Oncologic Applications of PET Scanning - CAM 759

Policy
General Notes:
Adult and Pediatric Malignancies: ONCOLOGICAL PET IS INDICATED FOR BIOPSY-PROVEN CANCER OR STRONGLY SUSPECTED CANCER BASED ON OTHER DIAGNOSTIC TESTING. The appropriateness of an ordered PET/CT study is dependent on which radiopharmaceutical will be used for the PET/CT.

FDG-PET/CT (fluorodeoxyglucose-positron emission tomography)

Lung nodule seen on LDCT or CT+ contrast (without known malignancy)

Solid component of dominant nodule (either solitary or clearly dominant) ≥ 8 mm and < 3 cm or part solid/mixed nodules with the solid component 8 mm or larger
Mixed nodule (i.e., ground glass and solid nodule) with solid component of the nodule ≥ 4 mm on LDCT when there has been
- Interval growth of the solid component of at least 1.5 mm on subsequent LDCT scans OR
- Interval development of a new mixed nodule on subsequent LDCT with the solid nodule component ≥ 4 mm

NOTE: > 3 cm is considered a mass; therefore, a tissue type is usually needed prior to PET (to determine if SCLC or NSCLC). However, if the chest CT imaging findings meet criteria for limited stage SCLC and no prior imaging shows metastatic disease elsewhere, PET can be approved prior to biopsy in order to guide biopsy of any FDG-avid adenopathy at the same time the primary is biopsied. If disease clearly is in both sides of the chest and/or outside the chest, then PET is not needed/approvable prior to tissue diagnosis.

Useful Definitions (to aid in using the following table[s])

Initial staging refers to imaging that is performed AFTER the diagnosis of cancer is made, and generally before any treatment.
Restaging includes scans that are either needed during active treatment* (subsequent treatment strategy**) to determine response to treatment, within 6 months after the end of treatment, or when there is clinical concern for recurrence (i.e., new imaging, new signs, rising labs/tumor markers or symptoms relative to type of cancer and entire clinical picture) (recurrence is not required to be biopsy proven)
*Active treatment includes traditional chemotherapy, immunotherapy, radiation, as well as patients on “maintenance therapy” who have known, or existing, metastatic disease being held in check by this treatment. Allogenic bone marrow transplant and CART T-cell therapy should be considered "active" treatment for at least 6 months after infusion/transplant and as such can be approved at 30 days, 100 days, and 6 months after the most recent infusion.
**Subsequent treatment strategy
- For restaging or monitoring response during active treatment (including immunotherapy), and/or a single evaluation after completion/cessation of therapy. The interval should ideally^‡ be 6 – 12 weeks after surgery, and 12 weeks after radiation (to avoid false positive findings that can be caused by treatment changes or healing).
- PET/CT can be performed 1 – 3 weeks after neoadjuvant chemotherapy or neoadjuvant chemoradiation if done for presurgical planning to evaluate for distant metastatic disease or to evaluate known metastatic disease located in areas separate from the site(s) being radiated.

^‡NOTE: a valid clinical reason explaining why the interval needs to be shorter than ideal must be present

Inconclusive imaging — see Background section at end of guidelines
Surveillance PET is generally not approvable. Surveillance means no active treatment, no current suspicion of recurrence and occurs 6 months or more after completion of treatment. Possible exceptions^† where PET “may be considered” for surveillance:
- Ewing’s
- Osteosarcoma
- Breast (Stage 4)
- Cervical (Stage 2 – 4)
- Diffuse Large B Cell Lymphoma when disease was only seen previously on PET
- Histiocytic neoplasms every 3-6 months for the first 2 years post completion of treatment
- Melanoma (Stage 2b – 4)
- Myeloma/plasmacytoma (ideally use same type imaging as was used in initial dx, up to 5 yrs after the diagnosis of plasmacytoma)
- Seminoma (Stage 2b, 2c and 3)

^†NOTE: These cases would need to include a clinical reason why PET is needed (i.e., being considered), rather than conventional imaging (CT, MRI, bone scan). Generally, this would be accepted only when ordered by the treating oncologist or clearly at their recommendation (not as routine follow-up ordered by PCP).

