PET Scanning- Oncologic Applications (Lung)
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Coverage and clinical-policy framework for use of 18F-FDG PET and FDG-PET/CT in diagnosis, staging, restaging, and surveillance of lung cancer for Blue Cross and Blue Shield of Kansas members.
Oncologic Applications for Lung has been split out into a separate medical policy, Positron Emission Tomography (PET) Scanning: Oncologic Applications (Lung).
Policy language updated to specify FDG-PET or FDG-PET/CT terminology replacing generic 'PET' in key policy statements.
Clarified definitions for Diagnosis, Staging, Restaging, and Surveillance within the policy guidelines.
Language suggesting PET be considered only after other imaging techniques or as a retrospective review was removed.
Coverage Criteria
Medically Necessary Indications
FDG-PET or FDG-PET/CT may be considered medically necessary when any of the following apply:
Source: policy statements (A. Lung Cancer, items 1-2).
Experimental / Investigational
FDG-PET or FDG-PET/CT is considered experimental / investigational for:
Source: policy statements (A. Lung Cancer, item 3).
Covered Indications
Covered when indications align with guideline-supported uses:
Supported by ACR and NCCN guidance (ACR 2019/2025; NCCN v.8.2025 for NSCLC, v.2.2026 for SCLC).
Meta-analyses and clinical guidance support use in this scenario.
ACR and NCCN cite PET/CT as usually appropriate for posttreatment evaluation when recurrence is suspected; biopsy confirmation advised because FDG avidity may persist up to 2 years after radiation.
Guideline-supported though evidence quality is low.
Not Medically Necessary / Not Covered
Not covered / not supported by evidence:
SUPE_R randomized trial (n=750) and section summaries for NSCLC and SCLC indicate lack of benefit for routine surveillance.
Small Cell Lung Cancer
Covered when criteria below are met for oncologic application:
Systematic reviews, meta-analyses, and guideline statements support use for these indications though study quality is low.
Policy section summary and national coverage entries indicate surveillance for SCLC is not supported.
National Coverage Summary
National FDG PET coverage summary indicates:
See national coverage table entries within the policy document.
FDG-PET and FDG-PET/CT have a defined role in staging small-cell lung cancer (SCLC) when the clinical or standard imaging assessment suggests limited-stage disease and results will influence curative-intent management. Conversely, when extensive-stage SCLC is already established by other imaging or clinical evaluation, FDG-PET/FDG-PET/CT is considered experimental/investigational for additional staging because it is unlikely to change overall management; in that situation, MRI or contrast-enhanced CT are preferred for further assessment. These distinctions reflect guideline-supported uses for clarifying stage when limited disease is suspected and the lower-quality evidence for additional PET utility once extensive disease is known.
Routine use of FDG-PET or FDG-PET/CT for surveillance after completion of definitive therapy in asymptomatic patients with non–small-cell lung cancer (NSCLC) is not supported. A large randomized trial (SUPE_R, n=750) comparing scheduled PET/CT surveillance to contrast-enhanced CT found that PET/CT detected more suspected recurrences but did not improve time to recurrence, rates of curative-intent treatment, recurrence-free survival, or overall survival and resulted in more invasive diagnostic procedures. Therefore, PET/CT is recommended for evaluation when there is specific clinical or imaging suspicion of recurrence rather than as routine surveillance.
Current evidence does not support the use of FDG-PET or FDG-PET/CT for routine surveillance of small-cell lung cancer (SCLC). Systematic reviews and meta-analyses indicate PET/CT may be useful for diagnosis, staging, and restaging of SCLC, but the evidence does not demonstrate benefit for surveillance imaging in asymptomatic patients.
FDG-PET or FDG-PET/CT is considered experimental/investigational for staging of SCLC when extensive-stage disease is already established and for other aspects of SCLC management that are not described as medically necessary in this policy. In established extensive-stage SCLC, additional PET imaging is unlikely to alter treatment decisions, and alternative imaging modalities (MRI or contrast-enhanced CT) are preferred for further evaluation.
