Medical Policy Manual Approved Revised Policy: Do Not Implement Until 3/2/19

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1 Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 3/2/19 Psitrn Emissin Tmgraphy (PET) fr Onclgic Applicatins DESCRIPTION Psitrn Emissin Tmgraphy (PET), als called PET imaging r a PET scan, is a frm f nuclear medicine imaging. PET imaging is based n the use f psitrn emitting radinuclide tracers cupled t rganic mlecules such as glucse, ammnia, r water. The radinuclide tracers simultaneusly emit tw high-energy phtns in ppsite directins that can be simultaneusly detected by a PET scanner. The PET scanner cnsists f multiple detectrs that encircle the area f interest. A variety f tracers are used fr PET scanning including xygen-15, nitrgen-13, carbn-11, and flurine-18. The mst cmmnly used raditracer in nclgy imaging is flurine-18 cupled with flurdexyglucse (FDG). FDG has a metablism related t glucse metablism. It has been cnsidered ptentially useful in cancer imaging, since tumr cells shw increased metablism f glucse. POLICY Psitrn emissin tmgraphy (PET) scans fr the nclgical applicatins listed belw are cnsidered medically necessary if the medical apprpriateness criteria are met: Adrenal Tumrs Anal Cancer Bne Cancers Breast Cancer Carcinma f Unknwn Primary Castleman s Disease Central Nervus System Tumrs Cervical Cancer Clrectal cancer Esphageal Cancer Extrathracic small cell carcinma metastases Gall bladder and biliary cancer Gastric Cancer Gastrintestinal/Pancreatic Neurendcrine Cancers Gastrintestinal Strmal Tumr Head and Neck Cancers Hematpietic Stem Cell Transplantatin Langerhans Cell Histicytsis (LCH) Leukemia (Chrnic Lymphcytic [CLL] and Small Lymphcytic Lymphma [SLL]) Lung Cancers Lymphmas Medullblastma, Supratentrial Primitive Neurectdermal Tumrs, and Pineblastma Melanmas and ther Skin Cancers Metastatic Cancer Multiple Myelma and Plasmacytmas Neurblastma Neurendcrine cancers Ovarian Cancer Pancreatic Cancer Paraneplastic Syndrmes Primary Peritneal Mesthelima This dcument has been classified as public infrmatin.

2 Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 3/2/19 Prstate Cancer Rhabdmysarcma Salivary Gland Cancer Sft Tissue Sarcmas Testicular and Nnepithelial Ovarian Cancer (Germ Cell Cancer) Thracic Cancers (Other than Esphageal and Lung) Thymic carcinma Thymma Thyrid Cancers Transitinal Cell Cancer Psitrn emissin tmgraphy (PET) scans fr the fllwing applicatins are cnsidered investigatinal: General Guidelines When imaging lesins less than 8 mm in size Surveillance imaging (unless specifically stated in the criteria) Distant r diffuse metastatic disease Metastatic disease in the central nervus system (CNS) Fllw-up after lcalized therapy (e.g., radifrequency ablatin, emblizatin, steretactic radiatin) Breast When used fr nn-invasive breast cancers When bvius multi-rgan metastatic disease is present PET mammgraphy Gastrintestinal Nn-invasive carcinmas Carcinmas cntained within a plyp Cln cancer that is cmpletely resected and lymph nde negative Anal margin carcinmas T1 gastric cancers Fllwing cmplete resectin f gastrintestinal strmal tumr (GIST) Liver lesins less than 1 cm in individuals withut a prir histry f cnfirmed malignancy When used fllwing interventinal radilgy prcedures invlving liver lesins, such as radifrequency ablatin (RFA) When used fllwing pstperative adjuvant chemtherapy with the fllwing: Resectin has remved all knwn grss disease Markers are nt elevated When used in the setting f bvius multi-rgan metastatic disease Gyneclgic Cancers Endmetrial cancer Vulvar cancer Vaginal cancer Uterine cancers Nn-invasive cervical cancer External genitalia cancer Head and Neck (Squamus cell carcinmas f the head and neck) This dcument has been classified as public infrmatin.