FDG PET

ONCOLOGICAL INDICATIONS FOR FDG PET
(SEE SPECIAL TRACERS SECTIONS FOR INDICATIONS OTHER TRACERS)

CANCER TYPE	INITIAL STAGING	RESTAGING
Adrenal (other than pheochromocytoma/ paraganglioma)	Not Indicated	Not Indicated
AIDS-related Kaposi Sarcoma	With prior inconclusive imaging	Not Indicated
Acute Lymphoblastic Leukemia (ALL)	Lymphomatous extramedullary disease	Lymphomatous extramedullary disease
Acute Myelogenous Leukemia (AML)	If suspected extramedullary involvement	If suspected/known extramedullary involvement
Anal (Note that normal size pelvic adenopathy can be considered as inconclusive)	With prior inconclusive imaging (can be done with PET (PET/CT or PET/MR^‡‡ if available))	With prior inconclusive imaging
Basal Cell (BCC of the skin)	Not Indicated	Not Indicated
Bladder	Muscle invasive only, with prior inconclusive imaging	With inconclusive imaging and supected metastatic disease or recurrence outside of the urinary tract
Breast	Indicated for stage IIb and above (if only T and N are provided, this equates to T3 (tumor > 50 mm); or T4 (tumor of any size with direct extension to chest wall and/or skin); or N2 (> 3 axillary LN, ipsilateral internal mammary node); or the combination of T2 (tumor > 20 mm but < 50 mm) plus N1 (any positive lymph node involvement)	With prior inconclusive imaging, if initial stagging was performed with PET OR if recurs with llb or higher disease (based pathology/imaging/exam) since no previous initial staging would have typicall been performed for lower grade breast cancer
Cervical	Indicated (can consider PET/MR^‡‡ if available)	Indicated
Chordoma	With prior inconclusive imaging	With prior inconclusive imaging
Cholangiocarcinoma	With prior inconclusive imaging	With prior inconclusive imaging

Chondrosarcoma (bone)	Not Indicated	Not Indicated
Colorectal	With prior inconclusive imaging OR potentially surgically curable M1 disease OR when considered for image-guided liver-directed therapies	With prior inconclusive imaging
Endometrial	With prior inconclusive imaging	With prior inconclusive imaging
Esophogeal and EGJ (esophagogastric junction epicenter < 2m into stomach)	Indicated	Indicated
Ewing Sarcoma — osseous	Indicated (all ages)	Patients < 30 yrs old: Indicated Patients > 30 yrs old: Indicated for known or suspected metastatic disease (based on PE/imaging)
Fallopian Tube Cancer	With prior inconclusive imaging	With prior inconclusive imaging
Gallbladder	With prior inconclusive imaging	With prior inconclusive imaging
GASTRIC (include EGJ tumors with epicenter > 2 cm into stomach)	With prior inconclusive imaging or if radiation is being considered (Not indicated for T1N0M0 or M1)	With prior inconclusive imaging, PET/CT is indicated for post radiation imaging
Gestational Trophoblastic Cancer	With prior inconclusive imaging	With prior inconclusive imaging
Head and neck (including mucosal melanoma of the head and neck)	Indicated May be done in conjunction with a dedicated face/neck MRI (or CT) when surgery or radiation is planned	Indicated Can concurrently approve a Neck MRI and PET 3 – 4 months after definitive treatment in patients with locoregionally advanced disease or with altered anatomy. PET should not be done earlier than 12 weeks after definitive treatment unless signs or symptoms of recurrence If final PET/CT is equivocal or borderline for residual disease, a repeat PET/CT at > 6 weeks may help identify those that can be safely observed without additional surgery