Evidence from randomized and meta-analytic studies indicates that routine surveillance PET/CT for NSCLC does not improve meaningful clinical outcomes. In the SUPE_R randomized trial (n=750), PET/CT surveillance detected more suspected recurrences but did not increase the proportion of recurrences treated with curative intent (48% in both arms), nor did it improve time to recurrence or overall survival, and it led to a higher rate of invasive diagnostic procedures. Meta-analyses and guideline summaries similarly conclude that PET/CT is useful for diagnosis, staging, and for evaluation when recurrence is suspected, but not for asymptomatic routine surveillance.
Based on current systematic reviews and meta-analyses, routine surveillance FDG-PET or FDG-PET/CT for small-cell lung cancer (SCLC) is considered not medically necessary. Although PET/CT may aid in staging and restaging—particularly when limited-stage disease is suspected—the available evidence does not support its use for routine monitoring in asymptomatic patients.
Covered Indications (Diagnosis, Staging, Restaging)
FDG-PET or FDG-PET/CT for lung cancer diagnosis, staging, restaging
Definitions and policy statements (Policy Guidelines and A. Lung Cancer).
Appropriate use recommendations
ACR 2019/2025 and NCCN guidance (NSCLC).
ACR 2025 surveillance criteria and NCCN SCLC guidance; biopsy confirmation required if PET suggests recurrence within previously irradiated areas.
Lung cancer (SCLC and NSCLC) — diagnosis, staging, restaging
Policy summaries and coding/definitions (Section summaries; Coding revisions).
Not Covered / Not Medically Necessary
Staging with FDG-PET or FDG-PET/CT is not covered when extensive-stage SCLC has already been established and when additional PET imaging would not alter other aspects of management. In such cases PET/CT is considered experimental/investigational and alternative imaging modalities (MRI or contrast CT) are preferred for further assessment.
Routine PET/CT as surveillance imaging after definitive therapy for NSCLC or SCLC in asymptomatic patients without specific clinical or imaging suspicion is not covered. High-quality evidence, including a large randomized trial, found no survival or curative-treatment benefit from scheduled PET/CT surveillance and documented increased downstream invasive procedures.
FDG-PET and FDG-PET/CT for routine surveillance of small-cell lung cancer in asymptomatic patients are not supported by the evidence and are therefore not covered. While PET/CT may be appropriate for diagnosis, staging, or restaging when clinical suspicion exists, its routine use for surveillance lacks demonstrated benefit.
Coding and Billing
| 18F-FDG | Fluorine 18 fluorodeoxyglucose radiotracer (regulatory status; common oncologic tracer) |
| 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 for attenuation correction and anatomical localization; limited area (e.g. chest, head/neck). |
| 78815 | Tumor imaging, PET with concurrently acquired CT for attenuation correction and anatomical localization; skull base to mid-thigh. |
| 78816 | Tumor imaging, PET with concurrently acquired CT for attenuation correction and anatomical localization; whole body. |
| A9552 | Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries. |
| A9597 | Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified. |
Provider Actions and Authorization
Verify benefits / Prior Authorization
Verify member benefits and prior authorization requirements with BCBSKS before ordering PET/CT. Member contract language and state or federal mandates take precedence over this policy and may affect coverage.
- Verify benefits with Blue Cross and Blue Shield of Kansas Customer Service.
- Coverage is subject to state/federal mandates and member contract language.
Prior Authorization for Surveillance PET/CT
Prior authorization is recommended for routine surveillance or repeated PET/CT studies performed without documented clinical suspicion of recurrence. Routine surveillance PET/CT for NSCLC/SCLC is not supported by the evidence and may be denied.
- Routine surveillance PET/CT (asymptomatic patients ≥6 months after treatment for solid tumors; ≥12 months for lymphoma) is not supported and may be denied.
- Prior authorization recommended when PET/CT is requested for surveillance or repeated studies without documented clinical indication.
Biopsy Confirmation After PET/CT–Detected Recurrence
If PET/CT detects suspected recurrent disease, obtain tissue (biopsy) confirmation prior to initiating additional definitive treatment because FDG avidity can persist after radiation and other therapies.
- Biopsy confirmation required before starting additional treatment based on PET/CT-detected recurrence.
