Prior Authorization / Code Applicability

Verify member benefits and obtain prior authorization as required by the member's contract before scheduling PET/PET‑CT. Coverage and precertification rules vary by plan; contact Blue Cross and Blue Shield of Kansas Customer Service to confirm eligibility and any specific prior authorization requirements.

• Affected codes include PET imaging CPT codes (e.g., 78811-78816, 78608-78609), PET radiopharmaceutical HCPCS (A9552, A9597, A9598), and G0235. Prior authorization may be required for these services per the member's plan.

Medical Necessity Tied to Policy

FDG‑PET or FDG‑PET/CT procedures are covered only when performed in accordance with the Policy section criteria for bone sarcoma and soft tissue sarcoma (e.g., staging/restaging for Ewing sarcoma and osteosarcoma; evaluation of response to TKI in GIST). Procedures performed for indications that do not meet the policy medical‑necessity criteria may be denied.

• Medical necessity for listed PET CPT/HCPCS codes is contingent on meeting the specific clinical criteria in the Policy section.
• Requests for PET for surveillance of bone or soft tissue sarcoma (asymptomatic follow-up) are not supported by the evidence and may be denied (see policy guidance).

Coding and Medical Necessity Documentation

Document the clinical rationale clearly in the request and medical record. Include the indication (diagnosis and clinical application), sarcoma type (e.g., Ewing sarcoma, osteosarcoma, GIST), relevant signs/symptoms, prior treatments, and how the PET result will affect management. For billing, document the performed procedure, diagnosis code(s), and radiopharmaceutical HCPCS code.

• Include sarcoma subtype, purpose of imaging (staging, restaging, response assessment), and prior imaging/treatment history in documentation.
• Record the exact CPT/HCPCS procedure code (e.g., 78812, 78815), radiopharmaceutical code (e.g., A9552), and ICD‑10 diagnosis codes on the claim.
• Indicate if the PET is being used to assess early response to TKI therapy (e.g., imatinib) for GIST, and provide timing relative to therapy (baseline, 2–4 weeks after initiation when applicable per NCCN).

Use in Therapy Response Assessment

Use FDG‑PET/CT for therapy response assessment when supported by the policy and guidelines — for example, early assessment of response to tyrosine kinase inhibitor (TKI) therapy in gastrointestinal stromal tumors (GIST). Obtain a baseline PET/CT if PET will be used for follow‑up assessment.

• NCCN guidance: FDG‑PET/CT may indicate TKI activity after 2–4 weeks of therapy; a baseline FDG‑PET/CT is recommended if using PET during follow‑up for unresectable, recurrent, or metastatic GIST.
• Clearly state in documentation that PET is for response assessment to TKI (or other specified therapy) and provide dates of therapy initiation and prior imaging.

Denial Triggers and Experimental/Investigational Indications

Requests for indications considered experimental/investigational by this policy (e.g., staging of chondrosarcoma; many soft tissue sarcoma diagnostic applications) are at high risk for denial. Surveillance imaging in asymptomatic patients is generally not supported and may be denied.

• Experimental/investigational examples: PET for staging chondrosarcoma; PET for distinguishing benign versus malignant soft tissue lesions, grading soft tissue sarcoma, detecting locoregional recurrence or distant metastasis for soft tissue sarcomas.
• Surveillance: PET for routine asymptomatic surveillance after treatment for bone or soft tissue sarcoma is not supported by the evidence and may be denied.

Verify benefits and prior authorization with BCBSKS

Verify member benefits and any applicable prior authorization requirements with Blue Cross and Blue Shield of Kansas before scheduling PET or PET/CT; member contract language and state/federal mandates take precedence.

Obtain prior authorization for PET/CT when indication is outside supported uses

When a PET/CT is requested for surveillance or other uses outside the policy’s supported indications, ensure prior authorization is obtained because PET/CT is required in those circumstances per payer rules.

Ensure procedure meets policy criteria and member contract for coverage

Coverage for PET and PET/CT requires that the requested procedure meet the policy’s medical necessity criteria and the member’s contract benefits; prior authorization may apply per payer rules.