Kaiser Permanente PET/PET‑CT Coverage Update

Coverage Criteria and Evidence-Based Indications

Solitary pulmonary nodule (SPN)

Covered when ALL of the following are met for solitary pulmonary nodule:

SPN initial indication: 1) Newly discovered solitary pulmonary nodule in the absence of known malignancy; AND 2) A concurrent thoracic CT has been performed; AND 3) A single indeterminate or possibly malignant lesion more than 0.8 cm in diameter has been detected; AND 4) Not recommended for ground-glass opacities/nodules; AND 5) Purpose of scan is to determine likelihood of malignancy to plan management> 0.8 cm

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General oncologic indications

Covered for confirmed oncologic diagnoses when standard staging/restaging studies are inconclusive and further characterization will affect management:

General oncologic PET necessity: PET may be medically necessary when a biopsy-proven or confirmed oncologic diagnosis exists AND standard staging/restaging diagnostic and imaging studies are inconclusive AND further characterization is required to make management decisions; AND the expected change in clinical management is documented in the clinical recordn/a

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Breast cancer

Breast cancer specific rules:

Breast cancer PET indications: PET may be indicated to assess for distant metastatic disease when: 1) Stage III or IV disease; OR 2) conventional imaging is equivocal; OR 3) a tumor-board rationale is provided for other cases; PET is NOT covered for initial diagnosis, axillary lymph node staging, routine surveillance, or routine monitoring of treatment responsen/a

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Cervical / Uterine cancer

Cervical and uterine cancer rules (effective Dec 1, 2025 noted):

Locally advanced cervical cancer PET: FDG PET/CT is reasonable for detection of metastases during pre-treatment staging in newly diagnosed locally advanced cervical cancer when no extra-pelvic metastasis is seen on conventional imaging (CT or MRI) to assist non-invasive detection of para-aortic or pelvic nodal involvementn/a

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Uterine/cervical PET criteria: Initial staging: PET/CT is not routine for stage IA but may be considered if conventional imaging is inconclusive; for stage IB1 and above, PET/CT of neck/chest/abdomen/pelvis/groin is considered when needed for treatment planning; Post-treatment: PET/CT may be considered 3-6 months after completion of treatment in specified higher-risk situations; Surveillance: PET/CT may be considered for confirmed or suspected stage IVB disease after conventional imaging when results would change management; Send cases to MD for review effective December 1, 2025n/a

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Colorectal cancer

Colorectal cancer rules:

Colon cancer PET indications: Initial staging: PET is not routinely indicated and should not supplant contrast-enhanced CT; PET may be indicated for metastatic colorectal adenocarcinoma when disease is potentially surgically curable;n/a

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Colorectal restaging/recurrence: Restaging: PET may be indicated when postoperative CEA or liver function tests remain elevated and other imaging is negative, or to evaluate a potentially resectable metastatic lesion to confirm extent prior to therapy; PET findings have been shown to influence surgical decision-making in some studiesn/a

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Lung cancer (NSCLC/SCLC)

Lung cancer rules:

Non-small cell lung cancer PET indications: Initial staging indicated for stages I-III A or B when active treatment is planned and PET results will alter management; PET may be used for radiation planning in patients with significant atelectasis or when IV contrast is contraindicated; PET has limitations including false positives from infection/inflammation and false negatives for small or low-activity lesions; serial PET scans are not recommended to follow response to therapyn/a

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Small cell lung cancer PET indications: Initial staging for small cell lung cancer may be considered as clinically indicated per standard staging protocolsn/a

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Lymphoma (Hodgkin and Non-Hodgkin)

Lymphoma rules:

Hodgkin lymphoma PET indications: Initial staging PET is essential during initial work-up; interim PET after 2-4 cycles has prognostic value if a change in treatment is anticipated; restaging after completion of therapy is indicated to assess response and characterize residual mass; surveillance is not recommendedn/a

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Non-Hodgkin lymphoma PET indications: For stage III and IV disease PET is indicated unless management would not change; diffuse large B-cell lymphoma: initial staging is essential and restaging at completion of treatment is indicated with minimum wait periods as specified; interim restaging is controversial and should be done only if a planned change in management is documentedn/a

