Prior authorization required for PET/CT oncology requests

Prior authorization is implied for FDG PET/CT used in oncologic indications and coverage is contingent on meeting the policy’s cancer‑specific criteria (i.e., conventional studies non‑diagnostic and use to determine an optimal biopsy site).

Authorize PET/CT or PET/MRI for cervical cancer staging/restaging

PET/CT or PET/MRI for cervical cancer initial staging or restaging requires prior authorization and must meet the listed stage‑specific criteria (e.g., Stage IB1–IB3, Stage II–IVA) or specified post‑therapy timing.

Authorization expected for listed PET/CT indications

Prior authorization is expected when PET/CT is ordered for the policy’s listed indications (initial staging, restaging, surveillance) to document the qualifying clinical scenario such as inconclusive conventional imaging, isolated metastasis amenable to local therapy, or rising tumor markers.

Observe ≥5‑week post‑radiation interval before restaging PET/CT

For esophageal/GE junction cancer restaging after chemoradiation, PET/CT should not be performed sooner than five weeks after completion of radiation therapy — prior authorization should reflect this timing.

Authorize PET/CT for initial staging after diagnosis or to confirm limited SCLC

Prior authorization is implied for PET/CT used for initial work‑up/staging after tissue diagnosis or to confirm extent of limited SCLC when conventional imaging indicates limited disease.

Single 3‑month follow‑up allowed if Deauville 4–5

A single follow‑up PET/CT at three months may be approved when the end‑of‑therapy PET/CT demonstrates Deauville score 4 or 5 FDG avidity; prior authorization should note this limited approval.

Authorize CAR‑T baseline and 30–60 day PET/CT with timing documented

Prior authorization is implied for PET/CT when used for CAR‑T therapy (one baseline and one 30–60 day post‑treatment scan); authorization should document intent for baseline and post‑treatment timing and note that single 3‑month follow‑up approvals (Deauville 4–5) are separate.

Require authorization for Merkel cell or specified metastatic indications

Prior authorization is required when PET/CT is requested for Merkel cell carcinoma restaging/recurrence or for specified metastatic disease evaluations (e.g., adrenal) and when conventional imaging is inconclusive or biopsy is not feasible.

Prior authorization may be required to document CAR‑T PET timing

When PET is requested for CAR‑T therapy scheduling, prior authorization may be required to document intent for one scan before treatment and one scan 30–60 days after completion.

Timing‑based authorization for CAR‑T and stem cell transplant imaging

Prior authorization requests should reflect planned timing for PET/CT around CAR‑T (once before and once 30–60 days after) and for stem cell transplant (once before and once within 30–100 days after transplant).

Authorize PET/CT for PRRT candidacy assessment

Prior authorization is required when PET/CT is performed to assess candidacy for peptide receptor radionuclide therapy (PRRT) with Lutetium‑177 Lu‑dotatate.

Authorize SSR PET for carcinoid restaging when CT/MRI inconclusive

PET/CT or PET/MRI using somatostatin‑receptor radiotracers (e.g., 68Ga‑DOTATATE, 68Ga‑DOTATOC) for restaging/recurrence of carcinoid requires prior authorization when CT/MRI are negative or inconclusive and continued suspicion exists.

Document SSR radiotracer use on authorization requests

Prior authorization requests should explicitly reference use of SSR radiotracers (68Ga‑DOTATATE, 68Ga‑DOTATOC, 64Cu‑DOTATATE) when PET/CT or PET/MRI is ordered for initial work‑up/staging of well‑differentiated GI/pancreatic NETs or when CT/MRI is inconclusive.

Require authorization for PRRT assessment with SSR PET

Prior authorization is required when PET/CT or PET/MRI is requested to assess candidacy for PRRT or for restaging/recurrence using listed SSR radiotracers.

Authorize DLBCL PET/CT and document CAR‑T pre/post scans

For DLBCL, PET/CT is medically necessary for restaging/recurrence; for CAR‑T cell therapy there should be one PET/CT before treatment and one 30–60 days after completion — prior authorization should document these scans.

Step‑up to NaF PET/CT for bone evaluation only after other modalities inconclusive

18F‑NaF PET/CT may be obtained for bone metastasis evaluation in breast cancer when CT, MRI, bone scan and FDG PET/CT are inconclusive; note this stepwise requirement on the authorization.

Use PET/CT when IV contrast is contraindicated for liver‑directed planning

When IV contrast is contraindicated and liver‑directed therapies are being considered for colorectal cancer, PET/CT may be used as part of initial work‑up/staging — document the contrast contraindication on the request.

