DraftUnitedHealthcarePolicy CSRAD010OH.D

Adult Oncology Imaging Guidelines (Ohio)

Clinical imaging coverage and medical necessity guidelines for adult oncology imaging services applicable to UnitedHealthcare Community Plan members in Ohio.

Policy Summary

PayerUnitedHealthcare

PolicyAdult Oncology Imaging Guidelines (Ohio)

Policy CodePolicy CSRAD010OH.D

Change TypeMinor editorial (no material changes)

Effective DateNov 1, 2025

Next Review Date

Key ActionSubmit relevant clinical documentation and specify radiotracer when requesting prior authorization for PET/CT or other advanced imaging.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-11-01effective date noted

V1.0.2025guideline version

Ohiogeographic applicability

GFR<30renal threshold

<8 mmPET/CT min lesion

78813+76498

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

PET/MRI reporting combo

Coverage Criteria and General Medical Necessity

General medical necessity criteria (preface)

Covered when ALL of the following are met:

note":"Operational: limited CT (CPT 76380) may be used when a restricted field-of-view answer the clinical question; document anatomic limits and rationale."}]}

General oncology imaging medical necessity

Covered when ALL of the following are met unless otherwise stated in disease-specific guidelines:

ALL of the following

A recent clinical evaluation or meaningful contact has occurred within 60 days unless this is a guideline-supported scheduled surveillance exam.
Histologic confirmation of malignancy (or recurrence) and clinical stage are provided when required by the disease-specific guideline.
Conventional imaging has been performed or is not sufficient to answer the clinical question (e.g., equivocal, indeterminate, or negative with continued suspicion).
Imaging will be used in a way that can change management (e.g., guide biopsy site selection, define resectability, plan radiation/ablative therapy, or determine candidacy for systemic therapy).
Timing and surveillance frequency comply with the general oncology timeframe: during chemotherapy/immunotherapy for measurable disease every 6–8 weeks (approximately every 2 cycles); during endocrine/hormonal therapy every 12 weeks; measurable metastatic disease off therapy every 12 weeks; minimal metastatic disease on maintenance therapy every 12 weeks; surveillance imaging typically not indicated beyond 5 years from completion of treatment for metastatic disease unless otherwise specified.

PET/CT covered indications (general)

PET/CT is covered when it will change management and specific criteria are met; several general exclusions apply.

ALL of the following

Delay PET/CT for at least 12 weeks after completion of radiation treatment unless required sooner for imminent surgical resection.
PET/CT may be considered prior to biopsy to select a more favorable biopsy site when prior biopsy was nondiagnostic or planned site is relatively inaccessible and PET/CT would alter the approach.
PET/CT may be indicated when conventional imaging (CT, MRI, or bone scan) is inconclusive or negative with ongoing clinical suspicion for recurrence or metastatic disease.
PET/CT should use PET/CT fusion codes (e.g., CPT 78815/78816); unbundling into separate PET and diagnostic CT codes is not supported. Choice of field-of-view (eyes-to-thighs vs whole-body) should follow diagnosis-specific guidance.

PET/CT not indicated

PET/CT is not indicated and generally not covered in the following situations:

ANY of the following

Evaluation of infection, inflammation, trauma, post-operative healing, granulomatous disease, or rheumatologic conditions as the primary indication.
Concomitant performance with separate diagnostic CT studies (unbundling).
When conventional imaging already demonstrates conclusive distant or diffuse metastatic disease; PET/CT will not change management.
Known metastatic disease limited to the CNS (PET/CT is not sensitive for intracranial disease).
Lesions smaller than 8 mm where PET resolution is inadequate to reliably detect disease.

PET Imaging Coverage Criteria

PET Imaging in Oncology is supported when ALL of the following are met:

ALL of the following

The requested PET study uses an evidence-supported radiotracer for the diagnosis or clinical question per diagnosis-specific guidance.
Clinical documentation demonstrates a specific decision that will be made based on PET results (e.g., change in therapy, surgical planning, biopsy site selection).
Conventional imaging is equivocal, indeterminate, or negative with persistent clinical concern, OR PET is being used for approved staging/restaging indications described in disease-specific sections.
Timing considerations: follow imaging timeframe guidance (e.g., delay 12 weeks after radiation, interval monitoring frequency during systemic therapies as outlined in general oncology timeframe).

Ablation and procedural imaging guidance

Covered when ALL of the following are met for ablation guidance:

ALL of the following

The procedure is a percutaneous ablative therapy where imaging guidance is required to place and monitor the ablative device (e.g., RFA, microwave ablation).
Documentation supports that imaging guidance will be used for initial electrode placement, monitoring repositioning if needed, and confirmation of adequate ablation (CPT 77013 for CT; CPT 77022 for MR guidance).
For bone tumor ablations, CPT 20982 is the appropriate guidance code rather than CPT 77013.
Only one unit of a guidance code (CT, MR, US, or fluoroscopy guidance) should be reported per encounter; do not separately bill a diagnostic imaging study that is part of the guidance procedure.

3D Rendering — Clinical Indications

3D rendering codes (76376, 76377) can be considered when ANY of the following clinical scenarios apply:

ANY of the following

Complex fractures, comminuted or displaced, or other pre-operative planning when conventional imaging is insufficient (spine fractures, pelvic/acetabulum, intra-articular fractures).
Congenital skull abnormalities in newborns/infants/toddlers for surgical planning.
Complex facial fractures or other complex surgical pre-operative planning scenarios where 3D reconstruction materially changes operative approach.
Cerebral angiography planning or other vascular reconstructions where 3D anatomy visualization is required.
Pelvic/uterine or adnexal conditions where initial ultrasound is indeterminate and 3D rendering would change management.

Imaging Guidance — Billing and Usage Criteria

Guidance procedure coding and billing rules apply when imaging is used to guide percutaneous procedures:

ALL of the following

CT-, MR-, or ultrasound-guidance procedure codes contain the imaging necessary to guide needles/catheters; do not routinely bill a separate diagnostic procedure code in conjunction with a guidance procedure code.
Use CPT 77011 for stereotactic CT localization scans when no radiologist interpretation is provided; if interpreted, use the appropriate diagnostic CT code not both.
Use CPT 77012 (CT) or CPT 77021 (MR) for imaging guidance of needle placement for percutaneous procedures; these codes should not be used with open/excisional surgical codes.
Use CPT 77013 (CT) or CPT 77022 (MR) for ablative procedure guidance including monitoring for repositioning and post-ablation confirmation; CPT 77013 is not for bone ablations (use CPT 20982).