Hepatocellular	With prior inconclusive imaging	with prior inconclusive imaging
Leukemia (refer to specific types listed in table when possible)	If there is lymph node involvement (lymphomatous features), soft tissue and/or extramedullary involvement (myeloid sarcoma) and/or if forms “chloromas” (leukemia tumor balls)	If there is lymph node involvement (lymphomatous features), soft tissue and/or extramedullary involvement (myeloid sarcoma) and/or if forms “chloromas” (leukemia tumor balls)
Lung Non-Small Cell Limited stage small cell Stage I III And T3/T4 if disease is encompassed in tolerable radiation plan (Potentially Curable) Extensive small cell Stage IV and T3 or T4 disease not able to be treated with curative intent	Indicated Indicated Not indicated	Indicated Indicated Not indicated
Lymphocytic Leukemia Chronic (CLL) and Small (SLL)	For suspected high-grade transformation or to guide biopsy with prior inconclusive imaging	With accelerated CLL or to guide biopsy with prior inconclusive imaging (includes negative CT with rising tumor markers or if conventional imaging documents mets, If clearly considering resection)
Lymphoma (Non-Hodgkins and Hodgkins)	Indicated (can consider PET/MR^‡‡)	Indicated (can consider PET/MR^‡‡)
Melanoma (See Uveal melanoma below for indications)	Only stage III, IV indicated	Only stage III, IV indicated
Merkel Cell	Indicated	Indicated
Mesothelioma (malignant) Pleural Peritoneal	Indicated only Prior to surgery for state I – IIIA Indicated	Indicated only prior to surgery for stage I-IIIA Indicated
Multiple Myeloma Smoldering myeloma (asymptomatic) Active myeloma Plasmacytoma	Indicated Indicated Indicated	Indicated annually or possibly more frequently as clinically indicated (labs and /or symptms to suggest progression) Indicated Indicated
Neuroblastoma	Indicated when MIBG is negative, inconclusive, or there are discordant findings between MIBG and pathology	Indicated when the FDG PET was used for initial staging or if MIBG has become inconclusive or discordant
Neuroendocrine Tumors (NET) Undifferentiated/Differentiated (including pheochromocytoma, paraganglioma, extrapulmonary large/small cell)	Indicated if used after prior negative or inconclusive Ga68 Dotatate scan	Indicated when FDG was used for initial staging, or when used after prior negative/inconclusive Ga68 Dotatate scan (or MIBG scan) OR after inconclusive conventional imaging
Ovarian	With prior inconclusive imaging	with prior inconclusive imaging
Occult primary	With prior inconclusive imaging appropriate to pathology of the biopsy that identified the occult malignancy	with prior inconclusive imaging
Osteosarcoma Osseous	For patients > 30 years old: Indicated when the prior bone scan is inconclusive or negative (i.e., the primary bone tumor is not seen on bone scan). PET can be approved in conjunction with MR of primary site For patients < 30 years old: Indicated PET can be approved in conjunction with MR of primary site	For patients > 30 yrs old: Indicated when disease is positive on prior FDG-PET or when there is inconclusive conventional imaging. PET can be approved in conjunction with MR of primary site For patients < 30 years old: Indicated PET can be approved in conjunction with MR of primary site
Pancreatic	With prior inconclusive imaging OR with any of the following high-risk features: borderline resectable disease markedly elevated CA19-9 > 180 U/ml large primary tumor/lymph nodes very symptomatic (jaundice, symptomatic gastric outlet obstruction, venous thromboembolism, extreme pain and excessive weight loss	When PET was used for initial staging and need to assess response to treatment in order to determine if now a surgical candidate
Penile	With prior inconclusive imaging	With prior inconclusive imaging
Peritoneal Cancer (Primary)	With prior inconclusive imaging	With prior inconclusive imaging
Post Transplant Lymphoproliferative Disorder (PTLD)	Indicated when the diagnosis is made OR if suspected based on abnormal PE, abnormal imaging or abnormal labs (i.e., significantly elevated or rising viral titers)	Indicated
Prostate (FDG PET only) See other PET tracer section below for prostate cancer	Not Indicated	Not Indicated
Renal	ONLY when conventional imaging is equivocal for metastatic disease and if present would alter initial treatment plan	ONLY when conventional imaging is clearly insufficient in these circumstances: For suspected recurrence/metastatic disease outside of the urinary tract To monitor treatment with a Tyrosine Kinase Inhibitor (such as sunitinib, sorafenib) for advanced RCC when disease was only seen previously on PET
Skin Squamous Cell	With prior inconclusive imaging	Not Indicated
Small Bowel Adenocarcinoma	Not Indicated	With prior inconclusive imaging
Soft Tissue Sarcoma (including soft tissue/extraosseous Ewing sarcoma and soft tissue/extraosseous osteosarcoma)/GIST/ Rhabdomyosarcoma)	For patients > 30 years old: with prior inconclusive imaging For patients < 30 years old: Indicated (does not require inconclusive conventional imaging)	For patients > 30 yrs old with prior inconclusive imaging For patients < 30 years old: Indicated (does not require inconclusive conventional imaging)
Testicular Seminoma Nonseminoma	Not Indicated	with prior inconclusive imaging or residual mass >3cm or 6 weeks post chemotherapy (If final PET/CT is equivocal or borderline for residual disease PET/CT, a repeat PET/CT a > 6 weeks may help identify those that can be safely observed without additional surgery) Not Indicated
Thymoma and Thymic Cancer	Indicated	Indicated
Thyroid Papillary, follicular Hurthle Anaplastic Medullary	Not Indicated If Tg is high and/or pathology is high risk With prior inconclusive imaging Not Indicated (see NET/Dotatate indications below)	Indicated with the following 3 criteria: A thyroidectomy and radioiodine ablation were done initially; AND Serum thyroglobulin is > 2 ng/ml (unstimulated or stimulated) OR there is a high anti-thyroglobulin antibody (anti-Tg Ab) > 1 year after treatment AND A Negative current I\u0002131/123 scan OR a Negative prior stimulated whole body I-131/ I-123 scan done at TG level similar to the current TG level (a current scan is needed if on radioiodine sensitizing medications) IF Tg is high and/or pathology is high-risk With prior inconclusive imaging With prior inconclusive imaging when calcitonin levels ≥ 150 pg/ml or CEA levels > 5 ng/ml post-surgery with prior insufficient Dotatate scan
Uterine	With prior inconclusive imaging	With prior inconclusive imaging
Uveal Melanoma	Not Indicated	With prior inconclusive imaging
Vaginal	Indicated	Indicated
Vulvar	≥ T2 or after prior inconclusive imaging	Indicated

