considered medically necessary to assess myocardial perfusion to diagnose CAD; to assess myocardial viability in patients with severe left ventricular dysfunction to determine candidacy for revascularization.
Oncologic: May be medically necessary for breast (detection of lesions, bony metastasis, staging of lymph nodes, monitoring, restaging for recurrence, rule out metastasis in early stage when findings are indicative); cervical (staging); colorectal (diagnosis, staging and monitoring, restaging); esophageal (diagnosis, staging, restaging); head and neck (unknown primary, initial staging of cervical lymph nodes, detection of residual or recurrent disease); primary hepatocellular non-resectable (to rule out extrahepatic metastases for patients being considered for selective internal radiation to the liver); non small cell lung (to distinguish between benign and malignant disease in patients with solitary pulmonary nodule when other results inconclusive or discordant, staging, restaging); lymphoma (initial staging, differentiating benign from malignant, restaging); melanoma (diagnosis, staging, restaging, detection of extranodal metastasis); ovarian (localization of recurrent ovarian in women with rising CA 125 levels and negative or equivocal CT); pancreatic (to differentiate between benigh and malignant when other tests are normal or equivocal, when results may alter treatment); testicular (post chemo for patients exhibiting signs of disease); thyroid (staging and restaging of cancer of follicular origin in presence of rising thyroglobulin levels and negative I-131); unknown primary (occult) in patients with single site of disease outside cervical nodes and patient considering localized treatment and negative work up for occult primary and PEt will be used to rule out or detect additional sites that would eliminate rationale for local treatment. Considered investigational for brain, bladder, primary hepatocellular carcinoma, ovarian and parathyroid(except as described above).
Other: PET may be necessary to identify or localize seizure foci in patients undergoing evaluation for neurosurgical treatment of epilepsy.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of Tennessee
Cardiac: Covered for symptomatic ischemic heart disease, assessment of myocardial viability in patients with severe left ventricular dysfunction to determine candidacy for revascularization; FDG for assessment of myocardial viability should only be used for obese patients where tissue attenuation is of concern, for patients for whom thallium testing has failed, or for patients for whom ECG testing has failed to provide conclusive evidence. Rb PET is appropriate to predict response to revascularization in symptomatic patients with ischemic disease.
Oncologic: Brain - to differentiate between necrosis and tumor recurrence when results may alter treatment; Breast - for detection of primary lesion, bone metastasis, staging of axillary lymph nodes, monitoring of treatment, rule out metastasis for newly diagnosed early stage if tumor >5cm, axillary lymphadenopathy is present; Cervical - during workup or staging when para -aortic lymph node is positive by surgical staging or with selective bulky stage 1B2, IIA, IIB, IIIA, IIIB, IV with positive adenopathy or if FNA is clinically indicated or invasive is found at simple hysterectomy stage 1A2 or there is persistent or recurrent disease; Colorectal - suspected recurrence or hepatic or extrahepatic metastases indicated by rising CEA and other tests normal or equivocal and results may alter management; head and neck - identifying unknown primary, initial staging of cervical lymph node metastases and detection of recurrent or residual following prior treatment; Liver - same as colorectal; Lung - FDG for evaluation of solitary nodule when conventional non invasive methods failed to distinguish between benign and malignant and results will alter treatment, and staging of known cancer; Lymphoma - initial staging, differentiating benign from malignant and followup when results may alter treatment; melanoma-FDG for detection of extranodal metastasis at initial staging or detection of extranodal metastasis after treatment if results will impact treatment; pancreatic - FDG to distinguish between benign and malignant when other tests normal or equivocal and results may alter treatment; testicular - after primary treatment with chemo in stage IIB, IIC or III seminoma testicular cancer; thyroid - for detection of recurrence or suspected metastasis and or differentiation between benign and malignant when thyroglobulin value and 131 iodine are non-diagnostic and results may alter treatment; esophageal - is there is no evidence of distant metastasis for staging prior to surgery to assess resectability with endoscopic ultrasound; unknown primary - in patients with single site disease outside cervical lymph nodes, patients considering local treatment for single site and and after negative workup for occult primary tumor or to rule out or detect additional sites.
