![]() T-cell lymphoma (includes peripheral T-cell lymphoma, Mycosis Fungoides/Sézary Syndrome, primary cutaneous CD30+ T-cell lymphoproliferative disorders).Post-transplant lymphoproliferative disorder.Non-Hodgkin's lymphoma (for select subtypes, see section II.B.8.).Head and neck cancers (excluding cancers of the central nervous system).Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) with suspected Richter's transformation. ![]() Diagnostic tests such as FDG-PET distinguish between dysfunctional but viable myocardial tissue and scar tissue in order to affect the management decisions in members with ischemic cardiomyopathy and left ventricular dysfunction.Īetna considers absolute quantitation of myocardial blood flow (AQMBF) a medically necessary adjunct to cardiac PET when criteria for evaluating myocardial viability above are met.įDG-PET is considered medically necessary to identify and monitor response to therapy for established or strongly suspected cardiac sarcoid.Īetna considers FDG-PET medically necessary for the following oncologic indications, when the following general and disease-specific criteria for diagnosis, staging, restaging and/or monitoring are met, and the FDG-PET scan is necessary to guide management: The identification of members with partial loss of heart muscle movement or hibernating myocardium is important in selecting candidates with compromised ventricular function to determine appropriateness for re-vascularization. The greater specificity of PET makes a SPECT following an inconclusive PET not medically necessary. For use in assessment of coronary artery disease after cardiac transplant.įluorodeoxy-D-glucose (FDG)-PET scans are considered medically necessary for the determination of myocardial viability prior to re-vascularization, either as a primary or initial diagnostic study or following an inconclusive SPECT.The PET scan is used in place of, but not in addition to, a single photon emission computed tomography (SPECT), in persons who meet medical necessity criteria for a cardiac SPECT (see CPB 0376 Single Photon Emission Computed Tomography (SPECT)) or.PET scans using rubidium-82 (Rb-82) or N-13 ammonia done at rest or with pharmacological stress are considered medically necessary for non-invasive imaging of the perfusion of the heart for the diagnosis and management of members with known or suspected coronary artery disease, provided such scans meet either one of the two following criteria: This Clinical Policy Bulletin addresses positron emission tomography (PET).Īetna considers positron emission tomography (PET) medically necessary for the following cardiac indications: ![]() OL7950366W Page_number_confidence 84.47 Pages 1168 Partner Innodata Pdf_module_version 0.0.20 Ppi 300 Rcs_key 24143 Republisher_date 20210121193649 Republisher_operator Republisher_time 2106 Scandate 20210114152642 Scanner Scanningcenter cebu Scribe3_search_catalog isbn Scribe3_search_id 9780534613143 Tts_version 4.Number: 0071 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References Urn:lcp:calculusconcepts0000stew_圆j1:epub:51963835-ceaa-422d-bab4-bfdf6c69506a Foldoutcount 0 Identifier calculusconcepts0000stew_圆j1 Identifier-ark ark:/13960/t5x73hx1w Invoice 1652 Isbn 0534613144ĩ780534377199 Ocr tesseract 4.1.1 Ocr_detected_lang en Ocr_detected_lang_conf 1.0000 Ocr_detected_script Latin Ocr_detected_script_conf 0.9933 Ocr_module_version 0.0.10 Ocr_parameters -l eng Old_pallet IA18192 Openlibrary_edition Access-restricted-item true Addeddate 05:01:32 Boxid IA40040518 Camera USB PTP Class Camera Collection_set printdisabled External-identifier ![]()
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