The policy includes multiple explicit exclusions across genitourinary cancer types. PET/PET-CT is experimental/investigational and not covered for non–muscle-invasive bladder tumors (stage < cT2), for most indications in penile cancer other than suspected inguinal node–positive disease, for renal cell carcinoma in all aspects of management, and for most uses in testicular cancer except evaluation of postchemotherapy seminoma residual masses. Additionally, PET applications not supported by evidence include many prostate cancer uses outside the specified indications for choline, fluciclovine, and PSMA-targeting agents.

The policy also states that PET used as a surveillance tool in asymptomatic individuals—defined as scans performed more than 6 months after completion of cancer therapy (or 12 months for lymphoma)—is considered experimental/investigational and not medically necessary.

Per guideline and policy statements, PET/CT should not be used to delineate the anatomy of the upper urinary tract. In bladder cancer, PET/CT is specifically not recommended for nonmuscle invasive disease and is intended for selected use in muscle-invasive disease where conventional imaging is inconclusive.

The NCCN guidance cited in the policy emphasizes FDG-PET/CT as a potentially useful adjunct for assessing regional or distant metastases in muscle-invasive bladder cancer but reiterates that PET/CT is not an anatomic study for upper urinary tract delineation.

The policy explicitly states that use of FDG-PET/CT is not supported for nonmuscle invasive bladder cancer (stage < cT2) and that PET scanning for those bladder tumors is considered experimental/investigational.

Section summaries and the Policy wording align: FDG-PET/CT is supported for staging/restaging of muscle-invasive bladder cancer in selected scenarios but not for nonmuscle-invasive disease.

For penile cancer, the policy limits PET/CT utility to patients with suspected inguinal lymph node–positive disease. The document states that PET/CT is not supported for diagnosis, staging, restaging, or surveillance of node‑negative penile cancer, and that PET scanning is considered experimental/investigational for other penile cancer indications.

Guideline and evidence summaries note that PET/CT may increase sensitivity for nodal disease in suspected node‑positive cases, but the evidence does not support PET use when nodes are clinically negative.

The policy indicates that evidence does not support the use of 11C‑choline PET (and PET/CT) or 18F‑fluciclovine PET (and PET/CT) for surveillance of prostate cancer. While these agents may be medically necessary for evaluation of suspected or biochemically recurrent disease, their use for routine surveillance in asymptomatic individuals lacks supporting evidence and is considered not medically necessary.

Choline and fluciclovine are described as appropriate for detection of recurrent small‑volume disease when conventional imaging is negative or equivocal, but explicitly not for surveillance purposes.

The policy and cited evidence do not support use of PSMA PET for the initial diagnosis of prostate cancer. Systematic reviews and guideline summaries note that PSMA PET lacks sufficient evidence for primary diagnosis, and ASCO recommendations advise against PET/CT for staging early low‑risk prostate cancer.

PSMA PET is, however, supported in selected staging and recurrence scenarios; the policy distinguishes those covered PSMA indications from unsupported initial diagnostic uses.

For testicular cancer, the policy indicates that PET is not supported for surveillance in asymptomatic individuals. PET/PET‑CT is described as useful for evaluation of residual masses following chemotherapy for seminoma but not supported for routine surveillance imaging in asymptomatic patients.

Surveillance use—imaging performed more than 6 months after completion of therapy (or 12 months for lymphoma) in asymptomatic individuals—is categorized as experimental/investigational and may be denied.

While the policy includes numerous explicit exclusions within its coverage and not‑medically‑necessary sections, the reference listings and bibliographic entries themselves do not uniformly list standalone coverage exclusions. The policy text and section summaries (rather than the reference list) contain the explicit exclusion statements used to determine coverage stance.

The references support the evidence base but do not replace the policy’s explicit exclusion language for specific indications.

The policy requires that PET or PET/CT scans considered medically necessary are those in which the imaging results will influence treatment decisions. If results are unlikely to affect management, the scan is considered not medically necessary and may be denied.

Providers should document the anticipated impact of PET findings on treatment planning when requesting authorization to align with the policy’s medical‑necessity requirement.

The policy defines surveillance imaging as scans performed more than 6 months after completion of cancer therapy in asymptomatic individuals, and as more than 12 months for lymphoma. PET scanning used in this surveillance context is considered experimental/investigational and not medically necessary.

This surveillance exclusion is distinct from imaging performed for suspected recurrence in symptomatic patients or when clinical/laboratory findings prompt targeted restaging.

The policy again emphasizes that FDG‑PET/CT and related FDG‑based PET tracers are not supported for nonmuscle invasive bladder cancer and are not supported for management of node‑negative penile cancer. These uses are designated experimental/investigational and not covered.

Those tracer‑specific exclusions are called out separately from broader modality or indication exclusions in the coverage statements and section summaries.

