Modifiedblue cross blue shield - kansasPolicy N/A

FDG-PET / PET-CT for hematologic oncology

Defines medical necessity and investigational uses of 18F-FDG PET or PET/CT for diagnosis, staging, restaging, and surveillance of hematologic malignancies (lymphoma and multiple myeloma) for BCBSKS members.

Policy Summary

Payerblue cross blue shield - kansas

PolicyFDG-PET / PET-CT for hematologic oncology

Policy CodePolicy N/A

Change TypeSeparate hematologic policyclarified FDG-PET/FDG-PET‑CT languagemedical-necessity tied to management impact

Effective DateN/A

Next Review DateN/A

Key ActionConfirm member benefits and obtain prior authorization documenting indication and expected impact on management.

SourceLink

POLICY UPDATE CHANGES

Oncologic Applications Hematologic was separated from the broader PET Scanning: Oncologic Applications medical policy into a distinct policy; medical policy language was unchanged.

Updated Description and Policy sections, including removal of wording that all policy statements apply to both PET and PET/CT scans and clarifications about FDG-PET or FDG-PET/CT language.

For clinically indicated situations, PET is considered medically necessary only if results will influence treatment decisions.

4oncologic PET applications discussed

6/12 mosurveillance timing

FDGprimary radiotracer

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56%false-positive proportion

6.8%non‑FDG‑avid relapse rate

12CPT/HCPCS codes listed

Coverage Criteria for FDG-PET / PET-CT — Hematologic Malignancies

inv-01: Hodgkin and non-Hodgkin lymphoma

Covered when used for staging or restaging

Lymphoma staging/restaging: FDG-PET or FDG-PET/CT may be considered medically necessary for initial staging or restaging of Hodgkin or non-Hodgkin lymphoma.

inv-02: Multiple myeloma

Covered when used for staging or restaging

Multiple myeloma staging/restaging: FDG-PET or FDG-PET/CT is considered medically necessary in the staging or restaging of multiple myeloma, particularly if the skeletal survey is negative.

inv-03: Lymphoma: Supported Uses

Covered when evidence supports diagnostic, staging, restaging, or treatment-response use in lymphoma:

Lymphoma - diagnostic/staging/restaging: Use of FDG-PET/CT is supported for diagnosis, staging, restaging, and evaluating treatment response in Hodgkin and non-Hodgkin lymphoma based on systematic reviews, meta-analyses, and an RCT; Deauville scoring is recommended for assessment.

Surveillance PET is not routinely supported due to high false-positive rates; management decisions should not be made on PET alone.

inv-04: Multiple Myeloma: Supported Uses

Covered when evidence supports diagnostic, staging, or restaging use in multiple myeloma:

Multiple myeloma - diagnostic/staging/restaging: FDG-PET and FDG-PET/CT are supported for diagnosis, staging, and restaging of multiple myeloma; PET may be used for initial workup and follow-up if initially used. PET/CT may be first choice for solitary extraosseous plasmacytoma.>3 focal lesions as adverse prognostic marker

Routine surveillance PET is not supported.

inv-05: Surveillance: Not Supported

Not covered or limited uses:

Surveillance: Routine surveillance PET/CT for Hodgkin lymphoma, non-Hodgkin lymphoma, and multiple myeloma is not supported due to risk of false-positives and limited evidence of improved outcomes.

Management should require clinical or pathologic correlation before changes.

inv-06: Covered oncologic indications (national FDG PET coverage)

National FDG PET coverage table: coverage stance by cancer type and by 'Initial' vs 'Subsequent' treatment strategy.

Coverage table entries: Each listed cancer type has a coverage determination for Initial Treatment Strategy and Subsequent Treatment Strategy as stated in the table; coverage presumes that PET results will influence treatment decisions.

