ACTH	adrenocorticotropic hormone
AFP	alpha-fetoprotein	AP	anteroposterior
betaHCG	beta human chorionic gonadotropin
CA 125	cancer antigen 125 test	CA 19-9	cancer antigen 19-9
CA 15-3	cancer antigen 15-3	CA 27-29	cancer antigen 27-29
CBC	complete blood count
CEA	carcinoembryonic antigen	CNS	central nervous system
CR	complete response
CTA	computed tomography angiography	DCIS	ductal carcinoma in situ
DLBCL	diffuse large B cell lymphomas
DRE	digital rectal exam	EGD	esophagogastroduodenoscopy
ENT	ear, nose, throat	EOT	end of therapy
ERCP	endoscopic retrograde cholangiopancreatography
ESR	erythrocyte sedimentation rate	EUA	exam under anesthesia
EUS	endoscopic ultrasound
FDG	fluorodeoxyglucose	FNA	fine needle aspiration
FUO	fever of unknown origin
GE	gastroesophageal	GI	gastrointestinal
GU	genitourinary
GTR	gross total resection	HG	high grade
HIV	human immunodeficiency disease
HRPC	hormone refractory prostate cancer	hypermet	hypermetabolic
IFRT	Involved field radiation therapy	inv	invasive
LAR	low anterior resection	LCIS	lobular carcinoma in situ
LDH	lactate dehydrogenase	LFT	liver function tests
LND	Lymph node dissection
MALT	mucosa associated lymphoid tissue	maint	maintenance
MEN	multiple endocrine neoplasia	MG	myasthenia gravis
MGUS	monoclonal gammopathy of unknown significance
MIBG	I-123 metaiodobenzylguanidine scintigraphy
MRA	magnetic resonance angiography	MRI	magnetic resonance imaging
MUGA	‘multiple gated acquisition’ cardiac nuclear scan
MWA	microwave ablation
NaF	Sodium Fluoride
NET	Neuroendocrine tumor
NCCN®	National Comprehensive Cancer Network
NHL	non-Hodgkin’s lymphoma	NPC	nasopharyngeal carcinoma
NSABP	National Surgical Adjuvant Breast and Bowel Project
NSAIDS	nonsteroidal anti-inflammatory drugs
NSCLC	non-small cell lung cancer
NSGCT	non-seminomatous germ cell tumor	PA	posteroanterior
PCI	prophylactic cranial irradiation
PET	positron emission tomography	COG	Children’s Oncology Group
PSA	prostate specific antigen	RFA	radiofrequency ablation
RPLND	retroperitoneal lymph node dissection
SqCCa	squamous cell carcinoma	SCLC	small cell lung cancer
SIADH	syndrome of inappropriate secretion of antidiuretic hormone
TCC	transitional cell carcinoma
TLH	total laparoscopic hysterectomy
TNM	tumor node metastasis staging system
TSH	thyroid-stimulating hormone
TURBT	trans-urethral resection of bladder tumor
VIPoma	vasoactive intestinal polypeptide	WLE	wide local incision
WB-MRI	whole body MRI
WM	Waldenstrom’s macroglobulinemia	WBXRT	Whole brain radiation therapy

This General Policy section provides an overview of the basic criteria for which oncology imaging may be medically necessary. Details regarding specific conditions or clinical presentations and the associated criteria for which imaging is medically necessary are described in subsequent sections.

ONC-1.1: Key Principles

For this condition imaging is medically necessary based on the following criteria:

AGE APPROPRIATE GUIDELINES
Age of Individual	Appropriate Imaging Guidelines
≥ 18 years old at initial diagnosis	® Adult Oncology Imaging Guidelines, except where directed otherwise by a specific guideline section
< 18 years old at initial diagnosis	® Pediatric Oncology Imaging Guidelines, except where directed otherwise by a specific guideline section
15 to 39 years old at initial diagnosis (defined as Adolescent and Young Adult (AYA) oncology individuals)	® When unique guidelines for a specific cancer type exist only in either Oncology or Pediatric Oncology, AYA individuals should be imaged according to the guideline section for their specific cancer type, regardless of the individual’s age ® When unique guidelines for a specific cancer type exist in both Oncology and Pediatric Oncology, AYA individuals should be imaged according to the age rule in the previous bullet

† Advanced imaging is not indicated for monitoring disease in individuals who choose to not receive standard oncologic therapy, but may be receiving alternative therapies or palliative care and/or hospice. All advanced imaging indicated for initial staging of the specific cancer type can be approved once when the member is considering initiation of a standard therapeutic approach (surgery, chemotherapy, or radiation therapy).

† Conventional Imaging (mostly CT, sometimes MRI or bone scan) of the affected area(s) drives much of initial and re-staging and surveillance. PET is not indicated for surveillance imaging unless specifically stated in the diagnosis-specific guideline sections

† Routine imaging of brain, spine, neck, chest, abdomen, pelvis, bones, or other body areas is not indicated except where explicitly stated in a diagnosis-specific guideline section, or if one of the following applies:

® Known prior disease involving the requested body area
® New or worsening symptoms or physical exam findings involving the requested body area (including non-specific findings such as ascites or pleural effusion)
® New finding on basic imaging study such as plain x-ray or ultrasound
® New finding on adjacent body area CT/MRI study (i.e., pleural effusion observed on CT abdomen)

® MRI Brain without and with contrast (CPT^® 70553) is the recommended study for evaluation of suspected or known brain metastases. If a non-contrast CT head shows suspicious lesion, MRI brain may be obtained to further characterize the lesion
® CT without and with contrast (CPT^® 70470) can be approved when MRI is contraindicated or not available, or if there is skull bone involvement
® Certain malignancies including, but not limited to melanoma, lung cancer and renal cell cancer have indications for brain imaging for asymptomatic members
® If stage IV disease is demonstrated elsewhere or if systemic disease progression is noted, refer to disease specific guidelines
® Initiation of angiogenesis therapy is not an indication for advanced imaging of the brain in asymptomatic members (Avastin/Bevacizumab; < 3% risk of bleeding and < 1% risk of serious bleeding)

® ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology
® ONC-31.5: Bone (including Vertebral) Metastases
® ONC-31.6: Spinal Cord Compression
® ONC-31.7: Carcinoma of Unknown Primary Site

® Horizon BCBSNJ guidelines support using Echocardiography (CPT^® 93306, CPT^® 93307, or CPT^® 93308) rather than MUGA scan for determination of LVED and/or wall motion EXCEPT in one of the circumstances described previously in Adult Cardiac Imaging Policy (Policy #149 in the Radiology Section); CD-3.4: MUGA Study – Cardiac Indications.
® The timeframe should be determine by the provider, but no more often than baseline and at every 6 weeks.
® May repeat every 4 weeks if cardiotoxic chemotherapeutic drug is withheld for significant left ventricular cardiac dysfunction.
® If the LVED is < 50% on echocardiogram than follow up can be done with MUGA at appropriate intervals.
® See also: Adult Cardiac Imaging Policy (Policy #149 in the Radiology Section); CD-12.1: Oncologic Indications for Cancer Therapeutics-Related Cardiac Dysfunction (CTRCD)

† CTA or MRA of a specific anatomic region is indicated when requested for surgical planning when there is suspected vascular proximity to proposed resection margin.

Use of Contrast

† CT imaging should be performed with contrast for known or suspected body regions, unless contraindicated.

® Shellfish allergy is not a contraindication to contrast. Members with known shellfish allergy do not have contrast reaction any more often than other atopic individuals or members with other food allergies.
® For iodinated contrast dye allergy, either CT scans without contrast or MRI scans without and with contrast are indicated.
® If CT scanning is considered strongly indicated in a member with known contrast allergy, CT with contrast may be considered to be safely performed following prednisone premedication over a 24 hour period prior to the study.

† Severe renal insufficiency, i.e. an eGFR less than 30, is a contraindication for an MRI using a gadolinium-based contrast agent (GBCA) as well. In members with eGFR greater than 40, GBCA administration can be safely performed. GBCA administered to members with acute kidney injury or severe chronic kidney disease can result in a syndrome of nephrogenic systemic fibrosis (NSF), but GBCAs are not considered nephrotoxic at dosages approved for MRI.

† Gadolinium deposition has been found in members with normal renal function following the use of gadolinium based contrast agents (GBCAs).

® The U.S. Food and Drug Administration (FDA) is investigating the risk of brain deposits following repeated use of GBCAs.
® The FDA has noted that, “It is unknown whether these gadolinium deposits are harmful or can lead to adverse health effects.” and have recommended:
¡ To reduce the potential for gadolinium accumulation, health care professionals should consider limiting GBCA use to clinical circumstances in which the additional information provided by the contrast is necessary.
¡ Health care professionals are also urged to reassess the necessity of repetitive GBCA MRIs in established treatment protocols.

Radiation Exposure

ONC-1.2: Phases of Oncology Imaging and General Phase-Related Considerations

For this condition imaging is medically necessary based on the following criteria:

Phases of Oncology Imaging	Definition
Screening	Imaging requested for members at increased risk for a particular cancer in the absence of known clinical signs or symptoms
Suspected Diagnosis	Imaging requested to evaluate a suspicion of cancer, prior to histological confirmation
Initial work-up and Staging	Imaging requested after biopsy confirmation and prior to starting specific treatment
Treatment response or Interim Restaging	Imaging performed during active treatment with chemotherapy, endocrine therapy or maintenance therapy
Restaging of locally treated lesions	Imaging performed to evaluate primary or metastatic lesions with ablation using radiofrequency, radioactive isotope, microwave or chemotherapy
Restaging / Suspected Recurrence	Imaging requested when there is suspicion for progression or recurrence of known cancer based on clinical signs/symptoms, laboratory tests or basic imaging studies
Surveillance	Imaging performed in members who are asymptomatic or have chronic stable symptoms, and are not receiving active treatment

General phase-related considerations:

† Imaging performed prior to diagnosis should not be repeated unless there is a delay of at least 6 weeks since previous imaging and treatment initiation or there are new or significantly worsening clinical signs or symptoms

Phase	Imaging Timeframe
After definitive local therapy of primary tumor (surgery or radiation therapy)	® Follow surveillance guidelines
During adjuvant chemotherapy	® Follow surveillance guidelines
After ablative therapy	® See disease-specific guidelines
During chemotherapy or immunotherapy for measurable disease	® Every 2 cycles (generally every 6 to 8 weeks)
During endocrine/hormonal therapy	® Every 3 months
Measurable metastatic disease being monitored off therapy	® Every 3 months
Minimal metastatic disease on maintenance therapy	® Every 3 months
Surveillance for history of metastatic disease with complete response and being observed off-therapy	® Imaging typically not indicated beyond 5 years from completion of treatment for metastatic disease

For this condition imaging is medically necessary based on the following criteria:

† This section does not apply to PET imaging. PET imaging considerations can be found in ONC-1.4: PET Imaging in Oncology

† Bone Scan:

® Primarily used for evaluation of bone metastases in members with solid malignancies.
® Indications for bone scan in members with history of malignancy include – bone pain, rising tumor markers, elevated alkaline phosphatase or in members with primary bone tumor.
® For evaluation of suspected or known bony metastases, CPT^® 78306 (Nuclear bone scan whole body), may be approved.
® Radiopharmaceutical Localization scan (CPT^® 78803) may be approved as an add-on test for further evaluation of a specific area of interest.
® CPT^® codes 78300 (Nuclear bone scan limited), 78305 (Nuclear bone scan multiple areas) or 78315 do not have any indications in oncology nuclear medicine imaging.

® Specific for low and intermediate grade neuroendocrine tumors which express specific cell surface somatostatin receptors. See cancer specific guidelines for recommended use.
® One of the following codes may be approved when Octreotide scan is requested:
¡ CPT^® 78802 (Radiopharmaceutical localization of tumor whole body single day study)
¡ CPT^® 78804 (Radiopharmaceutical localization of tumor whole body two or more days)
® In addition to one of the above CPT codes, CPT^® 78803 (Radiopharmaceutical localization of tumor SPECT) may be approved as an add-on test for further evaluation of a specific area of interest.

® This study is rarely performed for evaluation of the entire bone marrow in conditions like myeloproliferative disorders, sickle cell bone infarct or ischemia, avascular necrosis or myeloma
® The correct CPT code for this study is CPT^® 78104 (Diagnostic Nuclear Medicine Procedures on the Hematopoietic, Reticuloendothelial and Lymphatic System)

® Immunocompromised members with mass lesion detected on CT or MRI for differentiation between lymphoma and infection
® In distinguishing recurrent brain tumor from radiation necrosis
® Immunocompromised members with mass lesion detected on CT or MR for differentiation of lymphoma and infection

® CPT^® 78800, CPT^® 78801, CPT^® 78802, CPT^® 78804, CPT^® 78803 (SPECT), or CPT^® 78830, CPT^® 78831, or CPT^® 78832 (SPECT/CT)
® For evaluation of fever of unknown origin and osteomyelitis
® For suspected infections such as infected central lines, grafts or shunts

® Radiopharmaceutical Localization of tumor (CPT^® 78800, CPT^® 78801, CPT^® 78802, CPT^® 78803, or CPT^® 78804)
® This may be rarely used in place of PET/CT scan when PET/CT scan not available and PET/CT is indicated by guidelines for lymphoma, sarcoma, melanoma or myeloma

For this condition imaging is medically necessary based on the following criteria:

NOTE: Some payors have specific restrictions on PET imaging, and those coverage policies may supersede the recommendations for PET imaging in these guidelines.

† CPT codes:

® PET imaging in oncology should use PET/CT fusion imaging (CPT^® 78815 or CPT^® 78816) Unbundling PET/CT imaging into separate PET and diagnostic CT codes is otherwise not supported.
® The decision whether to use skull base to mid-femur (“eyes to thighs”) procedure code for PET (CPT^® 78812 or CPT^® 78815) or whole body PET (CPT^® 78813 or CPT^® 78816) is addressed in the diagnosis-specific guideline sections.
® ‘Limited area’ protocol is done infrequently, but may be considered, and is reported with PET (CPT^® 78811) or for PET/CT, (CPT^® 78814) and should be forwarded for Medical Director review.

