Prior authorization guidance

Policy establishes medical necessity criteria that payers may use for prior authorization decisions for PET non-oncologic studies; specific code-level prior authorization requirements are not listed in this portion of the document.

Repeat interval for cardiac sarcoidosis monitoring

PET (FDG metabolic with perfusion) for monitoring cardiac sarcoidosis may be repeated at intervals of 3–6 months if there is active disease or to inform therapeutic decisions.

AQMBF must accompany cardiac PET perfusion

Absolute quantitation of myocardial blood flow (AQMBF) is considered medically appropriate only when performed in conjunction with cardiac PET perfusion.

ETT findings that trigger prior authorization

Prior authorization considerations should reference specified abnormal or inconclusive ETT results such as failure to achieve 85% of maximum predicted heart rate, exercise ECG becoming uninterpretable (e.g., rate‑related LBBB), ST segment depression ≥ 1.0 mm, non‑sustained or sustained ventricular tachycardia, or CAC score ≥ 100.

Prior auth for pre-Class IC antiarrhythmic assessment

PET to assess for coronary artery disease is indicated prior to initiating a Class IC antiarrhythmic (flecainide or propafenone) and annually while on the medication; prior authorization may be required per plan rules.

Prior auth for bone infection PET/CT after equivocal MRI/CT

Prior authorization is required when FDG PET/CT is ordered for suspected bone infection only after MRI or CT are equivocal or cannot be performed and one of the specified indications (e.g., multifocal infection, hardware‑associated infection) is present.

Prior authorization for vascular PET/CT indications

Prior authorization is expected when PET/CT is requested as an alternative to nondiagnostic MRA/CTA or when PET/CT is used for initial staging in place of MRA/CTA for suspected diffuse large‑vessel involvement.

Prior authorization recommended for spinal infection PET/CT

Prior authorization is recommended for whole‑body FDG‑PET/CT in suspected spinal infection; requests should document that MRI cannot be performed or is inconclusive and include listed risk factors or abnormal x‑ray/CT findings.

Prior authorization for musculoskeletal PET/CT when MRI/CT equivocal

PET/CT for select musculoskeletal indications is indicated only when MRI or CT are equivocal or cannot be performed; prior authorization is required per payer rules for these non‑oncologic musculoskeletal PET/CT studies.

Confirm authorization for listed PET codes

Coverage for the listed PET CPT and HCPCS codes may require prior authorization depending on circumstances; providers should confirm coverage/authorization requirements before performing services.

• Codes listed in policy include 78811–78816, 78429–78430 and HCPCS A9526–Q9983, S8085.

Verify Medicare and local coverage decisions

If a Medicare product covers a service and there is no national or local Medicare coverage decision for the service, medical policy criteria apply; verify Medicare/local coverage and product terms prior to authorization.

Ensure imaging will change management

Appropriateness of PET imaging often depends on whether the result will change management; obtain and document that the requested PET study will affect therapeutic or diagnostic decisions.

Use cardiac PET after equivocal SPECT MPI

Cardiac PET perfusion may be used after an equivocal SPECT myocardial perfusion (SPECT MPI) stress test as an alternative imaging modality.

ETT component failures that justify imaging

Document ECG‑interfering conditions (e.g., complete left bundle branch block or ventricular paced rhythm) that make exercise treadmill testing inadequate or uninterpretable prior to requesting PET.

Document inability to exercise before stepping to alternatives

Providers should document inability to perform exercise (for example due to gait disturbance or need for assistive device) before proceeding to pharmacologic stress testing or imaging alternatives such as PET.

Stepwise evaluation required before AQMBF PET

Before performing AQMBF PET for suspected/known non‑obstructive CAD, demonstrate a normal/equivocal ETT or diagnostic uncertainty after other testing per the stepwise evaluation rules.

Prior imaging required before bone infection PET/CT

Require prior use or consideration of MRI or CT before FDG PET/CT for suspected bone infection unless those modalities are equivocal or contraindicated.

Required documentation of prior imaging attempts

Document that nondiagnostic or unavailable MRA/CTA (and where relevant indium‑111 or gallium‑67 studies) were attempted or not feasible before approving PET/CT for vascular infection or staging in place of MRA/CTA.

Imaging pathway: prefer MRI/CT before FDG‑PET/CT

Consider MRI or CT first; FDG‑PET/CT is indicated when x‑ray or CT are abnormal and MRI cannot be performed or is inconclusive.

