Coverage Policy Manual
Policy #: 2016022
Category: Radiology
Initiated: October 2016
Last Review: January 2025
  PET or PET/CT for Uterine Cancer
Description:
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 useful in cancer imaging because it has been found that tumor cells show increased utilization of glucose compared to non-malignant tissue and is the most common radiotracer that is utilized. For certain malignancies PET scans have been shown to be more accurate than other non-invasive tests in detecting malignant disease. However, as with all diagnostic tests, PET scans do not detect cancer 100% of the time that cancer is present (a false negative test), nor do all positive PET scans represent the presence of malignant disease (a false positive test). A false negative test may occur because a critical volume of malignant cells is necessary for a PET scan to be positive. PET scans may be false positive in the presence of inflammation or granulomatous disease.
 
In the United States PET/CT is usually done by a dedicated scanner that allows both forms of imaging on a single table but it can also be done with fusion or registration.
 
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:
Act 583 applies to all contracts subject to AR state law (this includes fully insured contracts, self-funded church sponsored health plans, and self-funded state and local government sponsored health plans except the Arkansas State and Public School Employees program). For a list of the plans subject to AR state law, please see policy guidelines below.
 
As required by Act 583 of the Arkansas Legislature, positron emission tomography to screen for or to diagnose cancer in a patient upon the recommendation of the patient's physician when the patient has a prior history of cancer is covered when the following criteria are met:
 
a) Documentation of the malignancy by pathologic or equivalent report, and
b) Performed no more often than every 6 months, and
c) Ordered by or in consultation with a specialist trained in pediatric oncology for an individual under the age of 18 (given the enhanced risk of radiation exposure in young).
 
Special Note regarding “prior history of cancer”: In applying Act 583 to any PET scan prior approval or coverage decision for those fully-insured contracts and self-funded church or government plans to which Act 583 applies, the patient-member will be considered to have a “prior history of cancer” as referenced in Act 583 if the patient-member either (a) has active cancer at the time a prior approval request is submitted, as documented by a pathologic or equivalent report or (b) previously had cancer, whether or not in remission at the time the prior approval request is submitted, as documented by a pathologic or equivalent report.
 
For additional information, please see policy 2021004 (PET or PET/CT for Cancer Surveillance and Other Oncologic Applications)
 
Policy Guidelines
List of Plans subject to Act 583:
 
  • Fully Insured Contracts
    • Arkansas Blue Cross Blue Shield
    • Health Advantage
    • Octave
  • Self-funded State and Local Government Sponsored Health Plans
    • Arkansas State Police
    • Arkansas State University (ASU)
    • Benton County
    • City of Rogers
    • City of Siloam Springs
    • MEMS
    • Mississippi County Hospital System
    • Northwest Arkansas Community College
    • Rogers Water Utilities
    • Southern Arkansas University (grandfathered plan)
    • St. Bernards Regional Medical Center
    • University of Central Arkansas
    • Washington County
  • Self-Funded Church Sponsored Health Plans
 
As stated above, this does not apply to Arkansas State and Public School Employee health plan participants and beneficiaries. For Arkansas State and Public School Employee health plan participants and beneficiaries, please see policy 2023025 (PET or PET/CT for Oncologic Applications for ASE/PSE Contracts) for additional information.
 
For Federal Employee Health Benefit Program and Medicare Advantage plan participants please use the appropriate policy set to review.
 
For other requests for PET or PET/CT scans, the following policy/coverage criteria applies:
 
Effective March 13, 2022
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
FDG-PET/CT for patients with uterine cancer (including uterine sarcoma) meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for patients for:
Diagnostic Workup:
      • Indicated when standard imaging cannot be performed or is nondiagnostic for extent of metastatic disease
Management:
      • Indicated when standard imaging cannot be performed or is nondiagnostic for recurrent or progressive disease
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
PET/CT for patients with uterine cancer does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for any other indication not listed as covered above including but not limited to:
    • Surveillance
 
For contracts without primary coverage criteria, PET/CT for patients with uterine cancer is considered investigational and is not covered for any indication or any circumstance other than those listed above including but not limited to:
    • Surveillance
Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
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
 
PET or PET/CT in the detection of lymph node metastases related to uterine cancer meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
 
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.
 