® Unless specified otherwise, the term “PET” refers to ¹⁸F-FDG-PET and PET/CT fusion studies
® Indications for PET/CT imaging using non-FDG radiotracers are listed in diagnosis-specific guidelines. The indications may be as follows:
¡ Covered:
¹⁸F-FDG
⁶⁸Gallium DOTATATE (NETSPOT^®) for low grade neuroendocrine tumors for localization of somatostatin receptor positive neuroendocrine tumors in adult and pediatric population
¹¹C Choline for prostate cancer
¹⁸F-Fluciclovine (AXUMIN^®) for prostate cancer
¡ Not covered:
¹⁸F-Na Fluoride PET bone scan
PET/CT imaging using isotopes other than those specified above



Most Common Isotopes
CPT/HCPCS Code	Code Description	Brand or common name	FDA approved?	Code reviewed by eviCore for Horizon?
A9552	fluorine-18 (F-18) fluorodeoxyglucose (FDG), diagnostic, per study dose, up to 45 millicuries	FDG	Yes, to assess abnormal glucose metabolism	No
A9580	Sodium fluoride f-18, diagnostic, per study dose, up to 30 millicuries	N/A	Yes, for bone imaging	No
A9587	Gallium GA-68, dotatate, diagnostic, 0.1 millicurie	NETSPOT®	Yes, for localization of somatostatin receptor positive neuroendocrine tumors in adult and pediatric population	No
C9461	Choline C 11, diagnostic, per study dose	N/A	Yes, for suspected prostate cancer recurrence	No
A9588	18F-Fluciclovine	AXUMIN®	Yes, for suspected prostate cancer recurrence	No

® Infection, inflammation, trauma, post-operative healing, granulomatous disease, rheumatological conditions
® Concomitantly with separate diagnostic CT studies
® Distant or diffuse metastatic disease
® Metastatic disease in the central nervous system (CNS)
® Lesions less than 8 mm in size
® Follow up after localized therapy (i.e. radiofrequency ablation, embolization, stereotactic radiation, etc.)
® Rare malignancies, due to lack of available evidence regarding the diagnostic accuracy of PET in rare cancers
® Surveillance
¡ Serial monitoring of FDG avidity until resolution.
¡ PET/CT avidity in a residual mass at the end of planned therapy is not an indication for PET/CT imaging during surveillance.
¡ Residual mass that has not changed in size since the last conventional imaging does not justify PET imaging
® Unless otherwise specified for a specific cancer type, once PET has been documented to be negative for a given member’s cancer or all PET-avid disease has been surgically resected, PET should not be used for continued disease monitoring or surveillance.

® Conventional imaging (CT, MRI or bone scan) reveals findings that are inconclusive or negative, with continued suspicion for recurrence
® The member is undergoing salvage treatment for a recurrent solid tumor with residual measurable disease on conventional imaging and confirmed repeat negative PET imaging will allow the member to transition from active treatment to surveillance.
® PET/CT may be considered prior to biopsy in order to determine a more favorable site for biopsy when a prior biopsy was nondiagnostic or a relatively inaccessible site is contemplated which would require invasive surgical intervention for biopsy attempt.

® Conventional imaging (CT, MRI or bone scan) reveals equivocal or suspicious findings
® No other specific metabolic imaging (MIBG, octreotide, technetium, etc.) is appropriate for the disease type
® The submitted clinical information describes a specific decision regarding the member’s care that will be made based on the PET/CT results
® These requests will be forwarded for Medical Director review

† PET mammography (PEM, generally reported with CPT^® 78811) is considered investigational at this time.

ONC-1.5: Unlisted Procedure Codes in Oncology

For this condition imaging is medically necessary based on the following criteria:

† Horizon BCBSNJ authorizes requests for CT or MRI associated with image-directed biopsy or radiation therapy treatment planning for some payors.

† Horizon BCBSNJ does not routinely authorize requests for PET associated with image-directed biopsy or radiation therapy treatment planning.

† There is often no unique procedure code for a service performed solely for treatment planning purposes. AMA instructions in the CPT state that if no specific code exists for a particular service, the service is reported with an unlisted code.

† Advanced imaging being used for radiation therapy treatment planning should not be authorized using any of the diagnostic imaging codes for CT, MRI or PET. In the absence of written payor guidelines, advanced imaging performed in support of radiation therapy treatment planning should be reported with:

® CPT^® 76498 for Unlisted MRI – when MRI will be used for treatment planning of radiation therapy to be delivered ONLY to the brain, prostate and cervix. The use of this code for radiation treatment planning of any other cancers/body parts not listed above, may be reviewed on a case-by-case basis and should be sent for Medical Director Review.
® CPT ^® 76497 for Unlisted CT – may NOT be used for radiation treatment planning. CT imaging performed in support of radiation therapy treatment planning is bundled in with the concurrent radiation treatment authorization codes and a separate authorization for treatment planning is not required.
® CPT^® 78999 for Unlisted procedure, nuclear medicine (PET) – Horizon BCBSNJ does not perform prior authorization for this CPT code for any payor. This code may not be reviewed or offered as an alternative recommendation to the provider.
® Imaging associated with image-directed biopsy should be reported with the corresponding interventional codes. See also: General Guidelines for Advanced Imaging Studies (Policy 011 in the Introduction Section); Preface-3: Clinical Information.
® For advanced imaging used solely for the purpose of Surgical planning, see General Guidelines for Advanced Imaging Studies (Policy 011 in the Introduction Section); Preface-3: Clinical Information.

For this condition imaging is medically necessary based on the following criteria:

For predisposition syndrome screening in adult members, see Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-2: Screening Imaging in Cancer Predisposition Syndromes

References

1. ACR Committee on Drugs and Contrast Media. ACR Manual on Contrast Media, version 10.3. Reston, VA: American College of Radiology; 2018.
2. The American College of Radiology. Practice parameter for the performance of skeletal scintigraphy (bone scan). Rev. 2017.
3. The American College of Radiology. Practice parameter for performing FDG-PET/CT in oncology. Rev. 2016.
4. The American College of Radiology. Practice parameter for the performance of tumor scintigraphy with gamma cameras). Rev. 2015.
5. Erdi YE. Limits of tumor detectability in nuclear medicine and PET. Mol Imaging Radionucl Ther. 2012;21(1):23-28. doi:10.4274/Mirt.128.
6. Hapani S, Sher A, Chu D, Wu S. Increased risk of serious hemorrhage with bevacizumab in cancer patients: a meta-analysis. Oncology. 2010;79(1):27-38. doi:10.1159/000314980.
7. ACR Appropriateness Criteria. Pretreatment planning of Invasive cancer of Cervix. Rev. 2015.
8. ACR Appropriateness Criteria. External Beam Radiation therapy treatment planning for clinically localized prostate cancer. Rev. 2016.
9. Metcalfe P, Liney GP, Holloway L, et al. The potential for an enhanced role for MRI in radiation-therapy treatment planning. Technol Cancer Res Treat. 2013;12(5):429-46. doi:10.7785/tcrt.2012.500342.
10. National Comprehensive Cancer Network (NCCN) Guidelines Version 3.2019. – January 18, 2019, Genetic/Familial High Risk Assessment: Breast and Ovarian, available at: https://www.nccn.org/professionals/physician_gls/pdf/genetics_screening.pdf. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Genetic/Familial High Risk Assessment: Breast and Ovarian V3.2019. – January 18, 2019 ©. 2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org.


ONC-2: Primary Central Nervous System Tumors

ONC-2.1: Primary Central Nervous System Tumors – General Considerations

ONC-2.2: Low Grade Gliomas

ONC-2.3: High Grade Gliomas

ONC-2.4: Medulloblastoma and Supratentorial Primitive Neuroectodermal Tumors (sPNET)

ONC-2.5: Ependymoma

ONC-2.6: Central Nervous System Germ Cell Tumors

ONC-2.7: CNS Lymphoma (also known as Microglioma)

ONC-2.8: Meningiomas (Intracranial and Intraspinal)

ONC-2.9: Spinal Cord Tumors (Benign and Malignant)

ONC-2.10: Choroid Plexus Tumors

This guideline section applies to primary CNS tumors only. For imaging guidelines in metastatic brain cancer, see the appropriate diagnosis-specific section or ONC-31.3: Brain Metastases for imaging guidelines.

ONC-2.1: General Considerations

For this condition imaging is medically necessary based on the following criteria:

† Primary brain tumors presenting only with uncomplicated headache are very uncommon. Most primary brain tumors present with specific CNS symptoms.

† Histologic confirmation is critical. Therapeutic decisions should not be made on radiographic findings alone, except for the following:

® Medically fragile members for whom attempted biopsy carries excess medical risk, as stated in writing by both the attending physician and surgeon.
® Brain stem tumors or other sites where the imaging findings are pathognomonic and the risk of permanent neurological damage is excessive with even a limited biopsy attempt.

† Rare tumors occurring more commonly in the pediatric population should be imaged according to the imaging guidelines in: Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-4: Pediatric Central Nervous System Tumors

Indication	Imaging Study(ies)
Characterization and follow up of all brain tumors	® MRI Brain without and with contrast (CPT® 70553) ® CT Head without and with contrast (CPT® 70470) can be approved when MRI is contraindicated or not available, or there is skull bone involvement ® CT Head (contrast as requested) can be approved for preoperative planning when requested by the operating surgeon
Preoperative planning or to clarify inconclusive findings on MRI or CT	® MRA Head (CPT® 70544) or CTA Head (CPT® 70496)
Within 24 to 72 hours following brain tumor surgery	® MRI Brain without and with contrast (CPT® 70553)
Clinical deterioration or development of new neurological features	® MRI Brain without and with contrast (CPT® 70553)

MR Spectroscopy in Brain Tumors (MRS, CPT^® 76390)
NOTE: Some payors have specific restrictions on MR Spectroscopy, and those coverage policies may supersede the recommendations for MRS in these guidelines

† MRS is only supported for use in brain tumors of specified histologies where diagnostic accuracy has been established in peer-reviewed literature

® See diagnosis-specific guidelines for MRS indications

PET Brain Imaging (CPT^® 78608 and CPT^® 78609)
NOTE: Some payors have specific restrictions on PET Brain Metabolic Imaging, and those coverage policies may supersede the recommendations for this study in these guidelines.

† PET Brain Metabolic Imaging (CPT^® 78608) is only supported for use in brain tumors of specified histologies where diagnostic accuracy has been established in peer-reviewed literature

® See diagnosis-specific guidelines for PET indications below.
® According to Medicare NCD 220.6.17, FDG-PET may be approved once for initial treatment strategy and three times for subsequent treatment strategy for brain tumors. See: ONC-32.3: Brain PET for details.

† PET Brain perfusion imaging (CPT^® 78609) is not indicated in the evaluation or management of primary CNS tumors, and is nationally non-covered by Medicare per NCD 220.6.17.

† Body PET studies (CPT^® 78811, CPT^® 78812, and CPT^® 78813) and fusion PET/CT studies (CPT^® 78814, CPT^® 78815, or CPT^® 78816) are not indicated in the evaluation or management of primary CNS tumors

ONC-2.2: Low Grade Gliomas

For this condition imaging is medically necessary based on the following criteria:

These tumors are defined as having a WHO histologic grade of I or II (out of IV), can occur anywhere in the CNS, and includes the following tumors:
† Pilocytic Astrocytoma
† Fibrillary (or Diffuse) Astrocytoma
† Optic Pathway Gliomas
† Pilomyxoid Astrocytoma
† Oligodendroglioma
† Oligoastrocytoma
† Oligodendrocytoma
† Subependymal Giant Cell Astrocytoma (SEGA)
† Ganglioglioma
† Gangliocytoma
† Dysembryoplastic infantile astrocytoma (DIA)
† Dysembryoplastic infantile ganglioglioma (DIG)
† Dysembryoplastic neuroepithelial tumor (DNT)
† Tectal plate gliomas
† Cervicomedullary gliomas
† Pleomorphic xanthoastrocytoma (PXA)
† Any other glial tumor with a WHO grade of I or II
†

Indication	Imaging Study(ies)
Initial Staging	® MRI Brain without and with contrast (CPT® 70553) if not already done ® MRI Spine without and with contrast (Cervical-CPT® 72156, Thoracic-CPT® 72157, Lumbar-CPT® 72158) ® MRI Spine with contrast only (Cervical-CPT® 72142, Thoracic-CPT® 72147, Lumbar-CPT® 72149) can be approved if being performed immediately following a contrast-enhanced MRI Brain
After initial resection or other treatment (XRT, etc.)	® MRI Brain without and with contrast (CPT® 70553)
For members undergoing chemotherapy treatment	® MRI Brain without and with contrast (CPT® 70553) every 2 cycles ® Members with spinal cord involvement at diagnosis can have MRI without and with contrast of the involved spinal region on the same schedule as MRI brain
One of the following: ® Determine need for biopsy when transformation to high grade glioma is suspected based on clinical symptoms or recent MRI findings ® Evaluate a brain lesion of indeterminate nature when the PET findings will be used to determine whether biopsy/resection can be safely postponed	® PET Brain metabolic imaging (CPT® 78608)
One of the following: ® Distinguish low grade from high grade gliomas ® Evaluate a brain lesion of indeterminate nature when the MRS findings will be used to determine whether biopsy/resection can be safely postponed ® Distinguish radiation-induced tumor necrosis from progressive disease within 18 months of completing radiotherapy	® MR Spectroscopy (CPT® 76390)
Surveillance	® MRI Brain without and with contrast (CPT® 70553) every 3 months for 2 years, then every 6 months for 3 years, then annually ® Members with spinal cord involvement at diagnosis can have MRI spine without and with contrast (Cervical-CPT® 72156, Thoracic-CPT® 72157, Lumbar-CPT® 72158) on the same schedule as MRI Brain

ONC-2.3: High Grade Gliomas

For this condition imaging is medically necessary based on the following criteria:

These tumors are defined as having a WHO histologic grade of III or IV (out of IV can occur anywhere in the CNS (though the majority occur in the brain), and include the following tumors:

† Anaplastic astrocytoma
† Glioblastoma multiforme
† Diffuse intrinsic pontine glioma (DIPG, or “brainstem glioma”)
† Gliomatosis cerebri
† Gliosarcoma
† Anaplastic oligodendroglioma
† Anaplastic ganglioglioma
† Anaplastic mixed glioma
† Anaplastic mixed ganglioneuronal tumors
† Any other glial tumor with a WHO grade of III or IV