AQMBF accreditation and qualified personnel required

AQMBF should be performed only in accredited laboratories with board‑certified interpreting physicians experienced in AQMBF using standardized protocols; reports must include rest and stress MBF (ml/g/min) and MBFR (ratio of stress to rest) and RPP‑corrected values where applicable.

• Laboratory accreditation: IAC, ACR, or Joint Commission cardiac PET accredited.
• Interpreting physician board certification in Nuclear Cardiology, Nuclear Medicine, or Radiology with AQMBF training.
• Standardized protocols and reporting of MBF/MBFR and RPP‑corrected values.

Supporting imaging/biopsy documentation for incidental splenic findings

When PET/CT is requested for incidental splenic findings, prior imaging and documentation that MRI was inconclusive or biopsy is not feasible must be provided to support the request.

Echocardiography equivocal documentation for prosthetic valve PET

Documentation should demonstrate that transthoracic or transesophageal echocardiography was equivocal or nondiagnostic and that clinical suspicion for prosthetic valve endocarditis remains high before ordering FDG PET/CT.

Document device timing and surgical adhesive absence for prosthetic valve PET

Document timing of valve or device implantation (implantation ≥ 3 months ago) and absence of surgical adhesives used during implantation when seeking FDG PET/CT for prosthetic valve endocarditis.

• Implantation date showing ≥ 3 months since procedure.
• Statement that no surgical adhesives were used during the implantation.

Document ETT inconclusive details (e.g., <85% MPHR)

When seeking PET due to an inconclusive ETT, document specific details such as failure to reach 85% of maximum predicted heart rate or exercise ECG becoming uninterpretable (e.g., development of rate‑related LBBB).

• Record achieved % of MPHR and reason ETT was inconclusive.

Required clinical documentation for stress PET

Clinical documentation supporting stress PET should include use of home oxygen for daily activity, activity‑limiting dyspnea or heart failure, and the provider’s assessment that exercise testing is unsafe or inadequate.

Coronary imaging documentation for PET functional assessment

To support PET for functional assessment of moderate coronary stenosis, provide coronary imaging showing CCTA with 50–69% stenosis (CAD‑RADS 3) or invasive angiography with intermediate lesions when invasive physiologic testing has not been performed.

Imaging pathway documentation showing prior modalities nondiagnostic/unavailable

Documentation should demonstrate that prior imaging modalities (MRI, CT, MRA, CTA) were equivocal/indeterminate or could not be performed and indicate the specific clinical indication for PET (e.g., multifocal bone infection, hardware‑associated infection, suspected aortic infection).

Clinical justification for spinal infection PET

Clinical justification for spinal infection PET must include clinical suspicion plus at least one listed risk factor or laboratory marker of infection (e.g., fever, IV drug use, recent bacterial infection, elevated WBC/ESR/CRP, positive cultures) and abnormal x‑ray or CT when MRI cannot be done or is inconclusive.

AQMBF reporting requirements (rest/stress MBF and MBFR)

AQMBF reports must include rest MBF and stress MBF in ml/g/min and myocardial blood flow reserve (MBFR, ratio of stress to rest MBF); laboratories should also report RPP‑corrected resting MBF and MBFR where applicable.

Coding documentation: use policy CPT/HCPCS descriptors

Use the CPT and HCPCS code descriptors listed in the policy when submitting claims for PET procedures and radiopharmaceuticals to support billing and authorization.

Confirm member product covers the service

Confirm that the member’s product covers the requested PET service before applying medical policy criteria, as policy criteria apply only when the product covers the service.

Denial risk for unmet policy criteria

Requests that fail to meet any of the indication‑specific criteria listed in the policy (for example, none of the ANY or ALL conditions for lymphoproliferative, sclerosing mesenteritis, incidental splenic findings, or cardiac PET indications) are at risk of being found not medically appropriate and denied.

Prosthetic valve PET criteria required to avoid denial

FDG PET/CT for suspected prosthetic valve endocarditis is contingent on meeting criteria including echocardiography equivocal/nondiagnostic, CRP ≥ 40 mg/L, no evidence of prolonged antibiotic therapy, implantation ≥ 3 months ago, and no evidence of surgical adhesives used during implantation.

LVAD driveline infection unsupported—denial risk

Studies for suspected LVAD driveline infection may be denied if other studies and physical examination are inconclusive and do not support the diagnosis.