PET or PET/CT for the assessment of endometrial cancer recurrence meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness
 
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 or PET/CT for all other indications related to uterine cancer does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
 
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 or PET/CT for all other indications related to uterine cancer is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Effective prior to March 2018
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
PET or PET/CT does not meet primary coverage criteria that there be scientific evidence of effectiveness for diagnosis, staging or restaging of uterine cancer.
 
For members with contracts without primary coverage criteria, PET or PET/CT is considered investigational for diagnosis, staging or restaging of uterine cancer.
 
Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Rationale:
There is some evidence that Whole-body PET/CT is useful for (1) initial staging of cervical and endometrial cancer, posttherapy assessment, radiation therapy planning, and posttreatment surveillance of cervical cancer, and (2) assessment of recurrence of cervical, endometrial, or ovarian cancer in the presence of symptoms. It is also useful for staging and recurrence of uterine sarcomas, and for staging of vulvar and vaginal cancer (Oldan, 2016; Lai et al, 2007).  
 
Park et al (2008) performed a comparative study of PET/CT with MRI in the pre op detection of primary lesions and lymph node (LN) and distant metastases in patients with uterine corpus cancer.  In patients with uterine corpus cancer, PET/CT had moderate sensitivity, specificity and accuracy in detecting primary lesions and LN metastases, indicating that this method cannot replace surgical staging. The primary benefit of PET/CT is its sensitivity in detecting distant metastases and therefore may present an advantage in select patients who are poor candidates for surgical staging.
 
There has been evidence published that compare the imaging modalities used in evaluating endometrial cancer.  Several studies report that magnetic resonance has a higher sensitivity and utility in evaluating myometrial invasion and lymph node involvement.  Kinkel et al (1999) performed a meta-analysis comparing the utility of computed tomography (CT), ultrasonography (US), and magnetic resonance (MR) imaging in staging endometrial cancer and determined that contrast-enhanced magnetic resonance imaging (MRI) appears to be the best radiographic modality for detecting myometrial invasion or cervical involvement when compared with nonenhanced MRI, ultrasound, or computed tomography (CT). The majority of studies reported the sensitivity of enhanced MRI as approximately 80 to 90 percent (range 57 to 100 percent) for myometrial invasion. A study by Beddy et al (2012), has also concluded that contrast enhanced MR has a high diagnostic and staging accuracy in the assessment of myometrial invasion.
 
A study by Selman et al (2008) found MRI to be the best imaging modality, compared with CT or positron emission tomography (PET) with or without CT, for detecting lymph node metastases. However, the author also notes that preoperative imaging for this purpose still cannot replace surgical evaluation of lymph node involvement.  
 
In 2009, a NCCN Task Force reported on the clinical utility of PET in a variety of tumor types with the following summary statement:  
 
“Although uterine cancer is usually diagnosed at an early stage, it has the same tendency as ovarian cancer to spread as small nodal deposits for which PET has very low sensitivity. In a study of 30 patients, Suzuki et al (2007)  found that preoperative FDGPET detected none of 5 cases of lymph node involvement of 0.6 cm or less. PET was more sensitive than CT or MRI in visualizing non-nodal extrauterine lesions or the primary lesion (Suzuki et al, 2007; Chao et al, 2006) but, similar to ovarian cancer, the problem is that up-front surgery is indicated for staging and treatment of uterine cancer. PET imaging does not currently preclude the need for surgical staging.” (Podoloff et al, 2009).  
 
