Coverage Policy Manual
Policy #: 2005033
Category: Radiology
Initiated: September 1998
Last Review: December 2023
  PET or PET/CT for Primary Central Nervous System Cancer (Malignant Brain and Spinal Cord Tumors)
Description:
Note:  This policy is intended for those members with contracts that do not have requirements for prior approval for imaging procedures through an independent imaging review organization.
 
 
Positron Emission Tomography (PET) imaging uses radiotracers that can reveal both anatomical and physiological information.  The glucose analog, 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG), is potentially useful in cancer imaging because it has been found that tumor cells show increased utilization of glucose.
 
Definitions
 
Screening – testing in the absence of an established or clinically suspected diagnosis
 
Diagnosis - testing based on a reasonable clinical suspicion of a particular condition or disorder
 
Diagnostic Workup – initial staging of documented malignancy
 
Management – testing to direct therapy of an established condition, which may include preoperative or postoperative imaging, or imaging performed to evaluate the response to nonsurgical intervention. In oncologic imaging, management applies to patients with measurable disease and to imaging performed before or after planned treatment intervention, therapy response, restaging or clinically suspected recurrence.
 
Surveillance – periodic assessment following completion of therapy. In oncologic imaging, surveillance applies to asymptomatic patients in remission and/or without measurable disease
 
Cannot be performed or is nondiagnostic – applies when the test:
    • Is positive or indeterminate for clinically significant pathology when the information provided about the abnormality by the test is not sufficient to direct subsequent management
    • Is negative when the negative likelihood ratio of the test is both insufficient to confidently exclude the absence of suspected disease and unable to direct subsequent management. This typically applies in scenarios with moderate to high clinical pretest probability with negative testing or low pretest probability with clear evidence for net benefit
    • Has been previously nondiagnostic because of a persistent clinical factor (e.g., body habitus, immobility) that is very likely to make retesting nondiagnostic as well Cannot be performed due to a medical contraindication (e.g., contrast nephrotoxicity, allergy, or in highly radiation sensitive populations such as pediatrics and pregnancy) or reasonable unavailability related to lack of local expertise or service availability
Standard or conventional imaging: Refers to imaging that does not require a PET/CT. Depending on the clinical scenario and individual patient circumstances, this may include computed tomography, magnetic resonance imaging, ultrasound and/or scintigraphy.
  
Policy/
Coverage:
EFFECTIVE MARCH 13, 2022
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
FDG-PET/CT for patients with Primary Central Nervous System Cancer (malignant brain and spinal cord tumors) meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for:
 
Diagnostic Workup:
      • FDG-PET/CT Brain is not indicated and is not covered.
      • FDG-PET/CT Whole Body is Indicated for evaluation of possible systemic disease in PROVEN CNS lymphoma
 
Management:
      • FDG-PET/CT Brain is Indicated for differentiation of posttreatment scarring from residual or recurrent disease
      • FDG-PET/CT Whole Body is not indicated and is not covered.
 
For all fully insured contracts, all self-funded church-sponsored health plans and all self-funded government-sponsored health plans other than the Arkansas State and Public School Employees program, the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
PET/CT for patients with Primary Central Nervous System Cancer does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes and is not covered for:
    • Surveillance*
For members with contracts without primary coverage criteria, PET/CT for patients with Primary Central Nervous System Cancer is considered investigational and not covered for any indication not specifically listed as covered above, including but not limited to:
    • Surveillance*
Investigational services are Plan exclusions.
 
 
*For all fully insured contracts, all self-funded church-sponsored health plans and all self-funded government-sponsored health plans other than the Arkansas State and Public School Employees program, the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
Note: Standard or conventional imaging: Refers to imaging that does not require a PET/CT. Depending on the clinical scenario and individual patient circumstances, this may include computed tomography, magnetic resonance imaging, ultrasound and/or scintigraphy.
 
 
Effective Prior to MARCH 13, 2022
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
FDG-PET/CT meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for patients with Primary Central Nervous System Cancer (malignant brain and spinal cord tumors) for:  
Diagnostic Workup:
    • ONLY for proven CNS lymphoma, FDG-PET/CT Whole Body is indicated for evaluation of possible systemic disease.
Treatment Management:
    • Indicated for differentiation of posttreatment scarring from residual or recurrent disease.
 