3 Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 3/2/19 When used t determine the need fr neck dissectin fr individual with newly diagnsed head and neck cancer When used fr restaging f cancers f the head and neck when surgery is the primary treatment mdality (e.g. cmplete resectin/ radical neck dissectin) When cmplete respnse r prgressin is clearly bvius n physical examinatin When used fr salivary gland tumrs When used as a substitute fr panendscpy Leukemia (acute lymphblastic, acute myelid, and chrnic myelid) Lungs When using serial PET scans t evaluate lung ndules When ther imaging mdalities have cnfirmed skeletal disease metastasis frm ther primary sites (i.e., lung, breast, prstate, renal cell and ther urgenital cancers) Metastatic nn-small cell disease utside chest cavity (e.g., malignant pleural/pericardial effusin) When ther imaging shws extensive staged disease in small cell carcinma Fr restaging fr the fllwing: When surgery was the primary treatment and all knwn tumr was resected When tumrs were initially treated with radiatin therapy as the nly treatment mdality Miscellaneus (Carcinmas f unknwn primary site, sft tissue sarcma, generalized lymphadenpathy and mediastinal abnrmalities/ lymphadenpathy, liver lesins, adrenal lesins and neurendcrine lesins) Rutine bdy imaging f lymph ndes When used fllwing cmplete resectin When used fr generalized lymphadenpathy and mediastinal abnrmalities prir t histlgic diagnsis Primary brain tumrs Fr detectin, initial wrk up r staging fr primary brain tumrs Fr the use f FDG-PET in the evaluatin f metastatic depsits and well-differentiated brain tumrs Renal Cell Cancer Skin Cancers (Nn-Melanma) Unless specifically addressed within the plicy criteria (e.g., Merkel cell carcinma) Uterine Cancer MEDICAL APPROPRIATENESS Psitrn emissin tmgraphy (PET) fr nclgical applicatins is cnsidered medically apprpriate fr ANY ONE f the fllwing cnditins if criteria are met: Adrenal Tumrs with ANY ONE f the fllwing met: Initial wrkup r initial staging with ALL f the fllwing met: Phechrmcytma, paraganglima, r paraganglineurma Incnclusive cnventinal imaging PET results will direct immediate care decisins This dcument has been classified as public infrmatin.

4 Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 3/2/19 Restaging r recurrence with incnclusive cnventinal imaging Anal Cancer with ANY ONE f the fllwing met: Initial wrkup fr stage II - IV squamus cell carcinma f the anal canal Restaging r recurrence with ALL f the fllwing met: Stage III r IV squamus cell carcinma f the anal canal Incnclusive cnventinal imaging Bne Sarcma Chrdma with ANY ONE f the fllwing met: Initial wrkup r initial staging with incnclusive cnventinal imaging Restaging r recurrence with ALL f the fllwing met: Incnclusive cnventinal imaging Imaging frequency is ANY ONE f the fllwing: After cmpletin f raditherapy After every 2 cycles f chemtherapy Bne Cancer - Ewing Sarcma and Primitive Neurectdermal Tumrs with ANY ONE f the fllwing met: Initial staging with ALL f the fllwing met: Plain X-ray has been perfrmed Histlgic diagnsis has been established Treatment respnse with ALL f the fllwing met: Distant bne metastasis with ANY ONE f the fllwing met: After every 2 cycles f chemtherapy End f planned chemtherapy Restaging with ANY ONE f the fllwing met: After apprximately 12 weeks f neadjuvant chemtherapy and prir t lcal cntrl surgery Fllwing lcal cntrl surgery and planned chemtherapy Bne Cancer - Ostegenic Sarcma with ANY ONE f the fllwing met: Initial staging with ALL f the fllwing met: Plain X-ray has been perfrmed Histlgic diagnsis has been established Treatment respnse with ANY ONE f the fllwing met: Distant bne metastasis with ANY ONE the fllwing met: After every 2 cycles f chemtherapy End f planned chemtherapy Restaging with ANY ONE f the fllwing met: After weeks f neadjuvant chemtherapy and prir t lcal cntrl surgery Distant bne metastasis with ANY ONE f the fllwing met: Fllwing lcal cntrl surgery, whle bdy PET/CT every 4 mnths End f planned chemtherapy Breast Cancer with ANY ONE f the fllwing met: Initial wrkup r initial staging with ALL f the fllwing met: Incnclusive CT Incnclusive bne scan Restaging r recurrence with ALL f the fllwing met: Incnclusive CT, MRI, and/r bne scan fr suspected recurrence This dcument has been classified as public infrmatin.

