Economic Evaluation of PET and PET/CT in Oncology: Evidence and Methodologic Approaches

↵* Some Medicare contractors include anal cancer in their local coverage of “colorectal cancer”; for PET facilities served by those carriers, PET for subsequent treatment evaluation of anal cancer would be a covered indication.

↵† PET is not covered for initial staging of axillary lymph nodes in patients with breast cancer and of regional lymph nodes in patients with melanoma but is covered for detection of distant metastatic disease in high-risk patients with breast cancer or melanoma.

↵‡ PET is not covered for “diagnosis” of breast cancer to evaluate suggestive breast mass. However, PET is covered for initial treatment-strategy evaluation of patient with axillary nodal metastasis of unknown primary origin or patient with paraneoplastic syndrome potentially caused by occult breast cancer.

↵§ Patient must have prior CT or MRI negative for extrapelvic metastatic disease for PET to qualify as covered indication for initial treatment-strategy evaluation. Patients who do not qualify for this covered indication (e.g., because CT or MRI was not done or because either CT or MRI showed extrapelvic metastatic disease) can be entered on NOPR.

↵‖ To qualify as covered indication for subsequent treatment-strategy evaluation, thyroid cancer must be of follicular cell origin and have been previously treated by thyroidectomy and radioiodine ablation and patient must have serum thyroglobulin level > 10 ng/mL and negative whole-body ¹³¹I findings. Patients who do not qualify for this covered indication (e.g., because tumor is not of follicular cell origin, thyroglobulin is not elevated, or ¹³¹I whole-body imaging was not performed or is positive) can be entered on NOPR.

C = covered (not eligible for entry in National Oncologic PET Registry [NOPR]); NOPR = covered only with entry in NOPR; — = not covered nationally (not eligible for entry in NOPR).

Modified from http://www.cancerpetregistry.org/indications_facilities.htm.