For all fully insured contracts, all self-funded church-sponsored health plans, and all self-funded government-sponsored health plans (e.g., state and public-school employee plans), other than the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
PET/CT for patients with Primary Central Nervous System Cancer does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes:  
    • For screening and surveillance; OR
    • For any other indication not specifically listed above as meeting coverage criteria.
 
 *For all fully insured contracts, all self-funded church-sponsored health plans, and all self-funded government-sponsored health plans (e.g., state and public-school employee plans), other than the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
For members with contracts without primary coverage criteria, PET/CT for patients with Primary Central Nervous System Cancer is considered investigational:  
    • For screening and surveillance; OR
    • For any other indication not specifically listed above as meeting coverage criteria.
Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
 
Effective Prior to August 2021
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
FDG-PET/CT meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for patients with Primary Central Nervous System Cancer (malignant brain and spinal cord tumors) for:
 
Diagnostic Workup:  
    • ONLY for proven CNS lymphoma, FDG-PET/CT Whole Body is indicated for evaluation of possible systemic disease.
 
Treatment Management:  
    • Indicated for differentiation of posttreatment scarring from residual or recurrent disease.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
PET/CT for patients with Primary Central Nervous System Cancer does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes:  
    • For screening and surveillance; OR
    • For any other indication not specifically listed above as meeting coverage criteria.
 
For members with contracts without primary coverage criteria, PET/CT for patients with Primary Central Nervous System Cancer is considered investigational:  
    • For screening and surveillance; OR
    • For any other indication not specifically listed above as meeting coverage criteria.
 
Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Effective March 2018 to April 2021
 
“PET scan” refers to FDG PET or PET/CT.
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
The use of PET scanning meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
    • For the differentiation of recurrent brain tumor from scarring associated with treatment OR
    • For staging or restaging of brain cancer
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
The use of PET scanning does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for the following indications:
    • In the initial evaluation of suspected primary brain tumor or recurrent tumor in symptomatic patients.
    • For surveillance of asymptomatic patients with no clinical, laboratory, or radiological evidence of recurrence
    • For monitoring response to therapy for patients with malignant primary brain cancers (e.g., glioblastoma, low grade glioma, neuroblastoma)
    • PET scanning with any radiotracer other than FDG
 
For members with contracts without primary coverage criteria, the use of PET scanning is considered investigational for the following indications:
    • In the initial evaluation of suspected primary brain tumor or recurrent tumor in symptomatic patients.
    • For surveillance of asymptomatic patients with no clinical, laboratory, or radiological evidence of recurrence
    • For monitoring response to therapy for patients with malignant primary brain cancers (e.g., glioblastoma, low grade glioma, neuroblastoma)
    • PET scanning with any radiotracer other than FDG
 
 Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Effective Prior to March 2018
 
“PET scan” refers to FDG PET or PET/CT.
 
PET meets primary coverage criteria for effectiveness and is covered for the differentiation of recurrent brain tumor from scarring associated with treatment.
 
 
The following uses of PET are not covered based on benefit certificate primary coverage criteria that there be scientific evidence of effectiveness:
 
    • In the initial evaluation of suspected primary brain tumor or recurrent tumor in symptomatic patients
    • PET for surveillance of asymptomatic patients with no clinical, laboratory, or radiological evidence of recurrence does not meet member certificate of coverage Primary Coverage Criteria for effectiveness as there are no evidence-based studies which indicate improvement in health outcomes, and this use of PET is not recommended by NCCN.
    • PET scan for monitoring response to therapy for patients with malignant primary brain cancers (e.g., glioblastoma, low grade glioma, neuroblastoma) does not meet member certificate of coverage Primary Coverage Criteria for effectiveness as this use of PET scanning is being studied in an ongoing clinical trials (NCT01089868; NCT01089244; NCT01308905).
    • PET scanning with any radiotracer other than FDG
 
 
For contracts without primary coverage criteria, PET scanning is covered for the differentiation of recurrent brain tumor from scarring associated with treatment.
 