5 Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 3/2/19 Further characterizatin is needed t make treatment decisins Stage IV disease with ALL f the fllwing met: Bne metastasis nly site f Stage IV disease (excluding brain mets) Prir bne scan has nt been perfrmed fr serial cmparisn Carcinma f Unknwn Primary Site with ANY ONE f the fllwing met: Carcinma fund in lymph nde r rgan knwn nt t be primary and ANY ONE f the fllwing studies have failed t demnstrate site f primary: CT Chest and Abdmen/Pelvis with cntrast CT Neck with cntrast if cervical r supraclavicular invlvement CT with cntrast f any ther symptmatic site MRI with and withut cntrast f any ther symptmatic site Diagnstic (nt screening) mammgram and full pelvic exam MRI bilateral breasts if pathlgy cnsistent with breast primary and mammgram is incnclusive Sebaceus carcinma f the skin and ANY ONE f the fllwing studies have failed t demnstrate site f primary: CT Chest and Abdmen/Pelvis with cntrast CT Neck with cntrast if cervical r supraclavicular invlvement CT with cntrast f any ther symptmatic site MRI with and withut cntrast f any ther symptmatic site Axillary adencarcinma if ANY ONE f the fllwing studies have failed t demnstrate site f primary: CT Neck, Chest, and Abdmen with cntrast CT with cntrast f any ther symptmatic site MRI with and withut cntrast f any ther symptmatic site Diagnstic (nt screening) mammgram and full pelvic exam MRI bilateral breasts if pathlgy cnsistent with breast primary and mammgram is incnclusive Castleman s Disease with ANY ONE f the fllwing met: Initial staging with ALL f the fllwing met: Prir CT suggests unicentric disease Surgical resectin being cnsidered PET/CT t cnfirm unicentric disease Restaging r recurrence with ALL f the fllwing met: Indicated fr ANY ONE f the fllwing types f disease: Multicentric disease Surgically unresected unicentric disease after every 2 cycles f chemtherapy Indicated fr ANY ONE f the fllwing: Suspected recurrence Recurrent B symptms Rising LDH/IL-6/VEGF levels Central Nervus System Tumrs - Lw Grade Glima (WHO histlgic grade f I r II) with ALL f the fllwing met: Initial staging with PET brain metablic imaging with ANY ONE f the fllwing met: Transfrmatin t high grade glima is suspected based n symptms r recent MRI findings Evaluate a brain lesin f indeterminate nature Central Nervus System Tumrs High Grade Glima (WHO histlgic grade f III r IV) with ALL f the fllwing met: This dcument has been classified as public infrmatin.

6 Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 3/2/19 Initial staging with PET brain metablic imaging with ANY ONE f the fllwing met: T distinguish radiatin-induced tumr necrsis frm prgressive disease within 18-mnths f cmpleting raditherapy T evaluate incnclusive MRI findings t determine need fr bipsy r change in therapy, including a change frm active therapy t surveillance T evaluate a brain lesin f indeterminate nature Cervical Cancer with ANY ONE f the fllwing met: Initial wrkup r initial staging with ANY ONE f the fllwing met: Stage IB2 r higher Any size cervical cancer with ALL f the fllwing met: Incidentally fund in a hysterectmy specimen Incnclusive cnventinal imaging Restaging r recurrence with ANY ONE f the fllwing met: Incnclusive cnventinal imaging with ANY ONE f the fllwing: Difficult r abnrmal examinatin Elevated LFTs Signs r symptms f recurrence Radiatin r chemtherapy is primary therapy and surgical salvage is treatment ptin Clrectal Cancer with ANY ONE f the fllwing met: Initial wrkup r initial staging with ANY ONE f the fllwing met: Islated metastatic lesin(s) n ther imaging and individual is ANY ONE f the fllwing: Candidate fr aggressive surgical resectin Candidate fr ther lcalized treatment f metastasis fr curative intent Incnclusive cnventinal imaging Restaging r recurrence with ANY ONE f the fllwing met: Pstperative elevated r rising CEA r LFTs with negative recent cnventinal imaging Islated metastatic lesin(s) n cnventinal imaging and individual is ANY ONE f the fllwing: Candidate fr aggressive surgical resectin Candidate fr lcalized treatment t metastasis with curative intent Differentiate lcal tumr recurrence frm pstperative and/r pst-radiatin scarring Esphageal Cancer with ANY ONE f the fllwing met: Initial wrkup r initial staging with ALL f the fllwing met: Bipsy prven Prir t start f neadjuvant therapy in preparatin fr surgery N evidence f metastatic disease by cnventinal imaging Restaging r recurrence with ANY ONE f the fllwing met: Cnventinal imaging is incnclusive Salvage surgical candidate with recurrence and n metastatic disease dcumented by cnventinal imaging After cmpletin f radiatin therapy with ALL f the fllwing: Recent CT findings are incnclusive PET findings will alter immediate care decisin making PET imaging dne as early as 6 weeks after cmpletin f radiatin therapy Extrathracic Small Cell and Large Cell Neurendcrine Tumrs with ANY ONE f the fllwing met: Initial staging with ANY ONE f the fllwing met: This dcument has been classified as public infrmatin.

