BlueCross BlueShield of Tennessee Medical Policy Manual

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.

POLICY

See also:

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

No evidence was found to show that evaluation of positron emission tomography for miscellaneous indications considered investigational that could predict clinical events and/or improve individual outcomes.

SOURCES

American Academy of Neurology (2001) Practice Parameter: Diagnosis of dementia. Neurology 2001; 56:1143-1153.

American College of Radiology. (2012). ACR Appropriateness Criteria® ataxia. Retrieved October 4, 2013 from http://www.guideline.gov. (NGC: 009237)

American College of Radiology. (2012). ACR Appropriateness Criteria® seizures - child. Retrieved October 4, 2013 from http://www.guideline.gov. (NCG: 009667)

American College of Radiology. (2012). ACR Appropriateness Criteria® focal neurologic deficit. Retrieved October 4, 2013 from http://www.guideline.gov. (NCG: 009223)

American College of Radiology. (2014). ACR Appropriateness Criteria® dementia and movement disorders. Retrieved June 15, 2015 from http://www.guideline.gov. (NGC: 010450)

American College of Radiology. (2014). ACR Appropriateness Criteria® seizures and epilepsy. Retrieved June 15, 2015 from http://www.guideline.gov. (NGC:010452)

BlueCross Blue Shield Association. Medical Policy Reference Manual. (9:2015). Miscellaneous (noncardiac, nononcologic) applications of positron emission tomography (PET) (6.01.06). Retrieved June 20, 2016 from BlueWeb. (58 articles and/or guidelines reviewed)

Center for Medicare & Medicaid Services. CMS,gov. (2005, April) National Coverage Determination (NCD) for FDG PET for refractory seizures (220.6.9). Retrieved June 20, 2016 from: http://www.cms.gov.

Center for Medicare & Medicaid Services. CMS.gov. (2009, October) National Coverage Determination (NCD) for FDG PET for dementia and neurodegenerative diseases (220.6.13). Retrieved June 20, 2016 from: http://www.cms.gov.

Center for Medicare & Medicaid Services. CMS.gov. (2009, October) National Coverage Determination (NCD) for FDG PET for infection and inflammation (220.6.16). Retrieved June 20, 2016 from: http://www.cms.gov.

Center for Medicare & Medicaid Services. CMS.gov. (2013, March) National Coverage Determination (NCD) for positron emission tomography (PET) scans (220.6) Retrieved June 15, 2015 from: http://www.cms.gov.

National Institute of Healthcare Excellence (2006, reviewed May 2016) Supporting people with dementia and their carers in health and social care. Retrieved June 20, 2016 from:guidance.nice.org.uk.

Technology Evaluation Center. (February 2013) Beta amyloid imaging with positron emission tomography (PET) for evaluation of suspected Alzheimer’s disease or other causes of cognitive decline (Vol.27, No.5). Retrieved June 15, 2015 from http://www.bcbs.com/blueresources/tec/tec-assessments.html#topics. (110 articles and/or guidelines reviewed)

Winifred S. Hayes, Inc. Medical Technology Directory. (2011, January; last update March 2016). Positron emission tomography (PET) for Alzheimer’s disease. Retrieved June 20, 2016 from www.Hayesinc.com/subscribers. (121 articles and/or guidelines reviewed)

ORIGINAL EFFECTIVE DATE:  12/1992

MOST RECENT REVIEW DATE:  3/9/2017

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.

This document has been classified as public information.