 
For contracts without primary coverage criteria, the following services are considered investigational and are not covered:
 
    • PET in the initial evaluation of suspected primary brain tumor or recurrent tumor in symptomatic patients
    • PET for surveillance of asymptomatic patients with no clinical, laboratory, or radiological evidence of recurrence does not meet member certificate of coverage Primary Coverage Criteria for effectiveness as there are no evidence-based studies which indicate improvement in health outcomes, and this use of PET is not recommended by NCCN.
    • PET scan for monitoring response to therapy for patients with malignant primary brain cancers (e.g., glioblastoma, low grade glioma, neuroblastoma) does not meet member certificate of coverage Primary Coverage Criteria for effectiveness as this use of PET scanning is being studied in an ongoing clinical trials (NCT01089868; NCT01089244; NCT01308905).
    • PET scanning with any radiotracer other than FDG
  
Investigational services are an exclusion in the member certificate of coverage.  
Rationale:
ACR has appropriateness criteria for imaging of brain metastases but has no criteria for imaging of primary central nervous system malignancies.  
 
National Comprehensive Cancer Network (NCCN Guidelines®) for Central Nervous System Cancers, Version 1.2012:
Algorithms for diagnosis, treatment or follow-up of brain cancer do not include PET or PET/CT.  There is one common footnote that is displayed: Consider MR spectroscopy, MR perfusion, or brain PET to rule out radiation necrosis.  
 
Principles of Brain Tumor Imaging:
• May be useful in differentiating tumor from radiation necrosis but has some limitations;
• May also correlate with tumor grade or provide the optimal area for biopsy.
 
Podoloff, et al. (2009) reported recommendations of a NCCN Task Force about the clinical utility of PET in a variety of tumor types including brain.  A paucity of definitive data on the clinical efficacy of PET for brain cancer was noted and the recommendations made by the Task Force were based on lower-level evidence by panel consensus:
1) differentiation of recurrence from radiation necrosis,
2) may identify anaplastic transformation in non-enhancing, low-grade gliomas,
3) possible negative correlation with survival.  
 
The AHRQ Technology Assessment Program contracted with the University of Alberta Evidence-based Practice Center, to asses Positron Emission Tomography for Nine Cancers (Bladder, Brain, Cervical, Kidney, Ovarian, Pancreatic, Prostate, Small Cell Lung, Testicular).  The report was released on Dec 1, 2008.  Only six studies that provided evidence on the use of PET for brain cancer were identified.  They reported that limited evidence from low quality studies indicated the best indication for PET for brain cancer seemed to be differentiating between high and low grade gliomas.  The effect of PET as “part of a management strategy on patient-centered outcomes continue to be scarcely evaluated”.
 
Hillner et al. (2009) reported findings from the National Oncologic PET Registry. The Centers for Medicare and Medicaid Services (CMS) covers PET for brain cancer only as ‘coverage with evidence development’ (CED).  Brain cancer was not separately identified in the registry for this article.
 
The Canadian Agency for Drugs and Technologies in Health (CADTH) did not address brain cancer in their 2010 Health Technology Assessment, Positron Emission Tomography (PET) in Oncology: A Systematic Review of Clinical Effectiveness and Indications for Use.  This assessment did address the following cancers: breast, colorectal, head and neck, lung, lymphoma, melanoma, esophageal, and thyroid.  
 
Due to a lack of moderate- to high-level evidence that PET positively affects health outcomes limited coverage for this test is available.
 
2013 Update:
A review of literature on PubMed through February 2013 was performed. There were no published articles identified that would prompt a change in the coverage statement.
 