Indication	Imaging Study(ies)
Initial Staging	® MRI Brain without and with contrast (CPT® 70553) if not already done ® MRI Spine without and with contrast (Cervical-CPT® 72156, Thoracic-CPT® 72157, Lumbar-CPT® 72158) ¡ MRI Spine with contrast only (Cervical-CPT® 72142, Thoracic-CPT® 72147, Lumbar-CPT® 72149) can be approved if being performed immediately following a contrast-enhanced MRI Brain
Immediately following partial or complete resection	® MRI Brain without and with (CPT® 70553)
Immediately following radiation therapy (XRT)	® MRI Brain without and with contrast (CPT® 70553) once within 2 to 6 weeks following completion of treatment, and then go to surveillance imaging
For members undergoing chemotherapy treatment	® MRI Brain without and with contrast (CPT® 70553) every 2 cycles ® Members with spinal cord involvement at diagnosis can have MRI without and with contrast of the involved spinal region on the same schedule as MRI brain
One of the following: ® Distinguish low grade from high grade gliomas ® Evaluate a brain lesion of indeterminate nature when the MRS findings will be used to determine whether biopsy/resection can be safely postponed ® Distinguish radiation-induced tumor necrosis from progressive disease within 18 months of completing radiotherapy	® MR Spectroscopy (CPT® 76390)
One of the following: ® Distinguish radiation-induced tumor necrosis from progressive disease within 18 months of completing radiotherapy ® Evaluate inconclusive MRI findings when the PET findings will be used to determine need for biopsy or change in therapy, including a change from active therapy to surveillance ® Evaluate a brain lesion of indeterminate nature when the PET findings will be used to determine whether biopsy/resection can be safely postponed	® PET Brain metabolic imaging (CPT® 78608) ® PET Brain is not indicated in gliomas occurring in the brain stem due to poor uptake and lack of impact on member outcomes
Surveillance	® MRI Brain without and with contrast (CPT® 70553) every 3 months for 3 years and every 6 months thereafter ® Members with spinal cord involvement at diagnosis can have MRI spine without and with contrast (Cervical-CPT® 72156, Thoracic-CPT® 72157, Lumbar-CPT® 72158) on the same schedule as MRI Brain

ONC-2.4: Medulloblastoma and Supratentorial Primitive Neuroectodermal Tumors (sPNET)

For this condition imaging is medically necessary based on the following criteria:

Medulloblastoma and sPNET imaging indications in adult members are identical to those for pediatric members. See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-4.4: Medulloblastoma (MDB), Supratentorial Primitive Neuroectodermal Tumors (sPNET), and Pineoblastoma for imaging guidelines.

ONC-2.5: Ependymoma

For this condition imaging is medically necessary based on the following criteria:

Ependymoma imaging indications in adult members are identical to those for pediatric members. See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-4.8: Ependymoma for imaging guidelines.

ONC-2.6: Central Nervous System Germ Cell Tumors

For this condition imaging is medically necessary based on the following criteria:

Central nervous system germ cell tumor imaging indications in adult members are identical to those for pediatric members. See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-4.7: CNS Germinomas and Non-Germinomatous Germ Cell Tumors (NGGCT) for imaging guidelines.

ONC-2.7: CNS Lymphoma (also known as Microglioma)

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Initial Staging	All of the following are indicated: ® MRI Brain without and with contrast (CPT® 70553) ® MRI Cervical spine without and with contrast (CPT® 72156) ® MRI Thoracic spine without and with contrast (CPT® 72157) ® MRI Lumbar spine without and with contrast (CPT® 72158)
Extra-neural evaluation to confirm CNS primary *Members with CNS Lymphoma that is metastatic should be imaged according to: ® ONC-27: Non-Hodgkin Lymphomas for members age ≥ 18 years ® Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section);PEDONC-5.3: Pediatric Aggressive Mature B-Cell Non-Hodgkin Lymphomas (NHL) for members age ≤ 17 years	Any or all of the following are indicated: ® CT Chest with contrast (CPT® 71260) ® CT Abdomen/Pelvis with contrast (CPT® 74177) ® PET/CT (CPT® 78815) can be approved for evaluation of inconclusive findings on CT imaging
Treatment Response	® MRI without and with contrast of all positive disease sites every 2 cycles
Surveillance	® MRI without and with contrast of all positive disease sites every 3 months for 2 years, then every 6 months for 3 years, then annually thereafter

ONC-2.8: Meningiomas (Intracranial and Intraspinal)

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study(ies)
Initial Staging of Intracranial Meningioma	Any or all of the following are indicated: ® MRI Brain without and with contrast (CPT® 70553) ® CT Head (contrast as requested)
Initial staging of Intraspinal Meningioma	One of the following: ® MRI without and with contrast of appropriate spinal region (Cervical, Thoracic and Lumbar) ® CT without and with contrast of the appropriate spinal region (Cervical, Thoracic and Lumbar)
Treatment Response	® MRI without and with contrast of all positive disease sites every 2 cycles
Surveillance for Grade I (low grade) and Grade II (atypical) meningioma (completely resected, partially resected and unresected)	® Intracranial Meningioma: MRI Brain without and with contrast (CPT® 70553) at 3, 6, and 12 months, then annually for 5 years ® Intraspinal Meningioma: MRI without and with contrast CPT® 72156 (Cervical spine), CPT® 72157 (Thoracic spine), CPT® 72158 (lumbar spine) OR CT without and with contrast CPT® 72127 (Cervical spine), CPT® 72130 (Thoracic spine), CPT® 72133 (Lumbar spine) of the involved spinal level at 3, 6 and 12 months, and then annually for 5 years
Surveillance for Grade III (malignant or anaplastic) meningioma	® Intracranial Meningioma: MRI Brain without and with contrast (CPT® 70553) every 3 months for 3 years, and then every 6 months thereafter ® Intraspinal Meningioma: MRI or CT without and with contrast of the involved spinal region every 3 months for 3 years and then every 6 months thereafter

ONC-2.9: Spinal Cord Tumors (Benign and Malignant)

For this condition imaging is medically necessary based on the following criteria:

† See also: ONC-2.2: Low Grade Gliomas and ONC-2.3: High Grade Gliomas for imaging guidelines of low grade and high grade gliomas of the spinal cord

† See also: Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-4.9: Malignant Tumors of the Spinal Cord for imaging guidelines for other malignant spinal cord tumors

† See also: Pediatric Peripheral Nerve Disorder Imaging Policy (Policy #168 in the Radiology Section); PEDPN-2.1: Neurofibromatosis 1 and Pediatric Peripheral Nerve Disorder Imaging Policy (Policy #168 in the Radiology Section); PEDPN-2.2: Neurofibromatosis 2 for spinal tumors in members with Neurofibromatosis 1 or 2

† See also: ONC-31.6: Spinal Cord Compression for known secondary malignancy involving the spine/spinal canal/spinal cord

ONC-2.10: Choroid Plexus Tumors

For this condition imaging is medically necessary based on the following criteria:

Choroid Plexus Tumor imaging indications in adult members are identical to those for pediatric members. See Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-4.13: Choroid Plexus Tumors for imaging guidelines.

References

1. National Comprehensive Cancer Network (NCCN) Guidelines Version 1.2019 – March 5, 2019 Central Nervous System Cancers, available at: https://www.nccn.org/professionals/physician_gls/pdf/cns.pdf. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Central Nervous System Tumors Cancer V1.2019. – March 5, 2019 ^©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org.
2. Brandão LA,Castillo M. Adult brain tumors: clinical applications of magnetic resonance spectroscopy. Magn Reson Imaging Clin N Am. 2016;24(4):781-809. doi:10.1016/j.mric.2016.07.005.
3. Pasquier D, Bijmolt S, Veninga T, et al. Atypical and malignant meningioma: outcome and prognostic factors in 119 irradiated patients. A multicenter, retrospective study of the Rare Cancer Network. Int J Radiat Oncol Biol Phys. 2008;71(5):1388. doi:10.1016.j.ijrobp.2007.12.020.
4. Modha A, Gutin PH. Diagnosis and treatment of atypical and anaplastic meningiomas: a review. Neurosurgery. 2005;57(3):538-550.
5. Horská A, Barker PB. Imaging of brain tumors: MR spectroscopy and metabolic imaging. Neuroimaging Clin N Am. 2010;20(3):293-310. doi:10.1016/j.nic.2010.04.003.
6. Sundgren PC. MR Spectroscopy in radiation Injury. Am J Neuroradiol. 2009;30(8):1469-1476. doi:10.3174/ajnr.A1580.

ONC-3: Squamous Cell Carcinomas of the Head and Neck

ONC-3.0: Squamous Cell Carcinomas of the Head and Neck – General Considerations

ONC-3.1: Squamous Cell Carcinomas of the Head and Neck – Suspected/Diagnosis

ONC-3.2: Squamous Cell Carcinomas of the Head and Neck – Initial Work-up/Staging

ONC-3.3: Squamous Cell Carcinomas of the Head and Neck – Restaging/Recurrence

ONC-3.4: Squamous Cell Carcinomas of the Head and Neck – Surveillance/Follow-up

ONC-3.0: Squamous Cell Carcinomas of the Head and Neck – General Considerations

For this condition imaging is medically necessary based on the following criteria:

† Members with esthesioneuroblastoma should be imaged according to this guideline section

† For evaluation of squamous cell carcinoma from an unknown primary to the cervical lymph nodes, CT Neck (CPT^® 70491) and CT Chest (CPT^® 71260) are indicated. CT scans of the abdomen and pelvis are not routinely indicated, unless there are signs/symptoms related to these areas.

† Imaging of the CNS (head, spine) is indicated only to evaluate specific signs or symptoms or if concern for base of skull invasion suggesting spread to those areas

† Stage III/IV disease encompasses any primary tumor larger than 4 cm or documented lymph node positive disease

ONC-3.1: Squamous Cell Carcinomas of the Head and Neck – Suspected/Diagnosis

For this condition imaging is medically necessary based on the following criteria:

† See also: Adult Neck Imaging Policy (Policy #153 in the Radiology Section); NECK-4.1 and Adult Neck Imaging Policy (Policy #153 in the Radiology Section); NECK-5.1 for imaging guidelines for evaluation of suspected malignancy in the neck

† PET may be considered prior to biopsy in order to determine a more favorable site for biopsy when a prior biopsy was nondiagnostic or a relatively inaccessible site is contemplated which would require invasive surgical intervention for biopsy attempt

ONC-3.2: Squamous Cell Carcinomas of the Head and Neck – Initial Work-up/Staging

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
All Stages of Disease	® CT Neck with contrast (CPT® 70491) or MRI Orbits/Face/Neck (OFN) without and with contrast (CPT® 70543) ® Chest x-ray or CT Chest with contrast (CPT® 71260) ® Lymph system imaging (lymphoscintigraphy, CPT® 78195) is indicated for sentinel lymph node evaluation when nodes are not clinically positive
Nasal cavity and paranasal sinuses (bony erosion or skull base and intracranial involvement)	One of the following studies is indicated: ® CT Maxillofacial with contrast (CPT® 70487) ® CT Neck with contrast (CPT® 70491) ® MRI Orbits/Face/Neck without and with contrast (CPT® 70543)
Nasopharyngeal (NPC) Cancer	® MRI Orbits/Face/Neck without and with contrast (CPT® 70543) is the preferred study ¡ CT Neck (CPT® 70491) and/or CT Maxillofacial (CPT® 70487) with contrast can be approved if contraindication to MRI ® Chest x-ray or CT Chest with contrast (CPT® 71260)
For any of the following: ® Known stage III or IV disease ® Prior to start of primary chemoradiotherapy and have not undergone definitive surgical resection ® Nasopharyngeal primary site ® Inconclusive findings on conventional imaging (CT, MRI) ® In order to direct laryngoscopy/exam under anesthesia for biopsy ® Pulmonary nodule(s) ≥ 8 mm in size ® Cervical lymph node biopsy positive for squamous cell carcinoma and no primary site identified on CT or MRI of neck and chest ® Inconclusive findings suggestive of disease outside the head and neck area	® PET/CT (CPT® 78815)
Signs or symptoms of abdominal metastatic disease, including elevated liver function tests	® CT Abdomen with contrast (CPT® 74160)
Any head and neck cancer with neurological findings or suspicion of skull base invasion	® MRI Brain without and with contrast (CPT® 70553)

ONC-3.3: Squamous Cell Carcinomas of the Head and Neck – Restaging/Recurrence

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Following complete resection and/or radical neck dissection	See (ONC-3.4: Surveillance/Follow-up)
Following primary chemoradiotherapy for Stage III or IV disease	® CT Neck with contrast (CPT® 70491) or MRI Orbits/Face/Neck without and with contrast (CPT® 70543) ® PET/CT is indicated (no sooner than 12 weeks post completion XRT) for: ¡ Evaluating the need for salvage surgery/radical neck dissection in members with measurable residual disease on physical exam or recent CT or MRI ¡ Distinguishing active tumor from radiation fibrosis
Induction chemotherapy response	® CT neck with contrast (CPT® 70491) or MRI Orbits/Face/Neck without and with contrast (CPT® 70543) ® PET not indicated to assess response to induction chemotherapy
Suspected local recurrence	® CT Neck with contrast (CPT® 70491) or MRI Orbits/Face/Neck without and with contrast (CPT® 70543) ® CT Chest with contrast (CPT® 71260)
Biopsy proven local recurrence	Either one of the following: ® PET/CT (CPT® 78815) OR ® CT Neck with contrast (CPT® 70491) or MRI Orbits/Face/Neck without and with contrast (CPT® 70543) AND CT Chest with contrast (CPT® 71260)
Inconclusive conventional imaging (CT or MRI)	® PET/CT (CPT® 78815)
If new symptoms or chest previously involved	® CT Chest with contrast (CPT® 71260)

ONC-3.4: Squamous Cell Carcinomas of the Head and Neck – Surveillance/Follow-up

For this condition imaging is medically necessary based on the following criteria:

Indications	Imaging Study
All stages	Once within 6 months of completing all treatment: ® CT Neck with contrast (CPT® 70491) or MRI Orbits/Face/Neck without and with contrast (CPT® 70543) ® CT with contrast of any other involved body area
After initial post-treatment study, for any of the following: ® Nasopharyngeal primary site ® Physical exam unable to evaluate primary site for recurrence	Annually for 3 years: ® CT Neck with contrast (CPT® 70491) or MRI Orbits/Face/Neck without and with contrast (CPT® 70543)
	® CT Chest is not indicated for surveillance. Individuals with smoking history may undergo annual low dose CT cancer screening if criteria are met (See Adult Chest Imaging Policy (Policy #150 in the Radiology Section); CH-34: Lung Screening in the Chest Imaging Guidelines)

References

1. Pfister DG, Spencer S, Adelstein D et al. National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2019 – June 28, 2019 Head and Neck Cancers, available at: https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Head and Neck Cancer V2.2019 – June 28, 2019. ©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org.
2. Goel R, Moore W, Sumer B, Khan S, Sher D, Subramaniam RM. Clinical practice in PET/CT for the management of head and neck squamous cell cancer. AJR Am J Roentgenol. 2017;209(2):289-303. doi:10.2214/AJR.17.18301.