 
The Expert Panel on Women’s Imaging and Radiation Oncology for the American College of Radiology (2013) published clinical guidelines for the use if imaging in evaluation and follow-up of endometrial cancer (EC) with the following summary points:  
 
    • Because dynamic contrast-enhanced and diffusion weighted MRI demonstrates the highest accuracy for overall staging of endometrial cancer, it should be the preferred imaging modality for treatment planning when available.
    • Transvaginal US is still the screening examination of choice for the detection of EC, and it can be used to assess the depth of myometrial invasion and cervical involvement, albeit with less accuracy then MRI.
    • CT and MRI perform equivalently for assessing nodal involvement. MRI might have an edge with ADC mapping.
    • PET with concurrent diagnostic-quality abdominopelvic CT and/or MRI is the most accurate means of assessing adenopathy pretreatment and in the post-treatment evaluation of endometrial cancer patients with clinically suspected recurrence. However, cost-effectiveness or patient outcome analyses on the benefits of surveillance imaging have yet to be reported.
    • Patients with endometrial cancer should undergo preoperative diagnostic imaging in cases where there is strong desire to preserve fertility or there are clinical staging difficulties, including medical comorbidities that preclude surgery, large tumors, high histologic tumor grade, or possible cervical involvement.
    • Pretreatment imaging to determine tumor extent may be performed to plan surgery and, when necessary, triage to specialist referral for complete surgical staging with lymphadenectomy.
    • If pretreatment imaging is needed, MRI is the preferred modality for overall assessment of disease extent. However, for the assessment of lymphadenopathy and distant metastasis, CT is also acceptable. However, PET/CT is more appropriate for assessing lymphadenopathy in high-grade FDG-avid tumors.
    • For clinically suspected recurrence after treatment, PET/CT is the preferred imaging modality to confirm and localize the recurrent disease. There is not enough evidence to support post-therapy imaging surveillance for asymptomatic patients at this time.
 
Additionally, two studies have concluded that the evidence is insufficient to determine the role of FDG-PT/CT in uterine cancer.  Basu (2009) performed a study of PET and PET-CT imaging of gynecological malignancies and found that FDG-PET imaging was not routinely employed in endometrial adenocarcinomas.  Bhosale et al (2010) also studied the use of F-FDG PET in gynecologic malignancies other than ovarian and cervical cancer and concluded that the potential role of FDG-PET/CT in gynecologic malignancies such as endometrial cancer and uterine sarcomas has not been fully explored.  
 
2017 Update
A literature search conducted through September 2017 did not reveal any new information that would prompt a change in the coverage statement.  
 
2018 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2018. The key identified literature is summarized below.
 
ENDOMETRIAL CANCER AND 18F-FDG-PET AND 18F-FDG-PET/CT
Bollineni et al published a systematic review and meta-analysis on the diagnostic value of 18FFDG-PET for endometrial cancer (Bollineni, 2016). The literature search, conducted through August 2015, identified 21 studies for inclusion in the meta-analysis: 13 on detection of lymph node metastases (n=861) and 8 on detection of endometrial cancer recurrence (n=378). Pooled sensitivity and specificity for 18F-FDG-PET for detecting lymph node metastases were 72% (95% CI, 63% to 80%) and 94% (95% CI, 93% to 96%), respectively. Pooled sensitivity and specificity for 18F-FDG-PET for detecting endometrial cancer recurrence following primary surgical treatment were 95% (95% CI, 91% to 98%) and 91% (95% CI, 86% to 94%), respectively.
 
The evidence supports the use of 18F-FDG-PET and 18F-PET/CT for the diagnosis, staging and restaging, or surveillance of endometrial cancer.
 
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.
 
2022 Update
A literature review was performed through September 2021. Following is a summary of the key literature to date.
 
DIAGNOSTIC WORKUP
The staging system most widely adopted for uterine cancer is the International Federation of Gynecology and Obstetrics (FIGO) system, although the American Joint Committee on Cancer TNM system is also used. MRI pelvis is the preferred modality for assessing the extent of local disease and extension into the cervix. (1, 2) For fertility-sparing therapy, an MRI pelvis is indicated prior to hormonal therapy and dilatation and curettage; a review comparing MRI to transvaginal ultrasound reported better sensitivity for evaluating myometrial invasion with MRI although statistically the two exams were equivalent.3 When evaluation of lymph nodes is required, both CT and MRI provide similar sensitivity and specificity.(4, 5) In several small studies, PET has been shown to be equivalent or moderately better for detecting nodal disease when compared to MRI and CT; however, these differences rarely affect the decision for lymphadenectomy. (6-11) As the majority of endometrial cancers are confined to the uterus (75%) and lymph nodes (10%), systemic imaging is reserved for high-risk patients. (12) In an international prospective trial, the negative predictive value for low-risk endometrial cancer was 97%. (13) There is insufficient data to recommend PET/CT for routine assessment. Based on the National Comprehensive Cancer Network (NCCN) uterine cancer guidelines, European Society for Medical OncologyEuropean Society of Gynecological Oncology-European Society for Therapeutic Radiology and Oncology Consensus, and American College of Radiology guidelines, additional imaging for metastatic workup is optional. (14-16)
 