7 Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 3/2/19 N evidence f metastatic disease Cnventinal imaging is incnclusive fr determining lcalized vs distant metastatic disease Gall Bladder and Biliary Tumrs with ANY ONE f the fllwing met: Initial wrkup r initial staging with ALL f the fllwing met: N evidence f metastatic disease by cnventinal imaging T determine if individual is a surgical candidate Gastric Cancers with ANY ONE f the fllwing met: Initial wrkup r initial staging with ALL f the fllwing met: Stage equal t r greater than T2 N metastatic disease by cnventinal imaging Restaging r recurrence with incnclusive findings n cnventinal imaging Gastrintestinal Strmal Tumr (GIST) with ANY ONE f the fllwing met: Initial wrkup r initial staging with incnclusive cnventinal imaging Restaging r recurrence with incnclusive cnventinal imaging Treatment respnse with incnclusive cnventinal imaging Head and Neck Cancer Squamus Cell Carcinma with ANY ONE f the fllwing met: Suspected diagnsis with ANY ONE f the fllwing met: T determine a mre favrable site fr bipsy when prir bipsy was nndiagnstic T determine a mre favrable site fr bipsy when a relatively inaccessible site is cntemplated which wuld require invasive surgical interventin fr bipsy attempt Initial wrkup r initial staging with ANY ONE f the fllwing met: Knwn stage III r IV disease Naspharyngeal primary site Incnclusive cnventinal imaging (CT, MRI) Prir t start f primary chemraditherapy and have nt undergne definitive surgical resectin T direct laryngscpe/exam under anesthesia fr bipsy Pulmnary ndule(s) 8 mm in size Cervical lymph nde bipsy psitive fr squamus cell carcinma and n primary site identified n CT r MRI Incnclusive findings suggestive f disease utside the head and neck area Restaging r recurrence with ANY ONE f the fllwing met: Fllwing primary chemraditherapy fr Stage III r IV disease (n sner than 12 weeks fllwing radiatin therapy) with ANY ONE f the fllwing met: Evaluatin fr salvage surgery/radical neck dissectin in individuals with measurable residual disease n physical exam r n recent CT r MRI Distinguish active tumr frm radiatin fibrsis Incnclusive cnventinal imaging (CT r MRI) Bipsy prven lcal recurrence Hematpietic Stem Cell Transplantatin with ANY ONE f the fllwing met: Pst-Transplant with ANY ONE f the fllwing met: Incnclusive cnventinal imaging at Day +100 Tandem autlgus transplants (2-4 autlgus transplants back-t-back, spaced 6-8 weeks apart) PET permitted fllwing each separate transplant This dcument has been classified as public infrmatin.

8 Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 3/2/19 Langerhans Cell Histicytsis (LCH) with ANY ONE f the fllwing met: Multifcal bne invlvement bserved n skeletal survey Bne pain and negative skeletal survey Oher clinical symptms suggesting multisite disease Recurrence evaluatin Leukemia (Chrnic Lymphcytic (CLL) and Small Lymphcytic Lymphma (SLL) with ALL f the fllwing met: Suspected transfrmatin (Richter s) frm a lw grade lymphma t a mre aggressive type with ANY ONE f the fllwing met: New B symptms (e.g., fever, night sweats, unintended weight lss f > 10%) Rapidly grwing lymph ndes Extrandal disease develps Significant recent rise in LDH abve nrmal range Lung Cancer Nn-Small Cell (NSCLC) with ANY ONE f the fllwing met: Suspected r actual diagnsis with ANY ONE f the fllwing met: Evaluate pulmnary ndule measuring 8 mm (0.8 cm) t 30 mm (3 cm) seen n CT r MRI Evaluate pulmnary mass measuring 31 mm (3.1 cm) r greater seen n CT r MRI with ANY ONE f the fllwing met: Prir t bipsy when resectin will be perfrmed instead f bipsy if PET cnfirms limited disease Prir t bipsy if multiple pssible bipsy ptins are present t determine mst favrable site Initial wrkup r initial staging with ALL f the fllwing met: PET was nt perfrmed prir t histlgical diagnsis Indicated fr ANY ONE f the fllwing: All Stage I - IIIB disease Stage IV disease cnfined t the chest regin (pleura/pericardium r slitary site including lung ndules) Cnventinal imaging is incnclusive Restaging r recurrence with ANY ONE f the fllwing met: Suspected r bipsy prven recurrence lcalized t the chest cavity Incnclusive findings n cnventinal imaging Differentiate tumr frm radiatin scar/fibrsis Lung Cancer Small Cell (SCLC) with ANY ONE f the fllwing met: Early staging with ALL f the fllwing met: Cnfirm limited stage disease (nn-metastatic) Initial staging imaging (CT and MRI) shwed disease limited t the thrax Lymphma Anaplastic Large Cell with ANY ONE f the fllwing met: Initial staging r initial diagnsis T assess treatment respnse during chemtherapy Clarify incnclusive findings detected n cnventinal imaging Lymphma Burkitt s with ANY ONE f the fllwing met: Initial staging r initial diagnsis Evaluate treatment respnse during and/r after chemtherapy and/r radiatin therapy Clarify incnclusive findings n cnventinal imaging This dcument has been classified as public infrmatin.