ONC-4.0: Salivary Gland Cancers – General Considerations

ONC-4.1: Salivary Gland Cancers – Suspected/Diagnosis

ONC-4.2: Salivary Gland Cancers – Initial Work-up/Staging

ONC-4.3: Salivary Gland Cancers – Restaging/Recurrence

ONC-4.4: Salivary Gland Cancers – Surveillance/Follow-up

ONC-4.0: Salivary Gland Cancers – General Considerations

For this condition imaging is medically necessary based on the following criteria:

† Salivary gland tumors may originate within the parotid, submandibular, sublingual or minor salivary glands in the mouth.

† Histological subtypes include mucoepidermoid, acinic, adenocarcinoma, adenoid cystic carcinoma, malignant myoepithelial tumors and squamous cell carcinoma. Lymphoma and metastatic squamous carcinoma can also occur in the parotid gland.

† Over 80% of parotid gland tumors are benign. A bilateral parotid tumor is most likely Warthin’s tumor.

† The role of PET in salivary gland tumors has yet to be established.

ONC-4.1: Salivary Gland Cancers – Suspected/Diagnosis

For this condition imaging is medically necessary based on the following criteria:

See Adult Neck Imaging Policy (Policy #153 in the Radiology Section); NECK-11 and Adult Neck Imaging Policy (Policy #153 in the Radiology Section); NECK-4.1 for evaluation of salivary gland masses, salivary gland stones and neck masses.

ONC-4.2: Salivary Gland Cancers – Initial Work-up/Staging

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Biopsy-proven malignancy (only if none of these imaging studies has already been done)	One of the following can be approved: ® MRI Orbits/Face/Neck without and with contrast (CPT® 70543) ® CT Neck with contrast (CPT® 70491) ® CT Neck without contrast (CPT® 70490)
Skull base invasion	® MRI Brain without and with contrast (CPT® 70553)
Abnormalities on chest x-ray or if lymphadenopathy in neck	® CT Chest with contrast (CPT® 71260)
Pulmonary nodule(s) ≥ 8mm in size	® PET/CT (CPT® 78815)

ONC-4.3: Salivary Gland Cancers – Restaging/Recurrence

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Members with unresected disease receiving systemic therapy (chemotherapy)	One of the following may be approved every 2 cycles: ® CT Neck with contrast (CPT® 70491) and any other sites of disease ® MRI Orbits/Face/Neck without and with contrast (CPT® 70543) and any other sites of disease
Recurrence or progression suspected based on new or worsening signs or symptoms	One of the following may be approved: ® CT Neck with contrast (CPT® 70491) ® MRI Orbits/Face/Neck without and with contrast (CPT® 70543) In addition, for all members: ® CT Chest with contrast (CPT® 71260)
All other members	® No routine advanced imaging indicated

ONC-4.4: Salivary Gland Cancers – Surveillance/Follow-up

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Total surgical resection	® No routine advanced imaging indicated
Unresectable or partially resected disease, including those treated with XRT	® Either CT Neck (CPT® 70491) or MRI Orbits/Face/Neck (CPT® 70543) once within 6 months of completion of treatment

References

1. Pfister DG, Spencer S, Adelstein D et al. National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2019 – June 28, 2019 Head and Neck Cancers, available at: https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Head and Neck Cancer V2.2019 – June 28, 2019. ©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org.
2. Palacios E, Ellis M, Lam EC, Neitzschman H, Haile M. Pitfalls in imaging the submandibular glands with PET/CT. Ear Nose Throat J. 2015;94(10-11):E37-E39.
3. Seo YL, Yoon DY, Baek S, et al. Incidental focal FDG uptake in the parotid glands on PET/CT in patients with head and neck malignancy. Eur Radiol. 2015;25(1):171-177. doi:10.1007/s00330-0140339701.
4. Park HL, Yoo le R, Lee N, et al. The value of F-18 FDG PET for planning treatment and detecting recurrence in malignant salivary gland tumors: comparison with conventional imaging studies. Nucl Med Mol Imaging. 2013;47(4):242-248. doi:10.1007/s13139-013-0222-8.
5. Bertagna F, Nicolai P, Maroldi R. Diagnostic role of 18F-FDG-PET or PET/CT in salivary gland tumors: a systematic review. Rev Esp Med Nucl Imagen Mol. 2015;34(5):295-302.


ONC-5 Melanomas and Other Skin Cancers

ONC-5.0: Melanoma – General Considerations

ONC-5.1: Melanoma – Suspected/Diagnosis

ONC-5.2: Melanoma – Initial Work-up/Staging

ONC-5.3: Melanoma – Restaging/Recurrence

ONC-5.4: Melanoma – Surveillance/Follow-up

ONC-5.5: Non-Melanoma Skin Cancers –General Considerations

ONC-5.6: Non-Melanoma Skin Cancers –Initial Work-up/Staging

ONC-5.7: Non-Melanoma Skin Cancers –Restaging/Recurrence

ONC-5.8: Non-Melanoma Skin Cancers – Surveillance/Follow-up

ONC-5.9: Ocular Melanoma

ONC-5.0: Melanoma – General Considerations

For this condition imaging is medically necessary based on the following criteria:

† Melanomas can metastasize in an unpredictable fashion.

† Primary mucosal melanomas (i.e., gastrointestinal or sinus mucosa) are considered (and should be managed as) Stage III (i.e., node positive) at initial diagnosis.

ONC-5.1: Melanoma – Suspected/Diagnosis

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
All	® Imaging is not indicated until histologic diagnosis is confirmed

ONC-5.2: Melanoma – Initial Work-up/Staging

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Stage 0 or Ia (in situ or disease < 1 mm)	® Routine advanced imaging is not indicated
® Stage Ib (≤ 1 mm with ulceration or high mitotic rate) ® Stage II (lesions > 1 mm thick, but node negative)	® CT with contrast or MRI without and with contrast of specific areas, only if signs or symptoms indicate need for further evaluation ® Lymph system imaging (lymphoscintigraphy, CPT® 78195) is indicated for sentinel lymph node (SLN) evaluation
Any of the following: ® Stage III (sentinel node positive, palpable regional nodes) ® Stage IV (metastatic) ® Mucosal, including lip primary	® PET/CT (CPT® 78815 or CPT® 78816) OR ® CT with contrast of Chest (CPT® 71260) and CT Abdomen/Pelvis (CPT® 74177) ® CT Neck with contrast (CPT® 70491) is indicated for head or neck primary sites or if palpable lymph nodes are present in the neck ® MRI Brain without and with contrast (CPT® 70553)
® Primary site of melanoma is unknown and CT Chest and Abdomen/Pelvis are negative	® PET/CT (CPT® 78815 or CPT® 78816)

ONC-5.3: Melanoma – Restaging/Recurrence

For this condition imaging is medically necessary based on the following criteria:

All recurrences should be confirmed histologically, except when excessive morbidity from a biopsy may occur, such as a biopsy requiring craniotomy.

Indication	Imaging Study
Members receiving chemotherapy, with measurable disease	® CT Chest (CPT® 71260) and CT Abdomen/Pelvis (CPT® 74177) with contrast every 2 cycles (commonly every 6 to 8 weeks)
All in situ recurrences	® Restaging imaging is not needed after adequate aggressive local therapy (see Surveillance below)
Documented or clinically suspected (see top of page regarding biopsy morbidity) recurrence at: ® Primary site ® In-transit disease ® Regional lymph nodes ® Metastatic site	® CT Chest (CPT® 71260) and CT Abdomen/Pelvis (CPT® 74177) with contrast ® MRI Brain without and with contrast (CPT® 70553) ® PET/CT (CPT® 78815 or CPT® 78816) if inconclusive conventional imaging or isolated metastatic based on results of conventional imaging, initially
Brain imaging is indicated for: ® New discovery of metastatic disease or progression of metastatic disease ® Signs or symptoms of CNS disease ® If considering Interleukin (IL-2) therapy	® MRI Brain without and with contrast (CPT® 70553)

ONC-5.4: Melanoma – Surveillance/Follow-up

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Stage 0, IA, IB and IIA Melanomas	® No routine advanced imaging indicated
Stage IIB, IIC, IIIA and IIIB Melanomas	® CT Chest (CPT® 71260) and CT Abdomen/Pelvis (CPT® 74177) with contrast every 6 months for 5 years
Stage IIIC and IV Melanomas	® CT Chest (CPT® 71260) and CT Abdomen/Pelvis (CPT® 74177) with contrast every 3 months for 3 years, then every 6 months for 2 years ® MRI Brain without and with contrast (CPT® 70553) annually for 5 years
Liver metastases treated with focal therapy	® See also: ONC-31.2: Liver Metastases

ONC-5.5: Non-Melanoma Skin Cancers – General Considerations

For this condition imaging is medically necessary based on the following criteria:

† Advanced Imaging is generally not indicated for basal cell and squamous cell skin cancers

† PET/CT scan is not indicated for evaluation of non-melanoma skin cancers unless specified within the guidelines below (e.g. Merkel cell carcinoma)

† Merkel cell carcinoma is an unusual skin cancer with neuroendocrine-like histologic features, which has a high propensity (25% to 33%) for regional lymph node spread and occasionally, metastatic spread to lungs.

† Merkel cell carcinoma may present as a primary cancer or as a skin metastasis from a noncutaneous primary neuroendocrine carcinoma (i.e., small cell lung cancer), therefore conventional imaging is indicated initially to confirm the absence of metastasis prior to considering PET scan.

ONC-5.6: Non-Melanoma Skin Cancers – Initial Work-up/Staging

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Body area with unexplained signs or symptoms	® CT with contrast of that body area
Perineural invasion or local regional extension (i.e. bone; deep soft tissue) involvement	One of the following may be approved of the primary site: ® MRI without contrast or without and with contrast ® CT (contrast as requested)
Skin lesion may be a dermal metastasis from distant primary	® CT Chest (CPT® 71260) and Abdomen/Pelvis (CPT® 74177) with contrast ® PET/CT (CPT® 78815 or 78816) is indicated if conventional imaging (CT or MRI) is unable to identify a primary site
Squamous cell carcinoma head or neck skin with regional lymphadenopathy	® CT Neck (CPT® 70491) and CT Chest (CPT® 71260) with contrast
Merkel Cell carcinoma	® CT Chest (CPT® 71260) and Abdomen/Pelvis (CPT® 74177) with contrast ® CT with contrast of other involved body area(s) ® PET/CT (CPT® 78815 or 78816) if no metastatic disease identified on conventional imaging ® Lymph system imaging (lymphoscintigraphy, CPT® 78195) or sentinel lymph node evaluation ® MRI Brain with and without contrast (CPT® 70553)

ONC-5.7: Non-Melanoma Skin Cancers – Restaging/Recurrence

For this condition imaging is medically necessary based on the following criteria:

All recurrences should be confirmed histologically, except when excessive morbidity from a biopsy may occur, such as a biopsy requiring craniotomy.

Indication	Imaging Study
Recurrence where planned therapy is more extensive than simple wide local excision	® CT with contrast of the primary and recurrent site(s)
Recurrence of Merkel cell carcinoma	® CT Chest (CPT® 71260) and CT Abdomen/Pelvis (CPT® 74177) with contrast ® MRI Brain without and with contrast (CPT® 70553) ® PET/CT if no metastatic disease on any of the previous imaging studies

ONC-5.8: Non-Melanoma Skin Cancers – Surveillance/Follow-up

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Merkel cell cancer – only if node positive	® CT Chest (CPT® 71260) and CT Abdomen/Pelvis (CPT® 74177) with contrast every 6 months for 5 years ® Add CT Neck with contrast (CPT® 70491) if known prior neck disease or scalp/facial/neck disease
All others	® Routine advanced imaging for surveillance is not indicated ® Imaging indicated only for signs and symptoms of recurrent disease

ONC-5.9: Ocular Melanoma

For this condition imaging is medically necessary based on the following criteria:

General Considerations

† Approximately 95% of ocular melanomas arise from the uvea (iris, ciliary body and choroid) and 5% arise from the conjunctiva or orbit.

† Treatment is directed to the affected eye with systemic therapy reserved only for known metastatic disease.

† The most common site of metastatic disease is the liver.

† Surveillance of the affected eye is with clinical examination only; advanced imaging is supported for surveillance of systemic metastatic disease based on individual risk factors. See Risk categories below for surveillance recommendations.