Whole-body MRI (WBMRI) — Covered when ALL of the following are met

Whole-body MRI is covered when ALL of the following are met:

ALL of the following

The indication is a select cancer predisposition syndrome or an autoimmune condition for which WBMRI is recommended by the pediatric/special-population guideline (e.g., Li-Fraumeni, NF1/NF2, CMMRD, HPP syndromes) and documentation supports the syndrome-specific protocol.
A standardized WBMRI protocol is used and rationale for whole-body rather than region-based imaging is provided.
WBMRI is reported using CPT 76498; other reporting approaches (multiple diagnostic MRI codes, CPT 77084, etc.) are not appropriate.

PET‑MRI — PET‑MRI may be appropriate when EITHER of the following

PET‑MRI may be appropriate when EITHER of the following applies:

ANY of the following

The individual meets condition-specific guidelines for PET/MRI per disease-specific section.
The individual meets guideline criteria for PET/CT AND PET/CT is not available at the treating institution AND the provider requests PET/MRI in lieu of PET/CT. When approved, report PET/MRI as CPT 78813 + CPT 76498; diagnostic MRI codes may be used concurrently if clinically appropriate.

Limited or follow-up CT (76380); Unlisted Codes for Treatment Planning

Limited or follow-up CT (CPT 76380) and unlisted imaging for treatment planning:

ALL of the following

Limited area CT (CPT 76380) may be appropriate when a focused, limited field-of-view scan answers the clinical question and documentation describes the anatomic boundaries and clinical rationale.
Unlisted MRI/CT codes for treatment planning (e.g., CPT 76498) may be used when no specific CPT code accurately describes the imaging performed; a full description and justification must accompany the claim and prior authorization may be required.
Do not report 3D rendering codes separately when the planning dataset inherently generates a 3D dataset (e.g., CPT 77011); concurrent use of 3D codes may still require separate authorization and documentation of physician participation.

Rare malignancies — conditional approval

Rare malignancies — conditional approval for PET/CT when ALL of the following are met:

ALL of the following

Conventional imaging (CT, MRI, or bone scan) reveals equivocal or suspicious findings that PET/CT could clarify.
No alternative specific metabolic imaging (MIBG, octreotide, technetium, etc.) is appropriate for the disease type.
Submitted clinical information describes a specific management decision that will be based on PET/CT results (e.g., change in therapy, surgical approach).

Primary CNS Tumors — Imaging Criteria

Primary CNS tumors — imaging criteria by indication:

ALL of the following

High-grade gliomas — Initial and active therapy imaging: MRI brain with and without contrast (CPT 70553) is the preferred modality for initial staging and for assessment during active therapy. PET brain or PET/CT is generally not indicated for intracranial metastatic disease; PET/CT may be used for extracranial staging if clinically indicated per systemic disease guidelines.
High-grade gliomas — Surveillance: MRI brain with and without contrast is appropriate for surveillance; frequency should follow disease-specific guidance and general oncology timeframe. PET/CT is not routinely indicated for intracranial surveillance.
CNS lymphoma — Initial staging, treatment response, surveillance: MRI brain with and without contrast is recommended for intracranial evaluation. Whole-body imaging for systemic lymphoma staging should follow lymphoma-specific guidelines; PET/CT using appropriate radiotracer may be indicated for systemic staging when it will change management.
Meningiomas — Initial staging, treatment response, surveillance: MRI brain with and without contrast is the recommended study. PET/CT is not routinely indicated for intracranial meningioma evaluation unless specific disease guidance indicates a role for metabolic imaging.

Restaging / Recurrence; Surveillance / Follow-up

Restaging and surveillance general principles:

ALL of the following

Restaging/recurrence imaging should be requested when clinical concern, new symptoms, or conventional imaging findings suggest recurrence or progression and results will change management (e.g., guide salvage therapy, resection, or radiation).
Surveillance/follow-up imaging intervals should follow disease-specific guidance and the general oncology timeframe; routine surveillance imaging is not supported beyond recommended intervals and typically not beyond 5 years for many metastatic disease scenarios unless specified.
PET/CT is generally not indicated for routine surveillance or serial monitoring in the absence of active therapy unless disease-specific guidance supports it.

Thyroid cancer surveillance; MTC monitoring; ATC monitoring

Thyroid cancer and related histologies — surveillance and specialized PET use:

ALL of the following

Medullary thyroid cancer (MTC): use of PET/CT with disease-appropriate radiotracer (e.g., 68Ga-DOTATATE) may be indicated for staging or restaging when conventional imaging is equivocal and results would change management; biochemical evidence (rising calcitonin/Ctn or CEA) with negative conventional imaging may justify advanced imaging per disease-specific guidance.
Anaplastic thyroid cancer (ATC): imaging for staging and treatment planning should follow disease-specific guidance; PET/CT may be useful for systemic staging when it will alter management decisions.
Differentiated thyroid cancer surveillance often relies on neck ultrasound and serum thyroglobulin; PET/CT may be indicated in selected scenarios (e.g., rising Tg with negative radioactive iodine scan) per guideline-directed recommendations and appropriate radiotracer selection.

SCLC coverage criteria; NSCLC coverage criteria; NSCLC Suspected/Diagnosis; NSCLC Initial Work-up/Staging; NSCLC Restaging/Recurrence; NSCLC Surveillance

Lung cancer coverage criteria (SCLC and NSCLC):

ALL of the following

Small cell lung cancer (SCLC): PET/CT may be used for staging/restaging when it will affect management, consistent with disease-specific guidance; brain MRI is indicated for intracranial assessment as specified. PET/CT should not be used for routine surveillance without active therapy unless disease-specific exceptions apply.
Non–small cell lung cancer (NSCLC): Suspected/diagnosis and initial work-up/staging: PET/CT (whole-body) using FDG is appropriate for initial staging to evaluate for extrathoracic disease and guide staging and management when findings will change therapy (e.g., surgical candidacy). Brain MRI is recommended for suspected or high-risk intracranial disease; CT chest/abdomen as indicated.
NSCLC Restaging/Recurrence: PET/CT is appropriate when conventional imaging is inconclusive or to assess for recurrence when results will change management (e.g., consideration of salvage surgery or radiation).

Esophageal and GE Junction Cancer Imaging; Malignant Pleural Mesothelioma Criteria

Esophageal, GE junction cancer, and malignant pleural mesothelioma imaging criteria:

ALL of the following

Esophageal and GE junction cancer: PET/CT is appropriate for initial staging when it will alter management (e.g., detect distant metastases that change surgical candidacy) and for restaging when conventional imaging is inconclusive; delay PET/CT 12 weeks after radiation unless earlier imaging is required for imminent surgery.
Malignant pleural mesothelioma: Use conventional imaging for initial staging and consider PET/CT when findings are equivocal or when PET/CT would change management; documentation must show how PET results will alter care.