The evidence summarized in the policy does not support surveillance imaging with 11C‑choline or 18F‑fluciclovine PET/PET‑CT. Although these tracers are appropriate for detecting recurrent prostate cancer in symptomatic or PSA‑rising individuals, their use for routine surveillance in asymptomatic patients is not supported by the available data.

Policy language and the subsection summary explicitly state these tracer uses are not supported for surveillance.

PSMA PET is not supported for initial diagnosis or primary staging in patients with very low, low, or favorable intermediate risk prostate cancer, and ASCO recommends against PET/CT for staging early low‑risk disease. The policy restricts PSMA PET to guideline‑concordant scenarios (eg, unfavorable intermediate/high/very‑high risk, biochemical recurrence, equivocal conventional imaging, or selection for PSMA‑targeted therapy).

Use of PSMA agents outside those specified indications is considered experimental/investigational.

The policy states that FDG‑PET and FDG‑PET/CT are not supported for surveillance of testicular cancer. While FDG‑PET/CT may be medically necessary to evaluate postchemotherapy residual masses in seminoma, routine surveillance imaging with FDG tracers in asymptomatic individuals is not supported.

Surveillance requests in testicular cancer should therefore be evaluated against the policy’s surveillance exclusion criteria.

Although the policy contains explicit not‑medically‑necessary and not‑covered statements within its main text and section summaries, the external reference listings themselves do not consistently contain separate, explicit 'not medically necessary' labels. The policy language—rather than the reference list—defines the actual coverage and exclusion determinations.

Clinicians and billing staff should rely on the policy statements and section summaries for coverage decisions rather than expecting the reference list to contain exclusional language.

The policy’s NOT COVERED section enumerates uses considered experimental/investigational and therefore not covered. These include PET/PET‑CT for non–muscle‑invasive bladder tumors; most penile cancer indications except suspected inguinal node‑positive disease; many prostate cancer indications outside the specified choline/fluciclovine/PSMA uses; all renal cell carcinoma applications; most testicular cancer uses except seminoma residual mass evaluation; and PET as surveillance (>6 months post‑therapy or ≥12 months for lymphoma) in asymptomatic individuals.

These exclusions drive prior authorization and denial decisions when PET is requested for the listed not‑covered indications.

The policy explicitly lists PET surveillance scans in asymptomatic patients performed more than 6 months after completion of therapy (or ≥12 months for lymphoma) as not covered. It also identifies PET/CT requests to delineate upper urinary tract anatomy as not covered and not an appropriate use of PET/CT.

These not‑covered items are anchored to the policy’s surveillance definition and to guideline language that PET/CT is not an anatomic delineation modality for the upper urinary tract.

Multiple entries in the policy’s not‑covered list specify that FDG‑PET/CT for nonmuscle invasive bladder cancer is not covered. The subsection summaries and policy statements consistently articulate that FDG‑PET/CT is supported only for selected muscle‑invasive bladder cancer indications and not for nonmuscle‑invasive disease.

Requests for FDG‑PET/CT for nonmuscle invasive bladder tumors may be denied per the policy.

The policy repeats that FDG‑PET/CT for nonmuscle invasive bladder cancer is considered experimental/investigational and not covered. This exclusion appears in multiple sections and summaries to avoid misinterpretation of the limited indications for bladder PET.

Coverage for bladder cancer is thus restricted to staging/restaging of muscle‑invasive disease in selected clinical contexts.

FDG‑PET/CT for nonmuscle invasive bladder cancer is consistently listed as not covered and experimental/investigational in the policy. The policy language stresses appropriate use is limited to muscle‑invasive disease when conventional imaging is inconclusive.

Billing and authorization staff should apply this exclusion when evaluating claims or prior‑authorization requests for bladder PET in nonmuscle invasive settings.

The policy’s not‑covered determinations again identify FDG‑PET/CT for nonmuscle invasive bladder cancer as experimental/investigational and not covered. Multiple not‑covered entries repeat this finding to ensure clarity across sections.

Requests for PET/CT in nonmuscle invasive bladder cancer should be evaluated against the policy’s explicit exclusion language.

A further not‑covered entry reiterates that FDG‑PET/CT is not supported for nonmuscle invasive bladder cancer. The repetition across not‑covered listings highlights that PET is reserved for muscle‑invasive disease when indicated.

This repeated exclusion supports consistent application of the policy across prior authorization and claims adjudication.

Background: Positron emission tomography (PET) is a nuclear imaging technique that uses positron‑emitting radiotracers to image metabolic or molecular processes. Tracer selection depends on tumor type and clinical question; for example, FDG is commonly used for many tumor types, whereas PSMA‑targeting agents, choline, and fluciclovine are used for prostate cancer applications. PET may be performed with or without CT or MRI fusion (PET/CT or PET/MRI) to provide anatomic localization.

The policy applies these principles by matching tracer choice and PET modality to the specific genitourinary cancer indications supported by evidence and guideline recommendations.