Ocular Melanoma Risk Categories
Low Risk	Medium Risk	High Risk
T1	T2 and T3	T4
Class IA	Class IB	Class 2
Spindle cell histology	Mixed Spindle and Epitheloid cells	Epitheloid cell histology
No extraoccular extension	No extraoccular extension	Extraoccular extension present
No ciliary body involvement	No ciliary body involvement	Ciliary body involvement present
Chromosome mutations: Disomy 3 EIF1AZ mutation	Chromosome mutations: SF3B1 mutation	Chromosome mutations: BAP1 mutation PRAME mutation Monosomy 3 Gain of chromosome 8q

Indication	Imaging Study
Initial staging	Any or all of the following: ® CT Chest with contrast (CPT® 71260) ® CT Abdomen/Pelvis with contrast (CPT® 74177) ® MRI orbits/face/neck without and with contrast (CPT® 70543)
Restaging/Suspected Recurrence	Any or all of the following: ® CT Chest with contrast (CPT® 71260) ® CT Abdomen/Pelvis with contrast (CPT® 74177) ® MRI orbits/face/neck without and with contrast (CPT® 70543)
Surveillance: (see Risk Categories Table above) ® Low Risk ® Medium Risk ® High Risk	® No routine surveillance imaging ® CT Chest with contrast (CPT® 71260) and CT Abdomen with contrast (CPT® 74160) annually for 10 years ® CT Chest with contrast (CPT® 71260) and CT Abdomen with contrast (CPT® 74160) every 6 months for 5 years, then annually for 10 years

References

1. Coit DG, Thompson JA, Albertini MR, et al, National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2019 – March 12, 2019 Cutaneous Melanoma, available at: https://www.nccn.org/professionals/physician_gls/pdf/melanoma.pdf Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Melanoma V2.2019 – March 12, 2019 ©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org.
1. Coit DG, Thompson JA, Albertini MR, et al, National Comprehensive Cancer Network (NCCN) Guidelines Version 1.2018 – March 15, 2018 Uveal Melanoma, available at: https://www.nccn.org/professionals/physician_gls/pdf/uveal.pdf Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Melanoma V1.2018 – March 15, 2018 ©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org .
2. Bichakjian CK, Olencki T, Aasi SZ, et al. National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2019 – January 18, 2019 Merkel Cell Carcinoma, available at: https://www.nccn.org/professionals/physician_gls/pdf/mcc.pdf Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Merkel Cell Carcinoma V2.2019 - June 19, 2019 ©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org .
3. Bichakjian CK, Olencki T, Aasi SZ et al. National Comprehensive Cancer Network (NCCN) Guidelines Version 1.2019 – August 31, 2018 Basal Cell Skin Cancer, available at: https://www.nccn.org/professionals/physician_gls/pdf/nmsc.pdf Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Basal Cell Skin Cancer V1.2019 – August 31, 2018 ©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org .
4. Bichakjian CK, Olencki T, Aasi SZ, et al, National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2019 – October 23, 2018 Squamous Cell Skin Cancer, available at: https://www.nccn.org/professionals/physician_gls/pdf/squamous.pdf Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Squamous Cell Skin Cancer V2.2019 – October 23, 2018 ©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org .
5. Schröer-Günther MA, Wolff RF, Westwood ME, et al. F-18-fluoro-2-deoxyglucose positron emission tomography (PET) and PET/computed tomography imaging in primary staging of patients with malignant melanoma: a systematic review. Syst Rev. 2012;1:62. doi:10.1186/2046-4053-1-62.
6. Xing Y, Bronstein Y, Ross MI, et al. Contemporary diagnostic imaging modalities for the staging and surveillance of melanoma patients: a meta-analysis. J Natl Cancer Inst. 2011;103(2):129-142. doi:10.1093/jnci/djq455.
7. Rodriguez Rivera AM, Alabbas H, Ramjuan A, Meguerditchian AN. Value of positron emission tomography scan in stage III cutaneous melanoma: a systematic review and meta-analysis. Surg Oncol. 2014;23(1):11-16. doi: 10.1016/j.suronc.2014.01.002.
8. Nathan P, Cohen V, Coupland S, et al. Uveal melanoma UK national guidelines. European Journal of Cancer. 2015;51(16):2404-2412. doi:10.1016/j.ejca/2015.07.013.

ONC-6: Thyroid Cancer

ONC-6.0: Thyroid Cancer – General Considerations

ONC-6.1: Thyroid Cancer – Suspected/Diagnosis

ONC-6.2: Thyroid Cancer – Initial Work-up/Staging

ONC-6.3: Thyroid Cancer – Restaging/Recurrence

ONC-6.4: Thyroid Cancer – Surveillance/Follow-up

ONC-6.0: Thyroid Cancer – General Considerations

For this condition imaging is medically necessary based on the following criteria:

† PET for initial staging for anaplastic thyroid cancer is currently not recommended before conventional imaging since recommendations for PET are derived from observational studies and clinical trials with other methodological limitations.

† Members with measurable metastatic disease that are RAI refractory may be followed with conventional imaging, PET-CT scan is reserved for inconclusive findings.

† Whole body thyroid nuclear scan is coded with CPT^® 78018. If CPT^® 78018 is obtained and found to be positive, CPT^® 78020 may be approved as an add-on test to evaluate the degree of iodine uptake.

† Single photon emission computed tomography (SPECT) imaging may be performed as needed. SPECT/CT imaging (CPT^® 78803) Radiopharmaceutical Localization of Tumor SPECT may complement planar and pinhole imaging and can be approved as an add-on wherever radioiodine scans are indicated.

ONC-6.1: Thyroid Cancer – Suspected/Diagnosis

For this condition imaging is medically necessary based on the following criteria:

See Adult Neck Imaging Policy (Policy #153 in the Radiology Section); NECK-8.1: Thyroid Nodule for imaging guidelines for suspected thyroid malignancies

ONC-6.2: Thyroid Cancer – Initial Work-up/Staging

For this condition imaging is medically necessary based on the following criteria:

Follicular, Papillary and Hürthle Cell Carcinomas	Imaging Study
One of the following: ® Fixation suggested by clinical exam and/or ultrasound ® Substernal or bulky disease ® Disease precluding full ultrasound examination	One of the following: ® MRI Neck without contrast (CPT® 70540) ® MRI Neck without and with contrast (CPT® 70543) ® CT Neck without contrast (CPT® 70490) ® CT Neck with contrast (CPT® 70491) can be approved if contrast study is necessary for complete pre-operative assessment and use of IV contrast will not delay post-operative use of RAI therapy.
Post-thyroidectomy to assess thyroid remnant and to look for iodine-avid metastases for one of the following: ® Extent of thyroid remnant cannot be accurately ascertained from the surgical report or neck ultrasound ® When the results may alter the decision to treat ® Prior to administration of RAI therapy	® Whole body thyroid nuclear scan (CPT® 78018) ® The following may be approved as an add-on test: ¡ CPT® 78020 to evaluate the degree of iodine uptake ¡ SPECT (CPT® 78803), or SPECT/CT Hybrid study (CPT® 78830, 78831, or 78832)
Skeletal pain	One of the following: ® Bone scan See also: ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology ® Whole body nuclear thyroid scan (CPT® 78018) ® The following may be approved as an add-on test: ¡ CPT® 78020 to evaluate the degree of iodine uptake ¡ SPECT (CPT® 78803), or SPECT/CT Hybrid study (CPT® 78830, 78831, or 78832)
Suspicious findings on CXR, US, or substernal extension of mass	® CT Chest without contrast (CPT® 71250)
All other members	® Routine preoperative advanced imaging is not indicated

Medullary Thyroid Carcinomas	Imaging Study
All members with positive lymph nodes or calcitonin level > 500 pg/mL	Any or all of the following: ® CT Neck with contrast (CPT® 70491) ® CT Chest with contrast (CPT® 71260) ® CT Abdomen either with (CPT® 74160) or CT Abdomen without and with contrast (CPT® 74170) ® Bone scan see also: ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology
Skeletal pain	® Bone scan see also: ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology
Inconclusive finding on conventional imaging	® PET/CT (CPT® 78815)
Anaplastic Thyroid Carcinomas	Imaging Study
All	Any or all of the following: ® CT Neck with contrast (CPT® 70491) ® CT Chest with contrast (CPT® 71260) ® CT Abdomen/Pelvis with contrast (CPT® 74177) ® MRI Brain without and with contrast (CPT® 70553) ® Bone scan see also: ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology
Skeletal pain	® Bone scan see also: ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology
Inconclusive finding on conventional imaging	® PET/CT (CPT® 78815 or CPT® 78816)

ONC-6.3: Thyroid Cancer – Restaging/Recurrence

For this condition imaging is medically necessary based on the following criteria:

Follicular, Papillary and Hürthle Cell Carcinomas	Imaging Study
Within 2 weeks (ideally 7 to 10 days) following the administration of Radioactive Iodine therapy dose	® Whole body thyroid nuclear scan (CPT® 78018) ® The following may be approved as an add-on test: ¡ CPT® 78020 to evaluate the degree of iodine uptake ¡ SPECT (CPT® 78803), or SPECT/CT Hybrid study (CPT® 78830, 78831, or 78832)
Any of the following: ® Recurrence documented by biopsy ® Increasing thyroglobulin level without Thyrogen® stimulation ® Thyroglobulin level > 2 ng/mL or higher than previous after Thyrogen® stimulation ® Anti-thyroglobulin antibody present ® Evidence of residual thyroid tissue on ultrasound or physical exam after thyroidectomy or ablation	Any or all of the following: ® Whole body thyroid nuclear scan (CPT® 78018) ® The following may be approved as an add-on test: ¡ CPT® 78020 to evaluate the degree of iodine uptake ¡ SPECT (CPT® 78803), or SPECT/CT Hybrid study (CPT® 78830, 78831, or 78832) ® CT with contrast of any symptomatic body area ® MRI without and with contrast of any symptomatic body area
Any of the following: ® Negative radioiodine scan and rising thyroglobulin level ® Inconclusive findings on conventional imaging (including I-131 study)	® PET/CT (CPT® 78815)

Medullary and Anaplastic Thyroid Carcinomas	Imaging Study
Medullary carcinoma with elevated calcitonin or CEA, or signs or symptoms of recurrence	Any or all of the following: ® CT Neck with contrast (CPT® 70491) ® CT Chest with contrast (CPT® 71260) ® CT Abdomen either with (CPT® 74160) or without and with contrast (CPT® 74170) ® Bone scan See also: ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology
Anaplastic carcinoma with signs or symptoms of recurrence	Any or all of the following: ® CT Neck with contrast (CPT® 70491) ® CT Chest with contrast (CPT® 71260) ® Either CT Abdomen/Pelvis with contrast (CPT® 74177) OR MRI Abdomen (CPT® 74183) and Pelvis (CPT® 72197) without and with contrast
Inconclusive conventional imaging	® PET/CT (CPT® 78815)

ONC-6.4: Thyroid Cancer – Surveillance/Follow-up

For this condition imaging is medically necessary based on the following criteria:

Follicular, Papillary and Hürthle Cell Carcinomas	Imaging/Diagnostic Study
All members	® Neck ultrasound (CPT® 76536), chest x-ray, and laboratory studies every 6 months for the first year, then annually
For members with any of the following: ® Node positive disease ® RAI-avid metastases	® Whole body thyroid nuclear scan annually (CPT® 78018) ® The following may be approved as an add-on test: ¡ CPT® 78020 to evaluate the degree of iodine uptake ¡ SPECT (CPT® 78803), or SPECT/CT Hybrid study (CPT® 78830, 78831, or 78832)

Medullary Carcinomas	Imaging/Diagnostic Study
All members	® CEA and calcitonin are required for monitoring medullary carcinomas ® Routine surveillance imaging is not indicated

Anaplastic Thyroid Carcinomas	Imaging Study
All members	Every 3 months for 2 years: ® CT Neck with contrast (CPT® 70491) ® CT Chest with contrast (CPT® 71260) ® CT Abdomen/Pelvis with contrast (CPT® 74177)

References

1. Haddad RH, Lydiatt WM, Bischoff L, et al. National Comprehensive Cancer Network (NCCN) Guidelines Version 3.2018 – December 20, 2018 Thyroid carcinoma, available at: https://www.nccn.org/professionals/physician_gls/pdf/thyroid.pdf Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Thyroid carcinoma V3.2018 – December 20, 2018 ^©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org.
1. Slough CM, Randolph GW. Workup of well-differentiated thyroid carcinoma. Cancer Control. 2006;13(2):99-105. doi:10.1177/107327480601300203.
2. Smallridge RC, Ain KB, Asa SL, et al. American Thyroid Association guidelines for management of patients with anaplastic thyroid cancer. Thyroid. 2012;22(11):1104-1139. doi:10.1089/thy.2012.0302.
3. Wells SA Jr, Asa SL, Dralle H, et al. American Thyroid Association guidelines for the management of medullary thyroid carcinoma. Thyroid. 2015;25(6):567-610. doi:10.1089/thy.2014.0335.
4. Yeh MW, Bauer AJ, Bernet VA, et al. American Thyroid Association statement on preoperative imaging for thyroid cancer surgery. Thyroid. 2015;25:3-14. doi:10.1089/thy.2014.0096.
5. Haugen BR, Alexander EK, Bible KB, et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association guidelines task force on thyroid nodules and differentiated thyroid cancer. Thyroid. 2016;26(1):1-133. doi:10.1089/thy.2015.0020.
6. Silberstein EB, Alavi A, Balon HR, et al. The SNMMI Practice Guideline for therapy of thyroid disease with ¹³¹I3.0. J Nucl Med. 2012;53(10):1633-1651. doi:10.2967/jnumed.112.105148.
7. Avram AM, Fig LM, Frey KA, Gross MD, Wong KK. Preablation 131-I scans with SPECT/CT in postoperative thyroid cancer patients: what is the impact on staging? J Clin Endocrinol Metab. February 21, 2013 [Epub ahead of print].

ONC-7: Small Cell Lung Cancer

ONC-7.0: Small Cell Lung Cancer – General Considerations

ONC-7.1: Small Cell Lung Cancer – Suspected/Diagnosis

ONC-7.2: Small Cell Lung Cancer – Initial Work-up/Staging

ONC-7.3: Small Cell Lung Cancer – Restaging/Recurrence

ONC-7.4: Small Cell Lung Cancer – Surveillance/Follow-up

ONC-7.0: Small Cell Lung Cancer – General Considerations

For this condition imaging is medically necessary based on the following criteria:

† Combined histologies of Small and Non-Small cell are considered Small cell lung cancer. Use this guideline for imaging recommendations for small and large cell high-grade (poorly differentiated) neuroendocrine tumors of the lung.

† Imaging is presently guided by traditional staging of limited or extensive disease.

® Extensive stage is either metastatic disease or an extent which cannot be encompassed by a single radiotherapy portal.
® Limited staging is confined to one side of the chest.

