Medical Policy Miscellaneous Applications of Positron Emission Tomography (PET)

Transcription

1 Medical Policy Miscellaneous Applications of Positron Emission Tomography (PET) Table of Contents Policy: Commercial Coding Information Information Pertaining to All Policies Policy: Medicare Description References Authorization Information Policy History Policy Number: 624 BCBSA Reference Number: Related Policies Oncologic Applications of PET Scanning, #229 PET Scanning in Oncology to Detect Early Response during Treatment, #335 Cardiac Applications of PET Scanning, #623 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Positron emission tomography (PET) using 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) may be MEDICALLY NECESSARY in: The assessment of selected patients with epileptic seizures who are candidates for surgery or The diagnosis of chronic osteomyelitis. The use of PET for all other miscellaneous indications is INVESTIGATIONAL, including, but not limited to: CNS diseases o Autoimmune disorders with CNS manifestations, including: Behçet's syndrome Lupus erythematosus o Cerebrovascular diseases, including: Arterial occlusive disease (arteriosclerosis, atherosclerosis) Carotid artery disease Cerebral aneurysm Cerebrovascular malformations (AVM and Moya Moya disease) Hemorrhage Infarct Ischemia o Degenerative motor neuron diseases, including: Amyotrophic lateral sclerosis Friedreich's ataxia Olivopontocerebellar atrophy Parkinson's disease 1

2 Progressive supranuclear palsy Shy-Drager syndrome Spinocerebellar degeneration Steele-Richardson-Olszewski disease Tourette's syndrome o Dementias, including: Alzheimer's disease Multi-infarct dementia Pick's disease Frontotemporal dementia Dementia with Lewy-Bodies Presenile dementia o Demyelinating diseases, such as multiple sclerosis o Developmental, congenital, or inherited disorders, including: Adrenoleukodystrophy Down's syndrome Huntington s chorea Kinky-hair disease (Menkes syndrome) Sturge-Weber syndrome (encephalofacial angiomatosis) and the phakomatoses o Miscellaneous Chronic fatigue syndrome Sick building syndrome Post-traumatic stress disorder o Nutritional or metabolic diseases and disorders, including: Acanthocytes Hepatic encephalopathy Hepatolenticular degeneration Metachromatic leukodystrophy Mitochondrial disease Subacute necrotizing encephalomyelopathy o Psychiatric diseases and disorders, including: Affective disorders Depression Obsessive-compulsive disorder Psychomotor disorders Schizophrenia o Pyogenic infections, including: Aspergillosis Encephalitis o Substance abuse, including the CNS effects of alcohol, cocaine, and heroin o Trauma, including brain injury and carbon monoxide poisoning o Viral infections, including: Acquired immune deficiency syndrome (AIDS) AIDS dementia complex Creutzfeldt-Jakob syndrome Progressive multifocal leukoencephalopathy Progressive rubella encephalopathy Subacute sclerosing panencephalitis o Mycobacterium infection o Migraine o Anorexia nervosa o Cerebral blood flow in newborns o Vegetative versus "locked-in" state Pulmonary diseases o Adult respiratory distress syndrome 2