Kawai (2013) conducted a study to clarify the usefulness and limitation of FDG-PET in the diagnosis of primary central nervous system lymphoma (PCNSL).  FDG-PET was performed in 25 histologically-proven PCNSL cases and the maximum standardized uptake value (SUV<sub>max</sub>) and the tumor-to-normal tissue count density (T/N) ratio of the tumors were measured. In 25 histologically-proven cases of PCNSL, 19 showed typical neuro-radiological findings and 6 showed atypical findings such as disseminated or no lesions.  FDG-PET was also performed in 28 histologically-proven glioblastoma multiforme (GBM) and 7 clinically and neuroradiologically-suspected but histologically-unproven PCNSL cases and the uptake values were compared with histologically-proven PCNSL.  Typical PCNSL showed very high FDG uptake in the tumors, which were significantly higher than those in GBM.  Receiver operating characteristic (ROC) curve analysis demonstrated that the T/N ratio had a higher accuracy in discrimination between PCNSL and GBM with a sensitivity of 0.95 and a specificity of 0.75 when a cutoff value was set on the T/N ratio of 1.8.   Patients with suspected PCNSL showed very high and similar FDG uptake values to those in histologically proven typical PCNSL.  These patients responded very well to chemotherapy and radiotherapy for PCNSL.  The authors concluded that FDG-PET is very useful in the diagnosis of typical PCNSL and can differentiate PCNSL from GBM with a high sensitivity and specificity.   Moreover, FDG-PET has a supplementary role to the neuro-radiological diagnosis of histologically unproven PCNSL. However, the role of FDG-PET is limited in the diagnosis of atypical PCNSL, but dynamic analysis of FDG-PET may overcome this issue.
 
2014 Update
A review of literature on Medline through January 2014 was performed. There were no published articles identified that would prompt a change in the coverage statement.
 
A systematic review and meta-analysis addressed use of fluorine-18 fluoro-ethyl-tyrosine (FET) in detecting primary brain tumors (Dunet, 2012).  While it used a sophisticated meta-analytic method, it did not compare use of 18F-FET PET with another imaging modality for diagnosis of brain tumors, so no conclusions can be reached about comparative effectiveness.  A 2013 meta-analysis found limited utility for 18F-FDG-PET in differentiating brain tumors (Zhao, 2013).  Diagnostic performance was better with 11C-methionine PET.  However, another meta-analysis found dynamic susceptibility contrast-enhanced MRI performed better than 11C-methionine PET in glioma recurrence detection (Deng, 2013).
 
2014 Update
A literature search conducted through April 2014 did not reveal any new information that would prompt a change in the coverage statement.
 
A systematic review and meta-analysis addressed use of fluorine-18 fluoro-ethyl-tyrosine (FET) in detecting primary brain tumors. While it used a sophisticated meta-analytic method, it did not compare use of 18F-FET PET with another imaging modality for diagnosis of brain tumors, so no conclusions can be reached about comparative effectiveness. A 2013 meta-analysis found limited utility for 18F-FDG-PET in differentiating brain tumors (Zhao, 2013). Diagnostic performance was better with 11C-methionine PET. However, another meta-analysis found dynamic susceptibility contrast-enhanced MRI performed better than 11C-methionine PET in glioma recurrence detection (Deng, 2013).
 
The NCCN guidelines on non-small-cell lung cancer indicate PET may be used in the staging of disease, detection of metastases, treatment planning, and detection of disease recurrence (NCCN, 2014). However, PET is not recommended for detection of brain metastasis from lung cancers. The NCCN guidelines on SCLC indicate PET may be used in the staging of disease and treatment planning but “is not recommended for routine follow-up” (NCCN, 2014).
  
2015 Update
A literature search conducted through January 2015 did not reveal any new information that would prompt a change in the coverage statement.
 
2017 Update
A literature search conducted through February 2017 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Darunanithi and colleagues published a study comparing efficacies of (18)F-FDG PET/CT and 3,4-dihydroxy-6-[(18)F]fluoro-phenylalanine ((18)F-FDOPA) PET/CT in detection of recurrent gliomas (Darunanithi, 2013). A total of 28 patients (age 38.82 ± 1.25 years; 85.7% men) with histopathologically proven glioma with clinical/imaging suspicion of recurrence were evaluated using (18)F-FDG PET/CT and (18)F-FDOPA PET/CT. (18)F-FDG PET/CT and (18)F-FDOPA PET/CT images were evaluated qualitatively and semiquantitatively. The combination of clinical follow-up, repeat imaging and/or biopsy (when available) was taken as the reference standard. Based on the reference standard, 21 patients were positive and 7 were negative for tumour recurrence. The sensitivity, specificity and accuracy of (18)F-FDG PET/CT were 47.6%, 100% and 60.7%, respectively, and those of (18)F-FDOPA PET/CT were 100%, 85.7% and 96.4%, respectively. The results of (18)F-FDG PET/CT and (18)F-FDOPA PET/CT were concordant in 57.1% of patients (16 of 28) and discordant in 42.9% (12 of 28). The difference in the findings between (18)F-FDG PET/CT and (18)F-FDOPA PET/CT was significant (P = 0.0005, McNemar's test). The difference was significant for low-grade tumours (P = 0.0039) but not for high-grade tumours (P = 0.250).
 
