Positron Emission Tomography (PET) for Miscellaneous Applications
DESCRIPTION
Positron emission tomography (PET) images biochemical reactions and physiological functions by measuring concentrations of radioactive chemicals that are partially metabolized in the body region of interest. Radiopharmaceuticals or tracers used for PET are introduced into the body by intravenous injection or by respiration. The scanners used for PET imaging are very similar to those used for radiograph computed tomography, but PET requires more complicated technology and computerized mathematical models of physiologic functions and tracer kinetics for the generation of images. This policy only addresses non-oncologic and non-cardiac indications.
POLICY
Positron emission tomography (PET) is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Positron emission tomography (PET) for the diagnosis or evaluation of all other non-oncologic and/or non-cardiac conditions/diseases is considered investigational.
MEDICAL APPROPRIATENESS
Positron emission tomography (PET) is considered medically appropriate if ANY ONE of the following criteria are met:
Dementia with documentation of ALL of the following:
Need to distinguish between Alzheimer disease and frontotemporal dementia
History of six months of cognitive decline
Evaluation has ruled out alternative neurodegenerative disease or causative factors
Cause of clinical symptoms is uncertain
Results will help guide future treatment
Encephalitis suspected when diagnosis remains unclear after evaluation of ALL the following:
MRI Brain
CSF Analysis
Lab test
Epilepsy with need for presurgical planning
Extra-cranial giant cell arteritis with documentation of ALL of the following:
Conventional imaging studies (e.g., CTA or MRA) reveal findings that are inconclusive or negative
Suspicion for aortic root, arch, or abdomen involvement
Mediastinal lymphadenopathy after biopsy if ANY ONE of the following are met:
Enlarged lymph nodes, 15 mm or greater, with unknown etiology
Increasing lymph node size on follow-up conventional imaging studies (e.g., CT Chest)
Retroperitoneal fibrosis if ANY ONE of the following are met:
Initially to determine treatment
Follow-up to determine treatment if there is an anticipated change based on results (e.g., immunosuppression therapy or stent removal)
Sarcoidosis if ANY ONE of the following are met:
Help guide biopsy location if ALL of the following are met:
Known lesion on CT Chest is difficult to access, to help identify alternative biopsy location
No apparent lung involvement and to identify an extrapulmonary biopsy site
Differentiation of reversible granulomatous disease from irreversible pulmonary fibrosis and will affect treatment options
To determine treatment options when either current treatment will be modified or new treatment introduced
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
SOURCES
ACCF/AHA Task Force on Practice Guidelines. (2013). Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations). Retrieved February 25, 2022 from https://jacc.org.
Akaike, G., Itani, M., Shah, H., Ahuja, J., Yilmaz Gunes, B., et al. (2018). PET/CT in the diagnosis and workup of sarcoidosis: Focus on atypical manifestations. Radiographics: A Review Publication of the Radiological Society of North America, Inc, 38 (5), 1536–1549. (Level 5 evidence)
American College of Radiology (ACR). (2015). ACR appropriateness criteria® radiological management of thoracic nodules and masses. Retrieved February 25, 2022 from https://acsearch.acr.org.
American College of Radiology (ACR). (2019). ACR appropriateness criteria® dementia. Retrieved February 24, 2022 from https://acsearch.acr.org.
American College of Radiology (ACR). (2019). ACR appropriateness criteria® seizures and epilepsy. Retrieved February 28, 2022 from https://acsearch.acr.org.
American College of Radiology (ACR). (2020). ACR ACNM ASNR SNMMI practice parameter for brain PET-CT imaging in dementia. Retrieved February 24, 2022 from https://www.acr.org/-/media/ACR/Files/Practice-Parameters/brain-pet-ct-dementia.pdf.
American College of Radiology (ACR). (2021). ACR appropriateness criteria® nontraumatic aortic disease. Retrieved February 25, 2022 from https://acsearch.acr.org.
Baughman, R. P., Culver, D. A., & Judson, M. A. (2011). A concise review of pulmonary sarcoidosis. American Journal of Respiratory and Critical Care Medicine, 183 (5), 573-581. (Level 5 evidence)
Centers for Medicare & Medicaid Services. CMS.gov. NCD for FDG PET for dementia and neurodegenerative diseases (220.6.13). Retrieved February 24, 2022 from http://www.cms.gov.