3 o Diffuse panbronchiolitis o Emphysema o Obstructive lung disease o Pneumonia Musculoskeletal diseases o Spondylodiscitis o Joint replacement follow-up Other o Giant cell arteritis o Vasculitis o Inflammatory bowel disease o Sarcoidosis. Medicare HMO Blue SM and Medicare PPO Blue SM Members PET for Dementia and Neurodegenerative Diseases BCBSMA covers an FDG PET scan for the following indication(s) for Medicare HMO Blue and Medicare PPO Blue members in accordance with CMS NCD: In patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both AD and FTD and meets the following additional conditions: The patient s onset, clinical presentation, or course of cognitive impairment is such that FTD is suspected as an alternative neurodegenerative cause of the cognitive decline. Specifically, symptoms such as social disinhibition, awkwardness, difficulties with language, or loss of executive function are more prominent early in the course of FTD than the memory loss typical of AD; The patient has had a comprehensive clinical evaluation (as defined by the American Academy of Neurology (AAN)) encompassing a medical history from the patient and a well-acquainted informant (including assessment of activities of daily living), physical and mental status examination (including formal documentation of cognitive decline occurring over at least 6 months) aided by cognitive scales or neuropsychological testing, laboratory tests, and structural imaging such as magnetic resonance imaging (MRI) or computed tomography (CT); The evaluation of the patient has been conducted by a physician experienced in the diagnosis and assessment of dementia; The evaluation of the patient did not clearly determine a specific neurodegenerative disease or other cause for the clinical symptoms, and information available through FDG PET is reasonably expected to help clarify the diagnosis between FTD and AD and help guide future treatment; The FDG PET scan is performed in a facility that has all the accreditation necessary to operate nuclear medicine equipment. The reading of the scan should be done by an expert in nuclear medicine, radiology, neurology, or psychiatry, with experience interpreting such scans in the presence of dementia; A brain single photon emission computed tomography (SPECT) or FDG PET scan has not been obtained for the same indication. (The indication can be considered to be different in patients who exhibit important changes in scope or severity of cognitive decline, and meet all other qualifying criteria listed above and below (including the judgment that the likely diagnosis remains uncertain). The results of a prior SPECT or FDG PET scan must have been inconclusive or, in the case of SPECT, difficult to interpret due to immature or inadequate technology. In these instances, an FDG PET scan may be covered after one year has passed from the time the first SPECT or FDG PET scan was performed.) The referring and billing provider(s) have documented the appropriate evaluation of the Medicare beneficiary. Providers should establish the medical necessity of an FDG PET scan by ensuring that the following information has been collected and is maintained in the beneficiary medical record: o Date of onset of symptoms; o Diagnosis of clinical syndrome (normal aging; mild cognitive impairment (MCI); mild, moderate or severe dementia); o Mini mental status exam (MMSE) or similar test score; 3

4 o Presumptive cause (possible, probable, uncertain AD); o Any neuropsychological testing performed; o Results of any structural imaging (MRI or CT) performed; o Relevant laboratory tests (B12, thyroid hormone); and, o Number and name of prescribed medications. BCBSMA covers an FDG PET scan in patients with MCI or early dementia for the following indication(s) for Medicare HMO Blue and Medicare PPO Blue members in accordance with CMS NCD: only in the context of an approved clinical trial that contains patient safeguards and protections to ensure proper administration, use and evaluation of the FDG PET scan, and The clinical trial must compare patients who do and do not receive an FDG PET scan and have as its goal to monitor, evaluate, and improve clinical outcomes. In addition, it must meet the following basic criteria: o Written protocol on file; o Institutional Review Board review and approval; o Scientific review and approval by two or more qualified individuals who are not part of the research team; and, o Certification that investigators have not been disqualified. BCBSMA does not cover all other uses of FDG PET for patients with a presumptive diagnosis of dementia-causing neurodegenerative disease (e.g., possible or probable AD, clinically typical FTD, dementia of Lewy bodies, or Creutzfeld-Jacob disease) for which CMS has not specifically indicated coverage for Medicare HMO Blue and Medicare PPO Blue members in accordance with CMS NCD: National Coverage Determination (NCD) for FDG PET for Dementia and Neurodegenerative Diseases ( ) National Coverage Determination (NCD) for Positron Emission Tomography (PET) Scans (220.6) FDG PET for Refractory Seizures Medicare covers FDG-PET for pre-surgical evaluation for the purpose of localization of a focus of refractory seizure activity. Limitations: Covered only for pre-surgical evaluation. Documentation that these conditions are met should be maintained by the referring physician in the beneficiary's medical record, as is normal business practice. National Coverage Determination (NCD) for FDG PET for Refractory Seizures ( ) FDG PET for Osteomyelitis Positron emission tomography (PET) using 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) may be MEDICALLY NECESSARY in the diagnosis of chronic osteomyelitis. Prior Authorization Information Commercial Members: Managed Care (HMO and POS) Prior authorization is NOT required. 4

5 Commercial Members: PPO, and Indemnity Prior authorization is NOT required. Medicare Members: HMO Blue SM Prior authorization is NOT required. Medicare Members: PPO Blue SM Prior authorization is NOT required. CPT Codes / HCPCS Codes / ICD-9 Codes The following codes are included below for informational purposes. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member. A draft of future ICD-10 Coding related to this document, as it might look today, is included below for your reference. Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. CPT Codes CPT codes: Code Description Brain imaging, positron emission tomography (PET); metabolic evaluation Brain imaging, positron emission tomography (PET); Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck) Positron emission tomography (PET) imaging; skull base to mid-thigh Positron emission tomography (PET) imaging; whole body Positron emission tomography (PET) imaging with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck) Positron emission tomography (PET) imaging with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh Positron emission tomography (PET) imaging with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body HCPCS Codes HCPCS codes: A9526 A9552 A9580 ICD-9 Diagnosis Codes ICD-9-CM Code Description Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 millicuries Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries diagnosis codes: Code Description Senile dementia, uncomplicated Presenile dementia, uncomplicated Presenile dementia with delirium Presenile dementia with delusional features Presenile dementia with depressive features 5

