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MP 6.01.06 Miscellaneous (Noncardiac, Nononcologic) Applications of Positron Emission Tomography

Medical Policy    
Original Policy Date
Last Review Status/Date
Reviewed with literature search/2:2015
  Return to Medical Policy Index


Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically. 

Blue Cross of Idaho follows AIM Specialty Health Radiology Clinical Appropriateness Guidelines.

These guidelines can be accessed at:

Regarding Medicare Advantage Patients:

Blue Cross of Idaho Medicare Advantage plans follow the medical policies of the Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) for the Medicare contractors in the state of Idaho.

Policy History  

Date Action Reason
12/01/95 Add to Radiology section New policy
01/30/98 Replace policy Reviewed with changes; new CPT codes
07/10/98 Replace policy Revised policy; updated regulatory status to PET
07/10/99 Replace policy Original policy on PET scans put into two policies; 6.01.06 noncardiac application and 6.01.20 cardiac applications; recommendation for noncardiac applications of PET are unchanged
08/18/00 Replace policy Revised because cardiac and oncologic applications of PET scans now addressed in separate policies, Nos. 6.01.20 and 6.01.26, respectively. Policy statement regarding remaining applications, unchanged
12/17/03 Replace policy Policy updated. Policy statements added regarding musculoskeletal uses (investigational); for remaining applications, policy statements unchanged
11/9/04 Replace policy Policy updated with CMS decision regarding PET scans for dementia; policy statement unchanged, still consider PET for dementia as investigational
12/14/05 Replace policy Policy updated; search for systematic review, meta-analyses, and decision analyses found no sources that would change policy positions. HCPCS coding updated
04/17/07 Replace policy Policy updated with literature search; reference numbers 17–22 added. Policy statements changed: chronic osteomyelitis added as “may be considered medically necessary” and giant cell arteritis added as “investigational.” Code table updated
08/13/09 Replace policy Policy updated with literature search; references 23 through 28 added. Two additional dementia subtypes added to policy statement (frontotemporal dementia and dementia with Lewy Bodies); policy statements otherwise unchanged.
11/11/10 Replace policy Policy updated with literature search; minor changes to policy statements (investigational indication for schizophrenia moved from dementias to psychiatric diseases and disorders; “vasculitis” added to investigational “other” category). References 29-36 added
12/08/11 Replace policy Policy updated with literature search. “Non-cardiac, non-oncologic” added to title. Mycobacterium infection and inflammatory bowel disease added as investigational indications. Regulatory status information moved to Description section. Rationale re-written. References 19-21, 26-28, 31-34 added; other references renumbered or removed.
2/14/13 Replace policy Policy updated with literature search; Sarcoidosis added as investigational indication, no other changes to policy statement.
2/13/14 Replace policy Policy updated with literature search on January 23, 2014; reference 12 added; no changes to policy statement
2/12/15 Replace policy Policy updated with literature review through January 27, 2015; references 13-14, 19, 25, 28-29, 38-40, 42, 47-49, and 51-60 added; reference 50 updated. Vascular prosthetic graft infection, fever of unknown origin, and inflammation of unknown origin added as investigational indications. Acanthocytosis and assessment of cerebral blood flow in newborns revised but no other changes to policy statements.
3/30/15 replace local policy policy updated to reflect AIM Specialty Health as the vendor and resource for med nec review

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