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 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 very similar to those used for x-ray computed tomography, but PET requires more complicated technology and computerized mathematical models of physiologic functions and tracer kinetics for generation of images.
POLICY
Positron emission tomography (PET) for the diagnosis of epileptic seizures is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Positron emission tomography (PET) for the diagnosis of chronic osteomyelitis is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Positron emission tomography (PET) for the diagnosis of other conditions / diseases, including, but not limited to, the following is considered investigational:
Autoimmune disorders with CNS manifestations, including:
Behçet's syndrome
Lupus erythematosus
Cerebrovascular diseases, including:
arterial occlusive disease (arteriosclerosis, atherosclerosis)
cerebral aneurysm
hemorrhage
ischemia
cerebrovascular malformations (AVM and Moyamoya disease)
carotid artery disease
infarct
Degenerative motor neuron disease, including:
Amyotrophic lateral sclerosis
Friedreich's ataxia
Olivopontocerebellar atrophy
Parkinson's disease
Progressive supranuclear palsy
Spinocerebellar degeneration
Steele-Richardson-Olszewski disease
Gilles de la Tourette's syndrome;
Shy-Drager syndrome
Dementias, including:
Alzheimer's disease
Pick's disease
Schizophrenia
Multi-infarct dementia
Presenile dementia
Demyelinating diseases such as:
Multiple sclerosis
Developmental, congenital or inherited disorders, including:
Adrenoleukodystrophy
Huntington's chorea
Kinky hair disease (Menkes syndrome)
Down's syndrome
Phakomatoses
Sturge-Weber syndrome (encephalofacial angiomatosis)
Miscellaneous
Chronic fatigue syndrome
Sick building syndrome
Post-traumatic stress disorder
Nutritional or metabolic disease and disorders, including:
Acanthocytes
Hepatic encephalopathy
Hepatolenticular degeneration
Metachromatic leukodystrophy
Mitochondrial disease
Subacute necrotizing encephalomyelopathy
Psychiatric disease and disorders, including:
Affective disorders
Obsessive-compulsive disorder
Schizophrenia
Depression
Psychomotor disorders
Pyogenic infections, including:
Aspergillosis
Encephalitis
Substance abuse, including:
CNS effects of alcohol, cocaine and heroin
Trauma, including:
Brain injury
Carbon monoxide poisoning
Viral infections, including:
Acquired immune deficiency syndrome (AIDS)
AIDS dementia complex
Creutzfeldt-Jacob syndrome
Progressive multifocal leukoencephalopathy
Progressive rubella encephalopathy
Subacute sclerosing panencephalitis
Migraine
Anorexia nervosa
Cerebral blood flow in newborns
Vegetative versus "locked-in" state
Pulmonary Diseases
Adult respiratory distress syndrome
Diffuse panbronchiolitis
Emphysema
Obstructive lung disease
Pneumonia
Musculoskeletal diseases
Spondylodiscitis
Joint replacement follow-up
Other
Giant cell arteritis
See also:
Milliman Care Guideline - PET, Myocardial
MEDICAL APPROPRIATENESS
Positron emission tomography for the diagnosis of epileptic seizures is considered medically appropriate for ALL of the following:
Complex partial seizures that have failed to respond to medical therapy and have been advised to have a resection of a suspected epileptogenic focus located in a region of the brain accessible to surgery
Conventional techniques for seizure localization must have been tried and provided data that suggested a seizure focus, but were not sufficiently conclusive to permit surgery
Positron emission tomography (PET) for the diagnosis of chronic osteomyelitis is considered medically appropriate when conventional diagnostic testing is inconclusive.
ADDITIONAL INFORMATION
No evidence was found to show that evaluation of positron emission tomography for miscellaneous indications considered investigational could predict clinical events and improve individual outcomes.
SOURCES
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ORIGINAL EFFECTIVE DATE: 12/1992
MOST RECENT REVIEW DATE: 5/9/2009
ID_BT
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