9 Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 3/2/19 Lymphma - Central Nervus System (als knwn as Micrglima) with ANY ONE f the fllwing met: Initial staging with ALL f the fllwing: T cnfirm CNS primary CT imaging results are incnclusive Lymphma Cutaneus (includes Peripheral T-Cell, Primary Cutaneus B Cell, Mycsis Fungides/Sézary Syndrme, Primary Cutaneus CD30+T Cell Lymphprliferative Disrders) with ANY ONE f the fllwing met: Initial staging r initial diagnsis End f chemtherapy and/r radiatin evaluatin Lymphma Diffuse Large B Cell (DLBCL), Grade 3 Fllicular, Grey Zne, Primary Mediastinal B Cell, Pst-Transplant Lymphprliferative Disrder and Viral-Assciated Lymphprliferative Disrder with ANY ONE f the fllwing met: Initial staging r initial diagnsis Treatment respnse during and/r after chemtherapy and/r radiatin therapy Clarify incnclusive findings n cnventinal imaging Lymphma Fllicular (WHO Grade 1-2) with ANY ONE f the fllwing met: Initial staging r initial diagnsis if radiatin therapy is being cnsidered fr Stage I r II disease End f therapy evaluatin Suspected transfrmatin (Richter s) frm a lw grade lymphma t a mre aggressive type with ANY ONE f the fllwing met: New B symptms (e.g., fever, night sweats, unintended weight lss f > 10%) Rapidly grwing lymph ndes Extrandal disease develps Significant recent rise in LDH abve nrmal range Lymphma Hdgkin with ANY ONE f the fllwing: Classical Hdgkin lymphma with ANY ONE f the fllwing met: Initial staging r initial diagnsis T determine a mre favrable site fr bipsy when a relatively inaccessible site is cntemplated Treatment respnse as frequently as every 2 cycles and after chemtherapy End f radiatin therapy evaluatin (after 12 weeks f cmpletin f radiatin therapy) Surveillance with a single fllw-up PET/CT when end f therapy PET/CT dcuments Deauville 4 r 5 FDG avidity Ndular Lymphcyte-Predminant Hdgkin with ANY ONE f the fllwing met: Initial staging r initial diagnsis Treatment respnse as frequently as every 2 cycles End f chemtherapy evaluatin End f raditherapy evaluatin (after 12 weeks f cmpletin f radiatin therapy) Suspected transfrmatin (Richter s) frm a lw grade lymphma t a mre aggressive type with ANY ONE f the fllwing met: New B symptms (e.g., fever, night sweats, unintended weight lss f > 10%) Rapidly grwing lymph ndes Extrandal disease develps Significant recent rise in LDH abve nrmal range This dcument has been classified as public infrmatin.

10 Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 3/2/19 Surveillance with a single fllw-up PET/CT if the end f therapy PET/CT dcuments Deauville 4 r 5 FDG avidity Lymphma Mantle Cell with ANY ONE f the fllwing met: Initial staging r initial diagnsis if ALL f the fllwing are met: Stage I r II disease Radiatin therapy is being cnsidered End f therapy evaluatin Lymphma Marginal Zne & MALT Lymphmas (Mucsa Assciated Lymphid Tissue) with ANY ONE f the fllwing met: Initial staging r initial diagnsis if ALL f the fllwing are met: Stage I r II disease Radiatin therapy is being cnsidered End f therapy evaluatin Medullblastma, Supratentrial Primitive Neurectdermal Tumrs, and Pineblastma with ANY ONE f the fllwing: PET Brain Metablic Imaging with ANY ONE f the fllwing are met: Distinguish radiatin-induced tumr necrsis frm prgressive disease within 18 mnths f cmpleting raditherapy Evaluate incnclusive MRI findings if ANY ONE f the fllwing are met: T determine need fr bipsy T determine need fr change in therapy, including a change frm active therapy t surveillance Evaluate a brain lesin f indeterminate nature Melanmas and Other Skin Cancers with ANY ONE f the fllwing met: Melanma initial wrk-up r initial staging with ANY ONE f the fllwing met: Stage III (sentinel nde psitive, palpable reginal ndes) Stage IV (metastatic) Mucsal, including lip primary Primary melanma site unknwn with ALL f the fllwing met: CT Chest negative CT Abdmen/Pelvis negative Melanma restaging r recurrence with ALL f the fllwing met: Dcumented r clinically suspected recurrence at ANY ONE f the fllwing: Primary site In-transit disease Reginal lymph ndes Metastatic site Dcumentatin f ANY ONE f the fllwing: Incnclusive cnventinal imaging Islated metastatic disease based n results f initial cnventinal imaging Merkel Cell carcinma initial wrk-up r initial staging with ALL f the fllwing met: N metastatic disease identified n cnventinal imaging Merkel Cell carcinma restaging r recurrence with ALL f the fllwing met: N metastatic disease n any f the previus imaging studies Other Nn-melanma skin cancers initial wrk-up r initial staging with ALL f the fllwing met: This dcument has been classified as public infrmatin.

