Confirm radiotracer-specific eligibility before ordering PET

Certain PET radiotracers are covered only when the patient meets the radiotracer‑specific clinical eligibility criteria in the policy (examples include fluciclovine F‑18 or choline C‑11 for prostate restaging with consecutive PSA rise and PSA ≥ 1 ng/mL; Ga‑68 PSMA and piflufolastat F‑18 for specified prostate staging/recurrence indications; Ga‑68/64Cu DOTATATE/TOC for somatostatin‑receptor–positive NETs when criteria are met).

• Fluciclovine F‑18 or choline C‑11: medically necessary for restaging when prior prostatectomy/radiation, consecutive PSA rise, PSA ≥ 1 ng/mL, and negative CT/bone scan are documented.
• Ga‑68 PSMA‑11 and piflufolastat F‑18 (Pylarify): medically necessary for newly diagnosed and suspected recurrence per policy criteria.
• Ga‑68/64Cu DOTATATE/TOC: medically necessary for SSTR‑expressing NETs or pheochromocytoma/paraganglioma when selection criteria are met; investigational for other indications.

Bill using the CPT/HCPCS codes listed in the policy

Use the CPT and HCPCS procedure and radiopharmaceutical codes listed in the policy when the applicable selection criteria are met; bill the PET study using the covered CPT/HCPCS codes shown in the coding section.

• Bill myocardial PET studies with listed CPT codes (for example 78429–78434, 78459, 78491–78492) and the matching HCPCS radiopharmaceutical codes (A9526, A9552, A9555) when cardiac criteria are satisfied.
• Bill general PET/PET‑CT using CPT codes 78811–78816 and the HCPCS radiotracer codes (A9552, A9587, A9588, A9595, etc.) corresponding to the tracer used.

Ensure procedure and tracer codes accurately match the indication

Ensure the procedure and radiotracer coding match the indicated clinical scenario: the policy identifies specific CPT procedure codes and HCPCS radiotracer J/A codes that must correspond to the covered indication and tracer.

• Match the study area/procedure CPT code (e.g., 78812 skull base to mid‑thigh) with the appropriate HCPCS radiopharmaceutical code for the tracer administered (e.g., A9595 for piflufolastat F‑18).
• Do not use HCPCS codes listed as not covered for the indications in the CPB (see HCPCS not‑covered list).

Obtain prior authorization / document intent for gynecologic cancer PET

PET for primary staging of endometrial cancer and uterine sarcoma has limited sensitivity for nodal staging; when ordering PET for these gynecologic indications, prior authorization or additional documentation of intended use (primary staging vs restaging/recurrence) may be required.

• Document whether PET is being requested for primary staging or for evaluation of suspected metastasis/recurrence, since sensitivity for primary nodal staging is limited.
• Consider prior authorization when whole‑body PET/CT is requested for initial workup or surveillance in select endometrial/uterine sarcoma patients per NCCN guidance.

Consider prior authorization for whole‑body PET/CT in select cancer staging

Consider prior authorization when whole‑body PET/CT is requested for initial workup or surveillance in select cancers (for example endometrial carcinoma, uterine sarcoma, or pancreatic cancer) because guideline statements recommend selective use and evidence is limited.

• Provide clinical justification and prior imaging results when requesting whole‑body PET/CT for initial staging or surveillance in these select scenarios.
• NCCN and ASCO guidance note PET/CT may be considered in high‑risk or indeterminate cases but is not routine.

Amyloid/FDG PET for Alzheimer vs frontotemporal dementia is investigational

Aetna deems PET for differentiating Alzheimer disease from frontotemporal dementia investigational; prior authorization is likely required and such requests may be denied as not medically necessary.

• Amyloid or FDG PET requested to distinguish Alzheimer disease from frontotemporal dementia should include supporting rationale, but Aetna considers this use experimental/investigational.

Obtain PET/CT before surgical staging in NSCLC and document confirmation plans

For NSCLC, obtain PET/CT prior to surgical evaluation and document that positive PET/CT findings for distant or mediastinal disease will be confirmed pathologically or by other radiologic means before avoiding surgery.

• Ensure PET/CT and CT used for staging are within 60 days before proceeding with surgical evaluation.
• Document plans for pathologic confirmation (e.g., mediastinoscopy, biopsy) if PET/CT indicates mediastinal or distant metastatic disease.

Amyloid PET (Medicare CED): one study per beneficiary with FDA‑approved tracer

Medicare CED limits amyloid PET coverage: for Medicare beneficiaries amyloid PET may be covered only once under approved CED trials and must use an FDA‑approved radiopharmaceutical; only one study will be paid per beneficiary.

• When ordering amyloid PET for a Medicare beneficiary, document trial enrollment status and confirm the radiopharmaceutical is FDA‑approved per CED requirements.

Document clinical context when requesting specialty prostate PET tracers

NCCN guidance supports selective use of certain PET tracers for prostate cancer (for example 11C‑choline, 18F‑fluciclovine, 18F‑NaF) in specific staging and recurrence scenarios; when ordering these specialty tracers, document the clinical scenario (PSA, prior treatments) to justify use.

• Include PSA level, prior definitive therapy, and prior imaging results when requesting fluciclovine or choline PET for biochemical recurrence.
• Note that detection sensitivity increases with higher PSA; document PSA threshold per policy where applicable (e.g., PSA ≥ 1 ng/mL for fluciclovine/choline).

Obtain prior authorization for investigational or non‑FDA cleared tracers

Newer or investigational PET tracers (for example some PSMA agents or investigational FES applications) may require prior authorization consistent with investigational status and local payer rules; verify payer-specific prior authorization requirements before scheduling.

• If tracer availability or FDA clearance is limited, include rationale and supporting evidence in the prior authorization request.
• Check payer/institution rules for investigational‑tracer authorization processes.

