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PET/CT Indications

Aetna
FDG PET/CT Indications – Members benefit plan always supercedes the medical coverage

Indication	Covered	Non-covered	Specific Criteria must be met
Alzheimer’s/Dementia		X
Brain		X
Breast
Diagnosis		X
Initial Staging of axillary nodes/Staging of distant metastasis/Restaging/Monitoring	X		X
Cervical
Staging as adjunct to conventional imaging	X		X
Other staging/Diagnosis/Restaging/Monitoring		X
Colorectal
Diagnosis/Monitoring		X
Staging/Restaging	X		X
Esophagus
Diagnosis/Monitoring		X
Staging/Restaging	X		X
Head & Neck (non-CNS/thyroid)
Diagnosis		X
Staging/Restaging	X		X
Monitoring		X
Lymphoma
Diagnosis		X
Staging/Restaging	X		X
Monitoring		X
Melanoma
Diagnosis/Monitoring		X
Staging/Restaging	X		1 PET/CT PER YEAR
Non-Small Cell Lung
Diagnosis/Monitoring		X
Staging/Restaging	X		X
Ovarian		X
Pancreatic		X
Small Cell Lung		X
Soft Tissue Sarcoma		X
Solitary Pulmonary Nodule (characterization;<4cm)
Diagnosis			X
Staging/Restaging/Monitoring		X
Thyroid
Staging of follicular cell tumors	X		X
Restaging of medullar cell tumors		X
Diagnosis, other staging & restaging, monitoring		X
Testicular		X
All other cancers not listed herein (all indications)		X
Refractory Seizures	X		X
Monitoring = monitor response to treatment when a change in therapy is anticipated. General Frequency limitation: 90 days HMO/PPO/EPO plan members: Pre-cert/Auth through Medsolutions required www.aetna.com Provider must register in order to log on to the site.

BCBS - Texas Christian University
FDG PET/CT Indications – Members benefit plan always supersedes the medical coverage

Indication	Covered	Non-covered	Specific Criteria must be met
Alzheimer’s/Dementia		X
Brain
Diagnosis, staging, restaging		X
Breast
Diagnosis		X
Initial Staging of axillary nodes/Staging of distant metastasis	X		X
Monitoring/Restaging		X
Cervical
Staging as adjunct to conventional imaging/Other staging/ Diagnosis/Restaging Monitoring		X
Colorectal
Diagnosis/Monitoring		X
Staging/Restaging	X		X
Esophagus
Staging/Restaging	X		X
Diagnosis/Monitoring		X
Head & neck (non-CNS/thyroid)
Diagnosis	X		X
Staging/Restaging/Monitoring		X
Lymphoma
Diagnosis		X
Staging/Restaging	X		X
Monitoring		X
Melanoma
Diagnosis		X
Staging/Restaging	X		1 PET/CT PER YEAR
Monitoring		X
Non-Small Cell Lung
Diagnosis/Monitoring		X
Staging/Restaging	X		X
Ovarian		X
Pancreatic		X
Small Cell Lung		X
Soft Tissue Sarcoma		X
Solitary Pulmonary Nodule (characterization; <4cm)
Diagnosis	X		X
Staging/Restaging/Monitoring		X
Thyroid
Staging of follicular cell tumors/Restaging of follicular cell tumors/Diagnosis, other staging & restaging/Monitoring		X
Testicular		X
All other cancers not listed herein (all indications)		X
Refractory Seizures	X		X

Monitoring = monitor response to treatment when a change in therapy is anticipated. General Frequency limitation: 90 days RQI is required for PET/CT www.bcbstx.com

Cigna
FDG PET/CT Indications – Members benefit plan always supersedes the medical coverage

Indication	Covered	Non-covered	Specific Criteria must be met
Alzheimer’s/Dementia		X
Brain
Diagnosis, staging, restaging	X		X
Breast
Diagnosis/Staging of distant metastasis/Restaging	X		X
Initial staging of axillary nodes	X		X
Monitoring		X
Cervical
Staging as adjunct to conventional imaging	X		X
Other staging/Diagnosis/Restaging/Monitoring		X
Colorectal
Diagnosis/Staging/Restaging	X		X
Monitoring		X
Esophagus
Diagnosis/Staging/Restaging	X		X
Monitoring		X
Head & Neck (non-CNS/thyroid)
Diagnosis/Staging/Restaging	X		X
Monitoring		X
Lymphoma
Staging/Restaging	X		X
Monitoring		X
Melanoma
Diagnosis	X
Staging/Restaging	X		1 PET/CT PER YEAR
Monitoring		X
Non-Small Cell Lung
Diagnosis/Staging/Restaging	X		X
Monitoring		X
Ovarian		X
Pancreatic		X
Small Cell Lung		X
Soft Tissue Sarcoma
Solitary Pulmonary Nodule (characterization; <4cm)
Diagnosis	X		X
Staging/Restaging/Monitoring		X
Thyroid
Staging of follicular cell tumors		X	X
Restaging of follicular cell tumors	X		X
Diagnosis, other staging & restaging		X
Testicular		X
All other cancers not listed herein (all indications)		X
Refractory Seizures	X		X
Pre-cert/Auth required for some plan members (Medsolutions) General Frequency limitation: 90 days Monitoring = monitor reqponse to treatment when a change in therapy is anticipated. www.cignaforhcp.com