11 Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 3/2/19 Skin lesin may be a dermal metastasis frm distant primary Cnventinal imaging (CT r MRI) is unable t identify a primary site Metastatic Cancer with ANY ONE f the fllwing met: (when primary cancer is knwn, PET request shuld be reviewed by primary cancer guideline) Adrenal Gland Metastases with ANY ONE f the fllwing met: Adrenal mass equal t r greater than 4 cm Enlarging slitary adrenal mass Incnclusive findings n recent CT scan Brain Metastases when ALL f the fllwing are met: Indicated fr ANY ONE f the fllwing: Slitary brain metastasis suspected with prir diagnsis f cancer Brain metastasis and n knwn primary tumr Indicated fr ANY ONE f the fllwing Incnclusive cnventinal imaging Cnfirm stable systemic disease r absence f ther metastatic disease Liver Metastases with ANY ONE f the fllwing met: T cnfirm slitary metastasis amenable t resectin n cnventinal imaging LFT s and/r tumr markers cntinue t rise with negative CT and MRI results Lung Metastases with ANY ONE f the fllwing met: Lung ndule(s) greater than r equal t 8 mm T cnfirm slitary metastasis amenable t resectin n cnventinal imaging Multiple Myelma and Plasmacytmas with ANY ONE f the fllwing met: Initial wrkup r initial staging with ANY ONE f the fllwing met: Negative r incnclusive cnventinal imaging Determine if a plasmacytma is slitary Suspicin f extrasseus plasmacytmas Suspected prgressin f malignancy fr ANY ONE f the fllwing: Mnclnal Gammpathy f Unknwn Significance (MGUS) Smldering Myelma (SMM) Restaging r recurrence with ANY ONE f the fllwing met: Negative PET will allw change in management frm active treatment t maintenance r surveillance Neurblastma with ANY ONE f the fllwing met: MIBG-negativity dcumented at initial diagnsis At majr decisin pints such as hematpietic stem cell transplantatin r surgery if MIBG and CT/MRI are incnclusive Neurendcrine Cancers with ANY ONE f the fllwing met: Brnchpulmnary r Thymic Carcinid with ANY ONE f the fllwing met: Initial wrkup r initial staging with ANY ONE f the fllwing met: After cmplete resectin if ALL f the fllwing are met: This dcument has been classified as public infrmatin.