MANAGEMENT
Follow-up imaging should be guided by patient symptoms, risk assessment, and clinical concern for recurrent or metastatic disease. For patients with endometrial carcinoma who have undergone fertility-sparing treatment, MRI pelvis with contrast is preferred after 6 months of failed medical therapy, especially if considering further fertility-sparing approaches. In a small prospective study from Korea, PET for suspected disease recurrence had a sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 100%, 83.3%, 96%, 95%, and 100%, respectively. PET/CT detected 3/24 (12.5%) recurrences in patients with elevated tumor markers but negative CT abdomen and pelvis findings. (17)
 
SURVEILLANCE
Following treatment for uterine sarcoma specifically, the NCCN recommends CT of the Chest, Abdomen and Pelvis every 3-6 months for the first 3 years, and then every 6-12 months for the next 2 years. (14) Otherwise, the National Comprehensive Cancer Network, American College of Radiology, and Society of Gynecologic Oncology do not recommend routine use of surveillance imaging. (14, 16, 18) The most important component for surveillance of asymptomatic uterine cancer is physician history and physical with vaginal cytology, as the vaginal cuff is the most common site of recurrence. Cancer antigen (CA) 125 may be used if initially elevated. In a systematic review by Fung et al., the overall risk of recurrence was 13% for all patients and 3% or less for patients at low risk. Approximately 70% of all recurrences were symptomatic. (19) In a retrospective study, recurrences in high-grade endometrial carcinomas were discovered by symptoms 56% of the time and physical exam 18% of the time. Surveillance CT only detected 15% of asymptomatic recurrences. (20) Limited data is available for MRI and PET/CT in surveillance of asymptomatic patients.18 In a small prospective study, PET detected asymptomatic uterine cancer recurrence in only 4% of patients.17A retrospective study evaluating adherence to Society of Gynecological Oncology guidelines resulted in an appreciable decline in CT imaging, CA125, and clinical exams with no effect on outcomes. (21)
 