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Head and neck cancers / Occult primary

Head & neck and occult primary:

Head and neck cancer PET indications: Staging indicated for stage III-IV disease of oral/oropharynx, glottic/supraglottic larynx, hypopharynx, ethmoid and select sinonasal sites; nasopharyngeal cancer may be appropriate for PET for stage II if node positive; restaging post-treatment only for stage III-IV (minimum 12 weeks after radiation); PET for unknown primary is not routinely recommended and requires clear documentation of clinical reason and prior negative evaluation (flexible fiberoptic laryngoscopy and CT of the neck/cavity)n/a

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Thyroid, multiple myeloma, and other cancers

Thyroid and other cancers:

Thyroid cancer PET indications: PET/CT for localization is indicated in papillary/follicular thyroid carcinoma previously treated with thyroidectomy and radioiodine ablation when thyroglobulin is > 10 (stimulated or on suppression) AND structural imaging (ultrasound/CT) is negative; also for aggressive histologies or progressive metastatic disease despite prior treatmentTG > 10

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Multiple myeloma and plasmacytoma: Whole-body low-dose CT is preferred for initial workup of suspected multiple myeloma or solitary plasmacytoma; FDG PET/CT is reserved when whole-body low-dose CT or MRI is non-diagnostic and low-dose CT is preferred for follow-upn/a

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Gastroenteropancreatic neuroendocrine tumors (GEP-NET)

Neuroendocrine tumor PET guidance:

GEP-NET PET indications: Kaiser Permanente endorses somatostatin receptor (SSR) PET imaging recommendations for gastroenteropancreatic neuroendocrine tumors (GEP-NET); Lutathera criteria apply separatelyn/a

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Conditional coverage for Beta Amyloid PET

Selected conditional coverage statement for beta-amyloid PET:

Beta amyloid PET coverage: Covered when ALL of the following are met: 1) Patient is a candidate for monoclonal antibody therapy for Alzheimer’s disease; AND 2) Lumbar puncture (CSF testing) has been indeterminate OR lumbar puncture is contraindicated; contraindications include increased bleeding risk, inability to stop anticoagulation/antiplatelet therapy, substantial risk of spinal canal infection, congenital abnormalities increasing lumbar puncture risk, prior CSF leak, or prior failed lumbar puncture

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FDG PET not established for routine AD diagnosis

MTAC evidence conclusion for FDG PET in Alzheimer's disease/dementia:

FDG PET for AD/dementia: The use of FDG PET in the evaluation of Alzheimer’s disease or dementia does not meet Kaiser Permanente Medical Technology Assessment criteria due to insufficient evidence that adding FDG PET to standard clinical evaluation improves diagnostic accuracy or patient outcomes

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Breast cancer PET — limited / conditional

PET for breast cancer — evidence summary and limitations:

Breast cancer PET uses: FDG PET has potential roles in diagnosis, axillary staging, restaging, and monitoring chemotherapy response, but available studies show variable sensitivity and specificity and did not meet Kaiser Permanente MTAC diagnostic test evaluation criteria for routine use; evidence quality and methodology are limited

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Breast cancer — not supported

Summary assessment — breast cancer:

breast_pet_assessment: FDG PET for diagnosis, staging and restaging of breast cancer did not pass the Kaiser Permanente Medical Technology Assessment Diagnostic Test Evaluation Criteria

evidence search of 120 articles; limited supporting studies and methodological concerns (chunk 36)

Cervical cancer — not supported

Summary assessment — cervical cancer:

cervical_pet_assessment: The use of FDG-PET in the diagnosis or management of cervical cancer does not meet Kaiser Permanente MTAC criteria due to insufficient evidence of therapeutic impact and lack of comparative outcome data; however PET/CT may be reasonable for pre-treatment staging in newly diagnosed locally advanced disease when conventional imaging is negative

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Colorectal cancer — mixed support

Colorectal cancer — mixed support:

colorectal_pet_primary: FDG PET evidence supporting primary staging/diagnosis of colorectal cancer in the absence of CT testing is weak and does not meet criteria; PET should not supplant contrast-enhanced CT for initial staging