6 Senile dementia with delusional features Senile dementia with depressive features Senile dementia with delirium Vascular dementia, uncomplicated Vascular dementia, with delirium Vascular dementia, with delusions Vascular dementia, with depressed mood Alcohol-induced persisting dementia Drug-induced persisting dementia Dementia in conditions classified elsewhere without behavioral disturbance Dementia in conditions classified elsewhere with behavioral disturbance Dementia, unspecified, without behavioral disturbance Dementia, unspecified, with behavioral disturbance Alzheimer's disease Other frontotemporal dementia Dementia with lewy bodies Mild cognitive impairment, so stated Generalized nonconvulsive epilepsy, without mention of intractable epilepsy Generalized nonconvulsive epilepsy, with intractable epilepsy Generalized convulsive epilepsy, without mention of intractable epilepsy Generalized convulsive epilepsy, with intractable epilepsy Petit mal status Grand mal status Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, without mention of intractable epilepsy Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, with intractable epilepsy Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, with intractable epilepsy Infantile spasms, without mention of intractable epilepsy Infantile spasms, with intractable epilepsy Epilepsia partialis continua, without mention of intractable epilepsy Epilepsia partialis continua, with intractable epilepsy Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy Other forms of epilepsy and recurrent seizures, with intractable epilepsy Epilepsy, unspecified, without mention of intractable epilepsy Epilepsy, unspecified, with intractable epilepsy Chronic osteomyelitis, site unspecified Chronic osteomyelitis, shoulder region Chronic osteomyelitis, upper arm Chronic osteomyelitis, forearm Chronic osteomyelitis, hand Chronic osteomyelitis, pelvic region and thigh Chronic osteomyelitis, lower leg Chronic osteomyelitis, ankle and foot Chronic osteomyelitis, other specified sites Chronic osteomyelitis, multiple sites 6

7 ICD-10 Diagnosis Codes ICD-10-CM Diagnosis codes: Code Description F03.90 Unspecified dementia without behavioral disturbance F01.50 Vascular dementia without behavioral disturbance F01.51 Vascular dementia with behavioral disturbance F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance F03.91 Unspecified dementia with behavioral disturbance F05 Delirium due to known physiological condition F10.27 Alcohol dependence with alcohol-induced persisting dementia F Opioid abuse with intoxication with perceptual disturbance F13.27 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolyticinduced persisting dementia F13.97 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolyticinduced persisting dementia F18.17 Inhalant abuse with inhalant-induced dementia F18.27 Inhalant dependence with inhalant-induced dementia F18.97 Inhalant use, unspecified with inhalant-induced persisting dementia F19.17 Other psychoactive substance abuse with psychoactive substance-induced persisting dementia F19.27 Other psychoactive substance dependence with psychoactive substance-induced F19.97 persisting dementia Other psychoactive substance use, unspecified with psychoactive substance-induced persisting dementia G30.0 Alzheimer's disease with early onset G30.1 Alzheimer's disease with late onset G30.8 Other Alzheimer's disease G30.9 Alzheimer's disease, unspecified G31.09 Other frontotemporal dementia G31.83 Dementia with Lewy bodies G31.84 Mild cognitive impairment, so stated G Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, with status epilepticus G Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, without status epilepticus G Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus G Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, with status epilepticus G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with 7

