BlueCross BlueShield of Tennessee Medical Policy Manual

Positron Emission Tomography (PET) for Oncologic Applications

DESCRIPTION

Positron Emission Tomography (PET), also called PET imaging or a PET scan, is a form of nuclear medicine imaging. PET imaging is 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.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

SOURCES 

eviCore healthcare. (2018, May). Clinical Guidelines. Oncology imaging policy. Retrieved July 23, 2018.

eviCore healthcare. (2018, May). Clinical Guidelines. Pediatric oncology imaging policy. Retrieved July 23, 2018.

National Comprehensive Cancer Network. (2016, December). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Testicular cancer.

National Comprehensive Cancer Network. (2017). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Anal carcinoma.

National Comprehensive Cancer Network. (2017). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) B-cell lymphomas.

National Comprehensive Cancer Network. (2017). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Cervical cancer.

National Comprehensive Cancer Network. (2017). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Hodgkin lymphoma.

National Comprehensive Cancer Network. (2017). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Occult primary.

National Comprehensive Cancer Network. (2017, April). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Breast cancer.

National Comprehensive Cancer Network. (2017, August). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Bone cancer.

National Comprehensive Cancer Network. (2017, August). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Central nervous system cancers.

National Comprehensive Cancer Network. (2017, August). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Ovarian cancer.

National Comprehensive Cancer Network. (2017, February). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Prostate cancer.

National Comprehensive Cancer Network. (2017, February). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Soft tissue sarcoma.

National Comprehensive Cancer Network. (2017, July). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Malignant pleural mesothelioma.

National Comprehensive Cancer Network. (2017, June). NCCN Clinical Practice Guidelines in Oncology. (NCCN Guidelines®). Neuroendocrine tumors.

National Comprehensive Cancer Network. (2017, March). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Colon cancer.

National Comprehensive Cancer Network. (2017, May). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Bladder cancer.

National Comprehensive Cancer Network. (2017, May). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Head and neck cancers.

National Comprehensive Cancer Network. (2017, May). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Thyroid carcinoma.

National Comprehensive Cancer Network. (2017, October). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Esophageal and esophagogastric junction cancers.

National Comprehensive Cancer Network. (2017, October). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Gastric cancer.

National Comprehensive Cancer Network. (2017, October). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Melanoma.

National Comprehensive Cancer Network. (2017, September). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Kidney cancer.

National Comprehensive Cancer Network. (2017, September). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Non-small cell lung cancer.

National Comprehensive Cancer Network. (2017, September). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Pancreatic adenocarcinoma.

National Comprehensive Cancer Network. (2017, September). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Small cell lung cancer.

National Comprehensive Cancer Network. (2018). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Chronic lymphocytic leukemia/small lymphocytic lymphoma.

National Comprehensive Cancer Network. (2018). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Multiple myeloma.

ORIGINAL EFFECTIVE DATE:  9/1/2000

MOST RECENT REVIEW DATE:  3/2/2019

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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