2018 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2018. The key identified literature is summarized below.
 
BRAIN TUMORS AND 18F-FDG-PET, 18F-FET-PET, AND 11C METHIONINE PET
18F-FET PET
A systematic review and meta-analysis by Dunet et al (2016) included studies published through January
2015 in which patients with suspected primary or recurrent brain tumors underwent both fluorine 18
fluoro-ethyl-tyrosine PET (18F-FET-PET) and 18F-FDG-PET (Dunet, 2016). Four studies (total N=109 patients) met inclusion criteria. All 4 studies included in the meta-analysis had scores greater than 10 in the 15-point Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. 18F-FET PET (pooled sensitivity, 94%; 95% CI, 79% to 98%; pooled specificity, 88%; 95% CI, 37% to 99%) performed better than 18FFDG-PET (pooled sensitivity, 38%; 95% CI, 27% to 50%; pooled specificity, 86%; 95% CI, 31% to 99%) in the diagnosis of brain tumors. Target to background ratios of both FDG and FET were similar in detecting low- and high-grade gliomas.
 
Evidence for the use of PET to diagnose and stage brain cancer consists of several systematic reviews
and meta-analyses. The diagnostic capabilities of PET vary depending on the radiotracer used. There
was 1 direct comparison of radiotracers, with 18F-FET-PET showing better diagnostic accuracy than 18FFDG-PET. An indirect comparison between 18F-FDG-PET and 11C methionine PET showed that 11C
methionine PET performed better, and another indirect comparison of 11C methionine PET and MRI
showed a comparable diagnostic capability between the 2 methods. The evidence supports the use of
18F-FDG-PET, 18F-FET-PET, and 11C methionine PET for the diagnosis and staging and restaging of brain
tumors cancer but does not support their use for surveillance.
 
2019 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2019. No new literature was identified that would prompt a change in the coverage statement.
 
2020 Update
A literature search was conducted through February 2020.  There was no new information identified that would prompt a change in the coverage statement.  
 
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through January 2021. No new literature was identified that would prompt a change in the coverage statement.
 
December 2021 Update
A literature review was performed through September 2021. Following is a summary of the key literature to date.
 
DIAGNOSTIC WORKUP
The World Health Organization Classification of Tumors of the Central Nervous System is used to classify and grade gliomas. All patients require an MRI of the brain for initial evaluation unless contraindicated. Spine imaging is indicated for intracranial and spinal ependymoma, medulloblastoma, primary spinal cord tumors, leptomeningeal disease, and symptomatic or cerebrospinal fluid-positive central nervous system lymphoma. Imaging is also indicated for central nervous system lymphomas to assess for possible systemic involvement; one study found that PET/CT body had a significantly higher sensitivity (94%-98%) than CT and resulted in change in management in 34% of patients. (2) Per NCCN, MR spectroscopy and PET brain imaging are not generally useful in the initial evaluation of primary central nervous system cancers. However, the evidence to date is limited and PET imaging is currently a National Comprehensive Cancer Network (NCCN) level 2B recommendation. (3, 4)
 
MANAGEMENT
MR angiography, fMRI, MRS, or PET brain scan may be used to differentiate radiation necrosis from active tumor. (5) In a study comparing MRI to MRS, MRSplus diffusion-weighted imaging sequences was found to have above 95% sensitivity and specificity for distinguishing bacterial abscess from cystic tumor. (6) In a meta-analysis comparing the accuracy of MRSto PET, there was no significant difference between the two modalities. (7)
 