Require clinical criteria documentation for suspected Richter’s transformation

Before ordering PET/CT for suspected Richter’s transformation in CLL/SLL, ensure documentation supports B symptoms, rapidly growing lymph nodes, development of extranodal disease, or a significant recent rise in LDH — these criteria are required for medical necessity.

Pre‑biopsy PET/CT for pulmonary masses ≥31 mm only if it will change management

For a pulmonary mass ≥31 mm, PET/CT prior to biopsy is appropriate only when PET findings will change management (e.g., definitive resection/radiation instead of biopsy) or will guide selection of the optimal biopsy site among multiple options.

CAR‑T peri‑treatment PET/CT: one pre‑treatment and one 30–60 days post

For CAR‑T cell therapy, PET/CT is appropriate once before treatment and once 30–60 days after completion; authorization and scheduling should reflect these peri‑treatment timepoints.

Step‑up to PET/CT when prior imaging inconclusive or negative PET changes management

When a negative PET will permit management to change to maintenance or surveillance, or when conventional imaging is inconclusive, PET/CT is considered the next step; include this clinical intent in the authorization request.

Obtain/record prior imaging results before PET/CT when applicable

Providers should obtain or document prior imaging (CT, MRI, Octreotide, MIBG, or SPECT) before PET when those modalities are appropriate; PET is medically necessary only when those studies are negative or inconclusive.

Document SSR PET to assess somatostatin‑analogue therapy candidacy

For locally advanced or metastatic bronchopulmonary/thymic carcinoids not amenable to curative resection, PET with SSR radiotracers may be used to assess candidacy for somatostatin‑analogue therapy — state that treatment planning is the purpose on the authorization.

Document therapy‑timed imaging windows for lymphoma

Therapy‑timed imaging for lymphoma must follow the policy’s specified timing windows (e.g., treatment response and interim scans relative to chemotherapy cycles); reference the relevant cycle/timing on the request.

Specify chemotherapy cycle timing for interim DLBCL response PET/CT

Interim response PET/CT for DLBCL is permitted after 2–4 cycles of chemotherapy for stage II with extensive mesenteric disease and for stages III–IV; include cycle number and clinical indication on authorization.

Do not request PET/CT when conventional studies are diagnostic

When conventional studies (CT/MRI/bone scan) are diagnostic, requests for FDG PET/CT do not meet the policy’s medical appropriateness conditions and will not be approved; documentation must show conventional studies were non‑diagnostic.

Document biopsy non‑diagnostic or unsafe when requesting FES PET/CT

18F‑FES PET/CT to determine ER status is indicated only when biopsy of the metastatic site is non‑diagnostic/inconclusive or biopsy is risky/unable to be performed — include this documentation with the request.

Provide rising CEA or abnormal LFTs with negative imaging for colorectal restaging

For colorectal cancer restaging, provide documentation of rising postoperative carcinoembryonic antigen (CEA) or abnormal LFTs with recent negative conventional imaging to justify PET/CT.

Document isolated metastasis and candidacy for curative local therapy

When PET/CT is requested for metastasis‑directed restaging, document isolated metastatic lesion(s) on other imaging and that the patient is a candidate for aggressive surgical resection or other localized curative therapy.

Provide nodule/mass size and clinical rationale for lung PET/CT

Document pulmonary nodule size (8–30 mm) or pulmonary mass size (≥31 mm) with imaging reports and provide the clinical rationale (e.g., pre‑biopsy planning, selection of biopsy site, or intent to proceed to definitive resection/radiation) to support PET/CT necessity.

Document limited‑stage SCLC or inconclusive imaging for PET/CT

For initial SCLC staging, document that conventional CT chest/abdomen/pelvis and MRI brain indicate limited‑stage disease (confined to one side of the chest) or that conventional imaging is inconclusive to justify PET/CT.

Document timing and Deauville score for Hodgkin PET/CT requests

For Hodgkin lymphoma requests, document timing relative to prior PET/CT (>1 month), the number of chemotherapy cycles (if interim response), and end‑of‑therapy timing (e.g., at least 12 weeks after radiation) or Deauville score when seeking a 3‑month follow‑up.

Include specific clinical indication on authorization

Authorization requests must include the specific clinical reason for PET/CT (e.g., to identify an optimal biopsy site, suspected transformation, CAR‑T timing, Deauville 4–5 follow‑up, melanoma stage criteria, inconclusive conventional imaging, or Merkel cell recurrence) as listed in the policy.

Document biopsy‑proven recurrence or in‑transit concern for Merkel cell PET/CT

For Merkel cell carcinoma restaging when no prior conventional imaging exists, provide documentation of biopsy‑proven recurrence or clinical suspicion of in‑transit metastatic disease to support PET/CT.