MISCELLANEOUS (NON-ONCOLOGIC) INDICATIONS FOR FDG PET

(excluding brain and cardiac PET which have separate guidelines)

CANCER TYPE	INITIAL STAGING	RESTAGING
CASTLEMAN’S DISEASE	Indicated	Indicated
HISTIOCYTIC NEOPLASMS: Langerhan's Erdheim Chester Rosai-Dorfman	Indicated Indicated Indicated	Indicated if on active treatment for multiple bone disease, high risk bone disease or multisystem involvement Indicated if on active treatment Indicated if on active treatment
*SARCOIDOSIS ONLY if conventional testing (CXR, CT and inflammatory serology) remain inconclusive for known sarcoid to determine: if treatment might be helpful extent of disease, if it will potentially change management response to treatment OR if strongly supected sarcoid to determine most suitable site to biopsy
VASCULITIS In limited circumstances, with known vasculitis, AFTER conventional imaging (MRA/CTA/MR/CT) has clearly been shown to be insufficient to determine treatment Adjudications should occur on a case-by-case basis

NON-FDG PET TRACERS

GA68-DOTATATE, GA68-DOTATOC and CU64-DOTATATE FOR NET (Neuroendocrine Tumors)
CANCER TYPE	INITIAL STAGING	RESTAGING
CARCINOID EXTRAPULMONARY LARGE AND SMALL CELL MEN-1/MEN-2 SYNDOMES NEUROENDOCRINE TUMORS (NET) PHEOCHROMOCYTOMA PARAGANGLIOMA	Indicated PET/MR^##can be considered	Indicated PET/MR^‡‡ can be considered
MEDULLARY THYROID	Prior CT/ MRI insufficient to Determine extent of treatment plan Determine if candidate for invasive diagnostic/ therapeutic procedure Determine optimal anatomic location for invasive procedure	When calcitonin levels ≥ 150 pg/ml or CEA levels > 5 ng/ml post-surgery

YTTRIUM-90 (Y90)

Y90 PET SCAN: Indicated when performed immediately after treatment of liver malignancy (primary or metastatic) with Y90 (usually within 24 hours while Y90 is still detectible). The Y90 treatment is the tracer for this PET (see Y90 background section).