SURVEILLANCE
AIM Oncologic Imaging guidelines for monitoring of primary central nervous system cancers are in concordance with both NCCN Nervous System Cancers guidelines as well as the European Society for Medical Oncology High-Grade Malignant Glioma guidelines. (8, 9)
 
References
    1. Young RM, Jamshidi A, Davis G, et al. Current trends in the surgical management and treatment of adult glioblastoma. Ann Transl Med. 2015;3(9):121. PMID: 26207249
    2. Mohile NA, Deangelis LM, Abrey LE. The utility of body FDG PET in staging primary central nervous system lymphoma. Neuro-oncol. 2008;10(2):223-8. PMID: 18287338
    3. Blum RH, Seymour JF, Wirth A, et al. Frequent impact of [18F]fluorodeoxyglucose positron emission tomography on the staging and management of patients with indolent non-Hodgkin's lymphoma. Clin Lymphoma. 2003;4(1):43-9. PMID: 12837154
    4. Wohrer S, Jaeger U, Kletter K, et al. 18F-fluoro-deoxy-glucose positron emission tomography (18F-FDG-PET) visualizes follicular lymphoma irrespective of grading. Ann Oncol. 2006;17(5):780-4. PMID: 16497824
    5. Wen PY, Macdonald DR, Reardon DA, et al. Updated response assessment criteria for high-grade gliomas: response assessment in neuro-oncology working group. J Clin Oncol. 2010;28(11):1963-72. PMID: 20231676
    6. Lai PH, Hsu SS, Ding SW, et al. Proton magnetic resonance spectroscopy and diffusion-weighted imaging in intracranial cystic mass lesions. Surg Neurol. 2007;68 Suppl 1:S25-36. PMID: 17963918
    7. Wang X, Hu X, Xie P, et al. Comparison of magnetic resonance spectroscopy and positron emission tomography in detection of tumor recurrence in posttreatment of glioma: a diagnostic meta-analysis. Asia Pac J Clin Oncol. 2015;11(2):97-105. PMID: 24783970
    8. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Central Nervous System Cancers (Version 42.2020). Available at http://www.nccn.org. ©National Comprehensive Cancer Network, 2021.
    9. Stupp R, Brada M, van den Bent MJ, et al. High-grade glioma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2014;25 Suppl 3:iii93-101. PMID: 24782454
 
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2022. No new literature was identified that would prompt a change in the coverage statement.
 
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through November 2023. No new literature was identified that would prompt a change in the coverage statement.
CPT/HCPCS:
78811Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)
78812Positron emission tomography (PET) imaging; skull base to mid thigh
78813Positron emission tomography (PET) imaging; whole body
78814Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)
78815Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid thigh
78816Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body
References: Agency for Healthcare Research & Quality.(2008) Positron Emission Tomography for nine cancers (bladder, brain, cervical, kidney, ovarian, pancreatic, prostate, small cell lung, testicular). http://www.cms.gov/medicare-coverage-database/details/technology-assessments-details.aspx?TAId=54 &bc=BAAgAAAAAAAA& .

American College of Radiology.(2012) American College of Radiology Appropriateness Criteria. http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria.aspx , last accessed Apr 2012.

Barker FG 2nd, Chang SM, et al.(1997) 18-Fluorodeoxyglucose uptake and survival of patients with suspected recurrent malignant glioma. Cancer 1997; 79:115-26.

Chin HW, Fruin AH, et al.(1991) Application of positron emission tomogrpahy to neurological oncology. Nebr Med J 1991; 76:70-3.

Coleman RE, Hoffman JM, et al.(1991) Clinical application of PET for the evaluation of brain tumors. J Nucl Med 1991; 32:616-22.

Delbeke D.(1999) Oncological applications of FDG PET imaging: brain tumors, colorectal cancer lymphoma and melanoma. J Nucl Med 1999; 50:591-603.

Deng SM, Zhang B, Wu YW et al.(2013) Detection of glioma recurrence by (1)(1)C-methionine positron emission tomography and dynamic susceptibility contrast-enhanced magnetic resonance imaging: a meta-analysis. Nucl Med Commun 2013; 34(8):758-66.

Deshmukh A, Scott JA, et al.(1996) Impact of fluorodeoxyglucose positron emission tomography on the clinical management of patients with glioma. Clin Nucl Med 1996; 21:720-5.

