Positron Emission Tomography (PET) – Head Imaging 6.01.47
Effective date
May 15, 2026
Identified
Jun 20, 2026
Summary
Effective May 15, 2026, Excellus BCBS policy 6.01.47 sets the criteria for PET head imaging, which were removed from CMP 6.01.07. The 01/22/26 update added a medically necessary statement for amyloid brain PET (CPT 78814 or 78811) when a diagnosis of MCI or dementia due to Alzheimer disease is suspected, and a statement that perfusion PET brain (CPT 78609) is not medically necessary in the evaluation of dementia. FDG brain PET (CPT 78608) is medically necessary for mild cognitive impairment, dementia evaluation, Lewy body dementia versus Alzheimer disease, suspected encephalitis, and pre-surgical evaluation of refractory seizure when all listed criteria are met, and it is not medically necessary for Parkinson disease, normal pressure hydrocephalus, or chronic traumatic encephalopathy.
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01Already effective May 15, 2026: Billing team, FDG brain PET (CPT 78608) for dementia needs documentation of six months of cognitive decline from a detailed history of memory loss with impairment of day-to-day activities, confirmed by family members or others with knowledge of the individual's status.
02The same claims need results of structural imaging (MRI or CT head) and presumptive causes or etiologies of dementia that cannot occur exclusively during bouts of delirium and cannot be explained by another mental disorder.
03Bedside or neuropsychological testing results are needed when history and bedside mental status examination cannot provide a confident diagnosis.
04Perfusion PET brain (CPT 78609) is not medically necessary in the evaluation of dementia.
053D rendering (CPT 76376 or 76377) should not be billed in conjunction with PET imaging.
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