Other: PET FDG is appropriate for assessment of epilepsy patients who are candidates for surgery when conventional location techniques have failed; purpose is to avoid extended extraoperative EEG recording with implanted electrodes.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of Texas
Cardiac: May be medically necessary to assess myocardial perfusion defects and thus diagnose CAD when patient has at least intermediate risk and it is used in place of but not in addition to SPECT or previous SPECT was inconclusive. May be considered medically necessary to assess myocardial viability in patients with severe left ventricular dysfunction to determine candidacy for revascularization.
Oncologic: PET may be considered medically necessary for known or suspected malignancies (except screening, surveillance) when the findings on other imaging modalities are inconclusive or discordant and results of the PET or PET/CT will be deciding factor in determining treatment.Once PET is approved subsequent use for monitoring or staging will be considered medically necessary without requirement for retesting with traditional modalities providing it otherwise meets criteria. Not covered for ovarian, pancreatic, small cell or soft tissue sarcoma.
Other: May be necessary fo diagnosis of chronic osteomyelitis; assessment of selected patients with epileptic seizures who are candidates for surgery.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
Regence Blue Cross
Cardiac: May be medically necessary to assess myocardial perfusion to diagnose CAD when patients are at least intermediate risk and the PET scan is in place of but not in addition to SPECT or previous SPECT was inconclusive; myocardial viability in patients with severe left ventricular dysfunction who are candidates for revascularization.
Oncologic: May be necessary for diagnosis in cases where PET may avoid invasive diagnostic. May be necessary for staging when stage is in doubt after completion of standard workup including conventional imaging or when PET could replace an imaging study that is expected to be insufficient for clinical management and when clinical management would differ depending on the stage; Restaging: may be necessary for restaging after completion of treatment for detecting residual disease or suspected recurrence or to determine extent of known recurrence; or if it could replace one or more conventional imaging studies when it is expected that the study information will be insufficient for management of patient. Monitoring: May be necessary to monitor tumor response when change in therapy is contemplated.
Other: PET FDG may be necessary in assessment of patients with epilepsy who are candidates for surgery, when conventional techniques for seizure location are insufficient for surgery and to minimize extended pre-op EEG with implanted eletrodes; or for chronic osteomyelitis. All other investigational.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Blue Cross and Blue Shield of Vermont
Cardiac: Considered medically necessary when results will be used to determine course of action and elminate the need for other imaging studies or biopsies for specified indications. Cardiac: For patients with intermediate risk of CAD; to assess myocardial viability in patients with severe left ventricular dysfunction instead of SPECT to determine candidacy for revascularization or transplant.
Oncologic: Colorectal - to detect and assess resectability of hepatic or extrahepatic metastases; head and neck - identifying unknown primary, in patients with known head and neck to stage cervical lymph nodes and assess resectability, to detect residual or recurrent disease after treatment; lymphoma - initial staging or at followup; lung - in patients with solitary pulmonary nodule to distinguish between benign and malignant when prior results inconclusive or discordant and to stage in non-small cell; melanoma - to assess extranodal spread at initial stage or during followup treatment; thyroid - in patients requiring restaging of recurrent or residual of follicular cell origin previously treated and with serum thyroglobulin >10 ng/ml and negative I-131, for diagnosis, staging and restaging of medullary thryoid; unknown primary - single site outside cervical lymph nodes and considering local treatment and negative workup for occult and PET will rule out additional sites that would eliminate rationale for local treatment. All other investigational.
Other: For diagnosis of chronic osteomyelities; FDG PET for assessment of patients with epilepsy who are candidates for surgery when conventional techniques have failed to localize; for differential diagnosis of frontotemporal dementia and alzheimers for patients with recent diagnosis and documented cognitive decline of at least 6 months.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Anthem/Wellpoint
Cardiac: PET considered medically necessary for following indications when results can be expected to affect clinical management: Cardiac: 1) to assess myocardial viability in patients with severe left ventricular dysfunction to assess candicacy for surgery;2) to assess myocardial perfusion at rest or with pharmaco stress in diagnosis of CAD when any of following are present: unavailable or inconclusive SPECT; body habitus or other conditions that would result in attenuation problems with SPECT; conditions for which angiography would be technically challenging.