Dunet V, Pomoni A, Hottinger A, et al.(2016) Performance of 18F-FET versus 18F-FDG-PET for the diagnosis and grading of brain tumors: systematic review and meta-analysis. Neuro Oncol. Mar 2016;18(3):426-434. PMID 26243791

Dunet V, Rossier C, Buck A et al.(2012) Performance of 18F-fluoro-ethyl-tyrosine (18F-FET) PET for the differential diagnosis of primary brain tumor: a systematic review and Metaanalysis. J Nucl Med 2012; 53(2):207-14.

Fletcher JW, Djulbegovic B, et al.(2008) Recommendations on the use of 18F-FDG PET in oncology. J Nucl Med, 2008; 49:480-508.

Hilner BE, Siegel BA, et al.(2009) The impact of Positron Emission Tomography (PET) on expected management during cancer treatment. Cancer, 2009; 115:410-8.

Janus TJ, Kim EE, et al.(1993) Use of [18F] fluorodeoxyglucose positron emission tomography in patients with primary malignant brain tumors. Ann Neurol 1993; 33:540-8.

Karunanithi S, Sharma P, Kumar A, et al.(2013) 18F-FDOPA PET/CT for detection of recurrence in patients with glioma: prospective comparison with 18F-FDG PET/CT. Eur J Nucl Med Mol Imaging. 2013 Jul;40(7):1025-35. PMID:23525498

Kawai N, Miyake K, Okada M, et al.(2013) Usefulness and Limitation of FDG-PET in the Diagnosis of Primary Central Nervous System Lymphoma. No Shinkei Geka. 2013 Feb;41(2):117-26.

Kim EE, Chung SK, et al.(1992) Differentiation of residual or recurrent tumors from post-treatment changes with F-18 FDG PET. Radiographics 1992; 12:269-79.

Mujoomdar M, Moulton K, Nkansah E.(2010) Positron Emission Tomography (PET) in Oncology: a systematic review of clinical effectivenss and indications for use. Ottawa:Canadian Agency for Drugs and Technologies in Health (CADTH). 2010. http://www.cadth.ca.

National Comprehensive Cancer Network.(2012) NCCN Guidelines Version 1.2012 Central Nervous System Cancers. www.nccn.org, accessed Apr 2012.

National Comprehensive Cancer Network.(2014) Clinical Practice Guidelines in Oncology. Small Cell Lung Cancer V2.2014. Available online at: http://www.nccn.org/professionals/physician_gls/pdf/sclc.pdf. Last accessed January, 2014.

National Comprehensive Cancer Network.(2021) NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Central Nervous System Cancers (Version 2.2020). Available at http://www.nccn.org. ©National Comprehensive Cancer Network, 2021.

Nelson SJ, Huhn S, et al.(1997) Volume MRI and MRSI techniques for the quantitation of treatment response in brain tumors: presentation of a detailed case study. J Magn Reson Imaging 1997; 7:1146-52.

Podoloff DA, Ball DW, et al.(2009) NCCN Task Force: Clinical utility of PET in a variety of tumor types. NCCN, 2009; 7 [Suppl 2):1-23.

Positron Emission Tomography (PET) for Central Nervous System (CNS) Tumors. Hayes, Inc. June, 2001.

Positron Emission Tomogrpahy (PET) for central nervous system tumors. Hayes, Inc. March, 1998.

Rozental JM.(1991) Positron emission tomography PET and single-photon emission computed tomography (SPECT) of brain tumors. Neurol Clin 1991; 9:287-305.

Zhao C, Zhang Y, Wang J.(2013) A Meta-Analysis on the Diagnostic Performance of 18F-FDG and 11C-Methionine PET for Differentiating Brain Tumors. AJNR Am J Neuroradiol 2013.

Zhao C, Zhang Y, Wang J.(2013) A Meta-Analysis on the Diagnostic Performance of 18F-FDG and 11C-Methionine PET for Differentiating Brain Tumors. AJNR Am J Neuroradiol. 2013 Sep 12. [Epub ahead of print]
Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2024 American Medical Association.