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colorectal_pet_recurrence: There is evidence supporting accuracy of FDG PET for identifying colorectal cancer recurrence and metastases and PET findings have influenced surgical decision-making in some studies, though impact on long-term outcomes is not established

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Esophageal cancer — restricted use

Esophageal cancer — restricted use:

esophagus_not_firstline: FDG PET is not appropriate as a first-line diagnostic procedure for esophageal cancer and cannot accurately determine local invasion; positive PET findings should be verified histologically or radiologically before declaring unresectable disease

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esophagus_restaging: Limited evidence for PET in restaging symptomatic recurrent esophageal cancer; increased sensitivity may be offset by false positives from inflammation and benefits on outcomes are unproven

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Head and neck cancer — mixed evidence

Head and neck cancer — mixed evidence:

hnc_staging: Prospective studies (>50 patients) showed FDG PET may have superior sensitivity and specificity versus conventional imaging for lymph node staging in some settings, supporting use for initial staging in select patients; however variation across studies and limited data on management impact limit conclusions

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hnc_restaging: Evidence for PET in detecting recurrence is mixed with methodological limitations and specificity concerns post-treatment due to inflammation/scar; restaging should be reserved for appropriate clinical scenarios

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FES-PET — experimental/insufficient

FES-PET (18F-fluoro-estradiol) — experimental / insufficient evidence:

fes_pet_insufficient: Evidence is insufficient to support the use of FES-PET to assess estrogen receptor expression in advanced breast cancer due to very limited small studies and imperfect gold-standard comparisons; FES-PET does not meet Kaiser Permanente MTAC criteria

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Head & Neck Cancer

Head & Neck Cancer — evidence summary:

Head & neck PET evidence: Two prospective studies with sample sizes >50 showed FDG PET had superior sensitivity and specificity versus other modalities, but variation in predictive values and lack of data on management impact limit conclusions; overall use failed criterion 4 for diagnostic efficacy

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Melanoma

Melanoma (staging and restaging) evidence summary:

Melanoma PET evidence: Evidence is inconclusive for FDG PET for primary/regional disease and nodal basins; PET can detect distant metastases but sensitivity and specificity vary across studies and PET is not covered for regional lymph node evaluation

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C-11 Acetate for Prostate Cancer

C-11 Acetate for Prostate Cancer — assessment:

C-11 acetate PET: There is insufficient evidence to determine the diagnostic or monitoring ability of C-11 acetate PET for prostate cancer; available studies are small and limited and the tracer is limited by a short half-life requiring onsite cyclotron production

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Refractory Seizures Pre-Surgical Evaluation

Refractory seizures — presurgical evaluation:

FDG PET for epilepsy: FDG PET may be useful for presurgical localization in refractory seizures, but studies are small and methodologically limited and FDG PET failed criterion 2 of diagnostic modality evidence criteria; invasive recordings remain the most accurate localization method

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Bone Metastases

Bone metastases imaging:

18F-NaF and FDG PET for bone mets: 18F-NaF PET may be more sensitive with similar specificity compared to bone scintigraphy and 18F-FDG PET for detecting bone metastases, but published studies are small, heterogeneous, and often retrospective; overall 18F-FDG PET/CT does not meet Kaiser Permanente MTAC criteria for bone metastases

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Axumin (Fluciclovine)

Axumin (18F-fluciclovine) for recurrent prostate cancer:

Fluciclovine PET evidence: Low-quality evidence demonstrates high diagnostic performance of fluciclovine PET compared to standard imaging and other tracers in suspected prostate cancer recurrence and shows clinical utility in defining target volumes and changing management plans; however, MTAC concluded Axumin did not meet Kaiser Permanente MTAC criteria at the time of review

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Amyvid (Florbetapir) Background

Amyvid (18F-florbetapir) background and assessment:

Amyvid background: Amyvid (18F-florbetapir) is an FDA‑approved PET tracer that images beta‑amyloid pathology in patients evaluated for Alzheimer disease, but MTAC reviews found insufficient evidence that amyloid PET improves patient outcomes and a positive scan does not establish a diagnosis of AD

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High-level evidence conclusions / coverage stance

High-level evidence conclusions and coverage stance:

Axumin (fluciclovine) PET: Use of Axumin Injection for PET scan was reviewed and initially judged not to meet Kaiser Permanente MTAC criteria, although subsequent MPC actions adopted specific coverage criteria for Axumin PET in 2019 as noted elsewhere

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Florbetapir (Amyvid) PET for Alzheimer’s: MTAC concluded there was insufficient evidence at the time to determine that florbetapir-PET improves net health outcomes; FDA approval noted but a positive scan does not establish a diagnosis of AD

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Positron Emission Mammography (PEM): Positron Emission Mammography was reviewed and did not meet MTAC criteria and its criteria were archived and merged into the PET policy

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This policy defines PET/PET‑CT coverage for oncologic indications and selected non‑oncologic uses. For patients with a confirmed (typically biopsy‑proven) malignancy, PET may be medically necessary when standard staging/restaging studies are inconclusive and when the study is expected to change clinical management; the expected management change must be documented in the clinical record. Specific covered oncologic uses include staging, restaging, treatment response assessment and selected radiation planning situations (site‑ and stage‑dependent). Routine surveillance and serial PET for therapy monitoring are generally not recommended except where explicitly stated for particular cancer types (see cancer‑specific sections).

For Alzheimer disease and other dementias, beta‑amyloid PET (e.g., florbetapir/Amyvid) and related amyloid imaging are addressed separately: the policy now includes conditional coverage criteria for beta‑amyloid PET when the patient is a candidate for monoclonal antibody therapy and a lumbar puncture is indeterminate or contraindicated. By contrast, routine use of FDG PET for Alzheimer’s disease or dementia is not supported

Several primary‑diagnosis or first‑line uses of FDG PET (and some tracer‑specific PETs such as FES‑PET for ER expression) were evaluated and found not to meet MTAC criteria. Examples of unsupported primary or routine diagnostic uses include initial diagnosis or primary staging for breast cancer (including axillary staging), primary staging for cervical cancer, colorectal cancer as a replacement for CT, first‑line esophageal cancer staging, and FES‑PET to determine ER status. These indications are generally not covered unless clear justification and prior authorization documentation demonstrate why conventional imaging/biopsy cannot provide the needed information.

FDG PET is explicitly not covered for regional lymph node evaluation in melanoma. While PET can detect distant metastatic disease in melanoma, evidence does not support reliable assessment of regional nodal basins and sentinel node biopsy remains the standard for regional node evaluation.

Positron Emission Mammography (PEM) was previously reviewed by MTAC and the technology did not meet assessment criteria. The MPC approved archival of the separate PEM criteria and merged those criteria into the PET policy. Medicare‑related guidance and specific HCPCS/CPT codes (for example, Medicare examples G0252/G0219/G0235) are noted in the policy as Medicare‑considered not covered for certain breast and melanoma indications; providers should follow applicable Medicare LCD/NCD guidance when billing.

Routine surveillance PET is generally not recommended across multiple cancer types because of false positives from inflammation/infection and limited evidence that routine serial PET improves clinical outcomes. Surveillance PET after treatment is allowed only in specified situations where results would alter management and when documented justification is provided.

Specifically for Alzheimer’s disease, routine FDG PET is not supported. MTAC reviews concluded available studies did not demonstrate sufficient diagnostic or prognostic value to justify adding FDG PET to standard clinical evaluation for AD/dementia; amyloid PET tracers were reviewed separately with different, conditional coverage rules.

FDG PET is not supported for many examples of initial diagnosis or primary staging across tumor types. Representative unsupported examples include initial breast cancer diagnosis and axillary staging, FDG‑PET as a primary diagnostic/staging test for cervical cancer, FDG PET in place of contrast‑enhanced CT for primary colorectal staging, first‑line esophageal cancer staging, and use of FES‑PET as a routine test for ER status assessment in advanced breast cancer.

MTAC evidence reviews for Axumin (18F‑fluciclovine) concluded that low‑quality evidence demonstrates improved detection of recurrent prostate cancer compared with standard imaging and that Axumin PET can influence management (selection of salvage therapy, radiation planning, or systemic therapy). However, at the time of the MTAC review the use of Axumin was judged not to meet Kaiser Permanente MTAC criteria; subsequent MPC actions adopted coverage criteria for Axumin PET in defined indications in 2019 (see change log).

