CurrentCapital BluecrossPolicy MP 5.008

Positron Emission Mammography (PEM)

This policy governs the medical coverage stance for positron emission mammography (PEM) for Capital Blue Cross members and applies to specified products and programs administered by the plan.

Policy Summary

PayerCapital Bluecross

PolicyPositron Emission Mammography (PEM)

Policy CodePolicy MP 5.008

Change TypeNo material change

Effective Date10/1/2025

Next Review Date

Key ActionDo not bill or seek authorization for PEM using code 78999 because the procedure is investigational and not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MP 5.008Policy identifier

78999Investigational code

10–30 mSvRelative effective dose

75/100kEstimated LAR

Coverage Criteria

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ALL of the following

The use of positron emission mammography (PEM) for any indication is considered investigational (not medically necessary).
Rationale: Evidence does not demonstrate improved diagnostic accuracy or clinical utility compared with available alternatives.
PEM is associated with relatively high radiation exposure (ACR relative effective dose 10–30 mSv) and the ACR states PEM is not indicated for screening due to dose and lack of evidence in large screening populations.
Radiation risk considerations reduce the net benefit compared with lower-dose alternatives (e.g., mammography, MRI or ultrasound where appropriate).
Because of insufficient evidence of improved health outcomes and higher radiation dose, PEM should not be used for breast cancer screening, presurgical evaluation, or evaluation of suspicious lesions outside of a research setting.
Clinical utility not established; use only in approved clinical trials where outcomes are being systematically assessed.

The American College of Radiology (ACR) considers PEM limited by radiation dose and lack of evidence in large screening populations and assigns a relative effective dose of approximately 10–30 mSv to PEM. Because of this radiation burden, the ACR states PEM (and BSGI) in their present form are not indicated for routine breast cancer screening. The ACR also notes limited role for PEM in the evaluation of palpable breast masses.

PEM has not demonstrated improved diagnostic accuracy or clinical utility across relevant indications (screening, presurgical evaluation, and assessment of suspicious lesions). In addition, the relatively high radiation dose associated with PEM compared with alternative imaging modalities does not support its routine clinical use. Therefore, PEM is determined to be investigational and not medically necessary.

Covered Indications / When Considered

inv-22: Screening, diagnostic, or presurgical evaluation for breast lesions — not supported by evidence

Not supported indications — PEM is not covered for the following breast imaging uses because evidence is insufficient and radiation exposure is relatively high:

Screening: PEM has not been shown to be appropriate for breast cancer screening; ACR states PEM is usually not appropriate for average- or high-risk screening and the relatively high radiation dose does not favor its use.

High whole-body/relative effective dose (ACR: 10–30 mSv) and estimated cancer risk cited in policy rationale.

Diagnostic or presurgical evaluation: Evidence is insufficient to demonstrate that PEM provides improved diagnostic accuracy or clinical utility for diagnostic evaluation or presurgical planning of localized breast cancer compared with relevant comparators.

Prospective and retrospective studies cited do not establish clinical benefit; high radiation dose further disfavors use.

inv-23: General diagnostic imaging of breast lesions — references cited but policy deems PEM investigational.

References: Multiple references and guideline documents reviewed (including comparative and diagnostic-performance studies and meta-analyses) but the policy determines PEM remains investigational; specific clinical indications are not supported by the evidence.

See references in policy for study and guideline citations.

Not Covered Services

Positron Emission Mammography (PEM) procedures reported with investigational procedure codes such as 78999 are considered investigational and are not covered by this policy.

Positron Emission Mammography reported using procedure code 78999 is listed in the coding section as investigational and not covered and therefore will not be reimbursed under the plan when billed with that code.

Positron Emission Mammography (PEM) is considered investigational and not covered when reported with the specified unlisted procedure code 78999 as stated in the policy.

Services reported with investigational procedure codes, including 78999 for PEM, may be denied as the policy designates these services investigational and not covered.

Coding

Not Covered / Investigational Procedure CodesCPTNot Covered

78999

Unlisted procedure, radiology - investigational when used for PEM

Radiation Dose

Recommended FDG dose for PEM370 MBq (10 mCi)

Documentation Required

Coding / Documentation Note

Documentation must support that services billed for PEM are not reported using investigational or unlisted procedure code 78999 when the service is considered not covered. Claims lacking adequate documentation to demonstrate medical necessity and appropriate coding are subject to denial or retrospective audit.

Prior Authorization

Product variations / Prior Authorization May Vary

Prior authorization and product-specific coverage/prior authorization requirements may vary by plan. Providers should verify member eligibility and any prior authorization requirements with Capital BlueCross before scheduling or performing PEM to avoid claim denials.

Prior authorization requirements vary by product and benefit plan.
Verify member eligibility and obtain any required authorization prior to service.

Denial Risk

Investigational — Denial Risk

Investigational services, including PEM reported with code 78999, are subject to denial as not covered under this policy. Providers should be aware of denial risk and submit appropriate supporting documentation if seeking exception.

Investigational — denial risk for PEM (code 78999).
Claims may be denied if billed as investigational or lacking documentation of medical necessity.

Billing Rule

Claims Adjudication Note

Claims adjudication: The presence of code 78999 on a claim will prompt review for investigational use of PEM. Coverage decisions are based on member benefit terms and medical necessity documentation. Payment, if any, will be adjudicated in accordance with the member's plan.

Provider Actions and Billing Guidance

Prior Authorization

Check product-specific applicability and manuals

This policy applies only to certain Capital Blue Cross programs and products and is subject to benefit variations; check product-specific guidance (for example, FEP PPO members should be referred to the FEP Medical Policy Manual).