See listed cancer-specific entries

FDG-PET or FDG-PET/CT used as routine surveillance in asymptomatic patients is considered experimental/investigational and may be denied. Surveillance is defined as imaging performed ≥6 months after completion of cancer therapy (≥12 months for lymphoma) in individuals without objective signs or symptoms of recurrence; scans meeting that definition fall outside covered indications in this policy. [[Do not include this bracketed note]]

Guidelines support FDG-PET/CT for diagnostic workup, staging, restaging, and evaluation of treatment response in lymphoma, but they explicitly caution against routine surveillance and recommend clinical or pathologic correlation before management changes. For multiple myeloma, evidence reviews and NCCN guidance do not support routine PET/CT or whole-body MRI for routine assessment of treatment response; PET use should be tied to a specific diagnostic or management question. [[Do not include this bracketed note]]

National coverage determinations vary by cancer type: for example, prostate cancer is listed as Non-cover for the Initial Treatment Strategy (initial staging) but is covered for Subsequent Treatment Strategy (restaging/monitoring). Coverage determinations presume PET results will influence treatment decisions. [[Do not include this bracketed note]]

Surveillance FDG-PET or FDG-PET/CT in asymptomatic patients performed more than 6 months after therapy (or ≥12 months for lymphoma) is considered surveillance and is labeled experimental/investigational or not medically necessary under this policy; such timing thus places scans at risk for noncoverage absent objective signs or symptoms. [[Do not include this bracketed note]]

When PET results will not influence treatment decisions, the procedure is considered not medically necessary. The policy assumes that PET is medically necessary only if findings will alter management; otherwise the scan is excluded from coverage. [[Do not include this bracketed note]]

The policy explicitly states that FDG-PET or FDG-PET/CT is not medically necessary if the results will not influence treatment decisions. Documentation should therefore demonstrate the expected impact of the scan on staging or management to justify medical necessity. [[Do not include this bracketed note]]

Procedure Codes and Radiotracer References

Referenced radiotracerNDC

18F-FDG

Fluorine-18 fluorodeoxyglucose radiotracer referenced for PET imaging

Referenced guidelines and scoring (no billing codes in this segment)mixed

No codes listed

Listed PET and PET/CT procedure and radiopharmaceutical codesmixed

78608	Brain imaging, positron emission tomography (PET); metabolic evaluation
78609	Brain imaging, positron emission tomography (PET); perfusion evaluation
78811	Positron emission tomography (PET) imaging; limited area (e.g. Chest, head/neck)
78812	Positron emission tomography (PET) imaging; skull base to mid-thigh
78813	Positron emission tomography (PET) imaging; whole body
78814	Tumor imaging, PET with concurrently acquired CT; limited area (e.g. chest, head/neck)
78815	Tumor imaging, PET with concurrently acquired CT; skull base to mid-thigh
78816	Tumor imaging, PET with concurrently acquired CT; whole body
A9552	Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries
A9597	PET radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified

1–10 of 12

1/2

Surveillance timing

Surveillance definitionImaging in asymptomatic patients performed ≥6 months after completion of cancer therapy (≥12 months for lymphoma).

Surveillance clinical contextApplies to patients without objective signs or symptoms suggestive of cancer recurrence—different from restaging for suspected recurrence.

Policy stance on surveillanceFDG-PET or FDG-PET/CT used as routine surveillance is considered experimental/investigational and may be denied.

Number of focal bone lesions

Prognostic threshold>3 focal bone lesions on FDG-PET/CT are associated with significantly worse progression-free and overall survival in multiple myeloma.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization for PET/CT

Prior authorization is required for PET/CT studies in oncologic indications. Requests must specify the clinical indication and provide documentation that the scan is expected to influence patient management (e.g., staging, restaging for suspected recurrence, or initial workup when PET/CT is the chosen modality).

A clear statement of purpose (staging, restaging for suspected recurrence, detection of progression, initial workup for solitary extraosseous plasmacytoma, etc.)
Relevant prior imaging/results (CT, MRI, skeletal survey) and why PET/CT adds value
Timing relative to therapy completion (surveillance scans >6 months or >12 months for lymphoma are generally not supported)

Prior Authorization

Prior authorization: indicate purpose and expected management impact

When submitting a prior authorization, indicate the specific purpose of the PET/CT and describe how the result is expected to change management (for example: guide systemic therapy selection, determine need for biopsy or radiation, alter number of chemotherapy cycles, or detect progression when other testing is inconclusive). Vague indications such as "surveillance" without clinical concern are insufficient.