† For carcinoid (low grade neuroendocrine tumors) of the lung, see: ONC-15: Neuroendocrine Cancers and Adrenal Tumors

ONC-7.1: Small Cell Lung Cancer – Suspected/Diagnosis

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
® Abnormal chest x-ray or clinical suspicion remains high despite a normal chest x-ray in symptomatic member	® CT Chest without contrast (CPT® 71250) or ® CT Chest with contrast (CPT® 71260)
® Pulmonary nodule < 8 mm in size noted on CT Chest	® See: CH-16.2: Incidental Pulmonary Nodules Detected on CT Images
® Pulmonary nodule 8 mm (0.8 cm) to 30 mm (3 cm) seen on CT Chest or MRI Chest	® See CH-16.4: PET ® If PET is Positive: Qualifies as initial staging PET/CT
Mediastinal/Hilar Mass	See also: CH-2: Lymphadenopathy
Paraneoplastic syndrome suspected	See also: ONC-30.3: Paraneoplastic Syndromes

ONC-7.2: Small Cell Lung Cancer – Initial Work-up/Staging

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Initial staging	Any or all of the following: ® CT Chest with contrast (CPT® 71260) ® CT Abdomen/Pelvis with contrast (CPT® 74177) ® MRI Brain without and with contrast (CPT® 70553) ® Bone scan, if PET/CT not being done (See also: ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology)
Confirm limited stage (non-metastatic) disease if initial staging imaging (CT and MRI) shows disease limited to the thorax	® PET/CT (CPT® 78815)

ONC-7.3: Small Cell Lung Cancer – Restaging/Recurrence

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Treatment Response: ® After every 2 cycles of chemotherapy ® Following completion of chemoradiation	Any or all of the following: ® CT Chest with contrast (CPT® 71260) ® CT Abdomen with contrast (CPT® 74160) ¡ CT Abdomen/Pelvis with contrast (CPT® 74177) may be substituted for known pelvic disease or pelvic symptoms ® MRI Brain without and with contrast (CPT® 70553) for measurable brain metastases being treated with systemic therapy ® Bone scan (See also: ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology) ® PET is not indicated for evaluation of treatment response in SCLC, but can be considered on a case-by-case basis. These cases should be forwarded for medical director review.
Restaging (suspected recurrence)	Any or all of the following: ® CT Chest with contrast (CPT® 71260) ® CT Abdomen with contrast (CPT® 74160) ¡ CT Abdomen/Pelvis with contrast (CPT® 74177) may be substituted for known pelvic disease or pelvic symptoms ® Brain MRI without and with contrast (CPT® 70553) ® Bone scan (See: ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology) ® PET is not indicated for evaluation of recurrent SCLC, but can be considered on a case-by-case basis. These cases should be forwarded for Medical Director review.
Complete or partial response to initial treatment, if prophylactic cranial irradiation (PCI) is planned.	® MRI Brain without and with contrast (CPT® 70553)

ONC-7.4: Small Cell Lung Cancer – Surveillance/Follow-up

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Limited stage SCLC	® Every 3 months for one year, every 6 months for two years, and then annually:CT Chest without (CPT® 71250) or CT Chest with contrast (CPT® 71260) ® CT Abdomen without (CPT® 74150) or CT Abdomen with contrast (CPT® 74160) ® For new nodules, see: ONC-31.1: Lung Metastases
Extensive stage SCLC	Every 2 months for one year, every 4 months for two years, every 6 months for two years, and then annually: ® CT Chest without (CPT® 71250) or CT Chest with contrast (CPT® 71260) ® CT Abdomen without (CPT® 74150) or CT Abdomen with contrast (CPT® 74160) ® For new nodules, see: ONC-31.1: Lung Metastases
Screening for brain metastases, regardless of PCI status	MRI Brain without and with contrast (CPT® 70553) every 4 months for one year and then every 6 months for one year

References

1. Kalemkerian GP, Loo BW, Akerley W, et al. National Comprehensive Cancer Network (NCCN) Guidelines Version 1.2019 – April 9, 2019 Small cell lung cancer, available at: https://www.nccn.org/professionals/physician_gls/pdf/sclc.pdf Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Small cell Lung cancer V 1.2019 – April 9, 2019 Small ©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org.
2. Lu YY, Chen JH, Liang JA, Chu S, Lin WY, Kao CH. 18F-FDG PET or PET/CT for detecting extensive disease in small-cell lung cancer: a systematic review and meta-analysis. Nucl Med Commun. 2014;35(7):697-703. doi:10.1097/MNM.0000000000000122.
3. Carter BW, Glisson BS, Truong MT, Erasmus JJ. Small cell lung carcinoma: staging, imaging, and treatment considerations. Radiographics. 2014;34(6):1707-1721. doi:10.1148/rg.346140178.
4. Kalemkerian G. Staging and imaging of small cell lung cancer. Cancer Imag. 2011;11(1):253-258.

doi:10.1102/1470-7330.2011.0036.

ONC-8.0: Non-Small Cell Lung Cancer – General Considerations

For this condition imaging is medically necessary based on the following criteria:

† Non-small cell lung cancer includes adenocarcinoma, squamous cell carcinoma, adenosquamous and large cell tumors.

† See ONC-15.6: Bronchopulmonary or Thymic Carcinoid – Initial Staging for evaluation of low-grade neuroendocrine tumors (carcinoid) of the lung.

† See ONC-7: Small Cell Lung Cancer for evaluation of high-grade small cell and large cell neuroendocrine tumors of the lung.

† PET/CT scan is not generally indicated for initial staging or restaging of NSCLC with distant metastatic disease, pleural/pericardial effusion, or for multiple sites that are located outside the chest cavity, when found on conventional imaging (i.e., liver, bone and adrenal metastases, etc.).

† PET/CT may be considered to confirm solitary focus of metastatic disease (i.e., brain or adrenal) if being considered for an aggressive surgical management.

ONC-8.1: Non-Small Cell Lung Cancer – Asymptomatic Screening

For this condition imaging is medically necessary based on the following criteria:

See Adult Chest Imaging Policy (Policy #150 in the Radiology Section); CH-34: Lung Cancer Screening for criteria for low-dose CT scan chest for lung cancer screening.

ONC-8.2: Non-Small Cell Lung Cancer – Suspected/Diagnosis

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
® Abnormal chest x-ray or clinical suspicion remains high despite a normal chest x-ray in symptomatic member	® CT Chest without contrast (CPT® 71250) or ® CT Chest with contrast (CPT® 71260)
® Pulmonary nodule < 8 mm in size noted on CT Chest	® See: Adult Chest Imaging Policy (Policy #150 in the Radiology Section); CH-16.2: Incidental Pulmonary Nodules Detected on CT Images
® Pulmonary nodule 8 mm (0.8 cm) to 30 mm (3 cm) seen on CT Chest or MRI Chest	® See Adult Chest Imaging Policy (Policy #150 in the Radiology Section); CH-16.4: PET ® If PET is Positive: Qualifies as initial staging PET/CT
® Pulmonary mass 31 mm (3.1 cm) or greater seen on CT or MRI	® PET/CT (CPT® 78815) can be approved prior to biopsy if one or more of the following applies: ¡ Resection will be performed instead of biopsy if PET confirms limited disease ¡ Multiple possible biopsy options are present within the chest and PET findings will be used to determine the most favorable biopsy site ® Biopsy is indicated prior to PET imaging for all other indications in pulmonary masses ≥ 31 mm (3.1 cm) in size
Mediastinal/Hilar Mass	See also: Adult Chest Imaging Policy (Policy #150 in the Radiology Section); CH-2: Lymphadenopathy
Paraneoplastic syndrome suspected	See also: ONC-30.3: Paraneoplastic Syndromes

ONC-8.3: Non-Small Cell Lung Cancer – Initial Work-up/Staging

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
All members	Any or all of the following: ® CT Chest (CPT® 71260) with contrast ® CT Abdomen (CPT® 74160) with contrast ¡ CT Abdomen may be omitted if CT Chest report clearly documents upper abdomen through level of adrenals ® Bone scan, if PET/CT not being done See also: ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology
Any of the following: ® All Stage I-IIIB disease ® Stage IV disease confined to the chest region ® Conventional imaging is inconclusive ***PET is not indicated for metastatic disease present outside the chest cavity on CT, MRI, or bone scan	® PET/CT (CPT® 78815) if not already completed prior to histological diagnosis
Any of the following: ® All Stage II-IV disease ® Stage I disease and considering surgical resection as primary therapy	® MRI Brain without and with contrast (CPT® 70553)
Superior sulcus (Pancoast) tumor suspected	Any or all of the following: ® MRI Chest without and with contrast (CPT® 71552) ® MRI Cervical spine without and with contrast (CPT® 72156) ® MRI Thoracic spine without and with contrast (CPT® 72157)

ONC-8.4: Non-Small Cell Lung Cancer – Restaging/Recurrence

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Stage I or II members who undergo definitive local treatment with surgery, radiation, or radiosurgery	® Restaging imaging is not indicated. See also: Surveillance ONC-8.5: Surveillance/Follow-up
Measurable disease, undergoing active treatment	Any or all of the following every 2 cycles: ® CT Chest with (CPT® 71260) or CT Chest without contrast (CPT® 71250) ® CT Abdomen with contrast (CPT® 74160) ¡ CT Abdomen/Pelvis with contrast (CPT® 74177) may be substituted for known pelvic disease or pelvic symptoms ® MRI Brain without and with contrast (CPT® 70553) for measurable brain metastases being treated with systemic therapy
Any of the following: ® Locally advanced (Stage III, non-metastatic, unresectable) ® Inoperable tumor if chemotherapy or chemoradiation was the initial treatment modality ® Inadequately resected disease ® Suspected recurrence	Any or all of the following: ® CT Chest with (CPT® 71260) or CT Chest without contrast (CPT® 71250) ® CT Abdomen with contrast (CPT® 74160) ® CT Abdomen/Pelvis with contrast (CPT® 74177) may be substituted for known pelvic disease or pelvic symptoms
Determine resectability following neo-adjuvant therapy	® MRI Chest without and with contrast (CPT® 71552)
Newly identified lung nodule(s)	® See ONC-31.1: Lung Metastases for new nodule evaluation
Any of the following: ® Suspected/biopsy proven recurrence localized to the chest cavity ® Inconclusive findings conventional imaging ® To differentiate tumor from radiation scar/fibrosis	® PET/CT (CPT® 78815) ***PET is not indicated for metastatic disease present outside the chest cavity on CT, MRI, or bone scan
Any of the following: ® Following a demonstrated adequate response to neoadjuvant therapy if intracranial disease will preclude surgery ® Documented recurrence/progression ® New or worsening neurological signs or symptoms	® MRI Brain without and with contrast (CPT® 70553)

ONC-8.5: Non-Small Cell Lung Cancer – Surveillance/Follow-up

For this condition imaging is medically necessary based on the following criteria:

Indication	Study
Stage I-II	CT Chest with contrast (CPT® 71260) or CT Chest without contrast (CPT® 71250) every 6 months for 2 years and then annually ***Members treated with radiation therapy and residual abnormality on imaging may undergo CT Chest every 3 months for the first year after therapy, every 6 months in year 2, annually thereafter
Stage III-IV (metastatic sites treated with definitive intent)	® CT Chest with contrast (CPT® 71260) or CT Chest without contrast (CPT® 71250) every 3 months for 2 years, every 6 months for 3 years and then annually
New lung nodule	See: ONC-31.1: Lung Metastases

References

1. Ettinger DS, Wood DE, Aisner DL, et al, National Comprehensive Cancer Network (NCCN) Guidelines Version 5.2019 – June 7, 2019. Non small cell lung cancer, available at: https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Non small cell lung cancer V5.2019 – June 7, 2019. ©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org.
2. MacMahon H, Naidich DP, Goo JM, et al. Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner Society 2017. Radiology. 2017;284(1):228-243. doi:10.1148/radiol.2017161659.
3. Calman L, Beaver K, Hind D, Lorigan P, Roberts C, Lloyd-Jones M. Survival benefits from follow-up of patients with lung cancer: a systematic review and meta-analysis. J Thorac Oncol. 2011;6(12):1993-2004. doi:10.1097/JTO.0b013e31822b01a1.
4. Lou F, Huang J, Sima CS et al. Patterns of recurrence and second primary lung cancer in early-stage lung cancer survivors followed with routine computed tomography surveillance. J Thorac Cardiovasc Surg. 2013;145:75-81. https://www.ncbi.nlm.nih.gov/pubmed/23127371 .
5. Colt HG, Murgu SD, Korst RJ, et al. Follow-up and surveillance of the patient with lung cancer after curative-intent therapy: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines, Chest 2013;143:e437S-454S. https://www.ncbi.nlm.nih.gov/pubmed/23649451 .
6. Dane B, Grechushkin V, Plank A, et al. PET/CT vs. non-contrast CT alone for surveillance 1-year post lobectomy for stage I non-small cell lung cancer. Am J Nucl Med Mol Imaging. 2013; 3:408-416. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3784804/ .
7. Zhao L, He ZY, Zhong XN, et al. (18)FDG-PET/CT for detection of mediastinal nodal metastasis in non-small cell lung cancer: a meta-analysis. Surg Oncol. 2012;21(3):230-236. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0049561/ .
8. Li J, Xu W, Kong F, et al. Meta-analysis: accuracy of 18FDG PET-CT for distant metastasis in lung cancer patients. Surg Oncol. 2013;22(3):151-155. https://www.ncbi.nlm.nih.gov/pubmed/23664848 .
9. Ravenel JG. Evidence-based imaging in lung cancer: a systematic review. J Thorac Imaging. 2012; 27(5):315-324. http://journals.lww.com/thoracicimaging/Abstract/2012/09000/Evidence_based_Imaging_in_Lung_Cancer__A.8.aspx .
10. Bille A, Pelosi E, Skanjeti A, et al. Preoperative intrathoracic lymph node staging in patients with non-small-cell lung cancer: accuracy of integrated positron emission tomography and computed tomography. Eur J Cardiothorac Surg. 2009;36(3):440-445. https://academic.oup.com/ejcts/article-lookup/doi/10.1016/j.ejcts.2009.04.003 .


ONC-9: Esophageal Cancer

ONC-9.0: Esophageal Cancer – General Considerations

ONC-9.1: Esophageal Cancer – Suspected/Diagnosis

ONC-9.2: Esophageal Cancer – Initial Work-up/Staging

ONC-9.3: Esophageal Cancer – Restaging/Recurrence

ONC-9.4: Esophageal Cancer – Surveillance/Follow-up

ONC-9.0: Esophageal Cancer – General Considerations

For this condition imaging is medically necessary based on the following criteria:

† Clinicians must describe esophageal cancer by cell type and in which third of the esophagus it occurs.

† Cancers of the upper and middle third are usually squamous cell and are highly associated with tobacco and alcohol abuse.

† Cancers of the gastroesophageal (GE) junction are treated as lower third cancers. Lower third cancers are usually adenocarcinomas; 62% of these arise in the setting of Barrett’s esophagus, a condition associated with high body mass index (BMI).