PSMA TRACERS (such as F18 piflufolastat [Pylarify^®], GA 68 PSMA-11, GA 68 gozetotide [Locametz^®], and GA 68 gozetotide [Illuccix^®]); F18 FLUCICLOVINE (AXUMIN^®) and C11 CHOLINE For PROSTATE CANCER
CANCER	INITIAL STAGING	RESTAGING
PROSTATE (PET/CT or PET/MRI^‡‡) After a negative Axumin^® PET, a subsequent PSMA PET is not covered until a repeat PSA (done at least 3 months later) shows a progressive rise 11-Choline should be approved only if PSMA and/or Axumin^® are not available. Order of preference typically would be PSMA, then Axumin^®, then 11-Choline	Only PSMA (not Axumin^® or Choline) is indicated in initial staging for high risk; defined as 1 or more of the following: Gleason 8, 9 or 10 (specimen contains pattern 4 or 5) Gleason 7 IF primary pattern is 4 (4 + 3 = 7) Gleason 7 primary pattern 3 (3 + 4 = 7) must ALSO have a PSA > 10 and/or cT2b-cT3c disease Gleason 6 disease (3 + 3 = 6) must ALSO have a PSA > 20 and/or cT3a-cT4 disease > 50% cores positive for cancer in random biopsy The Primary Pattern refers to the 1st number in the Gleason Pattern	For post-surgery/radiation in suspected recurrence with at least two separate detectable PSA levels above the nadir for that patient for: Axumin^® (or Choline) Indicated if bone scan and CT/MRI are negative or inconclusive PSMA (preferred tracer) PSA < 10 Indicated PSA > 10 Indicated if bone scan and CT/MRI are negative or inconclusive
	Pelvic MRI can be approved concurrently if needed for surgical planning	For post surgery/radiation in known recurrence, PSMA is approvable if: Disease was previously seen only on PSMA PET For metastatic castrate resistant disease that have failed both taxanes and ARDI, PSMA is approvable if: Individual is a candidate for Lu-PSMA treatment (Pluvicto^®) (must be clearly documented in note) Restaging on Lu-PSMA treatment (Pluvicto^®)

BACKGROUND
Inconclusive Imaging includes the following:

Equivocal or ambiguous other prior standard imaging if results will change management
Biopsy guidance (e.g., tumors with necrosis)
High suspicion of metastases due to clinical or histopathological or laboratory considerations but with no evidence of metastases on standard initial staging
Clinical or laboratory disease progression with negative standard imaging
Contraindications to IV contrast, including allergy and chronic renal failure precluding MRI in a patient with a known or highly suspected malignancy
- PET/CT may be indicated if CT cannot be performed due to significant iodinated contrast allergy or chronic renal failure AND MRI cannot be performed due to significant gadolinium contrast allergy or if renal failure with GFR < 30 (RSNA, 2018).
Evaluation for other distant metastases prior to surgical resection of limited metastases/local disease and otherwise negative prior standard imaging
Response to neoadjuvant therapy when CT/MR insufficient
Residual masses after completion of therapy
Target definition for radiation planning
If previous conventional imaging has been inconclusive, and it seems reasonable to expect that to still be the case, new conventional imaging is NOT required

In situations where there is questionable disease in an area that requires significantly invasive procedures to obtain tissue (such as open surgical procedures), and malignancy is high on the radiographic differential diagnosis, it is reasonable and medically appropriate to attempt to gain as much information about diagnosis from imaging prior to subjecting the patient to tissue diagnosis that has real risk of morbidity/mortality.

Definition of Disease Progression:
For any signs of progression, as noted below, that could not be confirmed by other imaging, PET/CT is needed. Findings concerning for progression of disease include:

Worsening of symptoms such as pain or dyspnea
Evidence of worsening or new disease on physical examination
Declining performance status
Unexplained weight loss
Increasing alkaline phosphatase, alanine aminotransferase (ALT), aspartate transaminase (AST), or bilirubin
Hypercalcemia
New radiographic abnormality or increase in the size of pre-existing radiographic abnormality
New areas of abnormality on functional imaging (e.g., bone scan, PET/CT)
Increasing tumor markers (e.g., carcinoembryonic antigen (CEA), CA 15-3, CA27.29)

PET/CT also helps to differentiate active tumor from necrotic or inactive scar tissue, malignant from benign tissue, and recurrent tumor from nondescript benign changes.

Positron emission tomography-Computed Tomography (PET/CT) is a rapidly developing and changing technology that is able to detect biochemical reactions, e.g., metabolism, or abnormal distribution of cell receptors within body tissues. A radioactive tracer is used during the procedure. Unlike other nuclear medicine examinations, PET/CT can measure metabolic activity of the cells of body tissues, providing information about the functionality and structure of the particular organ or tissue examined. PET/CT may also detect biochemical changes that help to evaluate malignant tumors and other lesions.