Background and Evidence Summary

Positron emission tomography (PET) with positron-emitting tracers—most commonly F-18 FDG—images metabolic activity and can detect disease not seen on conventional imaging. PET may be useful for initial staging or restaging of hematologic malignancies (Hodgkin and non-Hodgkin lymphoma, multiple myeloma) when results are expected to influence management. However, routine surveillance in asymptomatic individuals is not supported by the evidence or guideline recommendations and is associated with high false-positive rates; therefore surveillance scans beyond the policy-defined timing windows (≥6 months after therapy; ≥12 months for lymphoma) are considered experimental/investigational or not medically necessary. Providers should verify member benefits and document the indication and expected management impact when ordering FDG-PET or FDG-PET/CT. [[Do not include this bracketed note]]

Definitions and Scoring Systems

Staging definition

DefinitionStaging refers to use of PET to determine the stage (extent) of the cancer at the time of diagnosis before any treatment is given.

Alternate termAlso referred to as initial staging; imaging is generally to determine whether the cancer is localized.

Policy noteStaging use is one of the policy's defined oncologic applications for PET imaging.

Restaging definition

DefinitionRestaging refers to imaging after treatment in two situations: (a) evaluation when disease recurrence is suspected based on signs/symptoms, and (b) determining extent of malignancy after completion of a full course of treatment.

Use casesIncludes evaluation for suspected recurrence and assessment after finishing therapy to establish residual disease extent.

Line of Therapy Applicability

inv-37: initial and restaging

Use cases: Initial staging at diagnosis and restaging following treatment or when recurrence is suspected

inv-38: first-line

PET-guided therapy modification: In advanced Hodgkin lymphoma, interim PET after 2 cycles can guide de-escalation (fewer cycles) for PET-negative patients and indicates PET-positive patients may not benefit from certain treatment intensification to improve PFS; documentation of PET result is required to justify therapy changes.

Documentation of PET result is required to justify therapy changes.

inv-39: initial_and_subsequent

Initial vs Subsequent Treatment Strategy:

Policy Summary

Payerblue cross blue shield - kansas

PolicyFDG-PET / PET-CT for hematologic oncology

Policy CodePolicy N/A

Change TypeSeparate hematologic policyclarified FDG-PET/FDG-PET‑CT languagemedical-necessity tied to management impact

Effective DateN/A

Next Review DateN/A

Key ActionConfirm member benefits and obtain prior authorization documenting indication and expected impact on management.

SourceLink

On This Page

FDG-PET/CT pooled sensitivity for detecting focal bone lesions in initial staging reported (pooled per-patient sensitivity ~0.807); concordance with MRI ~83% in paired data.

Implication for marrow biopsyDetection of multiple skeletal lesions by PET/CT may imply marrow involvement and influence the need for further invasive testing.

State whether the scan is for initial staging, restaging for suspected recurrence, response assessment informing therapy change, or detection of progression.
If used to guide therapy, document the management decision pathways that will depend on positive vs negative PET findings.

Denial Risk

Surveillance Denial Risk

Surveillance PET/CT carries a high denial risk. PET/CT performed in asymptomatic patients more than 6 months after completion of therapy (≥12 months for lymphoma) without objective signs or symptoms of recurrence is considered experimental/investigational and is routinely not covered.

Surveillance imaging defined as asymptomatic patients >=6 months post-therapy (>=12 months for lymphoma).
NCCN guidance: routine surveillance PET is not recommended due to false positives and should not be done routinely.

Denial Risk

Routine response assessment in multiple myeloma not endorsed

Routine response assessment in multiple myeloma with PET/CT is not endorsed for all patients. PET/CT may be used selectively for staging/restaging, particularly when skeletal survey is negative or when PET/CT was used at baseline and will be used to monitor progression, but it is not a routine treatment-response test for every patient.

NCCN does not recommend routine FDG-PET/CT or whole-body MRI for treatment response assessment in multiple myeloma.
Use PET/CT selectively when it will influence management (e.g., detect progression or when baseline PET/CT exists).

Denial Risk

Denial risk when scan won't change management

If the PET/CT results are unlikely to change treatment decisions, the scan may be considered not medically necessary and denied. Prior authorization reviewers will assess whether the proposed imaging will influence management.

Provide documentation of the specific clinical question and the management options contingent on scan findings.
Examples of scans at high risk for denial: routine surveillance in asymptomatic members, duplicate imaging without new indications, or scans performed when treatment plans are already finalized and not contingent on imaging.

