BlueCross BlueShield of Tennessee Medical Policy Manual

Positron Emission Tomography (PET) for Oncologic Applications

DESCRIPTION

Positron Emission Tomography (PET) scans are a form of high-tech imaging based on the use of positron emitting radionuclide tracers coupled to organic molecules such as glucose, ammonia, or water. The radionuclide tracers simultaneously emit two high-energy photons in opposite directions that can be simultaneously detected by a PET scanner. The PET scanner consists of multiple detectors that encircle the area of interest. A variety of tracers are used for PET scanning including oxygen-15, nitrogen-13, carbon-11, and fluorine-18. The most commonly used radiotracer in oncology imaging is fluorine-18 coupled with fluorodeoxyglucose (FDG). FDG has a metabolism related to glucose metabolism. It has been considered potentially useful in cancer imaging, since tumor cells show increased metabolism of glucose.

Throughout this policy the term “PET” refers FDG-PET imaging and also applies to PET/CT fusion studies. Surveillance refers to routine imaging studies requested for an individual who is not receiving any active treatment.

POLICY

General Guidelines

Breast

Esophageal

Gastrointestinal

Gynecologic Cancers

Head and Neck (Squamous cell carcinomas of the head and neck)

Leukemia

Lungs

Melanoma and Other Skin Cancers

Miscellaneous (Carcinomas of unknown primary site, soft tissue sarcoma, generalized lymphadenopathy and mediastinal abnormalities/ lymphadenopathy, liver lesions, adrenal lesions and neuroendocrine lesions)

Prostate Cancer

Primary brain tumors

Salivary Gland Cancers

Renal Cell Cancer

Uterine Cancer

See also:

MEDICAL APPROPRIATENESS

      • Restaging with ANY ONE of the following met:

        • After ~12 weeks of neoadjuvant chemotherapy and prior to local control surgery to confirm the absence of disease progression

        • Following local control surgery, whole body PET/CT or bone scan at the end of planned chemotherapy

        • If previously positive for bony metastases, whole body PET/CT or bone scan every 2 cycles during treatment and at the end of planned chemotherapy

      • Surveillance with ALL of the following met:

        • Incidentally found in a hysterectomy specimen

        • Inconclusive conventional imaging

      • Restaging or recurrence with ALL of the following met:

        • Difficult or abnormal examinations

        • Elevated LFTs

        • Signs or symptoms of recurrence

        • Inconclusive conventional imaging

      • Initial workup or initial staging with ANY ONE of the following met:

        • All Stage I-IIIB disease

        • Stage IV disease confined to the chest region (pleura/pericardium or solitary site including lung nodules; PET not indicated for metastatic disease outside the chest cavity on CT or MRI, or if malignant pleural/pericardial effusion present)

        • Conventional imaging is inconclusive

        • To confirm solitary focus of metastatic disease (i.e., brain or adrenal) if being considered for aggressive surgical management

      • Restaging or recurrence with ANY ONE of the following met:

        • Newly identified abnormalities localized to chest cavity on conventional imaging

        • Inconclusive conventional imaging

        • Differentiate tumor from radiation scar/fibrosis

      • Adrenal Gland Metastases

        • To confirm isolated adrenal lesion with ALL of the following are met:

          • No diagnosis-specific guideline available regarding PET imaging

          • Solitary adrenal metastasis

          • Conventional imaging does not reveal other metastatic disease

          • Primary tumor site controlled

          • Surgical resection or radiotherapy of adrenal metastasis is potentially curative

      • Bone Metastases (including Vertebral)

        • F-FDG-PET/CT on a case-by-case basis with ALL of the following are met:

          • Bone pain

          • Negative bone scan

          • Negative CT or MRI

      • Brain Metastases

        • When ANY ONE of the following are met:

          • Suspected brain metastasis with prior diagnosis of cancer and no diagnosis-specific guideline regarding PET imaging

          • Brain metastases and no known primary tumor

          • Inconclusive conventional imaging

          • Confirm stable systemic disease or absence of other metastatic disease

      • Carcinoma of Unknown Primary Site

        • For the following sites of metastases with ANY ONE of the following are met:

          • Carcinoma found in lymph node or organ known not to be primary and ANY ONE of the following studies have failed to demonstrate site of primary:

            • CT Chest and Abdomen/Pelvis with contrast

            • CT Neck with contrast if cervical or supraclavicular involvement

            • CT with contrast of any other symptomatic site

            • MRI with and without contrast of any other symptomatic site

            • Diagnostic (not screening) mammogram and full pelvic exam

            • MRI bilateral breasts if pathology consistent with breast primary and mammogram is inconclusive

          • Sebaceous carcinoma of the skin and ANY ONE of the following studies have failed to demonstrate site of primary:

            • CT Chest and Abdomen/Pelvis with contrast

            • CT Neck with contrast if cervical or supraclavicular involvement

            • CT with contrast  of any other symptomatic site

            • MRI with and without contrast of any other symptomatic site

          • Axillary adenocarcinoma if ANY ONE of the following studies have failed to demonstrate site of primary:

            • CT Neck, Chest, and Abdomen with contrast

            • CT with contrast  of any other symptomatic site

            • MRI with and without contrast of any other symptomatic site

            • Diagnostic (not screening) mammogram and full pelvic exam

            • MRI bilateral breasts if pathology consistent with breast primary and mammogram is inconclusive

      • Extrathoracic Small Cell Carcinoma Metastases

        • Initial staging with ALL of the following met:

          • No evidence of metastatic disease

          • Conventional imaging is inconclusive for determining localized vs distant metastatic disease

      • Liver Metastases

        • With ANY ONE of the following met:

          • To confirm solitary metastasis amenable to resection on conventional imaging

          • LFT’s and/or tumor markers continue to rise with negative CT and MRI results

      • Lung Metastases

        • With ANY ONE of the following met:

          • Lung nodule(s) ≥8 mm

          • To confirm solitary metastasis amenable to resection on conventional imaging

      • Primary Peritoneal Mesothelioma

        • Initial staging with ANY ONE of the following met:

          • No evidence of metastatic disease

          • Inconclusive finding on conventional imaging

        • Recurrence or restaging with inconclusive finding on conventional imaging

      • Restaging or recurrence with ALL of the following met:

        • Seminoma with residual mass  greater than 3 cm (30mm)

        • CT findings are inconclusive

        • PET findings will alter immediate care decision making (can be performed as early as 6 weeks after completion of XRT)

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

The terms PET and PET/CT are used interchangeably. The diagnostic and therapeutic decisions of breast cancer are identical for both males and females. This policy addresses breast cancer for all individuals.

SOURCES 

National Comprehensive Cancer Network. (2016, November). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Melanoma. Retrieved September 20, 2017 from http://www.nccn.org.

National Comprehensive Cancer Network. (2017, April). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Breast cancer. Retrieved September 20, 2017 from http://www.nccn.org.

National Comprehensive Cancer Network. (2017, August). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Bone cancer. Retrieved September 20, 2017 from http://www.nccn.org.

National Comprehensive Cancer Network. (2017, August). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Central nervous system cancers. Retrieved September 20, 2017 from http://www.nccn.org.

National Comprehensive Cancer Network. (2017, August). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Ovarian cancer. Retrieved September 20, 2017 from http://www.nccn.org.

National Comprehensive Cancer Network. (2017, July). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Non-small cell lung cancer. Retrieved September 20, 2017 from http://www.nccn.org.

National Comprehensive Cancer Network. (2017, May). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Thyroid carcinoma. Retrieved September 20, 2017 from http://www.nccn.org.

National Comprehensive Cancer Network. (2017, September). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Gastric cancer. Retrieved September 20, 2017 from http://www.nccn.org.

National Comprehensive Cancer Network. (2017, September). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Small cell lung cancer. Retrieved September 20, 2017 from http://www.nccn.org.

ORIGINAL EFFECTIVE DATE:  9/1/2000

MOST RECENT REVIEW DATE:  11/9/2017

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.

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