Modality-Specific and Disease-Specific Indications

Modality-specific appropriate uses (general preface list)

4 top-level modality-specific appropriate uses

Ultrasound uses: Indications include obstetric/gynecologic imaging, soft tissue and visceral chest/abdomen/pelvis/extremities, brain/spine when not obscured by bone, vascular imaging when not obscured by bone, procedural guidance, and initial evaluation of ill-defined soft tissue masses

Ultrasound may guide selection of further advanced imaging

CT uses: CT indicated for trauma screening, pulmonary disease evaluation, abdominal and pelvic viscera imaging, complex fractures, and when advanced anatomic detail is required or MRI is contraindicated

CT may be performed with or without IV contrast per indication

MRI uses: MRI indicated for brain and spinal cord imaging, characterization of soft tissue masses, musculoskeletal soft tissue evaluation, and when CT/US are inconclusive or MRI is preferred due to lack of radiation

CPT/HCPCS Coding and Billing Guidance

inv-114: Renal function threshold (contrast) — GFR <30 mL/min (increased risk)

Renal Function Threshold (Contrast)

inv-115: Units per encounter — Only one unit of guidance code reportable per individual encounter

Units per encounter

inv-117: Lesion size threshold for PET/CT — < 8 mm

Lesion size threshold for PET/CT

Imaging Frequency and Surveillance Intervals

Repeat imaging — justification

Repeat imaging general ruleRepeat imaging should be performed only when there is evidence of disease progression or recurrence, or when the repeat study is expected to affect clinical management

Documentation requirementSubmit recent clinical evaluation and prior imaging results to justify repeat studies

Avoid routine repeatsRepeating imaging without new signs/symptoms or management impact is generally not necessary and may be denied

Conventional imaging (CT/MRI) — surveillance interval

Conventional imaging intervalCT or MRI of involved/symptomatic sites: every 6–8 weeks (generally every 2 cycles of systemic therapy)

Context of useInterval recommended during active systemic chemotherapy for measurable disease

Prior Authorization, Documentation, and Billing Actions

Prior Authorization

PA & medical-necessity review under Ohio Admin. Code

Requests for services that are unproven or that exceed coverage or quantity limits will be evaluated for medical necessity under Ohio Administrative Code 5160-1-01; prior authorization may be required per plan rules.

Documentation Required

Provide clinical documentation and recent evaluation

Submit pertinent medical records and a recent clinical evaluation to establish medical necessity for advanced imaging or other designated procedures; do not order advanced imaging prior to a clinical evaluation unless the request is for guideline‑supported scheduled surveillance.

Prior Authorization

Obtain PA and document supervision for 3D rendering (CPT 76376/76377)

Contrast Use, Safety, and Reporting

Billing Rule

Evaluate renal function (GFR <30 mL/min) and contraindications before contrast

Assess renal function and other contraindications before administering contrast agents; avoid gadolinium‑based contrast agents if eGFR <30 mL/min and consider non‑contrast studies when contrast is contraindicated.

GFR <30 mL/min is a contraindication to GBCA use
Consider non‑contrast CT/MRI if renal failure, pregnancy, or iodinated contrast allergy concerns

Billing Rule

Consider GBCA safety and retention—document rationale when used

Consider gadolinium safety and retention concerns when using GBCAs; follow ACR/FDA guidance and document the rationale when contrast exposure is clinically necessary.

Investigational, Experimental, and Not-Covered Services

Unbundling PET and diagnostic CT — that is, billing separate PET and diagnostic CT procedures instead of a combined PET/CT study — is not supported. PET is typically performed as a combined PET/CT study and should be billed as the combined PET/CT procedure rather than as separate PET plus diagnostic CT services.

MRI with Xenon Xe 129 (CPT C9791) is considered investigational/experimental and is not supported for routine clinical use.

PET/MRI is generally not supported for the majority of oncologic indications because of limited standardization and evidence; it may be considered only in select circumstances (for example, when condition‑specific PET/MRI criteria are met or when PET/CT criteria are met but PET/CT is unavailable and the provider requests PET/MRI). For approved PET/MRI cases, the guideline specifies reporting as PET whole‑body (CPT 78813) plus MRI unlisted (CPT 76498). Routine use of PET/MRI for surveillance in place of PET/CT is not supported.

PET mammography (PEM) is regarded as experimental/investigational and is not supported by these guidelines. Requests for PET mammography (commonly reported with CPT 78811) may be denied as an unproven modality.

PET brain imaging is not indicated for gliomas located within the brainstem because of poor radiotracer uptake and lack of demonstrated impact on individual outcomes; PET brain in this setting is not supported.

Use of PET/CT in salivary gland tumors is considered not medically necessary for routine staging or surveillance. Condition‑specific conventional imaging (CT or MRI of the orbits/face/neck and chest imaging for selected histologies) is the appropriate first‑line approach; PET may be reserved only for narrowly defined circumstances where conventional imaging is inconclusive and management would change.

Definitions and Background

These guidelines evaluate a range of advanced imaging modalities (nuclear medicine, ultrasound, CT, MRI, PET, and PET/CT) for oncologic care and are evidence‑based, relying on peer‑reviewed literature, specialty society guidance, and expert input. The recommendations apply to the clinical scenarios and modalities described throughout the document and provide modality‑specific rules on appropriate use, timing (including surveillance intervals and recommended delays after radiation), and reporting. Overall, standard imaging (plain film, CT, MRI, ultrasound) should be considered first; advanced studies are appropriate when conventional imaging is inconclusive or when the result is expected to change management. Requests for services that are unproven or exceed coverage/quantity limits will be reviewed for medical necessity under the applicable Ohio administrative rules.

Definition — Investigational/experimental criteria

Investigational/Experimental definitionStudies, treatments, procedures, or devices may be considered investigational/experimental when supporting evidence is lacking, clinical utility not demonstrated, or collective opinion of support is absent

Evidence standardsSupporting evidence includes peer‑reviewed literature, randomized trials, cohort studies, and specialty society recommendations

ImplicationInvestigational services may be denied or require special review prior to approval

Prior Authorization — Rules and Expectations

Prior Authorization

Expect medical‑necessity review (Ohio Administrative Code 5160‑1‑01) for unproven/limited services

When requesting imaging that is stated as unproven or subject to coverage/quantity limits, expect medical necessity review under Ohio Administrative Code 5160-1-01; such requests may require prior authorization and supporting documentation.

Prior Authorization

PA may be required for 3D rendering regardless of underlying modality

Prior authorization may be required for 3D rendering codes (CPT 76376/76377) even if the underlying modality does not require PA; obtain PA per payer rules.

CPT 76376 and 76377 may need PA even when base imaging does not

Prior Authorization

PET‑MRI allowed only if PET‑CT criteria met and PET‑CT unavailable (report 78813+76498)

Approve PET‑MRI only when PET‑CT criteria are met and PET‑CT is unavailable, or when condition‑specific PET‑MRI criteria are satisfied; when approved report PET‑MRI as CPT 78813 + 76498.