Medicare, PacifiCare, Secure Horizons, Tricare, and other networks
FDG PET/CT Indications – Members benefit plan always supersedes the medical coverage

Indication	Covered	Non-covered	Specific Criteria must be met
Alzheimer’s Diseases vs. Fronto temporal Dementia
Diagnosis	X		X
Brain Tumor
Diagnosis, staging, restaging		X
Breast
Diagnosis/Staging of distant metastasis/Restaging	X		X
Diagnosis/Initial staging of axillary nodes		X
Monitoring	X
Cervical
Staging/Restaging as adjunct to conventional imaging	X		X
Diagnosis/Monitoring		X
Colorectal
Diagnosis			X
Staging/Restaging	X		X
Esophagus
Diagnosis			X
Staging/Restaging	X		X
Monitoring		X
Head & Neck (non-CNS/thyroid)
Diagnosis			X
Staging/Restaging	X		X
Monitoring		X
Lymphoma
Diagnosis			X
Staging/Restaging/Monitoring	X
Melanoma
Diagnosis		X
Staging/Restaging	X		1 PET/CT PER YEAR
Monitoring		X
Non-Small Cell Lung
Diagnosis/Staging/Restaging	X		X
Monitoring		X
Ovarian		X
Pancreatic		X
Small Cell Lung		X
Soft Tissue Sarcoma		X
Solitary Pulmonary Nodule (characterization; <4cm)
Diagnosis	X		X
Staging/Restaging/Monitoring		X
Thyroid
Restaging of follicular cell tumors	X		X
Diagnosis, other staging & restaging		X
Monitoring		X
Testicular		X
All other cancers not listed herein (all indications)		X
Refractory Seizures	X		Pre-surgical evaluation only
General Frequency limitation: 90 days Monitoring = monitor response to treatment when a change in therapy is anticipated. www.www.medicare.gov Provider must register in order to log on to the site.

United Healthcare
FDG PET/CT Indications – Members benefit plan always supersedes the medical coverage

Indication	Covered	Non-covered	Specific Criteria must be met
Alzheimer’s/Dementia
Diagnosis	X		X
Brain
Diagnosis, staging, restaging		X
Breast
Staging of distant metastasis/Restaging	X		X
Diagnosis/Initial staging of axillary nodes Monitoring		X
Cervical
Staging as adjunct to conventional imaging	X		X
Other staging/Diagnosis/Restaging/Monitoring		X
Colorectal
Diagnosis		X
Staging/Restaging	X		X
Esophagus
Diagnosis		X
Staging/Restaging	X		X
Monitoring		X
Head & Neck (non-CNS/thyroid)
Diagnosis		X
Staging/Restaging	X		X
Monitoring		X
Lymphoma
Diagnosis		X
Staging/Restaging/Monitoring	X
Melanoma
Diagnosis		X
Staging/Restaging	X		1 PET/CT PER YEAR
Monitoring		X
Non-Small Cell Lung
Diagnosis/Staging/Restaging	X
Monitoring		X
Ovarian		X
Pancreatic		X
Small Cell Lung		X
Soft tissue Sarcoma		X
Solitary Pulmonary Nodule (characterization; <4cm)
Diagnosis	X		X
Staging/Restaging/Monitoring		X
Thyroid
Staging of follicular cell tumors	X		X
Restaging of follicular cell tumors	X		X
Diagnosis, other staging & restaging
Monitoring		X
Testicular		X
All other cancers not listed herein (all indications)		X
Refractory Seizures	X		X
Members benefits plan always superseded the medical coverage. Some plan members may require pre-cert/auth General Frequency limitation: 90 days Monitoring = monitor response to treatment when a change in therapy is anticipated.

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