12 Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 3/2/19 Resectin fails t reslve secretin f pathlgic levels f hrmnes r neurtransmitter cmpunds Nuclear imaging (MIBG, Octretide, r Smatstatin scintigraphy) is negative Restaging r recurrence with negative r incnclusive cnventinal imaging Gastrintestinal/Pancreatic Neurendcrine Cancers with ANY ONE f the fllwing met: Suspected/Diagnsis with ALL f the fllwing met: Cntinued suspicin with negative/incnclusive CT scan r MRI Initial wrkup r initial staging with ANY ONE f the fllwing met: Incnclusive CT r MRI After cmplete resectin if ALL f the fllwing met: Resectin fails t reslve secretin f pathlgic levels f hrmnes r neurtransmitter cmpunds Negative nuclear imaging (Octretide, r Smatstatin scintigraphy) Restaging/recurrence with incnclusive cnventinal imaging Ovarian Cancer with ANY ONE f the fllwing met: Initial wrkup r initial staging with ANY ONE f the fllwing met: Primary peritneal disease with bipsy-prven malignancy cnsistent with varian carcinma Elevated tumr markers with negative r incnclusive CT imaging Restaging r recurrence with ANY ONE f the fllwing met: CT negative r incnclusive and ANY ONE f the fllwing CA-125 cntinues t rise Elevated LFTs Cnventinal imaging failed t demnstrate tumr Persistent radigraphic mass with rising tumr markers Pancreatic Cancer with ANY ONE f the fllwing met: Initial wrkup r initial staging if n evidence f metastatic disease n CT r MRI Restaging r recurrence with incnclusive cnventinal imaging pst chemradiatin (if given as curative therapy) Paraneplastic Syndrmes with ANY ONE f the fllwing met: Abnrmality n cnventinal imaging difficult t bipsy Incnclusive cnventinal imaging Primary Peritneal Mesthelima with ANY ONE f the fllwing met: Initial staging with ANY ONE f the fllwing met: N evidence f metastatic disease Incnclusive finding n cnventinal imaging Recurrence r restaging with incnclusive finding n cnventinal imaging Prstate Cancer with ANY ONE f the fllwing met: Recurrence r restaging with ALL f the fllwing met: CT scan and bne scan negative fr metastasis C Chline r F-Fluciclvine (Axumin) PET/CT scan is requested Prir treatment with prstatectmy and/r radiatin therapy with ALL f the fllwing: Cnsecutive rise in PSA PSA equal t r greater than 2 ng/ml This dcument has been classified as public infrmatin.

13 Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 3/2/19 Rhabdmysarcma with ANY ONE f the fllwing met: Initial staging after histlgic cnfirmatin f diagnsis Treatment respnse with ANY ONE f the fllwing met: Respnse assessment prir t lcal cntrl surgery Respnse assessment prir t radiatin therapy Evaluatin f residual mass visible n cnventinal imaging as part f end f therapy evaluatin Respnse assessment f disease visible n PET but nt cnventinal imaging Surveillance with ALL f the fllwing met: Cnventinal imaging (CT, MRI, US, plain film) incnclusive fr recurrence PET avidity will determine whether bipsy r cntinued bservatin is apprpriate Salivary Gland with ALL f the fllwing met: Initial wrkup r initial staging fr suspicius lung abnrmality bserved n CT chest Sft Tissue Sarcmas with ANY ONE f the fllwing met: Initial wrkup r initial staging with ANY ONE f the fllwing met: Grade f tumr in dubt fllwing bipsy Cnventinal imaging suggests slitary metastasis amenable t surgical resectin Cnventinal imaging incnclusive Planning neadjuvant therapy Prir t surgical resectin fr tumrs greater than 3cm (30mm) Treatment respnse with incnclusive cnventinal imaging Recurrence r restaging with ANY ONE f the fllwing met: Differentiate tumr frm radiatin r surgical fibrsis Determine respnse t neadjuvant therapy Cnfirm ligmetastatic disease prir t curative intent surgical resectin Cnventinal imaging incnclusive r suspicius fr recurrence Testicular, Ovarian and Extragnadal Germ Cell Tumrs with ANY ONE f the fllwing: Restaging r recurrence with ALL f the fllwing met: Seminma with residual mass greater than 3 cm (30mm) CT findings are incnclusive PET findings will alter immediate care decisin making (can be perfrmed as early as 6 weeks after cmpletin f radiatin therapy) Thracic Cancers (Other than Esphageal and Lung) with ANY ONE f the fllwing met: Malignant Pleural Mesthelima with ANY ONE f the fllwing: Initial wrkup r initial staging with ALL f the fllwing met: Cytlgically r pathlgically prven Indicated fr ANY ONE f the fllwing: N evidence f metastatic disease Incnclusive cnventinal imaging Restaging with ALL f the fllwing met: Fllwing inductin chemtherapy prir t surgical resectin N evidence f metastatic disease Thymic Carcinma with ANY ONE f the fllwing: Initial wrkup r initial staging with ANY ONE f the fllwing met: All Stage I-IIIB disease This dcument has been classified as public infrmatin.

