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MP 6.01.26 Oncologic Applications of PET Scanning

Medical Policy    
Section
Radiology 
Original Policy Date
4/30/00
Last Review Status/Date
Updated by AIM -Last reviewed/2:2015
Issue
2:2015
  Return to Medical Policy Index

Disclaimer

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 Diagnostic Imaging Clinical Guidelines.

These guidelines can be accessed at:

AIM Specialty Health

Click on PET, other PET applications including oncologic tumor for these specific guidelines.

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.

Codes

Number

Description

CPT 

 

See Policy Guidelines 

ICD-9 Procedure 

 

 

ICD-9 Diagnosis 

140 – 149.9

Malignant neoplasm of lip, oral cavity and pharynx code range

 

150.0-150.9 

Malignant neoplasm of esophagus code range

 

153.0-153.9

Malignant neoplasm of colon code range

  154.0 Malignant neoplasm of rectosigmoid junction (includes colon with rectum)

 

157.0-157.9

Malignant neoplasm of pancreas code range

  160.0-160.9 Malignant neoplasm of nasal cavities, middle ear and accessory sinuses code range
  161.0-161.9 Malignant neoplasm of larynx code range

 

162.2 – 162.9 

Malignant neoplasm, bronchus, lung code range

 

172.0-172.9

Malignant melanoma of skin code range

  174.0-174.9 Malignant neoplasm of female breast code range
  175.0-175.9 Malignant neoplasm of male breast code range
  180.0-180.9 Malignant neoplasm of cervix uteri code range
  183.0 Malignant neoplasm of ovary
  186.0-186.9 Malignant neoplasm of testis
  193 Malignant neoplasm of thyroid gland
  195.0 Malignant neoplasm of head, face and neck NOS

 

199.0-199.1

Malignant neoplasm without specification of site (unknown primary)

 

201.0-201.9

Hodgkin's disease code range

  202.0-202.8 Other malignant neoplasm of lymphoid tissue (other lymphomas)

HCPCS 

 

See Policy Guidelines 

ICD-10-CM (effective 10/1/15) C00.0-C14.8 Malignant neoplasm of lip, oral cavity and pharynx code range
  C15.3-C15.9 Malignant neoplasm of esophagus code range
  C18.0-C18.9 Malignant neoplasm of colon code range
  C19 Malignant neoplasm of rectosigmoid junction (includes colon with rectum)
  C25.0-C25.9 Malignant neoplasm of pancreas code range
  C30.0-C31.9 Malignant neoplasm of nasal cavities, middle ear and accessory sinuses code range
  C32.0-C32.9 Malignant neoplasm of larynx code range
  C34.0-C34.92 Malignant neoplasm of bronchus and lung code range
  C40.0-C41.9 Malignant neoplasms of bone and articular cartilage code range
  C43.0-C43.9 Malignant melanoma of skin code range
  C50.011-C50.929 Malignant neoplasm of breast code range
  C53.0-C53.9 Malignant neoplasm of cervix uteri code range
  C56.0-C56.9 Malignant neoplasm of ovary code range
  C62.00-C62.92 Malignant neoplasm of testis code range
  C73 Malignant neoplasm of thyroid gland
  C76.0 Malignant neoplasm of head, face and neck NOS
  C80.0-C80.1 Malignant neoplasm without specification of site (unknown primary)
  C81.00-C81.99 Hodgkin’s disease code range
  C82.00-C88.9 Other malignant neoplasm of lymphoid tissue (other lymphomas)
ICD-10-PCS (effective 10/1/15)   ICD-10-PCS is for use only on inpatient services. There are a few specific PET ICD-10-PCS codes such as the following:
  CB32KZZ, CB32YZZ Nuclear medicine, respiratory system, positron emission tomographic (PET) imaging, lungs and bronchi, code by radionuclide
  CB3YYZZ Nuclear medicine, respiratory system, positron emission tomographic (PET) imaging, respiratory system

Type of Service 

Radiology 

Place of Service 

Outpatient 

 


Policy History

 

Date Action Reason
04/30/00 Add to Radiology section New policy
08/18/00 Replace policy Policy statement of PET for pancreatic cancer revised to be consistent with TEC Assessment. New policy statement on PET for head and neck cancer, based on 2000 TEC Assessment
02/15/02 Replace policy Policy revised with TEC Assessments; new policy statement on PET applications for breast and esophageal cancer, additional coding information
05/15/02 Replace policy Policy updated: Appendix updated with new Medicare policy on PET scanning for breast cancer; policy statement unchanged
07/12/02 Replace policy Policy revised: new policy statement on ovarian cancer and unknown primary; reference added to 2002 TEC Assessments; expanded Rationale section
12/17/03 Replace policy Policy regarding PET for breast cancer updated based on 2003 TEC; no change in policy statement. Other oncologic aspects of PET scanning not reviewed. New Medicare policy changes added. New 2004 HCPCS code added (G0296)
11/9/04 Replace policy CPT codes updated in policy guidelines section
12/15/05 Replace policy Policy revised: new policy statements on small cell lung cancer, testicular cancer, and soft tissue sarcoma. Updated reviews of evidence are provided for pancreatic cancer, esophageal cancer, breast cancer and ovarian cancer. CPT and HCPCS coding updated
10/13/2006 Revised policy Policy updated
02/15/07 Local Policy Policy revised with literature search. Updated reviews of evidence provided for esophageal cancer and breast cancer; no change in policy statement. Reference numbers 10 and 17 added
10/20/08 Replace policy  policy statement update; added specific criteria for medically necessary indications 
11/11/10 Replace policy (no longer local) adapted BCBSA TEC policy
02/09/12 Replace policy Policy updated with literature review. New medically necessary indications added for initial diagnosis and staging of bone cancer and cervical cancer; policy statement revised for head/neck cancer and lymphoma. Extensive rewrite of Rationale section; references 20-22 added.
2/14/13 Replace policy Policy updated with literature review. References 22-35 added. Policy statements revised with investigational indications added to breast cancer, colorectal cancer, soft tissue sarcomas and thyroid cancer. Thyroid cancer revised to include both differentiated and poorly differentiated disease. Prostate cancer moved to section on Other Oncologic Applications; also added to this section are diagnosis of brain tumors, restaging of gastric cancer, staging of multiple myeloma, evaluation of neuroendocrine tumors and staging of inguinal lymph nodes in patients with squamous cell carcinoma of the penis.
2/2015   policy updated to reflect AIM Specialty Health as the vendor and resource for med nec review