Verify applicability to the member’s product and consult the product-specific manual (e.g., FEP Medical Policy Manual) for coverage rules.

Prior Authorization

Prior authorization does not confer coverage for investigational PEM

Prior authorization does not change the investigational status of PEM; authorization alone does not make investigational services covered.

Even if prior authorization is requested or obtained, PEM reported with investigational code 78999 remains not covered.

Documentation Required

Claims subject to member benefit determination and medical necessity

Claims are adjudicated based on the member’s benefit program, eligibility on the date of service, and medical necessity; final payment depends on the applicable contract terms.

Confirm member eligibility and applicable benefit terms for the date of service; final claim processing follows the member’s contract and benefit limitations.

Denial Risk

Denial risk when using investigational procedure codes

Services reported with investigational procedure codes (for example, 78999 for PEM) are not covered and may be denied.

Avoid submitting claims using investigational codes for PEM to reduce risk of denial.

Denial Risk

78999 for PEM is investigational and likely to be denied

Use of procedure code 78999 to report Positron Emission Mammography (PEM) is considered investigational and therefore not covered; claims submitted with this code may be denied.

Do not submit claims for PEM using CPT 78999 if seeking coverage—this code is listed as investigational for PEM.

Note

Follow product-specific notes (e.g., FEP PPO)

Refer to product-specific notes in the policy (for example, FEP PPO guidance) to determine applicability and any special procedures for authorization or claim handling for the member’s product.

Check the product variations section and the appropriate product manual referenced therein for any special instructions.

Note

Check for additional product-specific provider guidance

Consult the policy’s product variation guidance for any additional provider actions or notifications required by specific member programs administered by Capital Blue Cross.

Contact Provider Services or review the applicable product manual when unsure about product-specific requirements.

Prior Authorization

Verify product-specific prior authorization rules

Policy applicability and prior authorization requirements may vary by product; always check the member’s product manual (e.g., FEP PPO refers to the FEP Medical Policy Manual) before requesting authorization.

Verify whether the member’s product is covered by this policy and follow the referenced product manual for authorization procedures.

Prior Authorization

Investigational PEM not payable despite authorization

Investigational services (PEM reported with code 78999) are not covered regardless of prior authorization; authorization cannot be used to validate coverage for investigational procedures.

Do not rely on prior authorization to make investigational PEM services payable.

Background

Positron Emission Mammography (PEM) is a high-resolution, limited-field dedicated PET technique that uses a small, high-resolution detector system positioned against compressed breasts. PEM images the distribution of positron-emitting radiotracers (commonly fluorine-18 FDG) with detectors mounted on compression paddles, allowing detection of small lesions but delivering substantially higher radiation exposure than standard mammography.

inv-20: PEM definition

DefinitionPositron emission mammography (PEM) is a form of PET that uses a high‑resolution, mini‑camera detector system positioned on compressed breasts to image distribution of positron‑emitting radiotracers (commonly fluorine‑18 FDG).

TechniqueDedicated, small field‑of‑view detectors are mounted on compression paddles to provide higher resolution images than whole‑body PET

Clinical notePEM provides functional rather than anatomic information and can detect lesions as small as 2–3 mm

inv-21: PEM definition / radiotracer details

Dedicated breast PET imagingPEM is dedicated breast PET imaging using radiotracers such as fluorine‑18‑fluorodeoxyglucose (FDG)

Radiotracer administrationFDG (fluorine‑18‑fluorodeoxyglucose) is administered intravenously for PEM studies

ReferencesPolicy references studies and reviews on PEM diagnostic performance and radiation dose (see references list)

Contrast / Radiotracer Rules

Billing Rule

PEM uses IV FDG; recommended dose 370 MBq (10 mCi)

PEM uses fluorine-18 fluorodeoxyglucose (FDG) administered intravenously; the label-recommended FDG dose cited in the policy is 370 MBq (10 mCi).

Administer FDG intravenously for PEM.
Use the label-recommended FDG dose of 370 MBq (10 mCi) as cited.

Billing Rule

No contrast-specific imaging rules provided

The policy does not provide any additional contrast-specific imaging rules for PEM in this document portion.

No contrast-specific imaging guidance for PEM is included in this policy document section.

Definitions

inv-20: PEM definition

Concise definitionPositron emission mammography (PEM) is a high‑resolution, small field‑of‑view PET technique using detectors mounted on compression paddles to image positron‑emitting radiotracers in the breast.

PurposeDesigned to detect and characterize breast lesions with higher spatial resolution than whole‑body PET

Imaging typeFunctional imaging using PET radiotracers (commonly 18F‑FDG)

inv-21: PEM — dedicated breast PET imaging

Radiotracer exampleFluorine‑18‑fluorodeoxyglucose (18F‑FDG)

Administration routeIntravenous injection of FDG prior to imaging

Dose referenceLabel‑recommended FDG dose cited as 370 MBq (10 mCi)

Revision History

09/16/2020policy_review

Consensus review conducted; coding reviewed with no changes to the policy statement noted in the policy history.

10/01/2025effective_dateLatest

Policy effective date updated to 10/01/2025 as listed in policy metadata.

Policy Summary

PayerCapital Bluecross

PolicyPositron Emission Mammography (PEM)

Policy CodePolicy MP 5.008

Change TypeNo material change

Effective Date10/1/2025

Next Review Date

Key ActionDo not bill or seek authorization for PEM using code 78999 because the procedure is investigational and not covered.

SourceLink

On This Page

OpenPayer

Positron Emission Mammography (PEM)

Coverage Criteria

Covered Indications / When Considered

Not Covered Services

Coding

Provider Actions and Billing Guidance

Prior Authorization

Background

Contrast / Radiotracer Rules

Frequency Limits

Definitions

Revision History