- FDG may remain avid in treated areas for up to 2 years; correlate clinically and pathologically.
Coding Informational Note
The CPT/HCPCS and radiopharmaceutical codes listed in this policy are provided for informational purposes only. Inclusion of a code does not guarantee coverage or reimbursement; services are medically necessary only if performed in accordance with the policy statements and the member's contract.
- Codes are informational and may not be comprehensive.
- Code(s) listed are medically necessary ONLY if the procedure is performed according to the Policy section.
Step Therapy Note
Previous guidance suggesting PET/CT be used only after other imaging modalities has been removed. This policy does not impose a step-therapy sequence requiring CT/MRI prior to PET/CT in all cases; however, clinical documentation should justify the selected imaging modality. Use CT for routine surveillance when supported by evidence and guidelines.
- Removed language that mandated PET only after other modalities.
- Clinical documentation should support the chosen imaging strategy (eg, when CT is preferred for routine surveillance).
Definitions
Contrast and Modality Rules
PET tracer and radiation considerations
PET commonly uses the 18F-FDG tracer and PET/CT combines metabolic and anatomic data; radiation exposure from PET and PET/CT is considered moderate to high and should be considered when ordering imaging.
- 18F-FDG is the most common tracer for oncologic PET imaging.
- PET/CT provides combined metabolic and anatomic information but involves moderate-to-high radiation exposure.
MRI preferred for brain metastasis detection
PET is not recommended for detection of brain metastases from lung cancers; MRI is the preferred imaging modality for brain metastasis evaluation.
- NCCN notes PET is not recommended for detection of brain metastasis from lung cancers; use MRI for brain imaging.
- Meta-analysis comparing MRI and FDG-PET for brain metastases supports MRI preference.
Prefer MRI or contrast CT when extensive-stage SCLC is established
If extensive-stage small-cell lung cancer is already established, MRI or contrast-enhanced CT is preferred for further staging evaluation rather than PET/CT.
- Guidelines support PET/CT when limited-stage SCLC is suspected, but prefer MRI or contrast CT if extensive-stage disease is established.
- Use alternative imaging modalities for staging when extensive-stage SCLC is present.
Prior Authorization
Verify benefits and prior authorization with BCBSKS
Verify member benefits and prior authorization requirements with BCBSKS before ordering PET or PET/CT; member contract language takes precedence for coverage determinations.
- Prior authorization requirements are determined by the member's contract and payer rules.
- Contact BCBSKS Customer Service to confirm coverage and any required authorizations.
Prior authorization recommended for surveillance PET/CT
Prior authorization is recommended for PET/CT when used for routine surveillance or for repeated studies without documented clinical suspicion, per policy guidance.
- PET/CT is appropriate for initial staging and suspected recurrence but prior authorization may be needed for surveillance uses.
- Document clinical suspicion to support medical necessity for surveillance imaging.
Use listed codes in prior authorization workflows as applicable
The codes provided in the policy (procedure and radiopharmaceutical codes) may be used in authorization workflows per payer rules; confirm code use with BCBSKS during authorization.
Background
Positron emission tomography (PET) is a nuclear medicine imaging technique that uses positron-emitting radiotracers—most commonly 18F‑FDG (fluorine 18 fluorodeoxyglucose)—to image tissue metabolic activity. PET provides functional information about glucose metabolism and, when combined with CT as FDG-PET/CT, pairs metabolic data with anatomic localization. Depending on the clinical question, PET can help distinguish benign from malignant lesions, detect regional nodal disease and distant metastases, and aid in staging, restaging, and treatment planning. Radiation exposure is moderate to high and tracer selection varies by tumor type and indication.
Revision History
Policy language updated to specify FDG-PET or FDG-PET/CT replacing generic 'PET' in key policy statements and added A1: FDG-PET or FDG-PET/CT; A1 PET wording removed; A1a removed; A2/A3 changed from PET to FDG-PET or FDG-PET/CT.
Oncologic Applications for Lung was split out from a broader Positron Emission Tomography (PET) Scanning: Oncologic Applications medical policy into a separate lung-specific policy.
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