MTAC conclusions summarized in the document: Axumin PET was reviewed with low‑quality evidence showing diagnostic performance but initially judged not to meet MTAC criteria until later MPC coverage actions; Amyvid (18F‑florbetapir) PET for amyloid was reviewed and MTAC concluded evidence was insufficient to demonstrate improved net health outcomes for routine AD diagnosis; Positron Emission Mammography was reviewed and did not meet MTAC criteria and was later archived and merged into the PET policy.

Specific Covered Indications

Procedure and Radiopharmaceutical Codes

Referenced procedure codesCPT

CPT codes not listed in this extract

Document mentions low-dose whole-body CT often submitted as CPT 76497 but full code lists not provided in this window.

Radiotracers mentionedmixed

18F-florbetapir (Amyvid)	Radiotracer referenced for PET in Alzheimer’s disease
18F-NaF	PET tracer for detection of bone metastases
18F Fluoro-Estradiol (FES-PET)	PET tracer to measure estrogen receptor expression in breast cancer
C-11 Acetate	PET tracer for diagnosing primary and metastatic prostate cancer
Fluorodopa F-18	PET tracer for Parkinsonian syndromes

Considered Medically Necessary CPT/HCPCS codes when criteria metmixedCovered

78811	Positron emission tomography (PET) imaging; limited area (eg, chest/head/neck)
78812	Positron emission tomography (PET) imaging; skull base to mid-thigh
78813	Positron emission tomography (PET) imaging; whole body
78814	Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation
78815	Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation
78816	Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; whole body
78608	Brain imaging, PET; metabolic evaluation
78609	Brain imaging, PET; perfusion evaluation
78429	Myocardial imaging, PET, metabolic evaluation study (including ventricular wall motion(s) and/or ejection fraction(s), when performed)
78459	Myocardial imaging, PET, metabolic evaluation study single study

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Medicare Considered not coveredHCPCS | CPTNot Covered

G0235	Not otherwise specified (Medicare considered not covered example)
G0252	PET imaging, full and partial-ring PET scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer — Medicare considered not covered
G0219	PET imaging whole body; melanoma — Medicare considered not covered indications

SPN size threshold

SPN size threshold> 0.8 cm (single indeterminate or possibly malignant lesion on CT)

Concurrent imaging requirementConcurrent thoracic CT must be performed

Ground-glass nodulesNot recommended for ground-glass opacities/nodules

Prior Authorization, Documentation, and Operational Steps

Note
Use of the Clinical Review Criteria
Use of the Clinical Review Criteria does not guarantee coverage. These criteria are intended to assist in administering plan benefits and do not replace the member's Evidence of Coverage. Kaiser Permanente reserves the right to modify or suspend these criteria at any time.

Prior Authorization
MD review / case-by-case prior review
All prior authorization requests for PET and related advanced imaging where the indication or interval is unclear must be sent to a Kaiser Permanente MD for case-by-case review. This includes requests outside stated indications or for novel radiopharmaceuticals.
Send full clinical rationale and tumor-board documentation when available.

Prior Authorization
Medical Director review for short-interval repeats

Prior Authorization Rules and Exceptions

Prior Authorization
PET/CT MD review effective Dec 1, 2025 for select categories
Effective Dec 1, 2025, certain PET/CT categories (for example uterine/cervical cancer cases) require Medical Director review and case‑by‑case assessment prior to authorization.
MD review is required for specified PET/CT categories starting Dec 1, 2025.

Prior Authorization
Medical Director review for short‑interval repeats or incomplete documentation
Requests for PET studies more frequently than specified or with incomplete documentation (for example repeat short‑interval studies) require Medical Director review prior to authorization.
Short‑interval repeats or incomplete documentation will prompt Medical Director review.

Prior Authorization
Prior authorization required for unsupported primary diagnosis/staging PET or FES‑PET
Requests for PET or FES‑PET for primary diagnosis or staging indications that are unsupported by the policy require prior authorization with documentation of clinical rationale and prior imaging/biopsy attempts.