Provide prior imaging and pelvic exam for occult primary PET/CT

When PET/CT is requested for an occult primary, document prior CT/MRI, bone scan, diagnostic mammogram and full pelvic exam, or CT showing isolated metastatic disease for planned definitive curative therapy.

Document prior diagnostic PET/CT and specific reason for repeat PET/CT

When requesting repeat whole‑body FDG PET/CT, include documentation that PET/CT was used at initial diagnosis and state the treatment‑response rationale (e.g., after completion of primary therapy, non‑secretory myeloma, inconclusive labs, or extra‑osseous plasmacytoma response).

Include prior imaging results demonstrating negative/inconclusive studies

Prior authorization requests should include prior imaging modality and results (CT, MRI, Octreotide, MIBG, SPECT) showing negative or inconclusive findings when FDG PET/CT or SSR PET is requested based on inconclusive prior studies.

Support FDG PET/CT requests with documentation of negative prior studies or abnormal markers

When FDG PET/CT is requested because other imaging or somatostatin‑receptor studies are negative, provide documentation such as persistent abnormal markers after resection or biopsy‑proven NET of unknown primary with prior negative CT/MRI and SSR study.

Provide prior CT/MRI and SSR study results for neuroendocrine PET/CT

Supporting imaging documentation for neuroendocrine tumor PET/CT requests must show continued suspicion after negative or inconclusive CT/MRI or somatostatin‑receptor studies, or evidence supporting PRRT candidacy assessment.

Document clinical reason for lymphoma PET/CT (biopsy selection, CAR‑T timing, transformation)

For lymphoma PET/CT requests, document the clinical reason (e.g., to select biopsy site, suspected transformation, CAR‑T timing) and prior relevant studies to justify medical necessity.

Require biopsy confirmation or specified recurrence evidence for restaging PET/CT

For diagnostic restaging PET/CT, provide biopsy confirmation of recurrence or specific suspected‑recurrence circumstances (e.g., bone involvement) as described in the policy.

Denial risk if conventional studies are diagnostic

Requests for PET/CT when conventional studies are diagnostic will not meet appropriateness criteria and may be denied; ensure documentation demonstrates conventional studies were non‑diagnostic.

High denial risk for routine surveillance in asymptomatic patients

Routine surveillance PET/CT in asymptomatic individuals with no clinical or laboratory evidence of disease (including breast cancer) is not routinely medically necessary and may be denied; indicate clinical concern or markers if applicable.

Denial risk for colorectal surveillance and small bowel initial staging

PET/CT requests for surveillance of colorectal cancer or initial staging of small bowel cancer are identified as not medically necessary and may be denied unless specific restaging criteria (e.g., rising CEA, isolated metastasis) are documented.

Do not order PET/CT for small bowel initial staging or routine surveillance without qualifiers

Ordering PET/CT for initial staging of small bowel cancer or routine surveillance in asymptomatic individuals without clinical or laboratory evidence of disease are explicit denial triggers — do not submit without qualifying documentation.

Surveillance PET/CT requests without clinical/lab evidence face denial

Requests for PET/CT for routine surveillance in an asymptomatic individual with no clinical or laboratory evidence of disease may be denied; include objective findings or markers to justify imaging when relevant.

Surveillance PET/CT in asymptomatic patients not routinely covered

Routine PET/CT surveillance in asymptomatic individuals without clinical or laboratory evidence of disease is not routinely medically necessary and may be denied — ensure the request documents an approved indication.

Restaging PET for SCLC is usually not covered — case‑by‑case exceptions only

PET imaging for evaluation of treatment response or recurrence of SCLC is generally not medically necessary and may be denied unless considered on a case‑by‑case basis with supporting documentation.

Denial trigger: PET/CT prior to histologic lymphoma confirmation or routine surveillance

PET/CT requests prior to histologic confirmation of lymphoma or routine surveillance PET/CT in asymptomatic individuals with no clinical/laboratory evidence of disease may be denied; do not submit pre‑biopsy indications without histologic support.

Surveillance exclusion: asymptomatic patients without evidence of recurrence

Surveillance PET/CT imaging for an asymptomatic individual with no clinical or laboratory evidence of recurrent disease is an exclusion and may be denied — document clinical rationale if imaging is requested.

Liver PET for post‑ablation response or routine surveillance is not covered

PET imaging of the liver is not medically necessary to assess response to ablation therapy or for routine surveillance of asymptomatic individuals after treatment completion; authorization for these reasons may be denied.

PET/CT may be denied if low‑dose skeletal CT is available and practical

Use of PET/CT when whole‑body low‑dose skeletal CT is available and practical may not meet medical necessity; document why CT is unavailable or impractical when requesting PET/CT for suspected recurrence/progression.