ETT‑precluding ECG findings (document to justify PET)

Uninterpretable ECG findings that preclude an adequate ETT include complete left bundle branch block, ventricular paced rhythm, pre‑excitation (e.g., WPW), ST segment depression ≥ 1.0 mm (not nonspecific ST/T changes), LVH with repolarization abnormalities, T‑wave inversion in ≥2 contiguous inferior/lateral leads, or digitalis therapy; document these when relying on ECG non‑interpretability.

Document physical limitations preventing ETT

Physical limitations that may prevent adequate ETT—such as gait disturbance, use of assistive devices, neuromuscular abnormalities, need for home oxygen, or activity‑limiting dyspnea/heart failure—should be documented to support alternative stress imaging.

Safety‑related denial risks for stress testing

Requests for stress testing may be denied for safety reasons in patients with unstable angina or concern for acute coronary syndrome, recent elevated troponin, severe aortic valve disease, or uncontrolled severe hypertension.

Pulmonary nodule size threshold—denial risk for <8 mm/ground‑glass

PET is not supported for incidental solid pulmonary nodules smaller than 8 mm or for ground‑glass opacities; requests outside the ≥ 8 mm solid nodule criterion may be denied.

Investigational indication: impotence/erectile dysfunction

PET imaging for impotence/erectile dysfunction is considered investigational and will be denied.

Not medically appropriate: Gaucher disease

PET/CT for evaluation of Gaucher disease is considered not medically appropriate and may be denied.

Routine spinal assessment excluded—denial risk

Routine PET/CT for assessment of spinal disorders, fusions, or unsuccessful spine surgery other than neoplastic disease is not medically appropriate and may be denied.

Do not bill CPT 76376/76377 with PET

Do not bill 3D rendering codes (CPT 76376 or 76377) in conjunction with PET imaging; such billing may trigger denial.

Coverage conditionality—codes may not be covered in all circumstances

Coverage for codes listed in the policy may be conditional and not covered in all circumstances; verify code‑level coverage before proceeding.

Product‑dependent coverage—verify member product

Confirm the member’s product covers the service; medical policy criteria apply only when the product covers the service and lack of coverage may lead to denial.

Authorization for repeat cardiac sarcoidosis PET at 3–6 months

Repeated PET for active cardiac sarcoidosis may be authorized at 3–6 month intervals; obtain authorization consistent with this frequency limit when applicable.

AQMBF requires concurrent cardiac PET perfusion for authorization

AQMBF is medically appropriate only when performed together with cardiac PET perfusion; prior authorization should reflect that AQMBF is an add‑on to PET perfusion.

Prior auth when ETT inconclusive/abnormal—submit ETT findings

When ETT is inconclusive or shows specified abnormal results (e.g., failure to reach 85% MPHR, ST depression ≥ 1.0 mm, CAC ≥ 100), prior authorization for PET may be required and documentation of the ETT findings should be submitted.

Prior auth for PET before/while on Class IC antiarrhythmics

Obtain prior authorization for PET performed prior to initiating or annually while on Class IC antiarrhythmics per plan rules.

Prior auth: FDG PET/CT for bone infection after equivocal MRI/CT

Prior authorization is required for FDG PET/CT for suspected bone infection only after MRI or CT are equivocal or cannot be done and a qualifying indication (e.g., multifocal infection) is present.

Prior auth for PET/CT as alternative to nondiagnostic MRA/CTA

Prior authorization is expected for PET/CT when used as an alternative to nondiagnostic MRA/CTA or for initial staging in place of MRA/CTA for suspected diffuse large‑vessel involvement; document prior nondiagnostic vascular imaging.

Prior auth: whole‑body FDG‑PET/CT for suspected spinal infection

Prior authorization is required when whole‑body FDG‑PET/CT is requested for suspected spinal infection if MRI cannot be performed or is inconclusive and x‑ray/CT are abnormal; include documented risk factors or laboratory markers of infection.

Prior auth required for musculoskeletal PET/CT when MRI/CT equivocal

Prior authorization is required for PET/CT in musculoskeletal indications when MRI or CT are equivocal or unavailable; submit documentation of prior imaging and clinical indication.

Verify authorization requirements for listed PET/PET‑CT codes

Verify plan rules and authorization requirements for the PET/PET‑CT codes listed in the policy prior to performing services, as coverage and authorization requirements may vary by product.

Radiotracer operational and contrast rules

Many PET radiotracers require on‑site cyclotron production because of short half‑lives; exceptions include fluorine‑18 and rubidium‑82. Follow radiotracer operational and contrast rules when scheduling and billing studies.