8 complex partial seizures, not intractable, without status epilepticus G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus G Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus G Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus G Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus G Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus G Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus G Other generalized epilepsy and epileptic syndromes, not intractable, with status epilepticus G Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus G Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus G Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus G Epileptic seizures related to external causes, not intractable, with status epilepticus G Epileptic seizures related to external causes, not intractable, without status epilepticus G Other epilepsy, not intractable, with status epilepticus G Other epilepsy, not intractable, without status epilepticus G Other epilepsy, intractable, with status epilepticus G Other epilepsy, intractable, without status epilepticus G Lennox-Gastaut syndrome, not intractable, with status epilepticus G Lennox-Gastaut syndrome, not intractable, without status epilepticus G Lennox-Gastaut syndrome, intractable, with status epilepticus G Lennox-Gastaut syndrome, intractable, without status epilepticus G Epileptic spasms, not intractable, with status epilepticus G Epileptic spasms, not intractable, without status epilepticus G Epileptic spasms, intractable, with status epilepticus G Epileptic spasms, intractable, without status epilepticus G40.89 Other seizures G Epilepsy, unspecified, not intractable, with status epilepticus G Epilepsy, unspecified, not intractable, without status epilepticus G Epilepsy, unspecified, intractable, with status epilepticus G Epilepsy, unspecified, intractable, without status epilepticus G40.A01 Absence epileptic syndrome, not intractable, with status epilepticus G40.A09 Absence epileptic syndrome, not intractable, without status epilepticus G40.A11 Absence epileptic syndrome, intractable, with status epilepticus G40.A19 Absence epileptic syndrome, intractable, without status epilepticus G40.B01 Juvenile myoclonic epilepsy, not intractable, with status epilepticus G40.B09 Juvenile myoclonic epilepsy, not intractable, without status epilepticus G40.B11 Juvenile myoclonic epilepsy, intractable, with status epilepticus G40.B19 Juvenile myoclonic epilepsy, intractable, without status epilepticus M86.30 Chronic multifocal osteomyelitis, unspecified site M Chronic multifocal osteomyelitis, right shoulder M Chronic multifocal osteomyelitis, left shoulder M Chronic multifocal osteomyelitis, unspecified shoulder M Chronic multifocal osteomyelitis, right humerus 8

9 M Chronic multifocal osteomyelitis, left humerus M Chronic multifocal osteomyelitis, unspecified humerus M Chronic multifocal osteomyelitis, right radius and ulna M Chronic multifocal osteomyelitis, left radius and ulna M Chronic multifocal osteomyelitis, unspecified radius and ulna M Chronic multifocal osteomyelitis, right hand M Chronic multifocal osteomyelitis, left hand M Chronic multifocal osteomyelitis, unspecified hand M Chronic multifocal osteomyelitis, right femur M Chronic multifocal osteomyelitis, left femur M Chronic multifocal osteomyelitis, unspecified femur M Chronic multifocal osteomyelitis, right tibia and fibula M Chronic multifocal osteomyelitis, left tibia and fibula M Chronic multifocal osteomyelitis, unspecified tibia and fibula M Chronic multifocal osteomyelitis, right ankle and foot M Chronic multifocal osteomyelitis, left ankle and foot M Chronic multifocal osteomyelitis, unspecified ankle and foot M86.38 Chronic multifocal osteomyelitis, other site M86.39 Chronic multifocal osteomyelitis, multiple sites M86.40 Chronic osteomyelitis with draining sinus, unspecified site M Chronic osteomyelitis with draining sinus, right shoulder M Chronic osteomyelitis with draining sinus, left shoulder M Chronic osteomyelitis with draining sinus, unspecified shoulder M Chronic osteomyelitis with draining sinus, right humerus M Chronic osteomyelitis with draining sinus, left humerus M Chronic osteomyelitis with draining sinus, unspecified humerus M Chronic osteomyelitis with draining sinus, right radius and ulna M Chronic osteomyelitis with draining sinus, left radius and ulna M Chronic osteomyelitis with draining sinus, unspecified radius and ulna M Chronic osteomyelitis with draining sinus, right hand M Chronic osteomyelitis with draining sinus, left hand M Chronic osteomyelitis with draining sinus, unspecified hand M Chronic osteomyelitis with draining sinus, right femur M Chronic osteomyelitis with draining sinus, left femur M Chronic osteomyelitis with draining sinus, unspecified femur M Chronic osteomyelitis with draining sinus, right tibia and fibula M Chronic osteomyelitis with draining sinus, left tibia and fibula M Chronic osteomyelitis with draining sinus, unspecified tibia and fibula M Chronic osteomyelitis with draining sinus, right ankle and foot M Chronic osteomyelitis with draining sinus, left ankle and foot M Chronic osteomyelitis with draining sinus, unspecified ankle and foot M86.48 Chronic osteomyelitis with draining sinus, other site M86.49 Chronic osteomyelitis with draining sinus, multiple sites M86.50 Other chronic hematogenous osteomyelitis, unspecified site M Other chronic hematogenous osteomyelitis, right shoulder M Other chronic hematogenous osteomyelitis, left shoulder M Other chronic hematogenous osteomyelitis, unspecified shoulder M Other chronic hematogenous osteomyelitis, right humerus M Other chronic hematogenous osteomyelitis, left humerus M Other chronic hematogenous osteomyelitis, unspecified humerus 9

