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.

One Instance of when a PET scan is the imaging technology of choice is in a pre-surgical evaluation for the purpose of localization of a focus of refractory seizure activity in either children or adults. Another would be for an adult abdominal lymphatic lesion with an inconclusive biopsy, as lymphadenopathy from neoplasms as well as from benign sources of inflammation can result in a positive PET scan; the use of PET may not be helpful prior to biopsy. As the causes of mediastinal masses in children are generally different than those in adults imaging considerations are different. A PET scan may be indicated prior to a mediastinal mass biopsy.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

SOURCES

American College of Radiology (ACR). (2014). ACR appropriateness criteria ® seizures and epilepsy. Retrieved July 20, 2018 from https://acsearch.acr.org.

American College of Radiology (ACR). (2015). ACR appropriateness criteria ® radiologic management of thoracic nodules and masses. Retrieved July 20, 2018 from https://acsearch.acr.org.

Chen, J., Wu, Z., Sun, B., Li, D., Wang, Z., Liu, F., & Hua, H. (2016). Intraabdominal desmoplastic small round cell tumors: CT and FDG-PET/CT findings with histopathological association. Oncology Letters, 11, 3298-3302. (Level 4 evidence)

eviCore healthcare. (2019, February). Clinical guidelines: abdomen imaging policy v1.0.2019. Retrieved July 2, 2019 from www.evicore.com. (2 articles and/or guidelines reviewed)

eviCore healthcare. (2019, February). Clinical guidelines: chest imaging policy v1.0.2019. Retrieved July 2, 2019 from www.evicore.com. (5 articles and/or guidelines reviewed)

eviCore healthcare. (2019, February). Clinical guidelines: head imaging policy v1.0.2019. Retrieved July 2, 2019 from www.evicore.com. (5 articles and/or guidelines reviewed)

eviCore healthcare. (2019, February). Clinical guidelines: musculoskeletal imaging policy v1.0.2019. Retrieved July 2, 2019 from www.evicore.com. (24 articles and/or guidelines reviewed)

eviCore healthcare. (2019, February). Clinical guidelines: neck imaging policy v1.0.2019. Retrieved July 2, 2019 from www.evicore.com. (12 articles and/or guidelines reviewed)

eviCore healthcare. (2019, February). Clinical guidelines: pediatric head imaging policy v1.0.2019. Retrieved July 2, 2019 from www.evicore.com. (6 articles and/or guidelines reviewed)

eviCore healthcare. (2019, February). Clinical guidelines: pediatric musculoskeletal imaging policy v1.0.2019. Retrieved July 2, 2019 from www.evicore.com. (13 articles and/or guidelines reviewed)

eviCore healthcare. (2019, February). Clinical guidelines: pediatric abdomen imaging policy v1.0.2019. Retrieved July 2, 2019 from www.evicore.com. (22 articles and/or guidelines reviewed)

eviCore healthcare. (2019, February). Clinical guidelines: pediatric chest imaging policy v1.0.2019. Retrieved July 2, 2019 from www.evicore.com. (13 articles and/or guidelines reviewed)

eviCore healthcare. (2019, February). Clinical guidelines: pelvis imaging policy v1.0.2019. Retrieved July 2, 2019 from www.evicore.com. (2 articles and/or guidelines reviewed)

Gaddy, H. & Riegel, A. (2016). Unexplained lymphadenopathy: evaluation and differential diagnosis. American Family Physician, 94 (11), 896-903. (Level 5 evidence)

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)

Krumholz, A., Wiebe, S., Gronseth, G., Shinnar, S., Levisohn, P., Ting, T., et al. (2007). Practice parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review).  Neurology, 69 (21), 1996-2007. (Level 1 evidence)

Naeem, F., Metzger, M., Arnold, S., & Adderson, E. (2015). Distinguishing benign mediastinal masses from malignancy in a histoplasmosis-endemic region. Journal of Pediatrics, 167 (2), 409-415. (Level 4 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.

Redondo-Cerezo, E., Martínez-Cara, J., Esquivias, J., de la Torre-Rubio, P., González-Artacho, C., García-Marín, M. et al. (2015). Endoscopic ultrasonography-fine needle aspiration versus PET-CT in undiagnosed mediastinal and upper abdominal lymphadenopathy: a comparative clinical study. European Journal of Gastroenterology and Hepatology, 27 (4), 455-459. Abstract retrieved July 31, 2018 from PubMed database.

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.

Thacker, P., Mahani, M., Heider, A., & Lee, E. (2015). Imaging evaluation of mediastinal masses in children and adults: practical diagnostic approach based on a new classification system. Journal of Thoracic Imaging, 30 (4), 247-267. Abstract retrieved July 31, 2018 from PubMed database.

ORIGINAL EFFECTIVE DATE:  12/1992

MOST RECENT REVIEW DATE:  9/26/2019

ID_EC

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