Prior Authorization

Benefit and Indication Verification

Verify member benefits and medical necessity prior to scheduling PET/CT. Ensure that the indication aligns with the policy's covered uses (diagnosis, staging, restaging for suspected recurrence) and that surveillance exclusions are considered.

Confirm member eligibility and any plan-specific imaging coverage rules with BCBSKS Customer Service.
Document prior non-diagnostic or inconclusive imaging (CT, MRI, skeletal survey) when PET/CT is being requested as the next diagnostic step.

Documentation Required

Documentation to justify medical necessity

Provide complete documentation to justify medical necessity: clinical history, signs or symptoms prompting the study, prior imaging reports, dates of treatment completion, and how PET findings will affect management. For lymphoma, include Deauville scoring when applicable and correlate PET findings with clinical and pathologic data.

Clinical problem list and objective findings (e.g., new/worsening symptoms, abnormal labs, or focal findings on other imaging).
Dates and types of recent cancer-directed therapies and timing relative to requested scan.
For lymphoma, include Deauville 5-point score or request that it be reported, and note that management decisions should not rely on PET alone without clinical/pathologic correlation.

Note

Imaging sequence consideration

Imaging sequence considerations: PET/CT is typically used after standard imaging (CT, MRI, skeletal survey) is inconclusive or when CT/MRI are contraindicated. For multiple myeloma, consider PET/CT particularly if skeletal survey is negative or when PET/CT was obtained at baseline and will be used for follow-up.

Document prior standard imaging and reasons PET/CT is needed (inconclusive results, contraindication to contrast, or specific clinical question).
When PET/CT detects ≥3 skeletal lesions in lymphoma workup, marrow biopsy may be unnecessary per NCCN guidance.

Note

Imaging Sequence for Multiple Myeloma

Imaging sequence for multiple myeloma: use PET/CT as an option for initial workup and for restaging when it will inform management. PET/CT is first choice for solitary extraosseous plasmacytoma and may be used to detect progression; however, it is not mandated as routine for response assessment.

Prefer PET/CT when skeletal survey is negative or inadequate to detect focal lesions.
If PET/CT is used at baseline, document intent to use the same modality for subsequent assessments that will guide management decisions.

Documentation Required

Document PET-based therapy adjustment

When PET results lead to therapy changes, document the PET-based therapy adjustment in the medical record and in the prior authorization request (e.g., escalation, de-escalation, change in radiation field, need for biopsy). Records should clearly link PET findings to the intended management change.

State the anticipated treatment decisions contingent on positive vs negative PET findings.
Include references to trial- or guideline-based algorithms (for example, PET-directed cycle adjustments in Hodgkin lymphoma) when applicable.

DocumentationWhen restaging will alter management, documentation that PET results will influence treatment decisions is required.

Surveillance definition

DefinitionSurveillance refers to imaging in asymptomatic patients performed ≥6 months after treatment (≥12 months for lymphoma) to detect recurrence.

Distinction from restagingSurveillance is for patients without objective signs/symptoms; restaging is performed when recurrence is suspected.

Coverage implicationRoutine surveillance PET/CT is considered experimental/investigational and may be denied per policy.

Deauville 5-point PET scale

Score 1No uptake.

Score 2Uptake ≤ mediastinum.

Score 3Uptake > mediastinum but ≤ liver.

Score 4Uptake moderately higher than liver.

Score 5Uptake markedly higher than liver and/or new lesions.

FDG-PET / FDG-PET/CT definition

Modality definitionFDG-PET or FDG-PET/CT refers to positron emission tomography using fluorodeoxyglucose F-18, performed with or without concurrently acquired CT for attenuation correction and anatomical localization.

Policy qualifierPolicy statements were updated to specify FDG-PET or FDG-PET/CT; medical necessity assumes PET results will influence treatment decisions.

Coding contextListed CPT/HCPCS procedure and radiopharmaceutical codes are informational; coverage depends on adherence to policy indications and impact on management.

For most listed cancer types, FDG-PET is covered for both Initial Treatment Strategy and Subsequent Treatment Strategy (restaging/monitoring), with specified exceptions (eg, prostate initial staging non-cover); refer to the national coverage table for specifics.

Refer to national coverage table entries for specifics