10 M Other chronic hematogenous osteomyelitis, right radius and ulna M Other chronic hematogenous osteomyelitis, left radius and ulna M Other chronic hematogenous osteomyelitis, unspecified radius and ulna M Other chronic hematogenous osteomyelitis, right hand M Other chronic hematogenous osteomyelitis, left hand M Other chronic hematogenous osteomyelitis, unspecified hand M Other chronic hematogenous osteomyelitis, right femur M Other chronic hematogenous osteomyelitis, left femur M Other chronic hematogenous osteomyelitis, unspecified femur M Other chronic hematogenous osteomyelitis, right tibia and fibula M Other chronic hematogenous osteomyelitis, left tibia and fibula M Other chronic hematogenous osteomyelitis, unspecified tibia and fibula M Other chronic hematogenous osteomyelitis, right ankle and foot M Other chronic hematogenous osteomyelitis, left ankle and foot M Other chronic hematogenous osteomyelitis, unspecified ankle and foot M86.58 Other chronic hematogenous osteomyelitis, other site M86.59 Other chronic hematogenous osteomyelitis, multiple sites M86.60 Other chronic osteomyelitis, unspecified site M Other chronic osteomyelitis, right shoulder M Other chronic osteomyelitis, left shoulder M Other chronic osteomyelitis, unspecified shoulder M Other chronic osteomyelitis, right humerus M Other chronic osteomyelitis, left humerus M Other chronic osteomyelitis, unspecified humerus M Other chronic osteomyelitis, right radius and ulna M Other chronic osteomyelitis, left radius and ulna M Other chronic osteomyelitis, unspecified radius and ulna M Other chronic osteomyelitis, right hand M Other chronic osteomyelitis, left hand M Other chronic osteomyelitis, unspecified hand M Other chronic osteomyelitis, right thigh M Other chronic osteomyelitis, left thigh M Other chronic osteomyelitis, unspecified thigh M Other chronic osteomyelitis, right tibia and fibula M Other chronic osteomyelitis, left tibia and fibula M Other chronic osteomyelitis, unspecified tibia and fibula M Other chronic osteomyelitis, right ankle and foot M Other chronic osteomyelitis, left ankle and foot M Other chronic osteomyelitis, unspecified ankle and foot M86.68 Other chronic osteomyelitis, other site M86.69 Other chronic osteomyelitis, multiple sites Description Positron emission tomography (PET) images biochemical and physiological functions by measuring concentrations of radioactive chemicals that are partially metabolized in the body region of interest. Radiopharmaceuticals used for PET are generated in a cyclotron or nuclear generator and introduced into the body by intravenous injection or by respiration. The scanners used for PET imaging are somewhat similar to those used for x-ray computed tomography (CT), but PET requires complicated technology and computerized mathematical models of physiologic functions and tracer kinetics for the generation of images. 10

11 Summary Positron emission tomography (PET) for selected patients with epilepsy and patients with chronic osteomyelitis may be considered medically necessary. There is insufficient evidence on the value of PET for other miscellaneous (non-cardiac, non-oncologic) indications. Studies are needed that demonstrate that PET will result in a change in management that will improve patient outcomes in order to determine that it is a clinically useful test. Policy History Date Action 7/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/ /2014 New references from BCBSA National medical policy. 8/2013 PET for osteomyelitis for Medicare Advantage clarified. PET for refractory seizures for Medicare Advantage clarified. 8/2013 BCBSA National medical policy review. New investigational indications described. Effective 8/1/ /2011- Medical policy ICD 10 remediation: Formatting, editing and coding updates. 4/2012 1/2012 Reviewed - Medical Policy Group - Neurology and Neurosurgery. 10/2011 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. 7/2011 Reviewed - Medical Policy Group - Hematology and Oncology. 4/2011 Reviewed - Medical Policy Group - Cardiology and Pulmonology. 1/2011 Reviewed - Medical Policy Group - Neurology and Neurosurgery. 11/2010 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. 9/2010 Reviewed - Medical Policy Group - Hematology and Oncology. 4/2010 Reviewed - Medical Policy Group - Cardiology and Pulmonology. 3/2010 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. 1/2010 Reviewed - Medical Policy Group - Neurology and Neurosurgery. 1/2010 BCBSA National medical policy review. Changes to policy statements. 11/2009 BCBSA National medical policy review. Changes to policy statements. 4/2009 Reviewed - Medical Policy Group - Cardiology and Pulmonology. 4/2009 BCBSA National medical policy review. Changes to policy statements. 4/2008 Reviewed - Medical Policy Group - Cardiology and Pulmonology. 4/2008 BCBSA National medical policy review. 4/2007 Reviewed - Medical Policy Group - Cardiology and Pulmonology. 11