Policy Change Log

Policy Summary

PayerUnitedHealthcare

PolicyAdult Oncology Imaging Guidelines (Ohio)

Policy CodePolicy CSRAD010OH.D

Change TypeMinor editorial (no material changes)

Effective DateNov 1, 2025

Next Review Date

Key ActionSubmit relevant clinical documentation and specify radiotracer when requesting prior authorization for PET/CT or other advanced imaging.

SourceLink

On This Page

Supported radiotracers include FDG and specific non-FDG tracers when indicated by diagnosis (e.g., 68Ga-DOTATATE, 64Cu-DOTATATE, 11C-Choline, 18F-Fluciclovine, 68Ga-PSMA-11, 18F-Pylarify, 68Ga Gozetotide, 18F-Flotufolastat, 18F-Fluoroestradiol).

PET/CT is NOT indicated for: infection/inflammation/trauma/post-operative healing/granulomatous or rheumatologic disease; concomitant separate diagnostic CT studies; conclusive distant/diffuse metastatic disease on recent conventional imaging; CNS metastatic disease; lesions < 8 mm; routine follow-up after localized therapy; serial monitoring/surveillance of individuals not on active anti-tumor therapy; serial monitoring of FDG avidity until resolution; or when PET has been documented negative and no PET-avid disease remains unless otherwise specified.

Follow-up after localized ablative therapies (e.g., RFA, embolization, stereotactic radiation) for routine surveillance unless disease-specific guidance allows.

Serial surveillance/monitoring of individuals who are not receiving active anti-tumor therapy or are on maintenance therapy without expectation that PET findings will change management.

PET/CT for rare malignancies is generally not covered due to limited evidence unless the rare cancer-specific exceptions are met (see Rare malignancies node).

PET/MRI: generally not supported for most oncologic conditions but may be approved when ALL of the following are met: the individual meets condition-specific guideline criteria for PET/MRI OR the individual meets guideline criteria for PET/CT AND PET/CT is not available at the treating institution AND the provider requests PET/MRI in lieu of PET/CT. When approved, report PET/MRI as CPT 78813 + CPT 76498 and include diagnostic MRI codes as appropriate.

Operational: PET mammography (PEM) is considered experimental and investigational and is not supported.

Only one unit of any guidance code should be reported per encounter (date of service).

NSCLC Surveillance: Routine surveillance PET/CT is not supported; follow disease-specific surveillance intervals and use CT or MRI per guidelines.

MRI protocols (with and without contrast) should follow condition-specific guidance

PET/CT uses: PET/CT is indicated for oncologic metabolic evaluation when PET will change management; PET/CT should be performed as combined PET/CT and not unbundled

Use supported radiotracers and PET/CT fusion coding per guideline

Imaging modality-specific indications and coding

MRI-guided breast biopsy — coding and appropriate use

Breast biopsy coding: Use CPT 19085 for the first MRI-guided breast biopsy lesion and CPT 19086 for each additional concurrent lesion; CPT 77021 is not appropriate for MRI-guided breast biopsy

Document procedure details and interpretation as required

3D rendering for pre-operative planning and complex anatomy

3D rendering for pre-operative planning and complex anatomy — ONE of the following applies

3D rendering scenarios: Complex bony conditions, congenital skull abnormalities, complex facial fractures, spine/pelvic/acetabular intra-articular fractures, cerebral angiography, and select indeterminate pelvic/abdominal cases where conventional imaging is insufficient

Concurrent physician supervision of post-processing should be documented

Imaging modality-specific indications and coding

Imaging modality-specific indications and coding — 5 top-level nodes

Guidance and ablation coding: Guidance codes (CT/MR/US/fluoroscopy) include imaging necessary to perform percutaneous procedures; CPT 77013 limited to non-bone ablations, CPT 20982 for bone ablations, and only one unit of guidance code may be reported per encounter

Do not bill routine diagnostic codes in conjunction with guidance codes

Whole-body CT/WBMRI coding: Whole-body CT screening for asymptomatic individuals is not indicated; WBMRI reportable as CPT 76498 and is generally limited to select predisposition syndromes

WBMRI lacks standardization; use CPT 76498 when performed

PET/CT and PET/MRI coding: PET/CT should be reported as PET/CT fusion codes (78815/78816) with specified radiotracer; PET/MRI may be reported as CPT 78813 + CPT 76498 when PET/CT criteria are met but PET/CT is unavailable and provider requests PET/MRI

Unbundling PET and diagnostic CT is not supported

Limited CT (76380): Use CPT 76380 when a limited or follow-up CT is performed and a full diagnostic CT protocol is not completed (eg limited sinus CT, targeted slices for known pulmonary nodule)

Not appropriate to use for treatment planning or to cover extra slices when a diagnostic CT code is reported

Quantitative MR analysis: Category III quantitative mp-MRI and volumetric MRI analysis codes are considered investigational or not medically necessary for routine clinical practice

These Category III codes should not be used for routine clinical reporting

Bone metastases evaluation

Bone metastases evaluation — ONE of the following may be approved

Bone scan indications: Bone scan (CPT 78306) is indicated for evaluation of suspected or known bony metastases in individuals with bone pain, rising tumor markers, or elevated alkaline phosphatase; SPECT/SPECT-CT (78803/78830/78831/78832) may be used as add-ons for focal evaluation

Use PET/CT where specified by disease-specific guidance

PET/CT to guide biopsy site selection

PET/CT to guide biopsy site selection — ONE of the following applies

Pre-biopsy PET/CT for site selection: PET/CT may be considered to select a biopsy site when a prior biopsy was nondiagnostic or the contemplated biopsy site would require invasive surgical intervention; documentation must state how PET/CT will influence biopsy site selection

Document prior nondiagnostic biopsy and intended biopsy strategy

PET/CT for unclear conventional imaging, biopsy planning, or management‑changing restaging

PET/CT for unclear conventional imaging, biopsy planning, or management‑changing restaging — ONE top-level node

PET/CT appropriate problem-solving: PET/CT may be approved when conventional imaging is inconclusive or negative with continued clinical suspicion for recurrence, or to guide biopsy site selection after nondiagnostic biopsy, or when PET/CT results will change management (e.g., permit transition from active therapy to surveillance)

Specify radiotracer and decision to be made based on PET/CT

Nuclear bone scan

Nuclear bone scan — ONE top-level node

Bone scan use: For evaluation of suspected or known bony metastases when indicated by bone pain, rising tumor markers, or abnormal labs; SPECT/SPECT-CT may be used to further evaluate focal findings

78306 is the primary whole-body bone scan code referenced

Low grade glioma — initial staging

Low-grade glioma initial staging: MRI Brain without and with contrast (CPT 70553) and MRI Spine without and with contrast (CPTs 72156/72157/72158) when indicated for neuraxis evaluation

Use CT head (70470) if MRI contraindicated

High grade glioma — post-treatment assessment

High-grade glioma post-treatment imaging: Immediate post-resection MRI Brain without and with contrast (CPT 70553) and MRI within 2-6 weeks after completion of radiation therapy for high-grade gliomas; MRI brain every 2 cycles during chemotherapy