ONC-9.1: Esophageal Cancer – Suspected/Diagnosis

For this condition imaging is medically necessary based on the following criteria:

† See also: Adult Neck Imaging Policy (Policy #153 in the Radiology Section); NECK-3.1: Dysphagia for imaging guidelines for evaluation of suspected esophageal malignancy

ONC-9.2: Esophageal Cancer – Initial Work-up/Staging

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Biopsy proven	® CT Chest (CPT® 71260) and CT Abdomen with contrast (CPT® 74160) ¡ CT Abdomen/Pelvis with contrast (CPT® 74177) may be approved instead of CT Abdomen if there are pelvic signs or symptoms
Upper 1/3 or neck mass	® CT Neck with contrast (CPT® 70491) for upper 1/3 primary and/or neck mass
If no evidence of metastatic disease by conventional imaging	® PET/CT (CPT® 78815)

ONC-9.3: Esophageal Cancer – Restaging/Recurrence

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
After primary chemoradiation therapy prior to surgery	® CT Chest (CPT® 71260) and CT Abdomen (CPT® 74160) with contrast
Post-surgical resection	® See Surveillance ONC-9.4: Surveillance/Follow-up
® If conventional imaging is inconclusive or ® Salvage surgical candidate with recurrence and no metastatic disease documented by conventional imaging	® PET/CT (CPT® 78815) ¡ PET imaging can be done as early as 6 weeks after completion of XRT if recent CT findings are inconclusive and PET findings will alter immediate care decision making
For any of the following: ® Signs or symptoms of recurrence ® Biopsy proven on follow-up endoscopy ® Recurrence suggested by other imaging (i.e. CXR or barium swallow)	® CT Chest (CPT® 71260) and CT Abdomen (CPT® 74160) with contrast
If previously involved or new signs or symptoms	® CT Pelvis with contrast (CPT® 72193) and/or CT Neck with contrast (CPT® 70491)

ONC-9.4: Esophageal Cancer – Surveillance/Follow-up

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Stage 0-I disease	® No routine advanced imaging indicated
Stage II-III disease	® CT Chest (CPT® 71260) and CT Abdomen (CPT® 74160) with contrast every 6 months for 2 years
Stage IV disease	® See: ONC-1.2: Phases of Oncology Imaging and General Phase-Related Considerations

References

1. Ajani JA, D’Amico TA, Almhanna K, et al, National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2019 – May 29, 2019. Esophageal and esophagogastric junction cancers, available at: https://www.nccn.org/professionals/physician_gls/pdf/esophageal.pdf Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Esophageal and esophagogastric junction cancers V2.2019 – May 29, 2019. ©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org.
2. Klaeser B, Nitzsche E, Schuller JC, et al. Limited predictive value of FDG-PET for response assessment in the preoperative treatment of esophageal cancer: results of a prospective multi-center trial (SAKK 75/02). Onkologie. 2009;32(12):724-730. doi:10.1159/000251842.
3. Malik V, Lucey JA, Duffy GJ, et al. Early repeated 18F-FDG PET scans during neoadjuvant chemoradiation fail to predict histopathologic response or survival benefit in adenocarcinoma of the esophagus. J Nucl Med. 2010;51(12):1863-1869. doi:10.2967/jnumed.110.079566.
4. Stiekema J, Vermeulen D, Vegt E, et al. Detecting interval metastases and response assessment using 18F-FDG PET/CT after neoadjuvant chemoradiotherapy for esophageal cancer. Clin Nucl Med. 2014;39(10):862-867. doi:10.1097/RLU.0000000000000517.
5. Sudo K, Xiao L, Wadhwa R, et al. Importance of surveillance and success of salvage strategies after definitive chemoradiation in patients with esophageal cancer. J Clin Oncol. 2014;32(30):3400-3405. doi:10.1200/JCO.2014.56.7156.
6. Lou F, Sima CS, Adusumilli PS, et al. Esophageal cancer recurrence patterns and implications for surveillance. J Thorac Oncol. 2013;8(12):1558–1562. doi:10.1097/01.JTO.0000437420.38972.fb.
7. Goense L, van Rossum PS, Reitsma JB, et al. Diagnostic performance of 18F-FDG PET and PET/CT for the detection of recurrent esophageal cancer after treatment with curative intent: a systematic review and meta-analysis. J Nucl Med. 2015;56(7):995-1002. doi:10.2967/jnumed.115.155580.


ONC-10: Other Thoracic Tumors

ONC-10.1: Malignant Pleural Mesothelioma – Suspected/Diagnosis

ONC-10.2: Malignant Pleural Mesothelioma – Initial Work-up/Staging

ONC-10.3: Malignant Pleural Mesothelioma – Restaging

ONC-10.4: Malignant Pleural Mesothelioma – Surveillance

ONC-10.5: Thymoma and Thymic Carcinoma – Suspected/Diagnosis

ONC-10.6: Thymoma and Thymic Carcinoma – Initial Work-up/Staging

ONC-10.7: Thymoma and Thymic Carcinoma – Restaging

ONC-10.8: Thymoma and Thymic Carcinoma – Surveillance

ONC-10.1: Malignant Pleural Mesothelioma – Suspected/Diagnosis

For this condition imaging is medically necessary based on the following criteria:

† See Adult Chest Imaging Policy (Policy #150 in the Radiology Section); CH-9: Asbestos Exposure for imaging guidelines for evaluation of suspected mesothelioma

ONC-10.2: Malignant Pleural Mesothelioma – Initial Work-up/Staging

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Cytologically or pathologically proven	® CT Chest (CPT® 71260) and CT Abdomen (CPT® 74160) with contrast ® CT Abdomen/Pelvis with contrast (CPT® 74177) may be approved instead of CT Abdomen if there are pelvic signs or symptoms ® PET/CT (CPT® 78815) if no evidence of metastatic disease or inconclusive conventional imaging
Preoperative planning	® MRI Chest without and with contrast (CPT® 71552)

ONC-10.3: Malignant Pleural Mesothelioma – Restaging

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Signs or symptoms of recurrence	® CT Chest (CPT® 71260) and CT Abdomen (CPT® 74160) with contrast ® CT Abdomen/Pelvis with contrast (CPT® 74177) may be approved instead of CT Abdomen if there are pelvic signs or symptoms
Treatment with chemotherapy	Every 2 cycles: ® CT Chest (CPT® 71260) and CT Abdomen (CPT® 74160) with contrast ® CT Abdomen/Pelvis with contrast (CPT® 74177) may be approved instead of CT Abdomen if there are pelvic signs or symptoms
Following induction chemotherapy prior to surgical resection	® CT Chest (CPT® 71260) and CT Abdomen (CPT® 74160) with contrast ® CT Abdomen/Pelvis with contrast (CPT® 74177) may be approved instead of CT Abdomen if there are pelvic signs or symptoms ® PET/CT (CPT® 78815) if no evidence of metastatic disease
Inconclusive Chest CT	® MRI Chest without and with contrast (CPT® 71552)

ONC-10.4: Malignant Pleural Mesothelioma – Surveillance

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
All	® CT Chest with contrast (CPT® 71260) and previously involved regions every 3 months for 2 years, then annually thereafter

ONC-10.5: Thymoma and Thymic Carcinoma – Suspected/Diagnosis

For this condition imaging is medically necessary based on the following criteria:

† See Adult Chest Imaging Policy (Policy #150 in the Radiology Section); CH-20: Mediastinal Mass for imaging guidelines for evaluation of suspected thymic malignancies

† See ONC-15.6:Bronchopulmonary or Thymic Carcinoid – Initial Staging for imaging guidelines for thymic carcinoid

ONC-10.6: Thymoma and Thymic Carcinoma – Initial Work-up/Staging

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Encapsulated or invasive limited disease	® CT Chest with contrast (CPT® 71260)
Extensive mediastinal involvement on Chest CT	® CT Abdomen with contrast (CPT® 74160) ® CT Neck with contrast (CPT® 70491)
Inconclusive finding on CT	One of the following: ® PET/CT (CPT® 78815) ® MRI Chest without and with contrast (CPT® 71552)
Preoperative planning	® MRI Chest without and with contrast (CPT® 71552)
Thymic Carcinomas	® Image according to ONC-8: Non-Small Cell Lung Cancer

ONC-10.7: Thymoma and Thymic Carcinoma – Restaging

For this condition imaging is medically necessary based on the following criteria:

Indication	Study
Adjuvant therapy following surgical resection	® Follow surveillance imaging
For suspected recurrence	® CT Chest with contrast (CPT® 71260)
Recurrence with extensive mediastinal involvement on chest CT	® CT Abdomen with contrast (CPT® 74160) ® CT Neck with contrast (CPT® 70491)
Thymic carcinomas	See ONC-8: Non-Small Cell Lung Cancer
Inconclusive finding on CT	One of the following: ® PET/CT (CPT® 78815) ® MRI Chest without and with contrast (CPT® 71552)
Extensive disease on chemotherapy	® CT Neck (CPT® 70491), CT Chest (CPT® 71260), and CT Abdomen (CPT® 74160) with contrast, every 2 cycles of therapy ® Following induction chemotherapy prior to surgical resection, PET/CT (CPT® 78815) if no evidence of metastatic disease

ONC-10.8: Thymoma and Thymic Carcinoma – Surveillance

For this condition imaging is medically necessary based on the following criteria:

Indication	Study
Thymoma	® CT Chest with contrast (CPT® 71260) and previously involved regions every 6 months for 2 years, then annually for next 10 years
Thymic carcinomas	® CT Chest with contrast (CPT® 71260) every 6 months for 2 years and then annually for 5 years

References

1. Ettinger DS, Wood DE , Aisner DL et al. National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2019 – April 1, 2019. Malignant Pleural Mesothelioma, available at: https://www.nccn.org/professionals/physician_gls/pdf/mpm.pdf Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Malignant Pleural Mesothelioma V2.2019 – April 1, 2019. ©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org.
2. Ettinger DS, Wood DE , Aisner DL et al. National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2019 – March 11, 2019. Thymoma and Thymic carcinoma, available at: https://www.nccn.org/professionals/physician_gls/pdf/thymic.pdf Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Thymoma and Thymic carcinoma, V 2.2019 – March 11, 2019. ©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org.
3. Sørensen JB, Ravn J, Loft A, Brenøe J, Berthelsen AK, Nordic Mesothelioma Group. Preoperative staging of mesothelioma by 18F-fluoro-2-deoxy-D-glucose positron emission tomography/computer tomography fused imaging and mediastinoscopy compared to pathological findings after extrapleural pneumonectomy. Eur J Cardiothorac Surg. 2008;34:1090-1096. doi:10.1016/j.ejcts.2008.07.050.
4. Wilcox BE, Subramaniam RM, Peller PJ, et al. Utility of computed tomography-positron emission tomography for selection of operable malignant pleural mesothelioma. Clin lung cancer. 2009;10:244-248. doi: 10.3816/CLC.2009.n.033.
5. Marom EM. Imaging thymoma. J Thorac Oncol. 2010;5(10 Suppl 4):S296-S303. doi:10.1097/JTO.0b013e3181f209ca.
6. Marom EM. Advances in thymoma imaging. J Thorac Imaging. 2013;28(2):69-80. doi:10.1097/RTI.0b013e31828609a0.
7. Hayes SA, Huang J, Plodkowski AJ, et al. Preoperative computed tomography findings predict surgical resectability of thymoma. J Thorac Oncol. 2014;9(7):1023-1030. doi:10.1097/JTO.0000000000000204.
8. Mineo TC, Ambrogi V. Malignant pleural mesothelioma: factors influencing the prognosis. Oncology. 2012;26(12):1164-75.

ONC-11: Breast Cancer

ONC-11.0: Breast Cancer – General Considerations

ONC-11.1: Breast Cancer – Suspected/Diagnosis

ONC-11.2: Breast Cancer – Initial Work-up/Staging

ONC-11.3: Breast Cancer – Restaging/Recurrence

ONC-11.4: Breast Cancer – Surveillance/Follow-up

ONC-11.0: Breast Cancer – General Considerations

For this condition imaging is medically necessary based on the following criteria:

† Advanced imaging to evaluate for distant metastases is not indicated for pre-invasive or in-situ breast cancer (histologies such as DCIS and LCIS). Bone scan has a high concordance rate with PET for detecting bone metastases.

† Scintimammography and Breast Specific Gamma Imaging (BSGI) are considered investigational.

† NOTE: Some payors have specific restrictions on PET imaging, and those coverage policies may supersede the recommendations for PET imaging in these guidelines.