Current References
    1. Sala E, Rockall AG, Freeman SJ, et al. The added role of MR imaging in treatment stratification of patients with gynecologic malignancies: what the radiologist needs to know. Radiology.2013;266(3):717-40. PMID: 23431227
    2. Kinkel K, Kaji Y, Yu KK, et al. Radiologic staging in patients with endometrial cancer: a meta-analysis. Radiology.1999;212(3):711-8. PMID: 10478237
    3. Alcazar JL, Gaston B, Navarro B, et al. Transvaginal ultrasound versus magnetic resonance imaging for preoperative assessment of myometrial infiltration in patients with endometrial cancer: a systematic review and meta-analysis. Journal of Gynecologic Oncology. 2017;28(6):e86. PMID: 29027404
    4. Connor JP, Andrews JI, Anderson B, et al. Computed tomography in endometrial carcinoma. ObstetGynecol.2000;95(5):692-6. PMID: 10775731
    5. Rockall AG, Meroni R, Sohaib SA, et al. Evaluation of endometrial carcinoma on magnetic resonance imaging. Int J Gynecol Cancer. 2007;17(1):188-96. PMID: 17291252
    6. Bese T, Sal V, Demirkiran F, et al. The combination of preoperative fluorodeoxyglucose positron emission tomography/computed tomography and sentinel lymph node mapping in the surgical management of endometrioid endometrial cancer. Int J Gynecol Cancer. 2016;26(7):1228-38. PMID: 27643647
    7. Bollineni VR, Ytre-Hauge S, Bollineni-Balabay O, et al. High diagnostic value of 18F-FDG PET/CT in endometrial cancer: systematic review and meta-analysis of the literature. J Nucl Med. 2016;57(6):879-85. PMID: 26823564
    8. Kitajima K, Murakami K, Yamasaki E, et al. Accuracy of 18F-FDG PET/CT in detecting pelvic and paraaortic lymph node metastasis in patients with endometrial cancer. AJR Am J Roentgenol. 2008;190(6):1652-8. PMID: 18492920
    9. Kitajima K, Suzuki K, Senda M, et al. Preoperative nodal staging of uterine cancer: is contrast-enhanced PET/CT more accurate than non-enhanced PET/CT or enhanced CT alone? Ann Nucl Med. 2011;25(7):511-9. PMID: 21670955
    10. Park JY, Kim EN, Kim DY, et al. Comparison of the validity of magnetic resonance imaging and positron emission tomography/computed tomography in the preoperative evaluation of patients with uterine corpus cancer. Gynecol Oncol. 2008;108(3):486-92. PMID: 18201753
    11. Signorelli M, Crivellaro C, Buda A, et al. Staging of high-risk endometrial cancer with PET/CT and sentinel lymph node mapping. Clin Nucl Med. 2015;40(10):780-5. PMID: 26053711
    12. Chan JK, Cheung MK, Huh WK, et al. Therapeutic role of lymph node resection in endometrioid corpus cancer: astudy of 12,333 patients. Cancer. 2006;107(8):1823-30. PMID: 16977653
    13. Kang S, Nam JH, Bae DS, et al. Preoperative assessment of lymph node metastasis in endometrial cancer: AKorean Gynecologic Oncology Group study. Cancer. 2017;123(2):263-72. PMID: 28067948
    14. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Uterine Neoplasms (Version 1.2021). Available at http://www.nccn.org. ©National Comprehensive Cancer Network, 2021.
    15. Colombo N, Creutzberg C, Amant F, et al. ESMO-ESGO-ESTRO consensus conference on endometrial cancer: diagnosis, treatment and follow-up. Ann Oncol. 2016;27(1):16-41. PMID: 26634381
    16. Expert Panel on GYN and OB Imaging: Reinhold C, Ueno Y, Akin EA, et al. ACR Appropriateness Criteria® pretreatment evaluation and follow-up of endometrial cancer. J Am Coll Radiol. 2020;17(11S):S472-S86. PMID:33153558
    17. Park JY, Kim EN, Kim DY, et al. Clinical impact of positron emission tomography or positron emission tomography/computed tomography in the posttherapy surveillance of endometrial carcinoma: evaluation of 88patients. Int J Gynecol Cancer. 2008;18(6):1332-8. PMID: 18298562
    18. Salani R, Khanna N, Frimer M, et al. An update on post-treatment surveillance and diagnosis of recurrence in women with gynecologic malignancies: Society of Gynecologic Oncology (SGO) recommendations. Gynecol Oncol. 2017;146(1):3-10. PMID: 28372871
    19. Fung-Kee-Fung M, Dodge J, Elit L, et al. Follow-up after primary therapy for endometrial cancer: a systematic review. Gynecol Oncol. 2006;101(3):520-9. PMID: 16556457
    20. Hunn J, Tenney ME, Tergas AI, et al. Patterns and utility of routine surveillance in high grade endometrial cancer. Gynecol Oncol. 2015;137(3):485-9. PMID: 25838164
    21. Schwartz ZP, Frey MK, Philips S, et al. Endometrial cancer surveillance adherence reduces utilization and subsequent costs. Gynecol Oncol. 2017;146(3):514-8. PMID: 28734496
 
2023 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.
 
NCCN Guidelines for Uterine Neoplasms (Version 2022) reviewed with no change from Version 2021 with regard to PET applications in Uterine Neoplasms.
 
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2023. No new literature was identified that would prompt a change in the coverage statement.
 
NCCN Guidelines for Uterine Neoplasms (Version1.2024) reviewed with no change from Version 2022 with regard to PET applications in Uterine Neoplasms.
 