12 Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References 1. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Positron emission tomography for assessment of myocardial viability TEC Assessments 1994; Volume 9, Tab Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Positron emission tomography for diagnosis of cardiomyopathy. TEC Assessments 1994; Volume 9, Tab Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). FDG positron emission tomography for non-cns cancers. TEC Assessments 1995; Volume 10, Tab Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). FDG positron emission tomography for non-cns cancers. TEC Assessments 1997; Volume 12, Tab Willmann O, Wennberg R, May T et al. The contribution of 18F-FDG PET in preoperative epilepsy surgery evaluation for patients with temporal lobe epilepsy: a meta-analysis. Seizure 2007; 16(6): Englot DJ, Wang DD, Rolston JD et al. Rates and predictors of long-term seizure freedom after frontal lobe epilepsy surgery: a systematic review and meta-analysis. J Neurosurg 2012; 116(5): Termaat MF, Raijmakers PG, Scholten HJ et al. The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis. J Bone Joint Surg Am 2005; 87(11): de Winter F, van de Wiele C, Vogelaers D et al. Fluorine-18 fluorodeoxyglucose-positron emission tomography: a highly accurate imaging modality for the diagnosis of chronic skeletal infections. J Bone Joint Surg Am 2001; 83-A(5): Schiesser M, Stumpe KD, Trentz O et al. Detection of metallic implant-associated infections with FDG PET in patients with trauma: correlation with microbiologic results. Radiology 2003; 226(2): Guhlmann A, Brecht-Krauss D, Suger G et al. Fluorine-18-FDG PET and technetium-99m antigranulocyte antibody scintigraphy in chronic osteomyelitis. J Nucl Med 1998; 39(12): Meller J, Koster G, Liersch T et al. Chronic bacterial osteomyelitis: prospective comparison of (18)F- FDG imaging with a dual-head coincidence camera and (111)ln-labelled autologous leucocyte scintigraphy. Eur J Nucl Med Mol Imaging 2002; 29(1): Treglia G, Sadeghi R, Annunziata S et al. Diagnostic performance of Fluorine-18-Fluorodeoxyglucose positron emission tomography for the diagnosis of osteomyelitis related to diabetic foot: a systematic review and a meta-analysis. Foot (Edinb) 2013; 23(4): Centers for Medicare and Medicaid Services. National Coverage Determination for Positron Emission Tomography (FDG) for Dementia and Neurodegenerative Diseases ( ). Available online at: Title&KeyWordSearchType=And&bc=gAAAABAAAAAAAA%3d%3d&. Last accessed January, Matchar DB, Kulasingam S, Huntington A et al. Positron emission tomography, single photon emission computed tomography, computed tomography, functional magnetic resonance imaging, and magnetic resonance spectroscopy for the diagnosis and management of Alzheimer s dementia. Duke Center for Clinical Policy Research and Evidence Practice Center, Neuroimaging Work Group Alzheimer s Association. The use of MRI and PET for clinical diagnosis of dementia & investigation of cognitive impairment: a consensus report Available online at: Last accessed January, Neuroimaging in the diagnosis of Alzheimer s disease and dementia. Expert panel convened by the Neuroscience and Neuropsychology of Aging Program, National Institute of Aging (NIA), DHHS and the Centers for Medicare and Medicaid Services (CMS), DHHS Available online at: 12