Advanced modalities (MR spectroscopy, perfusion, PET brain) limited to specified histologies and indications

Problem-solving/biopsy guidance

Advanced imaging for problem-solving: To distinguish radiation necrosis from progressive tumor or to guide biopsy when MRI is inconclusive: MR Spectroscopy (76390) OR MRI Perfusion (as part of 70553) OR PET Brain metabolic imaging (78608), depending on histology and indication

PET Brain perfusion (78609) is not indicated for primary CNS tumors

Active treatment assessment for high-grade glioma

Therapy monitoring during chemotherapy: MRI Brain without and with contrast (CPT 70553) every 2 cycles for individuals undergoing chemotherapy; MRI Spine of involved region may be performed on the same schedule if indicatedevery 2 cycles

From guideline ONC-2.3

Initial staging for CNS lymphoma

CNS lymphoma initial staging: MRI Brain without and with contrast (70553) AND whole‑spine MRI without and with contrast (72156/72157/72158); extra‑neural evaluation with CT Chest (71260) and CT Abdomen/Pelvis (74177); FDG PET/CT (78815) may be approved if CT is inconclusive

Surveillance and treatment response imaging schedules specified in guideline

Restaging or clarifying inconclusive MRI for meningioma

Somatostatin receptor imaging: When MRI findings are inconclusive for meningioma restaging or to clarify extent, consider octreotide SPECT (78803) or SPECT/CT (78830) OR DOTATATE PET/CT (78814) depending on availability and clinical need

Somatostatin receptor PET supported for problem‑solving in meningioma

Initial Work-up/Staging

All stages — initial imaging

Head & neck initial workup: CT Neck with contrast OR MRI Orbits/Face/Neck without and with contrast AND CT Chest with contrast for initial staging of head and neck cancers; lymphoscintigraphy ± SPECT/CT for sentinel node evaluation when nodes are not clinically positive

Choose modality based on clinical scenario and need for anatomic detail

PET/CT Indications

Indications for PET/CT

Head & neck PET/CT indications: Known stage III/IV disease; to determine role of surgery vs chemoradiation for T3-T4 tumors; prior to primary chemoradiotherapy when no definitive surgery; inconclusive CT/MRI; to direct operative exam/biopsy; pulmonary nodules ≥8 mm; cervical node positive with no primary on CT/MRI; signs of abdominal metastatic disease; neurological findings or skull base invasion

NCCN supports PET/CT for initial staging of NPC and locoregionally advanced SCCa

Restaging/On-Treatment Imaging

Restaging and response assessment

Post-chemoradiation PET/CT timing: PET/CT after primary chemoradiotherapy should be performed no sooner than 12 weeks post completion of radiation; a negative post-treatment PET/CT generally obviates routine further surveillance imaging>=12 weeks

PET/CT earlier is associated with higher false positives

Induction chemotherapy response: CT Neck with contrast OR MRI OFN without and with contrast recommended after 2-3 cycles to assess response; PET is not routinely indicated for induction response assessmentafter 2-3 cycles

NCCN-aligned guidance

Measurable/metastatic disease on active treatment: Cross-sectional imaging of involved sites (CT Neck or MRI OFN plus CT with contrast of involved body sites) every 2 cycles (generally every 6-8 weeks)every 6-8 weeks

To monitor response and guide therapy

Surveillance/Follow-up

Surveillance after treatment

Post-treatment baseline for surgically treated patients: Obtain CT Neck with contrast OR MRI OFN without and with contrast once within 6 months of completing all treatment; perform CT of any other involved body area as indicatedwithin 6 months

Further surveillance imaging depends on disease-specific risk

High-risk or nonvisible primary surveillance: For nasopharyngeal primary or deep‑seated primaries not visualized on exam, consider annual CT Neck with contrast OR MRI OFN without and with contrast for 3 yearsannually x3 years

Majority of recurrences occur within 3 years

Salivary Gland Cancer - Initial Work-up

Salivary gland cancer staging

Initial cross-sectional imaging: For biopsy-proven salivary malignancy, one of: MRI Orbits/Face/Neck without and with contrast (70543) OR CT Neck with contrast (70491) OR CT Neck without contrast (70490); obtain CT Chest with contrast (71260) for pulmonary signs/symptoms or abnormal chest x-ray; MRI Brain with contrast if skull base invasion suspected

Select modality based on location, need to assess bone vs soft tissue

PET/CT in salivary tumors: Use of PET in salivary gland tumors is considered not medically necessary as a routine study

PET/CT reserved only for exceptional, documented situations

Salivary Gland Cancers — Initial Work-up/Staging

Biopsy-proven malignancy, Imaging Study = ONE of the following can be approved:

Initial cross-sectional options: MRI Orbits/Face/Neck without and with contrast (70543) OR CT Neck with contrast (70491) OR CT Neck without contrast (70490)

Choose based on clinical need

Skull base suspicion: If skull base invasion suspected: MRI Brain without and with contrast (70553)

Perineural and skull base invasion concern, esp. adenoid cystic carcinoma

Adenoid cystic chest imaging: For adenoid cystic carcinoma or when lymphadenopathy/pulmonary signs exist: CT Chest with contrast (71260)

Chest imaging supported due to high pulmonary metastasis risk

Salivary Gland Cancers — Restaging/Recurrence

Scenarios and allowed imaging:

Unresected disease on systemic therapy: Individuals with unresected disease receiving systemic therapy: CT Neck with contrast (70491) OR MRI OFN without and with contrast (70543) every 2 cycles; CT/MRI for other sites as indicatedevery 2 cycles

Supported per disease-specific guidance

Suspected recurrence: If recurrence suspected: CT Neck with contrast (70491) OR MRI OFN without and with contrast (70543) PLUS CT Chest with contrast (71260)

CT chest supported due to higher metastasis incidence at recurrence

Routine surveillance not indicated: All other individuals after complete resection: no routine advanced imaging indicated unless symptoms or specified histology warrant surveillance

Clinical follow-up prioritized

Salivary Gland Cancers — Surveillance/Follow-up

Post-treatment imaging recommendations based on resection status and histology:

Complete resection: After total surgical resection: no routine advanced imaging indicated

Clinical follow-up recommended

Unresectable or partially resected disease: obtain CT Neck with contrast (70491) OR MRI OFN without and with contrast (70543) once within 6 months of completion of treatmentonce within 6 months

Post-treatment baseline imaging

Adenoid cystic surveillance: Adenoid cystic carcinoma: CT Neck with contrast (70491) OR MRI OFN (70543) AND CT Chest with or without contrast (71260 or 71250) annually for up to 10 yearsannual for up to 10 years

Extended surveillance due to late recurrences

Melanoma — Staging, Restaging, and Surveillance

Stage-based imaging recommendations:

Do not image until confirmed: For suspected melanoma, do not perform advanced imaging until histologic diagnosis is confirmed

Imaging deferred until pathology

Early stage: Stage 0 or IA: routine advanced imaging not indicated. Stage IB and II: CT with contrast or MRI only if signs or symptoms indicate further evaluation; lymphoscintigraphy (78195) ± SPECT/CT (78830) for sentinel node evaluation when requested

Low yield of imaging in early stages

Advanced stage initial staging: Stage III or IV: MRI Brain without and with contrast (70553) AND PET/CT (78815/78816) OR CT Chest with contrast (71260) AND CT Abdomen and Pelvis with contrast (74177)

Brain MRI baseline due to CNS risk

Unknown primary after negative CT: If primary site unknown and CT Chest/Abdomen/Pelvis negative: PET/CT (78815/78816)

PET/CT to detect occult primary

Restaging on chemotherapy: Individuals with measurable disease receiving chemotherapy: CT Chest with contrast (71260) AND CT Abdomen and Pelvis with contrast (74177) every 2 cyclesevery 2 cycles

Response assessment interval

Surveillance stage-based: Stage 0–IIA: no routine advanced imaging. Stage IIB/IIC/IIIA/IIIB: CT Chest and CT Abdomen/Pelvis with contrast every 6 months for 2 years then annually for 3 years. Stage IIIC/IV: CT CAP with contrast every 3 months for 2 years then every 6 months for 3 years; MRI Brain annually for 3 yearsspecific intervals per stage

Surveillance intervals reflect recurrence risk

Cutaneous Melanoma - Surveillance by stage

Coverage and recommended imaging surveillance by melanoma stage

Stage 0, IA, IB, IIA: No routine advanced imaging indicated for surveillance in asymptomatic individuals

Stage IIB, IIC, IIIA, IIIB: CT Chest (71260) and CT Abdomen & Pelvis (74177) with contrast every 6 months for 2 years, then annually for 3 years

Primary extremity site imaging generally not indicated in asymptomatic individuals

Stage IIIC and IV: CT Chest and CT Abdomen/Pelvis with contrast every 3 months for 2 years, then every 6 months for 3 years; MRI Brain without and with contrast (70553) annually for 3 years

Non-Melanoma Skin Cancers - Initial workup, restaging, and surveillance

Imaging recommendations for BCC, SCC, Merkel cell carcinoma, and lesions suspicious for metastasis

BCC and SCC general: Routine advanced imaging generally not indicated; image only for unexplained signs/symptoms or when staging/workup indicates further evaluation

PET/CT not indicated except as specified

Body area with unexplained signs/symptoms: Obtain CT with contrast of the symptomatic body area

Select modality per clinical question

Perineural invasion or local extension: Obtain MRI (preferred) of the primary site or CT with contrast if MRI contraindicated

MRI favored for perineural spread; CT for bone involvement

Suspected dermal metastasis: CT Chest (71260) and CT Abdomen/Pelvis (74177) with contrast; PET/CT (78815/78816) if conventional imaging fails to identify a primary

PET/CT indicated when conventional imaging inconclusive

Merkel cell initial/staging: CT Chest and CT Abdomen/Pelvis with contrast; add CT Neck (70491) for upper disease; PET/CT if conventional imaging inconclusive; lymphoscintigraphy (78195) ± SPECT/CT (78830) for sentinel node evaluation

Node-positive Merkel cell surveillance described separately

Merkel cell recurrence/surveillance (node-positive): CT Chest and CT Abdomen/Pelvis with contrast every 6 months for 5 years; add CT Neck with contrast if prior neck/scalp/facial disease

Routine imaging not indicated for node-negative disease

Ocular (Uveal) Melanoma - Initial staging, restaging, and surveillance by risk

Imaging recommendations stratified by risk category (low, medium, high)

Initial staging for uveal melanoma: Any of: CT Chest with contrast (71260); CT Abdomen & Pelvis with contrast (74177) OR MRI Abdomen without and with contrast (74183) ± CT Pelvis (72913) or MRI Pelvis (72197); MRI Orbits/Face/Neck (70543)

Select modality based on risk and symptoms

Neurological signs/symptoms: MRI Brain without and with contrast (70553)

Restaging/suspected recurrence: MRI Brain (70553); MRI OFN (70543); CT Chest (71260) AND one of CT Abdomen/Pelvis (74177) OR MRI Abdomen (74183) with CT Pelvis (72913) OR MRI Abdomen (74183) with MRI Pelvis (72197); ultrasound abdomen may substitute for MRI abdomen if requested

Surveillance - Low risk: Annually for 10 years: CT Chest (71260) and CT Abdomen (74160) OR MRI Abdomen (74183)

Surveillance - Medium risk: Every 6 months for 2 years then annually to year 10: CT Chest (71260) and CT Abdomen (74160) or MRI Abdomen (74183)

Surveillance - High risk: Every 3 months for 2 years, every 6 months for 3 years, then annually to year 10: CT Chest (71260) and CT Abdomen (74160) or MRI Abdomen (74183)

Initial Work-up/Staging

ONE of the following clinical scenarios for initial work-up/staging and the corresponding approved imaging:

Locally advanced or fixation/substernal/bulky disease: MRI Neck without contrast (70540) OR MRI Neck without and with contrast (70543) OR CT Neck without contrast (70490) OR CT Neck with contrast (70491) as indicated

Select modality based on need for contrast and pre-operative assessment

Post-thyroidectomy remnant assessment/prior to RAI: Whole-Body Thyroid Nuclear scan (78018) with possible add-on CPT 78020 and/or SPECT (78803/78831) or SPECT/CT (78830/78832)

Used when remnant assessment will alter treatment or prior to RAI

Skeletal pain: Bone scan (78306) and/or whole-body thyroid nuclear scan and/or SPECT/SPECT-CT as appropriate

NM imaging guided by symptoms and clinical context

Suspicious chest x-ray or substernal extension: CT Chest without contrast (71250)

Elevated tumor markers (CEA/calcitonin) or very high calcitonin: CT Neck with contrast (70491), CT Chest with contrast (71260), CT Abdomen with contrast (74160) or CT Abdomen without and with contrast (74170), and Bone scan (78306)

For medullary thyroid carcinoma evaluate calcitonin/CEA thresholds per guideline

Inconclusive conventional imaging: 68 Ga DOTATATE PET/CT (78815) may be indicated when conventional imaging inconclusive

Document rationale for PET/CT radiotracer selection

AdjustmentsModify timing based on clinical course, treatment type, and disease-specific guidance

Whole‑Body MRI (CPT 76498) +/- Brain MRI (70553) — Annual

Whole‑Body MRI frequencyAnnual — Whole‑Body MRI (report using CPT 76498) with or without Brain MRI (CPT 70553) generally performed annually for select indications (e.g., Li‑Fraumeni Syndrome)