Oncologic: 1) head and neck cancer to identify unknown primary with metastatic to the cervical lymph nodes; to stage or assess resectability; to detect residual or recurrent head and neck after treatment; 2) thyroid for staging or restaging in specific circumstances; 3) staging or restaging or medullary thyroid; 4) to differentiate radiation necrosis from recurrence for brain cancer; 5) for evaluation of suspicious pulmonary nodule where curative treatment is contemplated; 6) for staging in non-small cell and small cell lung cancer; 7) for assessing spread of malignant melanoma beyond lymph nodes; 8) for staging or restaging lymphoma; 9) for localization of recurrent ovarian with rising CA 125 and neg or equivocal CT; 10) for restaging in patients with history of testicular and signs of recurrence; 11) for staging or restaging of confirmed esophageal when conventional radiographic is negative, inconclusive or non-diagnostic; 12) colorectal; 13) to differentiate between benign and malignant pancreatic lesions; 14) cervical; 15) breast; 16) musculoskeletal neoplasms for differentiation or staging; 17) for unknown primary presenting with metastatic outside cervical lymph nodes ; 18) for other malignancies where major surgery or curative high dose local radiation is recommended and PET may identify metastisis that would change treatment; 19) for initial diagnosis and ongoing assessment of response to chemo in pediatric patients with neuroblastoma.
Other: Neurological: identification or localization of seizure foci for epilepsy surgery candidates. Other: PET with or without PET/CT fusion to diagnosis chronic osteomyelitis of central skeleton. All other is considered investigational.
CareFirst (Northern VA)
Cardiac: Covered for assessment of myocardial viability (following inconclusive SPECT prior to revascularization), and evaluation of CAD.
Oncologic: PET covered for classification of solitary pulmonary nodules and diagnosis, staging and restaging of following oncological indications non small cell lung carcinoma, colorectal, lymphoma, melanoma, head and neck, thyroid, esophageal, breast, and cervical in accordance with policy guidelines.
Other: Pre-surgical evaluation of refractory seizures in accordance with policy guidelines.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
Regence Blue Cross
Cardiac: May be medically necessary to assess myocardial perfusion to diagnose CAD when patients are at least intermediate risk and the PET scan is in place of but not in addition to SPECT or previous SPECT was inconclusive; myocardial viability in patients with severe left ventricular dysfunction who are candidates for revascularization.
Oncologic: May be necessary for diagnosis in cases where PET may avoid invasive diagnostic. May be necessary for staging when stage is in doubt after completion of standard workup including conventional imaging or when PET could replace an imaging study that is expected to be insufficient for clinical management and when clinical management would differ depending on the stage; Restaging: may be necessary for restaging after completion of treatment for detecting residual disease or suspected recurrence or to determine extent of known recurrence; or if it could replace one or more conventional imaging studies when it is expected that the study information will be insufficient for management of patient. Monitoring: May be necessary to monitor tumor response when change in therapy is contemplated.
Other: PET FDG may be necessary in assessment of patients with epilepsy who are candidates for surgery, when conventional techniques for seizure location are insufficient for surgery and to minimize extended pre-op EEG with implanted eletrodes; or for chronic osteomyelitis. All other investigational.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
Mountain State Blue Cross and Blue Shield (affiliate of Highmark)
Cardiac: Covered when results of a SPECT are inconclusive for myocardial viability and for assessing myocardim perfusion in the diagnosis of CAD and to determine candidacy for revascularization.
Oncologic: PET can be used to diagnose and stage malignancies in place of other conventional imaging studies when it's expected that other studies will be insufficient for clinical management or when stage of cancer is in doubt following a standard workup or when clinical management will differ based on the stage of the cancer. PET is also covered for restaging when the physician suspects residual disease or a recurrence or it is necessary to determine extent of known recurrence or patient develops new or additional symptoms of disease. Surveillance: PET is not eligible when it is used to monitor tumor response when no change in treatment is being considered. Covered in accordance with specified conditions for breast, colorectal, brain, esophageal, gynecologic, head and neck (excluding CNS), lung, lymphoma, melanmoa, pancreas and thyroid.
Other: Covered for presurgical evaluation of refractory seizures; One PET per lifetime covered for patients with recent diagnosis of dementia and documented cognitive decline of at least 6 months who meet diagnostic criteria for Alzheimers and frontotemporal dementia.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Anthem/Wellpoint
Cardiac: PET considered medically necessary for following indications when results can be expected to affect clinical management: Cardiac: 1) to assess myocardial viability in patients with severe left ventricular dysfunction to assess candicacy for surgery;2) to assess myocardial perfusion at rest or with pharmaco stress in diagnosis of CAD when any of following are present: unavailable or inconclusive SPECT; body habitus or other conditions that would result in attenuation problems with SPECT; conditions for which angiography would be technically challenging.