13 Last accessed January, Yuan Y, Gu ZX, Wei WS. Fluorodeoxyglucose positron-emission tomography, single-photon emission tomography, and structural MR imaging for prediction of rapid conversion to Alzheimer disease in patients with mild cognitive impairment: a meta-analysis. AJNR Am J Neuroradiol 2009; 30(2): Mosconi L, Tsui W, Herholz K et al. Multicenter standardized 18F-FDG PET diagnosis of mild cognitive impairment, Alzheimer s disease, and other dementias. J Nucl Med 2008; 49(3): Durand-Martel P, Tremblay D, Brodeur C et al. Autopsy as gold standard in FDG-PET studies in dementia. Can J Neurol Sci 2010; 37(3): Mosconi L, Berti V, Glodzik L et al. Pre-clinical detection of Alzheimer's disease using FDG-PET, with or without amyloid imaging. J Alzheimers Dis 2010; 20(3): Herholz K, Westwood S, Haense C et al. Evaluation of a calibrated 18F-FDG PET score as a biomarker for progression in Alzheimer Disease and mild cognitive impairment. J Nucl Med 2011; 52(8): Zhang S, Han D, Tan X et al. Diagnostic accuracy of 18 F-FDG and 11 C-PIB-PET for prediction of short-term conversion to Alzheimer's disease in subjects with mild cognitive impairment. Int J Clin Pract 2012; 66(2): Treglia G, Mattoli MV, Leccisotti L et al. Usefulness of whole-body fluorine-18-fluorodeoxyglucose positron emission tomography in patients with large-vessel vasculitis: a systematic review. Clin Rheumatol 2011; 30(10): Lehmann P, Buchtala S, Achajew N et al. 18F-FDG PET as a diagnostic procedure in large vessel vasculitis- a controlled, blinded re-examination of routine PET scans. Clin Rheumatol 2011; 30(1): Gemmel F, Rijk PC, Collins JM et al. Expanding role of 18F-fluoro-D-deoxyglucose PET and PET/CT in spinal infections. Eur Spine J 2010; 19(4): Prodromou ML, Ziakas PD, Poulou LS et al. FDG PET Is a Robust Tool for the Diagnosis of Spondylodiscitis: A Meta-analysis of Diagnostic Data. Clin Nucl Med Basu S, Zhuang H, Torigian DA et al. Functional imaging of inflammatory diseases using nuclear medicine techniques. Semin Nucl Med 2009; 39(2): Meller J, Sahlmann CO, Gürocak O et al. FDG-PET in patients with fever of unknown origin: the importance of diagnosing large vessel vasculitis. Q J Nucl Med Mol Imaging 2009; 53(1): Hao R, Yuan L, Kan Y et al. Diagnostic performance of 18F-FDG PET/CT in patients with fever of unknown origin: a meta-analysis. Nucl Med Commun 2013; 34(7): Kapoor RR, James C, Hussain K. Advances in the diagnosis and management of hyperinsulinemic hypoglycemia. Nat Clin Pract Endocrinol Metab 2009; 5(2): Yang J, Hao R, Zhu X. Diagnostic role of 18F-dihydroxyphenylalanine positron emission tomography in patients with congenital hyperinsulinism: a meta-analysis. Nucl Med Commun 2013; 34(4): Treglia G, Taralli S, Calcagni ML et al. Is there a role for fluorine 18 fluorodeoxyglucose-positron emission tomography and positron emission tomography/computed tomography in evaluating patients with mycobacteriosis? A systematic review. J Comput Assist Tomogr 2011; 35(3): Chandler MB, Zeddun SM, Borum ML. The role of positron emission tomography in the evaluation of inflammatory bowel disease. Ann N Y Acad Sci 2011; 1228: Kiferle L, Politis M, Muraro PA et al. Positron emission tomography imaging in multiple sclerosiscurrent status and future applications. Eur J Neurol 2011; 18(2): Kwee TC, Kwee RM, Alavi A. FDG-PET for diagnosing prosthetic joint infection: systematic review and metaanalysis. Eur J Nucl Med Mol Imaging 2008; 35(11): Reinartz P. FDG-PET in patients with painful hip and knee arthroplasty: technical breakthrough or just more of the same. Q J Nucl Med Mol Imaging 2009; 53(1): Treglia G, Taralli S, Giordano A. Emerging role of whole-body 18F-fluorodeoxyglucose positron emission tomography as a marker of disease activity in patients with sarcoidosis: a systematic review. Sarcoidosis Vasc Diffuse Lung Dis 2011; 28(2): Practice parameter: diagnosis and prognosis of new onset Parkinson disease (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. 13

14 2010. Available online at: Last accessed January, Centers for Medicare & Medicaid Services. National Coverage Determination for FDG PET for Infection and Inflammation ( ) Available online at: Title&KeyWordSearchType=And&bc=gAAAABAAAAAAAA%3d%3d&. Last accessed January,