Dejaco, C., Ramiro, S., Duftner, C., Besson, F. L., Bley, T. A., Blockmans, D., et al. (2018). EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice. Annals of the Rheumatic Diseases, 77 (5), 636-643. (Level 2 evidence)
eviCore healthcare. (2022, January). Clinical guidelines: abdomen imaging guidelines v1.0.2022. Retrieved February 23, 2022 from www.evicore.com. (7 articles and/or guidelines reviewed)
eviCore healthcare. (2022, January). Clinical guidelines: chest imaging guidelines v1.0.2022. Retrieved February 23, 2022 from www.evicore.com. (13 articles and/or guidelines reviewed)
eviCore healthcare. (2022, January). Clinical guidelines: head imaging guidelines v1.0.2022. Retrieved February 23, 2022 from www.evicore.com. (52 articles and/or guidelines reviewed)
eviCore healthcare. (2022, January). Clinical guidelines: pediatric head imaging guidelines v1.0.2022. Retrieved February 23, 2022 from www.evicore.com. (11 articles and/or guidelines reviewed)
eviCore healthcare. (2022, January). Clinical guidelines: peripheral vascular disease (PVD) guidelines v1.0.2022. Retrieved February 23, 2022 from www.evicore.com. (29 articles and/or guidelines reviewed)
Fernando, A., Pattison, J., Horsfield, C., D'Cruz, D., Cook, G., & O'Brien, T. (2017). [18F]-Fluorodeoxyglucose positron emission tomography in the diagnosis, treatment stratification, and monitoring of patients with retroperitoneal fibrosis: A prospective clinical study. European Urology, 71 (6), 926-933. Abstract retrieved February 25, 2022 from PubMed database.
Harden, C., Huff, J., Schwartz, T., Dubinsky, R., Zimmerman, R., Weinstein, S., et al. (2007). Reassessment: neuroimaging in the emergency patient presenting with seizure (an evidence-based review). Neurology, 69, 1772-1780. (Level 1 evidence)
Keijsers, R. G., van den Heuvel, D. A., & Grutters, J. C. (2013). Imaging the inflammatory activity of sarcoidosis. The European Respiratory Journal, 41 (3), 743–751. (Level 1 evidence)
Munden, R. F., Carter, B. W., Chiles, C., MacMahon, H., Black, W. C., Ko, J. P., et al. (2018). Managing Incidental Findings on Thoracic CT: Mediastinal and Cardiovascular Findings. A White Paper of the ACR Incidental Findings Committee. Journal of the American College of Radiology: JACR, 15 (8), 1087-1096. (Level 5 evidence)
Ramey, W., Martirosvan, N., Lieu, C., Hasham, H., Lemole, G., & Winand, M. (2013). Current management and surgical outcomes of medically intractable epilepsy. Clinical Neurology and Neurosurgery, 115 (12), 2411-2418. Abstract retrieved October 26, 2017 from PubMed database.
Runowska, M., Majewski, D., & Puszczewicz, M. (2016). Retroperitoneal fibrosis - the state-of-the-art. Reumatologia, 54 (5), 256-263. (Level 5 evidence)
St Louis, E., & Cascino, G. (2016). Diagnosis of epilepsy and related episodic disorders. Continuum, 22 (1), 15-37. Abstract retrieved October 26, 2017 from PubMed database.
Stigt, J. A., Boers, J. E., Oostdijk, A. H., van den Berg, J. W., & Groen, H. J. (2011). Mediastinal incidentalomas. Journal of Thoracic Oncology: Official Publication of the International Association for the Study of Lung Cancer, 6 (8), 1345-1349. (Level 2 evidence)
Urban, M. L., Palmisano, A., Nicastro, M., Corradi, D., Buzio, C., & Vaglio, A. (2015). Idiopathic and secondary forms of retroperitoneal fibrosis: a diagnostic approach. La Revue de Medecine Interne, 36 (1), 15-21. (Level 5 evidence)
Vaglio, A., & Maritati, F. (2016). Idiopathic retroperitoneal fibrosis. Journal of the American Society of Nephrology, 27 (7), 1880-1889. (Level 5 evidence)
ORIGINAL EFFECTIVE DATE: 12/1992
MOST RECENT REVIEW DATE: 5/11/2023
ID_EC
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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