Oncologic: 1) head and neck cancer to identify unknown primary with metastatic to the cervical lymph nodes; to stage or assess resectability; to detect residual or recurrent head and neck after treatment; 2) thyroid for staging or restaging in specific circumstances; 3) staging or restaging or medullary thyroid; 4) to differentiate radiation necrosis from recurrence for brain cancer; 5) for evaluation of suspicious pulmonary nodule where curative treatment is contemplated; 6) for staging in non-small cell and small cell lung cancer; 7) for assessing spread of malignant melanoma beyond lymph nodes; 8) for staging or restaging lymphoma; 9) for localization of recurrent ovarian with rising CA 125 and neg or equivocal CT; 10) for restaging in patients with history of testicular and signs of recurrence; 11) for staging or restaging of confirmed esophageal when conventional radiographic is negative, inconclusive or non-diagnostic; 12) colorectal; 13) to differentiate between benign and malignant pancreatic lesions; 14) cervical; 15) breast; 16) musculoskeletal neoplasms for differentiation or staging; 17) for unknown primary presenting with metastatic outside cervical lymph nodes ; 18) for other malignancies where major surgery or curative high dose local radiation is recommended and PET may identify metastisis that would change treatment; 19) for initial diagnosis and ongoing assessment of response to chemo in pediatric patients with neuroblastoma.
Other: Neurological: identification or localization of seizure foci for epilepsy surgery candidates. Other: PET with or without PET/CT fusion to diagnosis chronic osteomyelitis of central skeleton. All other is considered investigational.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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Commercial Payers:
Aetna
Cardiac: PET considered medically necessary for following cardiac indications: evaluation of CAD when PET is used in place of SPECT or after inconclusive SPECT; for assessment of myocardial viability (FDG PET scans); PET-CT considered experimental for cardiac and neurologic indications.
Oncologic: Considered medically necessary for following oncologic indications: solitary pulmonary nodules; non-small cell lung carcinoma; small cell lung carcinoma; colorectal cancer; lymphoma; melanoma; esophageal; gastric; gastrointestinal stromal tumors; head and neck (excluding CNS); thyroid (excluding metastatic thyroid cancer); breast; cervical; ovarian; testicular; multiple myeloma and plasmacytomas; ewing sarcoma and osteosarcoma; soft tissue sarcoma; occult primary cancers. PET-CT considered medically necessary for oncologic indication where PET is considered medically necessary.
Other: FDG-PET considered medically necessary only for pre-op evaluation for localization of seizure activity. PET is considered experimental for Alzheimers, dementia, parkinsons, huntington or other indications not specified.
Cigna
Cardiac: PET covered to assess myocardial viability prior to revascularization when SPECT is inconclusive; or perfusion of the heart in patients with known or suspected CAD in lieu of SPECT or when SPECT is inconclusive.
Oncologic: PET or PET/CT covered as medically necessary for any suspected or known malignancy when findings on other imaging modalities are inconclusive and/or the results of PET will be deciding factor in determining treatment or surgical intervention.
Other: PET medically necessary for refractory seizures; Not covered for alzheimers, dementia, huntingons, psychiatric, parkinsons, or stroke.
United Healthcare
Cardiac: PET is proven for diagnosing and/or determining severity of CAD in symptomatic patients with suspected or known CAD or assessing myocardial viability and predicting improvement in ventricular contractile function in patients with CAD, severe left ventricular dysfunction and predominant heart failure system symptoms who are under consideration for revascularization.
Oncologic: Whole-body and regional PET is proven for diagnosis, initial staging and restaging of the following cancers: breast, colorectal, esophageal, head and neck excluding CNS, lymphoma, lung cancer, cervical, malignant melanoma. Covered for use in staging and restaging foliicular-derived (papillary, follicular, and Hurthle cell) thyroid cancer. Pet is proven for evaluation of solitary pulmonary nodule in patients with suspected cancer. Unproven for diagnosis, staging or restaging of other conditions including medullary thyroid cancer or for diagnosing, monitoring treatment response or determining prognosis for all types of thyroid cancer.
Other: FDG-PET unproven for Alzheimers or dementia.
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