† PET is not indicated for the following:

® Non-invasive breast cancers
® Prior to lymph node sampling in a member with clinical stage I, II, or operable IIIA disease
® Obvious multi-organ metastatic disease is present on CT or MRI

ONC-11.1: Breast Cancer – Suspected/Diagnosis

For this condition imaging is medically necessary based on the following criteria:

See Adult Breast Imaging Policy (Policy #177 in the Radiology Section); BR-5: Breast MRI Indications for imaging guidelines for evaluation of suspected breast cancer

ONC-11.2: Breast Cancer – Initial Work-up/Staging

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Any of the following: ® Biopsy proven invasive breast cancer or carcinoma in-situ ® Adenocarcinoma in axillary lymph node	® Bilateral Breast MRI (CPT® 77049)
Operable disease (stage I and II)	® No advanced imaging needed ® For planned sentinel lymph node (SLN) biopsy: Lymph system imaging (lymphoscintigraphy, CPT® 78195)
Clinical Stage III and Stage IV disease or for signs or symptoms of systemic disease (including elevated liver function tests or tumor markers)	Any or all of the following: ® CT Chest with contrast (CPT® 71260) and CT Abdomen/Pelvis (CPT® 74177) with contrast ® Bone scan See also: ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology
Inconclusive CT and bone scan	® PET/CT (CPT® 78815)
Bone pain	® Bone scan (see: ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology) ® See also: ONC-31.5: Bone (including Vertebral) Metastases ® See also: ONC-31.6: Spinal Cord Compression

ONC-11.3: Breast Cancer – Restaging/Recurrence

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Any of the following: ® Biopsy proven local recurrence ® Suspicion of recurrence with inconclusive mammogram and/or ultrasound (BIRADS 0) ® Mammogram and ultrasound conflicts with physical exam ® End of planned neoadjuvant chemotherapy to determine resectability	Bilateral MRI Breast without and with contrast (CPT® 77049)
Any of the following: ® Elevated LFTs ® Rising tumor markers ® Signs or symptoms of recurrence ® Biopsy proven recurrence	Any or all of the following: ® CT Chest (CPT® 71260) and CT Abdomen/Pelvis (CPT® 74177) with contrast ® Bone scan (See also: ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology)
Treatment response in members with metastatic disease and measurable disease on imaging	Any or all of the following for members being treated with chemotherapy, every 2 cycles: ® CT Chest (CPT® 71260) and CT Abdomen/Pelvis (CPT® 74177) with contrast ® Bone scan (see also: ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology) ® MRI Brain without and with contrast (CPT® 70553) for members receiving systemic treatment for brain metastases Any or all of the following for members being treated with endocrine/hormonal therapy, every 3 months: ® CT Chest (CPT® 71260) and CT Abdomen/Pelvis (CPT® 74177) with contrast ® Bone scan (See ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology)
Inconclusive CT, MRI, and/or bone scan for suspected recurrence, and further characterization is needed to make treatment decisions	® PET/CT (CPT® 78815)
Any of the following: ® Assessing for residual disease after surgery ® Assessing response to neoadjuvant chemotherapy ® After lumpectomy or mastectomy, prior to adjuvant therapy	® Neither PET nor CT are indicated for systemic restaging after neoadjuvant chemotherapy or after surgery
Bone metastasis as the only site of stage IV disease (excluding brain metastases) and a prior bone scan has not been performed for serial comparison	® PET/CT (CPT® 78815)

ONC-11.4: Breast Cancer – Surveillance/Follow–up

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Metastatic disease on a break from therapy with persistent measurable disease	Any or all of the following, every 3 months: ® CT Chest (CPT® 71260) and CT Abdomen/Pelvis (CPT® 74177) with contrast ® Bone scan (see also: ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology)
Asymptomatic non-metastatic disease	® No advanced imaging indicated
Breast imaging surveillance, including after bilateral mastectomy	® See BR-5: Breast MRI Indications for imaging guidelines

References

1. Gradishar WJ, Anderson BO, Balassanian R et al. National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2019 – July 2, 2019. Breast cancer, available at: https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Breast Cancer V 2.2019 – July 2, 2019. ©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines™, go online to NCCN.org.
2. Cardoso F, Costa A, Norton L, et al. ESO-ESMO 2nd international consensus guidelines for advanced breast cancer (ABC2). Ann Oncol. 2014;25(10):1871-1888. doi:10.1093/annonc/mdu385.
3. Khatcheressian JL, Hurley P, Bantug E, et al. Breast cancer follow-up and management after primary treatment: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013;31:961-965. doi:10.1200/JCO.2012.45.9859.
4. Puglisi F, Follador A, Minisini AM, et al. Baseline staging tests after a new diagnosis of breast cancer: further evidence of their limited indications. Ann Oncol. 2005;16(2):263-266. doi:10.1093/annonc/mdi063.
5. Rong J, Wang S, Ding Q, Yun M, Zheng Z, Ye S. Comparison of 18 FDG PET-CT and bone scintigraphy for detection of bone metastases in breast cancer patients. A meta-analysis. Surg Oncol. 2013;22(2):86-91. doi:10.1016/j.suronc.2013.01.002.
6. Hong S, Li J, Wang S. 18FDG PET-CT for diagnosis of distant metastases in breast cancer patients. A meta-analysis. Surg Oncol. 2013;22(2):139-143. doi:10.1016/j.suronc.2013.03.001.
7. Cheng X, Li Y, Liu B, Xu Z, Bao L, Wang J. 18F-FDG PET/CT and PET for evaluation of pathological response to neoadjuvant chemotherapy in breast cancer: a meta-analysis. Acta Radiol. 2012;53(6):615-627. doi:10.1258/ar.2012.110603.
8. Simos D, Catley C, van Walraven C, et al. Imaging for distant metastases in women with early-stage breast cancer: a population-based cohort study. CMAJ. 2015;187(12):E387-E397. doi:10.1503/cmaj.150003.
9. Crivello ML, Ruth K, Sigurdson ER, et al. Advanced imaging modalities in early stage breast cancer: preoperative use in the United States Medicare population. Ann Surg Oncol. 2013;20(1):102-110. doi:10.1245/s10434-012-2571-4.

ONC-12: Sarcomas – Bone, Soft Tissue and GIST

ONC-12.1: Bone and Soft Tissue Sarcomas – General Considerations

ONC-12.2: Soft Tissue Sarcomas – Initial Work-up/Staging

ONC-12.3: Soft Tissue Sarcomas – Restaging/Recurrence

ONC-12.4: Soft Tissue Sarcomas – Surveillance/Follow-up

ONC-12.5: Gastrointestinal Stromal Tumor (GIST)

ONC-12.6: Bone Sarcomas – Initial Work-up/Staging

ONC-12.7: Bone Sarcomas – Restaging/Recurrence

ONC-12.8: Bone Sarcomas – Surveillance/Follow-up

ONC-12.9: Benign Bone Tumors – General Considerations

ONC-12.10: Benign Bone Tumors – Initial Work-up/Staging

ONC-12.11: Benign Bone Tumors – Restaging/Recurrence

ONC-12.12: Benign Bone Tumors – Surveillance/Follow-up

ONC-12.1: Bone and Soft Tissue Sarcomas - General Considerations

For this condition imaging is medically necessary based on the following criteria:

Sarcomas are tumors of mesenchymal origin, classified as high-, intermediate-, and low-grade (G) tumors (sometimes described as “spindle cell” cancers). They can arise in any bony, cartilaginous, smooth muscle, skeletal muscle, or cardiac muscle tissue.

Sarcomas occur in both adult and pediatric members, but some are more common in one age group than the other. Unless specified below, members age ≥ 18 years old should be imaged according to this guideline section.

Exceptions include:

† Rhabdomyosarcoma members of all ages should be imaged according to guidelines in Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-8.2: Rhabdomyosarcoma

† Osteogenic sarcoma (Osteosarcoma) members of all ages should be imaged according to guidelines in Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-9.3: Osteogenic Sarcoma (OS)

† Ewing sarcoma and Primitive Neuroectodermal Tumor members of all ages should be imaged according to guidelines in Pediatric Oncology Imaging Policy (Policy #166 in the Radiology Section); PEDONC-9.4: Ewing Sarcoma and Primitive Neuroectodermal Tumors (ESFT)

† Kaposi’s sarcoma members of all ages should be imaged according to guidelines in ONC-31.10: Kaposi’s Sarcoma


ONC-12.2: Soft Tissue Sarcomas - Initial Workup/Staging

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Retroperitoneal or intraabdominal primary site	Any or all of the following: ® CT Chest with (CPT® 71260) or without contrast (CPT® 71250) ® Either CT Abdomen/Pelvis with contrast (CPT® 74177) or MRI Abdomen (CPT® 74183) and MRI Pelvis (CPT® 72197) without and with contrast
Any of the following: ® Extremity or trunk primary site ® Head or neck primary site ® Other histologies documented to have propensity for lymphatic spread and deep-seated tumors	Any or all of the following: ® MRI without and with contrast of involved area ® CT Chest with (CPT® 71260) or without contrast (CPT® 71250)
Any of the following: ® Angiosarcoma ® Alveolar soft part sarcoma ® Clear cell sarcoma ® Epithelioid sarcoma ® Hemangiopericytoma ® Leiomyosarcoma ® Other histologies documented to have propensity for lymphatic spread and deep-seated tumors	Any or all of the following: ® MRI without and with contrast of involved area ® CT Chest with (CPT® 71260) or without contrast (CPT® 71250) ® Either CT Abdomen/Pelvis with contrast (CPT® 74177) or MRI Abdomen (CPT® 74183) and MRI Pelvis (CPT® 72197) without and with contrast
Myxoid round cell liposarcoma	Any or all of the following: ® MRI without and with contrast of involved area ® CT Chest with (CPT® 71260) or without contrast (CPT® 71250) ® Either CT Abdomen/Pelvis with contrast (CPT® 74177) or MRI Abdomen (CPT® 74183) and Pelvis (CPT® 72197) without and with contrast ® MRI Cervical/Thoracic/Lumbar spine without and with contrast (CPT® 72156, CPT® 72157, and CPT® 72158)
Any of the following: ® Angiosarcoma ® Alveolar soft part sarcoma ® All members with signs/symptoms of brain metastases	® MRI Brain without and with contrast (CPT® 70553)
Any of the following: ® Grade of tumor in doubt following biopsy ® Conventional imaging suggests solitary metastasis amenable to surgical resection	® PET/CT (CPT® 78815 or CPT® 78816)
Desmoid Tumors	One of the following: ® CT without contrast or with contrast of the affected body part ® MRI without contrast or without and with contrast of the affected body part ® Imaging of lung, lymph node, and metastatic site for these tumors is not indicated
Dermatofibrosarcoma Protuberans (DFSP)	One of the following: ® CT without contrast or with contrast of the affected body part ® MRI without contrast or without and with contrast of the affected body part ® CT Chest with (CPT® 71260) or without contrast (CPT® 71250) for ¡ pulmonary symptoms ¡ abnormal chest x-ray ¡ sarcomatous differentiation

ONC-12.3: Soft Tissue Sarcomas - Restaging/Recurrence

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Any of the following: ® After preoperative radiotherapy ® After surgical resection ® After adjuvant radiotherapy	® MRI without and with contrast of affected body area ® CT without contrast or with contrast can be added if demonstrated bone involvement ® Chest or lymph node imaging is not indicated if no abnormality on previous imaging
Any of the following: ® Differentiate tumor from radiation or surgical fibrosis ® Determine response to neoadjuvant therapy ® Confirm oligometastatic disease prior to curative intent surgical resection	® PET/CT (CPT® 78815 or CPT® 78816)
Chemotherapy response for members with measurable disease	® CT with contrast or MRI without and with contrast of affected body area every 2 cycles
Local recurrence suspected	® Repeat all imaging for initial workup of specific histology and/or primary site
Preoperative planning prior to resection	Any or all of the following: ® MRI without contrast or without and with contrast of involved area ® CT (contrast as requested) of involved area
Dermatofibrosarcoma Protuberans (DFSP)	One of the following: ® CT without contrast or with contrast of the affected body part ® MRI without contrast or without and with contrast of the affected body part ® CT Chest with (CPT® 71260) or without contrast (CPT® 71250) for: ¡ pulmonary symptoms ¡ abnormal chest x-ray ¡ sarcomatous differentiation

ONC-12.4: Soft Tissue Sarcomas Surveillance/Follow Up

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Retroperitoneal/intra-abdominal primary site	Any or all of the following every 3 months for 2 years, then every 6 months for 2 more years, then annually: ® CT Chest with (CPT® 71260) or without contrast (CPT® 71250) ® CT Abdomen/Pelvis with contrast (CPT® 74177) ® CT with contrast or MRI without and with contrast of any other involved body areas
Extremity, trunk, or Head/Neck primary site, low grade Stage I disease	Any or all of the following every 6 months for 2 years, then annually until year 10: ® Chest x-ray ¡ CT Chest with (CPT® 71260) or without contrast (CPT® 71250) is indicated for new findings on CXR or new/worsening pulmonary signs/symptoms ® CT with contrast, MRI without contrast, or MRI without and with contrast of primary site if primary site not easily evaluated by physical exam
Extremity, trunk, or Head/Neck primary site, Stages II-IV disease.	Any or all of the following every 3 months for 2 years, then every 6 months for 2 more years, then annually: ® CT with contrast, MRI without contrast, or MRI without and with contrast of primary site ® CT Chest with (CPT® 71260) or without contrast (CPT® 71250) ® CT with contrast or MRI without and with contrast of any other involved body areas
Desmoid tumors	One of the following every 6 months for 3 years, then annually: ® CT without contrast or with contrast of the affected body part ® MRI without contrast or without and with contrast of the affected body part
Dermatofibrosarcoma Protuberans	® No routine imaging unless clinical signs/symptoms of recurrence

ONC-12.5: Gastrointestinal Stromal Tumor (GIST)

For this condition imaging is medically necessary based on the following criteria:

General Considerations
GISTs are mesenchymal neoplasms of the gastrointestinal (GI) tract, mostly found in the stomach and upper small bowel, commonly metastasizing to the liver and abdominal cavity and primarily treated with surgery.

Indication	Imaging Study
Suspected/Diagnosis	® CT Abdomen/Pelvis with contrast (CPT® 74177)
Initial Work-up/Staging	® CT Chest (CPT® 71260 ) and CT Abdomen/Pelvis (CPT® 74177) with contrast ® MRI Abdomen without and with contrast (CPT® 74183) is indicated for evaluation of liver lesions that are equivocal on CT imaging or for preoperative assessment of liver ® PET is indicated for evaluation of inconclusive findings on conventional imaging
Restaging/Recurrence	® CT Abdomen/Pelvis with contrast (CPT® 74177) ® CT Chest with contrast (CPT® 71260) if prior evidence of chest disease or signs or symptoms of chest disease ® PET is indicated for evaluation of inconclusive findings on conventional imaging
Treatment Response	® CT Abdomen/Pelvis with contrast (CPT® 74177) ® CT Chest with contrast (CPT® 71260) if prior evidence of chest disease or signs or symptoms of chest disease ® PET is indicated for evaluation of inconclusive findings on conventional imaging
Surveillance/Follow-up	® CT Abdomen/Pelvis with contrast (CPT® 74177) every 6 months for 5 years, then annually

ONC-12.6: Bone Sarcomas - Initial Workup/Staging

For this condition imaging is medically necessary based on the following criteria:

Indication	Imaging Study
Chondrosarcoma	Any or all of the following: ® MRI without contrast or without and with contrast of involved area ® CT (contrast as requested) of involved area ® CT Chest with (CPT® 71260) or without contrast (CPT® 71250)
Chordoma	Any or all of the following: ® MRI without contrast or without and with contrast of involved area ® CT (contrast as requested) of involved area ® CT Chest with (CPT® 71260) or without contrast (CPT® 71250) ® CT Abdomen/Pelvis with contrast (CPT® 74177) ® MRI Cervical (CPT® 72156), Thoracic (CPT® 72157), and Lumbar spine (CPT® 72158) without and with contrast ® Bone scan (see also: ONC-1.3: Nuclear Medicine (NM) Imaging in Oncology) ® PET may be approved for inconclusive conventional imaging

ONC-12.7: Bone Sarcomas - Restaging/Recurrence