Reporting guidanceThere is no established CPT for WBMRI; report as CPT 76498 when performed

Use caseWBMRI screening is limited to select cancer predisposition syndromes due to lack of standardization

MRI Brain every 3 months (surveillance example)

Routine MRI brain surveillanceMRI Brain without and with contrast (CPT 70553) every 3 months — commonly used as a surveillance interval example

Indications exampleUsed for early post-treatment surveillance in primary CNS tumors and other high‑risk scenarios

Follow-up planningContinue interval imaging per disease-specific guidance and adjust based on clinical findings

High‑grade glioma surveillance schedule

High‑grade glioma surveillance scheduleMRI Brain without and with contrast (CPT 70553) every 3 months for 3 years, then every 6 months thereafter

Spine imagingIf spinal involvement, obtain MRI Spine without and with contrast on the same schedule (CPTs 72156/72157/72158)

RationaleIntensive early surveillance reflects higher recurrence risk in high‑grade gliomas

PET/CT — delay after radiation

Post‑radiation PET/CT timingPET/CT should not be performed sooner than 12 weeks (≥12 weeks) after completion of radiation therapy unless required sooner for imminent surgery

ReasonEarly PET/CT post‑radiation is associated with higher false‑positive findings

ExceptionIf surgery is imminent (<12 weeks), timing may be adjusted with documentation explaining clinical need

CT or MRI for patients on systemic chemotherapy with measurable disease

Imaging frequency on systemic chemotherapyCT or MRI of involved/symptomatic sites every 2 cycles (usually every 6–8 weeks) for patients with measurable disease on systemic chemotherapy

Modality selectionUse CT or MRI of involved sites as clinically indicated; include CT Chest/Abdomen/Pelvis or MRI brain per disease-specific guidance

DocumentationProvide treatment cycle dates and clinical intent to support frequency

Melanoma surveillance schedules (examples)

Melanoma surveillance — stage‑based examplesCT Chest and CT Abdomen/Pelvis with contrast per stage-based intervals: e.g., Stage IIB–IIIB: every 6 months ×2 years then annually ×3 years; Stage IIIC–IV: every 3 months ×2 years then every 6 months ×3 years (MRI brain per stage as specified)

Brain imagingMRI Brain without and with contrast as indicated (e.g., annually for Stage IIIC/IV for up to 3 years)

Tailor to symptomsAdjust surveillance based on symptoms, histology, and clinician judgment

CT (various) — interval during therapy

CT involved‑site intervalCT of involved or symptomatic sites every 2 cycles (usually every 6–8 weeks) during systemic therapy

Typical useApplied for restaging and treatment response during active systemic therapy

Adjust per disease guidanceFollow disease‑specific sections for modality and exact interval adjustments

Ultrasound (76536) — Neck ultrasound schedule

Neck ultrasound surveillanceNeck ultrasound (CPT 76536) every 6 months for 2 years, then annually thereafter

ContextApplies to active surveillance or post‑treatment monitoring in thyroid cancer per guidance

DocumentationRecord prior ultrasound results and clinical rationale for interval chosen

Prior authorization may be required for 3D rendering CPT codes 76376 and 76377 even when prior authorization is not required for the underlying imaging procedure; document physician supervision/participation in 3D reconstruction as recommended.

Codes: CPT 76376, CPT 76377
Document concurrent physician supervision per ACR guidance

Prior Authorization

Specify radiotracer and obtain PA for PET/CT

Prior authorization is required/useful for PET/CT studies and for requests involving PET radiopharmaceuticals; the specific radiotracer planned must be specified in the request.

Use PET/CT fusion codes (e.g., CPT 78815/78816) — do not unbundle PET and diagnostic CT
Specify the radiotracer (e.g., 18F‑FDG, 68Ga‑DOTATATE) when requesting PET/CT

Prior Authorization

PA required for PET/MRI and unlisted planning codes

When PET/MRI is requested instead of PET/CT or when using unlisted imaging codes for treatment planning, obtain prior authorization; approved PET/MRI should be reported as CPT 78813 + CPT 76498 and unlisted MRI (76498) is the preferred code for MRI-based radiation planning of brain, prostate, or cervix.

Report PET/MRI as CPT 78813 + CPT 76498 when criteria met
Do not use CPT 76497 for CT radiation treatment planning (subject to denial)

Documentation Required

Document recent clinical evaluation (within 60 days) before advanced imaging

Document a recent clinical evaluation or meaningful contact within 60 days prior to ordering advanced imaging (unless the request is for guideline-supported scheduled surveillance); lack of a recent evaluation may place the request at risk for denial.

Documentation Required

Provide histology and staging documentation for medical‑necessity review

For staging or restaging, provide histologic confirmation of malignancy (or recurrence) and disease stage when required; absence of histologic documentation may lead to denial unless exceptions apply (e.g., prohibitive biopsy risk documented).

Documentation Required

Document planned PET radiotracer and intended management decision

For PET/CT requests, document the specific radiotracer to be used and include clinical information that describes the specific management decision that will be made based on the PET/CT results.

Documentation Required

Document clinical rationale and extent of disease (tumor grade, spine involvement)

Include documentation supporting tumor grade, spinal involvement, and the rationale for advanced imaging (e.g., MR perfusion, MR spectroscopy, PET) or whole‑spine imaging to justify studies for initial staging or problem‑solving.

Denial Risk

Avoid routine double‑contrast CT—overutilization trigger

Be aware that double contrast CT (both without and with contrast) has few indications and is identified as an overutilization trigger that may prompt denial; order CT contrast level per condition‑specific guidance.

Denial Risk

Risk of denial if no recent clinical evaluation documented

Advanced imaging requests lacking a recent clinical evaluation (within 60 days) or meaningful contact are at increased risk for denial.

Denial Risk

PET/CT timing and indication denial risks (lesion size <8 mm; <12 weeks post‑radiation; surveillance)

PET/CT performed earlier than 12 weeks after completion of radiation, for lesions <8 mm, or for surveillance in asymptomatic individuals not on active treatment are likely to be denied; delay PET/CT at least 12 weeks post‑radiation unless required for imminent surgery.

Avoid PET/CT for lesions <8 mm (sensitivity limitation)
Delay PET/CT >= 12 weeks after radiation when possible
Do not use PET/CT for routine surveillance off active therapy

Denial Risk

Avoid CPT 76497 for RT planning—may be denied as bundled service

Using unlisted CT (CPT 76497) for radiation treatment planning may trigger denial because CT planning is generally bundled with radiation treatment; prefer CPT 76498 for MRI‑based planning when appropriate and obtain PA if needed.

Billing Rule

Obtain MRI without and with gadolinium for initial staging when indicated

Order MRI brain and spine studies both without and with gadolinium contrast when indicated for initial staging and most follow‑up evaluations; failure to obtain both non‑contrast and contrast sequences when indicated could result in inadequate evaluation.