2025 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2024. No new literature was identified that would prompt a change in the coverage statement.
 
NCCN Guidelines for Uterine Neoplasms (Version 1.2024) reviewed with no change to PET applications.
CPT/HCPCS:
78812Positron emission tomography (PET) imaging; skull base to mid thigh
78813Positron emission tomography (PET) imaging; whole body
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: American College of Radiology (ACR) Expert Panel on Women’s Imaging and Radiation Oncology.(2013) Evaluation and Follow-up of Endometrial Cancer. 2013 version. ACR Appropriateness Criteria. Available at https://acsearch.acr.org/docs/69459/Narrative/

Antonsen SL, Jensen LN, Loft A, et al.(2013) MRI, PET/CT and ultrasound in the preoperative staging of endometrial cancer—a multicenter prospective comparative study. Gynecol Oncol 2013; 300-308. Available @ http://www.ncbi.nlm.nih.gov/pubmed/23200916.

Basu S, Li G, Alavi, A.(2009) ET and PET-CT Imaging of Gynecological Malignancies: Present Role and Future Promise. Expert Rev Anticancer Ther. 2009;9(1):75-96.

Beddy P, Moyle P, Kataoka M, Yamamoto AK, Joubert I, Lomas D, Crawford R, Sala E.(2012) Evaluation of depth of myometrial invasion and overall staging in endometrial cancer: comparison of diffusion-weighted and dynamic contrast-enhanced MR imaging. Radiology. 2012;262(2):530.

Bhosale P, Iyer R, Jhingran A, Podoloff D.(2010) PET/CT Imaging in Gynecologic Malignancies Other than Ovarian and Cervical Cancer. PET Clin. 2010 Oct;5(4):463-75. doi: 10.1016/j.cpet.2010.07.005. Epub 2010 Aug 11.

Bollineni VR, Ytre-Hauge S, Bollineni-Balabay O, et al.(2016) High diagnostic value of 18F-FDG PET/CT in endometrial cancer: systematic review and meta-analysis of the literature. J Nucl Med. Jun 2016;57(6):879-885. PMID 26823564

Chao A, Chang TC, Ng KK, et al.(2006) 18F-FDG PET in the management of endometrial cancer. Eur J Nucl Med Mol Imaging 2006;33:36–44.

Kinkel K, Kaji Y, Yu KK, Segal MR, Lu Y, Powell CB, Hricak H.(1999) Radiologic staging in patients with endometrial cancer: a meta-analysis. Radiology. 1999;212(3):711.

Lai CH, Yen TC, Chang TC.(2007) Positron emission tomography imaging for gynecologic malignancy. Curr Opin Obstet Gynecol. 2007 Feb;19(1):37-41.

National Comprehensive Cancer Network(2022) NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Uterine Neoplasms (Version 1.2022). Available at http://www.nccn.org. ©National Comprehensive Cancer Network, 2022.

Oldan JD, Patel PS.(2016) Positron Emission Tomography/Computed Tomography for Gynecologic Malignancies. Obstet Gynecol Surv. 2016 Sep;71(9):545-56. PMID: 27640609.

Park JY, Kim EN, Kim DY, Suh DS, Kim JH, Kim YM, Kim YT, Nam JH.(2008) Comparison of the validity of magnetic resonance imaging and positron emission tomography/computed tomography in the preoperative evaluation of patients with uterine corpus cancer. Gynecol Oncol. 2008;108(3):486.

Podoloff DA, Advani RH, Allred C, et al.(2009) NCCN Task Force Report: Clinical Utility of PET in a Variety of Tumor Types. J Natl Compr Canc Netw 2009;7 (Suppl 2):S1–23.

Selman TJ, Mann CH, Zamora J, Khan KS.(2008) A systematic review of tests for lymph node status in primary endometrial cancer. BMC Womens Health. 2008;8:8.

Suzuki R, Miyagi E, Takahashi N, et al.(2007) Validity of positron emission tomography using fluoro-2-deoxyglucose for the preoperative evaluation of endometrial cancer. Int J Gynecol Cancer 2007;17:890–896.
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.
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