Positron Emission Tomography (PET) When calling Anthem (1-800-533-1120) or using the Point of Care authorization system for a Health Service Review, the following clinical information may be needed to process your request. Being prepared with complete information will help expedite our response. Generally with all requests, we will need: Diagnosis or symptoms that the patient is displaying and the duration of symptoms Any rule out conditions Any previous radiological studies and results Any previous therapeutic treatment and the results of that treatment In some instances we will only need the diagnosis and symptoms. For these conditions, the following information may be asked. Please refer to the Anthem Coverage Guideline on PET scans for details Brain Myocardial Myocardial Tumor Colorectal 78607 PET brain imaging, complete study; tomographic (SPECT) 78608 PET brain, metabolic evaluation 78609 PET brain, per fusion evaluation 78610 Brain Imagery; Vascular flow only G0336 PET imaging, brain imaging for the differential diagnosis of Alzheimer s disease with aberrant features vs. frontotomporal dementia 78459 PET myocardial, metabolic evaluation 78491 PET myocardial, perfusion, single study 78492 PET myocardial, perfusion, multiple studies G0030 - G0031 PET myocardial perfusion imaging, following previous PET G0032 - G0035 PET myocardial perfusion imaging, following SPECT G0036 - G0037 PET myocardial perfusion imaging, following coronary angiography G0038 - G0047 PET myocardial perfusion imaging, following other studies (myocardial perfusion, echocardiogram, nuclear ventriculogram, rest ECG, stress ECG) 78811 PET tumor imaging, limited 78812 PET tumor imaging, skull to mid-thigh 78813 PET tumor imaging, whole body G0214 colorectal G0215 colorectal cancer Page 1 of 5 07/22/2005
Miscellaneous specific PET G0125 G0210 G0211 G0212 G0213 G0216 G0217 G0218 G0219 G0220 G0221 G0222 G0223 G0224 G0225 G0226 G0227 G0228 G0229 G0230 G0231 G0232 G0233 PET IMAGING PET imaging, regional or whole body, single pulmonary nodule lung lung lung colorectal cancer PET imaging whole body; for non covered indications PET imaging whole body or regional; diagnosis, head and neck cancer, excluding PET imaging whole body or regional; initial staging, head and neck cancer excluding PET imaging whole body or regional; restaging, head and neck cancer, excluding PET imaging; metabolic brain imaging for pre-surgical evaluation of refractory seizures PET imaging; metabolic assessment for myocardial viability following inconclusive SPECT study PET whole body, for recurrence of colorectal or colorectal metastatic cancer; gamma cameras only PET whole body; for recurrence of, gamma cameras only PET whole body; for recurrence of, gamma cameras only Page 2 of 5 07/22/2005
G0234 G0252 G0253 G0254 G0296 PET regional or whole body; for solitary pulmonary nodule following CT or for initial staging of pathologically diagnosed nonsmall cell lung cancer, gamma cameras only PET imaging, full and partial-ring PET scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer PET imaging for breast cancer, full and partial-ring PET scanners only, staging/restaging of local regional recurrence or distant metastases (i.e., staging/restaging after or prior to course of treatment) PET imaging for breast cancer, full and partial-ring PET scanners only, evaluation of response to treatment, performed during course of treatment PET imaging, full and partial-ring PET scanner only, for restaging of previously treated thyroid cancer of follicular cell origin following negative I-131 whole body scan Neurologic application o Is this to identify and or localize seizure foci? o Is the patient a surgical candidate for neurosurgical treatment? o Does the patient have intractable epilepsy? Cardiac application o Assess myocardial viability in those with severe left ventricular dysfunction to determine candidacy for a cardiac surgery procedure o Assess myocardial perfusion performed in the diagnosis of coronary disease with; Inconclusive or unavailable SPECT scan Body habitus or other condition for which SPECT may have attenuation problems (obesity, lg. breasts, left mastectomy, chest wall deformity, pleural or pericardial effusion, circulatory problems in inferior-septal areas of the heart) Technical difficulty (extensive prior MI) Conditions for which angiography may be technically challenging (e.g. low to intermediate probability of coronary artery disease, borderline stenosis) Conditions which have a high risk for morbidity (allergy to contrast medium, poor arterial access, renal dysfunction for which angiography increases the likelihood of renal failure. Oncologic application o Evaluate head and neck cancer Page 3 of 5 07/22/2005
To identify unknown primary with metastases to the cervical lymph nodes For staging of known head and neck cancer to assess respectability To detect residual/recurrent cancer following treatment o Detect recurrence of thyroid cancer with Negative I 131 scanning Elevated serum thyroglobulin concentrations >10 ng/ml o Differentiate radiation necrosis from recurrent tumor with intractable lesion on CT or MRI who was previously treated for a brain tumor o Assess response to treatment in patient with intractable lesion on CT or MRI who was previously treated for a brain tumor o Evaluate solitary pulmonary nodules to distinguish between benign and malignant disease when non invasive methods (x-ray and CT evaluation) have failed. o Staging with known non-small cell and small cell lung cancer o Assessing spread of malignant at initial staging or during follow up treatment. o Staging or restaging o Localization of recurrent ovarian cancer with Rising CA-125 levels Negative CT imaging o Restaging patients with history of testicular cancer with Post treatment signs/symptoms of recurrence Negative CT o Staging of confirmed when PET scan is used as an adjunct method of assessment when conventional radiographic and endoscopic techniques are inconclusive o Colorectal cancer to assess respectability of hepatic metastases to detect recurrence with rising CEA and or symptoms of recurrence to assess scarring versus bowel recurrence in previously resected colorectal cancer o Differentiate between benign and malignant pancreatic cystic lesions o Cervical cancer for staging or restaging o Breast cancer adjunct for staging distant metastasis adjunct for restaging locoregional recurrence or metastasis adjunct for monitoring tumor response to treatment o Musculoskeletal Neoplasm s for Differentiation of benign versus malignant primary and biological aggressiveness Page 4 of 5 07/22/2005
Staging and detection of recurrent disease with known musculoskeletal sarcoma and assess viability after chemotherapy before planning limb amputation o Cancer of unknown primary with metastatic disease outside the cervical lymph nodes for Local or regional treatment for a single site of metastatic disease is being considered PET scan will be used to rule out additional sites of disease which would eliminate rationale for local treatment Standard work up for occult primary tumor is negative Tumor is limited to a single site of disease o Other malignancies When major surgery is recommended To Identify presence of metastatic disease which will change the treatment plan Page 5 of 5 07/22/2005