14 Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 3/2/19 Stage IV disease cnfined t chest regin (pleura/pericardium r slitary site including lung ndules) Incnclusive cnventinal imaging Restaging r recurrence with ANY ONE f the fllwing met: Suspected r bipsy prven recurrence lcalized t chest cavity Incnclusive cnventinal imaging T differentiate tumr frm radiatin scar/fibrsis Thymma with ANY ONE f the fllwing: Initial wrkup r initial staging if incnclusive finding n CT Restaging with ANY ONE f the fllwing met: Incnclusive finding n CT Fllwing inductin chemtherapy prir t surgical resectin, if n evidence f metastatic disease Thyrid Cancer with ANY ONE f the fllwing met: Anaplastic and Medullary Thyrid Carcinmas with ANY ONE f the fllwing met: Initial wrkup r initial staging if cnventinal imaging incnclusive Restaging r recurrence if cnventinal imaging incnclusive Fllicular, Papillary and Hürthle Cell Carcinmas Restaging r recurrence with ANY ONE f the fllwing met: Negative radiidine scan and rising thyrglbulin level Incnclusive findings n cnventinal imaging Transitinal Cell Cancer with ANY ONE f the fllwing met: Initial wrkup r initial staging with ALL f the fllwing met: Used t determine neadjuvant therapy vs surgery as initial treatment Cnventinal imaging negative r incnclusive IMPORTANT REMINDERS Any specific prducts referenced in this plicy are just examples and are intended fr illustrative purpses nly. It is nt intended t be a recmmendatin f ne prduct ver anther, and is nt intended t represent a cmplete listing f all prducts available. These examples are cntained in the parenthetical e.g. statement. We develp Medical Plicies t prvide guidance t Members and Prviders. This Medical Plicy relates nly t the services r supplies described in it. The existence f a Medical Plicy is nt an authrizatin, certificatin, explanatin f benefits r a cntract fr the service (r supply) that is referenced in the Medical Plicy. Fr a determinatin f the benefits that a Member is entitled t receive under his r her health plan, the Member's health plan must be reviewed. If there is a cnflict between the Medical Plicy and a health plan, the express terms f the health plan will gvern. SOURCES evicre healthcare. (2018, May). Clinical Guidelines. Onclgy imaging plicy. Retrieved July 23, evicre healthcare. (2018, May). Clinical Guidelines. Pediatric nclgy imaging plicy. Retrieved July 23, Natinal Cmprehensive Cancer Netwrk. (2017). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Anal carcinma. This dcument has been classified as public infrmatin.

15 Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 3/2/19 Natinal Cmprehensive Cancer Netwrk. (2017). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) B-cell lymphmas. Natinal Cmprehensive Cancer Netwrk. (2017, May). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Bladder cancer. Natinal Cmprehensive Cancer Netwrk. (2017, August). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Bne cancer. Natinal Cmprehensive Cancer Netwrk. (2017, April). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Breast cancer. Natinal Cmprehensive Cancer Netwrk. (2017, August). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Central nervus system cancers. Natinal Cmprehensive Cancer Netwrk. (2017). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Cervical cancer. Natinal Cmprehensive Cancer Netwrk. (2018). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Chrnic lymphcytic leukemia/small lymphcytic lymphma. Natinal Cmprehensive Cancer Netwrk. (2017, March). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Cln cancer. Natinal Cmprehensive Cancer Netwrk. (2017, Octber). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Esphageal and esphaggastric junctin cancers. Natinal Cmprehensive Cancer Netwrk. (2017, Octber). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Gastric cancer. Natinal Cmprehensive Cancer Netwrk. (2017, May). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Head and neck cancers. Natinal Cmprehensive Cancer Netwrk. (2017). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Hdgkin lymphma. Natinal Cmprehensive Cancer Netwrk. (2017, September). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Kidney cancer. Natinal Cmprehensive Cancer Netwrk. (2017, July). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Malignant pleural mesthelima. Natinal Cmprehensive Cancer Netwrk. (2017, Octber). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Melanma. Natinal Cmprehensive Cancer Netwrk. (2018). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Multiple myelma. This dcument has been classified as public infrmatin.

16 Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 3/2/19 Natinal Cmprehensive Cancer Netwrk. (2017, June). NCCN Clinical Practice Guidelines in Onclgy. (NCCN Guidelines ). Neurendcrine tumrs. Natinal Cmprehensive Cancer Netwrk. (2017, September). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Nn-small cell lung cancer. Natinal Cmprehensive Cancer Netwrk. (2017). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Occult primary. Natinal Cmprehensive Cancer Netwrk. (2017, August). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Ovarian cancer. Natinal Cmprehensive Cancer Netwrk. (2017, September). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Pancreatic adencarcinma. Natinal Cmprehensive Cancer Netwrk. (2017, February). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Prstate cancer. Natinal Cmprehensive Cancer Netwrk. (2017, September). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Small cell lung cancer. Natinal Cmprehensive Cancer Netwrk. (2017, February). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Sft tissue sarcma. Natinal Cmprehensive Cancer Netwrk. (2016, December). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Testicular cancer. Natinal Cmprehensive Cancer Netwrk. (2017, May). NCCN Clinical Practice Guidelines in Onclgy (NCCN Guidelines ) Thyrid carcinma. EFFECTIVE DATE 3/2/2019 ID_EC This dcument has been classified as public infrmatin.