Prior authorization and documentation expected for PSMA PET use

Use of PSMA PET tracers (for example piflufolastat F‑18) should be limited to appropriate clinical scenarios (such as suspected recurrence where results will guide definitive therapy); prior authorization and documentation of clinical indication and prior imaging are expected.

• Document PSA level, prior treatments (e.g., radical prostatectomy), and why PSMA imaging will change management.
• When PSMA PET is used for staging or suspected recurrence that will guide definitive therapy, include that intent in the authorization request.

Document positive amyloid PET status when tied to aducanumab eligibility

If amyloid PET is being used to determine eligibility for aducanumab therapy, document a positive amyloid PET result consistent with clinical trial inclusion criteria and include the cognitive diagnosis and rationale in the authorization request.

• Document trial‑relevant criteria or treatment intent (e.g., consideration of aducanumab) when ordering amyloid PET.
• Provide prior cognitive evaluation and supporting clinical data.

Follow payer authorization rules for FDA‑approved PSMA PET agents and document intent

FDA approvals for 68Ga gozetotide (Illuccix/Locametz) support PSMA PET use for staging or suspected recurrence in prostate cancer; follow payer authorization rules and document the clinical scenario and intended management impact when requesting these scans.

• Include indication (suspected metastasis vs recurrence), PSA level, and planned management change in the prior authorization.
• Acknowledge known sensitivity/specificity limitations (e.g., Locametz pelvic nodal sensitivity ~0.40) in clinical decision documentation when relevant.

Consider prior authorization for preoperative PET/CT in cholangiocarcinoma

Because routine preoperative PET/CT use in cholangiocarcinoma is not established, consider prior authorization and include clinical justification when PET/CT is requested for preoperative staging.

• Provide CT/MRI findings and explain how PET/CT results would change preoperative management to support authorization.
• Note NCCN statement that routine preoperative PET/CT has not been established in prospective trials.

Check payer workflows; references section does not list new authorization rules

This excerpt provides literature references and does not define additional prior authorization rules beyond those elsewhere in the policy; follow local payer operational workflows for authorization unless specific tracer/indication rules are cited.

• Use the policy's prior authorization sections and payer portals to confirm requirements for a given tracer or clinical scenario.
• When in doubt, include the diagnostic question, prior imaging, and how PET will change management in the authorization request.

Do not order SPECT after an inconclusive FDG‑PET for myocardial viability

When FDG‑PET is used to assess myocardial viability, a subsequent SPECT performed after an inconclusive PET is not considered medically necessary; plan the viability assessment pathway accordingly and document alternatives if PET is inconclusive.

• If PET is inconclusive for viability, document rationale for any additional imaging other than SPECT, since SPECT after an inconclusive PET is not medically necessary per policy.
• Record whether PET replaces SPECT or is being used following an inconclusive SPECT as required by cardiac criteria.

Avoid PET for routine post‑treatment surveillance without signs/symptoms

PET performed for routine post‑treatment surveillance in asymptomatic patients (use beyond completion of treatment without signs/symptoms) is considered experimental/investigational and is expected to be denied; avoid ordering PET for surveillance without documented signs or symptoms.

• If surveillance PET is requested, include signs/symptoms or other clinical concern that justify its use; otherwise the request may be denied as investigational.
• Policy defines surveillance as use to detect recurrence or progression in the absence of signs/symptoms — this use is excluded.

Non‑covered PET modalities and screening indications may be denied

PET/MRI, PET with gamma camera, positron emission mammography, and PET for screening of asymptomatic members are listed as not covered or investigational; ordering these modalities for those indications risks denial.

• Do not request PET/MRI, PET with gamma camera, or PEM for routine clinical indications unless PET/CT is unavailable and policy criteria for FDG‑PET are met and payer allows exception.
• PET for screening asymptomatic individuals is not covered.

NaF‑18 PET for bone metastasis detection is noncovered by CMS

CMS has determined NaF‑18 PET for identification of bone metastases is not reasonable and necessary; use of NaF‑18 PET for this purpose may be denied and Medicare coverage is not expected.

• Avoid ordering NaF‑18 PET for bone metastasis detection for Medicare beneficiaries unless specific payer rules indicate otherwise.
• Consider alternative imaging (bone scan, CT/MRI) consistent with guidelines.

Plan for histologic confirmation of PET‑positive findings when feasible

Whenever PET identifies findings that will change management, histologic confirmation should be obtained whenever feasible because false‑positive PET results occur; document plans for biopsy or radiologic confirmation when PET results will determine definitive therapy.

• For PET‑positive nodal or distant disease where therapy will change, include plans for tissue confirmation or additional imaging to validate the PET finding.
• This recommendation is emphasized in prostate cancer recurrence scenarios and other contexts with known false‑positive rates.

Investigational tracer use may trigger denial without supporting evidence

Use of newer PET tracers described as investigational (for example some Ga‑68 PSMA applications prior to FDA clearance) may be subject to denial if FDA clearance or guideline endorsement is lacking; verify regulatory status and include supporting documentation for coverage consideration.

• If tracer is not FDA‑cleared for the requested indication, include evidence supporting clinical utility and explain intended management impact to reduce risk of denial.
• Payer rules may vary; check authorization requirements for investigational tracers.

Restrict PSMA PET to indication‑linked clinical scenarios to avoid denial

Limit PSMA PET use to appropriate indication‑linked scenarios (for example candidates for initial definitive therapy or patients with PSA‑defined recurrence where PET results will guide management); inappropriate indications may lead to prior authorization denial.

• Document clinical scenario (PSA, prior therapy, intended management) when requesting PSMA PET to demonstrate appropriateness per policy criteria.
• Requests outside the specified clinical scenarios should include strong justification and supporting evidence.