Imaging Frequency and Repetition Rules

PET frequency limit for cardiac sarcoidosis perfusion PET

Cardiac sarcoidosis perfusion PET frequencyNot more frequent than every 3 months without Medical Director review

Radiotracers referenced for perfusionAmmonia N-13 or Rubidium-82 for myocardial perfusion PET

Prior authorization for short-interval repeatsRequests within shorter intervals require Kaiser Permanente Medical Director review

Frequency limit (placeholder)

Frequency policy placeholderNo specific additional frequency limit provided in source; refer to Medical Director for exceptions

Authorization checkProviders must verify plan-specific prior authorization requirements via Pre-authorization Code Check

Contrast Use and Radiation Planning

Billing Rule
Allow PET for radiation planning when IV contrast contraindicated
PET may be used in radiation planning when IV contrast is contraindicated and improved targeting is sought; document rationale when combining PET with radiation planning.
Indicate that IV contrast is contraindicated and how PET will improve radiation targeting when requesting PET for radiation planning.

Note
No other explicit contrast rules in this segment
No additional explicit IV contrast rules are provided in this policy segment beyond use in radiation planning.
Follow site‑specific imaging protocols where no contrast‑specific guidance is given in the policy.

Not Covered / Not Medically Necessary Uses

NOT COVERED examples: PET is not covered for routine surveillance across many cancers and is not indicated for initial diagnosis of breast cancer or routine axillary nodal staging. Requests for PET for unsupported primary diagnostic/staging indications may be denied unless adequate justification and supporting documentation are submitted.

NOT COVERED: Routine FDG PET for Alzheimer’s disease or dementia is not supported by MTAC evidence reviews because studies did not demonstrate sufficient diagnostic/prognostic value to improve patient outcomes; FDG PET for routine evaluation of AD/dementia therefore does not meet Kaiser Permanente MTAC criteria.

NOT COVERED: FDG PET for initial diagnosis or primary staging is not supported for several cancers (examples include breast, cervical, and colorectal primary staging without prior CT) and may be denied absent clear justification and documentation of why conventional imaging/biopsy cannot provide the needed information.

NOT COVERED: FDG PET as first‑line diagnostic/staging for esophageal cancer and for regional lymph node evaluation in melanoma are considered unsupported indications and are not covered as routine tests.

NOT COVERED: FES‑PET for routine assessment of estrogen receptor expression in advanced breast cancer does not meet MTAC criteria and is considered experimental/insufficient; coverage requires prior authorization with supporting rationale.

NOT COVERED: Use of Axumin Injection for PET scan and the use of 18F‑FDG PET/CT for bone metastases were judged in MTAC reviews to not meet Kaiser Permanente Medical Technology Assessment Criteria at the time of those reviews; local prior authorization requirements apply and later MPC actions modified coverage for Axumin in defined indications.

Background and Rationale

Background: FDG PET is widely used in oncology to evaluate metabolic activity of tumors and can detect distant metastases earlier than structural imaging in some settings. However, PET has limitations including false positives from infection/inflammation and false negatives for small or low‑activity lesions; thus its role is indication‑specific and dependent on whether results will change management.

Key Definitions and Terminology

TNM staging definition

TNM componentsT = tumor size/extent; N = lymph node involvement; M = extent of metastasis

Use in policyTNM referenced to describe staging criteria for oncologic PET indications

DocumentationStage (e.g., Stage III/IV) may determine PET necessity when conventional imaging is equivocal

Solitary pulmonary nodule (SPN) definition

SPN definitionA single indeterminate or possibly malignant pulmonary lesion >0.8 cm on CT

Imaging contextRequires a concurrent thoracic CT to qualify

Exclusion note

Document Changes and Log

2015-08-05operational update

Added Medicare link to NCD 210.3 for colorectal cancer screening; subsequent operational additions include coverage articles and guideline updates through 2018

2018-05-01policy decision

MPC approved to adopt Axumin PET non-coverage criteria

2019-02-05policy decision

MPC approved adoption of coverage criteria for Axumin (18F-fluciclovine) injection for PET scan

OpenPayer

FDG PET / PET‑CT and PET imaging clinical review criteria (oncology and selected non‑oncologic indications)