Positron Emission Tomography (PET) - Non-Oncologic Applications - (Effective Date - 2026-10-15) 6.01.07

By October 15, 2026: Billing team must implement the following changes: (1) Update billing system to require prior authorization for all PET imaging claims under policy 6.01.07, with specific routing based on clinical indication (abdominal, cardiac, prosthetic valve, or LVAD); (2) Create authorization templates that match the policy's indication-specific criteria for each category (e.g., lymphoproliferative disorders, cardiac viability assessment, sclerosing mesenteritis, cardiac sarcoidosis); (3) Distribute policy summary to all providers ordering PET imaging, specifically noting that claims require documentation of medical necessity criteria; (4) Update encounter forms and EMR templates to include required documentation fields (e.g., prior imaging stability, lymph node size ≥10mm, cardiology test results, C-reactive protein levels ≥40 mg/L for valve endocarditis); (5) Train billing staff on the 21-page policy document to correctly identify which clinical scenario applies and what documentation is required; (6) Configure system alerts to flag missing required criteria before claim submission. Failure to implement prior authorization will result in claim denials. Providers must document all indication-specific criteria listed in the policy or claims will be subject to recoupment.