Prior imaging must be negative/inconclusive when required — otherwise denial risk

Requests may be denied if prior CT or MRI is not negative or inconclusive when continued suspicion is the indication; include prior imaging interpretation showing negativity or inconclusiveness with the request.

Surveillance PET/CT without clinical evidence faces high denial risk

PET imaging is not routinely medically necessary for surveillance imaging in asymptomatic individuals with no clinical or laboratory evidence of disease — such requests carry a high denial risk unless covered exceptions apply.

Carcinoid surveillance PET/CT in asymptomatic patients not routinely covered

PET/CT surveillance imaging for asymptomatic individuals with bronchopulmonary/thymic carcinoid and no clinical or laboratory evidence of disease is not routinely medically necessary and may be denied.

Surveillance PET/CT requests without qualifying findings will be denied

Requests for PET/CT surveillance imaging in an asymptomatic individual with no clinical or laboratory evidence of disease will be denied as not medically necessary unless a covered exception is documented.

Routine surveillance PET/CT in asymptomatic patients is generally not covered

PET/CT imaging is not routinely medically necessary for surveillance imaging in asymptomatic individuals without clinical or laboratory evidence of disease; such requests are at risk for denial unless specific criteria are met.

Implied requirement: meet listed criteria before FDG PET/CT coverage

FDG PET/CT coverage is contingent on meeting the policy’s general and cancer‑specific criteria (conventional studies non‑diagnostic and used to determine an optimal biopsy site); prior authorization should confirm criteria are met.

Specify PET/CT or PET/MRI and 3–6 month timing for cervical cancer

PET/CT or PET/MRI is the authorized modality for initial cervical cancer staging and for restaging/surveillance once at 3–6 months post‑therapy for specified stages — prior authorization should specify modality and timing.

Require documentation for non‑routine PET/CT indications

Prior authorization is required when PET/CT is requested for indications outside routine use or when documentation of qualifying criteria (isolated metastasis for curative intent, rising markers, inconclusive conventional imaging) is needed.

Authorize PET/CT for post‑diagnosis NSCLC or to confirm limited SCLC

PET/CT is medically necessary for initial staging after tissue diagnosis or to confirm limited SCLC when conventional imaging indicates limited disease — include this rationale in authorization requests.

Document Deauville 4–5 to authorize single 3‑month follow‑up

A single follow‑up PET/CT at 3 months may be approved for Deauville 4 or 5; ensure the end‑of‑therapy PET/CT showing Deauville 4–5 is documented on the authorization.

Authorize single 3‑month follow‑up (Deauville 4–5) and CAR‑T scans with timing documented

Single follow‑up at 3 months for Deauville 4–5 and CAR‑T baseline and 30–60 day post‑treatment scans require prior authorization that documents the specific indication and timing.

Authorize PET/CT for Merkel cell restaging or specified adrenal evaluations

PET/CT is required (authorization) when used for Merkel cell carcinoma restaging/recurrence or for specified adrenal metastatic evaluation as described in the policy; include the supporting clinical details.

Document/authorize CAR‑T related PET/CT scans

CAR‑T related PET/CT scans (one before and one 30–60 days after completion) may require documentation/authorization — include intent and timing on the request.

Require FDG PET/CT for CAR‑T and stem cell transplant timing

FDG PET/CT is required for pre/post CAR‑T and for pre/post stem cell transplant timing‑based studies (once before and once 30–60 days after CAR‑T; once before and once within 30–100 days after transplant) and should be reflected in authorization requests.

Authorize PET/CT/PET‑MRI for PRRT candidacy

PET/CT (or PET/MRI) is medically necessary to assess candidacy for PRRT with Lutetium‑177 Lu‑dotatate; prior authorization should reference PRRT assessment.

Document SSR agent when requesting SSR PET for NETs

Use of SSR radiotracers for initial work‑up/staging or when CT/MRI is inconclusive should be documented and prior authorization should reference the specific SSR agent requested.

Authorize SSR PET for PRRT candidacy or restaging with supporting documentation

PET/CT or PET/MRI used to assess PRRT candidacy or for restaging/recurrence with SSR radiotracers requires prior authorization with documentation of continued suspicion and prior negative/inconclusive CT/MRI.

Accept PET/CT when IV contrast is contraindicated for liver therapy planning

PET/CT is acceptable for initial work‑up/staging when IV contrast is contraindicated and liver‑directed therapies are being considered — document the contrast contraindication on the authorization to support medical necessity.

Justify PET/CT if low‑dose skeletal CT is available

When whole‑body low‑dose skeletal CT is available and practical, PET/CT may not be considered necessary; authorization requests should explain why CT is unavailable or impractical if PET/CT is being requested instead.