TYPICALLY, separate CT/MR scans being requested concurrently with a PET are not needed. There should be very few instances where separate studies are needed, and when this does happen, it is usually SITE-SPECIFIC. Most PET scanners now in use can "simultaneously" perform PET and CT (whether CT Attenuation or a Diagnostic CT). Contrast can be given for the CT portion of the PET/CT. A separate request for diagnostic CTs in addition to PET is therefore not needed. The ordering MDO can specify to the imaging provider details about what type of CT scan is desired to be done with the PET portion. "Exceptions" generally occur when CT is needed in a plane other than standard axial imaging (for example: coronal CT for facial bone imaging that might be needed for surgical reconstruction). Separate MRIs are likewise rarely needed, but are perhaps somewhat more frequently needed than additional, separate CTs, since MRI does allow multiple imaging planes and may provide additional information. When evaluating for these "exceptions", the reason additional separate imaging is needed should be clearly delineated before approval.

The degree of radioactive tracer uptake may indicate increased metabolism in the cells of body tissues or an abnormal distribution of cell receptors. Cancer cells may show increased radioactive tracer relative to tissue not involved with tumor. Radioactive tracer uptake is often higher in fast-growing tumors; PET/CT is often not as beneficial for slow growing tumors. Radioactive tracer uptake may occur in various types of active inflammation and is not specific for cancer. FDG is the most widely known and frequently requested radiotracer; however, the use of "special tracers" is a rapidly progressing field. These "special tracers" are typically somewhat specific to a certain cancer type due to their physiological properties. As such, a particularly careful review should be made when there is concern that a "special tracer" is needed or requested, regardless of whether the ST icon is present. If the notes clearly indicate the desired tracer (and guidelines are met for the tracer and cancer type), the case should be adjudicated according to the notes rather than the presence or absence of the ST icon. However, if the notes do not clearly indicate what tracer is requested, this needs to be clarified when there is discrepancy between notes and the ST icon (or lack thereof).

Patients with certain malignancies may benefit more from PET/MRI since it detects brain and liver metastases better when compared with PET/CT. NCCN does suggest consideration of PET/MR in some malignancies (see table for specific cancers), but not specifically replacing PET/CT. PET/MRI should only be considered for certain malignancies and in specific situations (such as when extensive travel would be needed, for pediatric cases, particularly those requiring sedation or when reasonably expect a need for multiple PET scans where radiation exposure from CT would be a significant factor). Typically, PET/CT should suffice; however, under some circumstances, with clear explanation of why PET/MR is preferred rather than PET/CT, PET/MR may be an appropriate study^‡‡(NCCN, 2020).

Langerhans Cell Histiocytosis (Jessop, 2020; Daldrup-Link, 2001; Obert, 2017; Phillips, 2009) is the most common type of histiocytosis, with variable presentations and sites involvement. The osseous structures are the most common site of involvement. PET/CT is highly sensitive and specific for whole body evaluation as FDG is a metabolite of the histocyte cell and allows for a reproducible evaluation for response to effectiveness of treatment on restaging exams. Some studies suggest PET/CT may be more effective in detecting bone lesions compared with MRI and bone scans in assessing disease response as healing/treatment changes of bone lesions on conventional imaging maybe delayed. PET/CT is, however, not the modality of choice in assessing disease response of lung or brain lesions; in these scenarios, Chest CT (HRCT) and Brain MRI would be the test of choice, respectively.

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This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

History From 2014 Forward

11/17/2022	Annual review, adding note for lung nodule and updating surveillance criteria for clarity and specificity.
11/01/2021	Annual review, adding statements regarding CAR-T therapy and medical necessity criteria for PTLD. Also updating description and references.
01/26/2021	Updating annual review date.
11/17/2020	Annual review with major format revision to a table format. Also multiple policy revisions related to NCCN recommendation changes. Updating description and references.
02/13/2020	Annual review, no change to policy intent. Updating rationale and references.
02/07/2019	Major revision of content for clarity without change to policy intent.
04/10/2018	Interim review to add medical necessity verbiage for Axumin (fluciclovine F 18) and a statement directing readers to CAM 512 as it relates to reimbursement for radiopharmaceuticals related to PET scanning.
03/15/2018	Annual review, policy revised to indicate the following: "Additional details added to policy statements. Updated guidelines, rationale and references
02/06/2017	Annual review, no change to policy intent.
02/17/2016	Annual review, no change to policy intent.
03/05/2015	Annual review, added verbiage related to medical necessity related to gastric cancer, added related policies and coding. Updated guidelines, rationale and references.
09/11/2014	Corrected typo error. No change in policy.
02/24/2014	Annual review. Updated rationale and references. Changing policy verbiage to indicate initial treatment strategy for breast cancer & melanoma is investigational.

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Oncologic Applications of PET Scanning - CAM 759