MRI Brain: CPT 70553 without and with contrast
MRI Spine: CPT 72156/72157/72158 without and with contrast (contrast-only spine acceptable if performed immediately after contrast brain MRI)

Denial Risk

Do not image suspected melanoma until histologic diagnosis confirmed

For suspected melanoma, do not perform advanced imaging until histologic diagnosis is confirmed; ordering routine advanced imaging for early‑stage cutaneous melanoma (Stage 0–IIA) without symptoms may result in denial.

Denial Risk

PET/CT generally not supported for routine SCLC response/surveillance

Routine PET/CT is not routinely supported for small cell lung cancer (SCLC) treatment response or surveillance and may be denied; use CT/MRI per guideline‑specified schedules and reserve PET/CT for case‑by‑case indications.

Follow CT Chest/Abdomen/Pelvis and MRI Brain schedules for SCLC per guideline
PET/CT not routine for SCLC response or surveillance

Denial Risk

Surveillance PET/CT for NSCLC discouraged—denial risk

FDG‑PET is discouraged for routine surveillance of NSCLC due to excessive false positives and may be denied when submitted for routine surveillance; follow stage‑based CT surveillance schedules instead.

Billing Rule

Perform MRI brain/spine without and with gadolinium when indicated

Perform MRI Brain and MRI Spine without and with gadolinium contrast as the standard protocol when indicated; MRI spine with contrast only may be approved if performed immediately after contrast‑enhanced brain MRI.

MRI Brain: CPT 70553 without and with contrast
MRI Spine: CPT 72156/72157/72158 without and with contrast (contrast‑only spine acceptable in limited workflow scenarios)

Billing Rule

Use IV contrast for CT Chest/Neck when indicated for staging or pre‑op assessment

Order CT Chest and CT Neck with IV contrast when indicated to improve detection of mediastinal/hilar adenopathy and for complete pre‑operative assessment or staging; select contrast per disease‑specific guidance.

Billing Rule

Use IV contrast for CT Neck/Chest/Abdomen when necessary to define disease extent

Use IV contrast for CT Neck/Chest/Abdomen when necessary to fully evaluate nodal disease, soft‑tissue extent, or for complete staging; document necessity to justify contrast use.

Routine advanced imaging is not indicated for many early‑stage disease scenarios. Examples include post‑total resection salivary gland cancers and early cutaneous melanoma (Stage 0, IA, IB, IIA) where routine cross‑sectional imaging is low yield; imaging in these settings should be symptom‑driven or based on specified high‑risk histology and documented clinical indications.

Routine PET/CT for surveillance or routine treatment response assessment in small cell lung cancer (SCLC) is not supported. PET is not indicated for routine surveillance due to radiation exposure and a high false‑positive rate; CT and MRI (for brain) remain the principal surveillance modalities with stage‑based interval recommendations.

FDG‑PET is not supported for routine surveillance of non‑small cell lung cancer (NSCLC) because of excessive false positive findings and associated risks of unnecessary procedures. Surveillance imaging guidance favors interval CT chest (and brain MRI when indicated) rather than routine PET surveillance.

Using PET/CT as the sole first‑line imaging modality for malignant pleural mesothelioma is not supported. PET/CT inadequately differentiates benign versus malignant changes related to asbestos exposure and can understage the primary site; conventional cross‑sectional imaging (contrast CT and MRI for surgical planning) is essential, with PET/CT reserved to confirm absence of metastatic disease or when conventional imaging is inconclusive prior to resection.

Definition — Standard imaging (plain film, CT, MRI, US)

Standard imaging defined'Standard' or 'conventional' imaging includes plain film, CT, MRI, and ultrasound and is generally used for initial and subsequent evaluations

Use prior to advanced imagingProviders should consider standard imaging before ordering advanced modalities unless condition‑specific guidance indicates otherwise

Role in care pathwaysAdvanced imaging is appropriate when standard imaging is inconclusive or insufficient to guide management

Definition — PET / PET-CT description

PET / PET‑CT descriptionPET is a nuclear medicine study using positron‑emitting radiotracers typically performed as combined PET/CT; PET/CT evaluates metabolic activity and is not routinely indicated for surveillance unless specified

Bundling guidanceUnbundling PET and diagnostic CT into separate codes is not supported — PET/CT should be billed as combined PET/CT fusion codes

Clinical usePET/CT may be indicated when conventional imaging is inconclusive or to guide biopsy/site selection

Definition — CPT 76376 vs 76377 distinction

CPT 76376 vs 76377 distinctionCPT 76376 is 3D rendering not requiring an independent workstation; CPT 76377 is 3D rendering requiring an independent workstation — both require documented physician supervision/participation

Billing note3D rendering codes should not be used for 2D reformatting, and prior authorization may be required for these codes even when the underlying modality is pre‑authorized

DocumentationDocument physician concurrent supervision or participation in the 3D reconstruction process per ACR recommendations

Definition — PET/MRI reporting combination and conditions

PET/MRI reporting and conditionsPET/MRI may be approved when PET/CT criteria are met and PET/CT is unavailable, or when condition‑specific PET/MRI criteria are satisfied; when approved report as PET Whole‑Body (CPT 78813) plus MRI unlisted (CPT 76498)

General limitationPET/MRI is generally not supported for most oncologic conditions due to lack of standardization in technique and interpretation

Documentation requirementRequests for PET/MRI should document why PET/CT is unavailable or why PET/MRI meets condition‑specific criteria; radiotracer and clinical decision must be specified

Prior Authorization

Specify radiotracer and use PET/CT fusion codes in PA requests

Specify the PET radiotracer in authorization requests; prior authorization is likely required for non‑routine radiotracers and for PET/CT fusion studies (use fusion codes rather than unbundled PET + CT billing).

Prior Authorization

PA likely for advanced imaging modalities used for problem‑solving/restaging

Expect prior authorization for advanced imaging used for problem‑solving, restaging, or extra‑neural evaluation (e.g., MR spectroscopy, MR perfusion, PET brain, somatostatin receptor PET) per payer policy.

Prior Authorization

Document justification for PET/CT in pulmonary nodules (8–30 mm) or select masses ≥31 mm

For pulmonary nodules 8–30 mm, document justification for PET/CT (CPT 78815); for masses ≥31 mm, document specific clinical reasons if requesting PET/CT prior to biopsy.

Nodule 8–30 mm: PET/CT indicated
Mass ≥31 mm: PET/CT prior to biopsy only if documented reasons (e.g., will change definitive treatment or guide biopsy site)

Prior Authorization

Ensure imaging aligns with specified indications and frequency limits for PA

Ensure any listed CT/PET/MRI study aligns with the guideline‑specified indications and frequency limits (e.g., CT every 2 cycles on chemotherapy, surveillance intervals); prior authorization may be required if studies fall outside these parameters.