CommercialCoverageHigh impact
Positron Emission Tomography (PET) - Non-Oncologic Applications 6.01.07
Excellus BlueCross BlueShield·Cardiology, Radiology, Nuclear Medicine +5 more·Radiology (x-rays) & Imaging
Effective date
May 15, 2026
We identified it
Jul 16, 2026
Summary
Excellus BlueCross BlueShield has established a comprehensive medical policy for PET imaging in non-oncologic applications, effective May 15, 2026. This policy defines specific clinical criteria and appropriate use for PET/CT imaging across multiple body systems (abdominal, cardiac, chest, musculoskeletal, spine, and vascular) while designating certain uses as not medically appropriate or investigational. Billing teams must ensure prior authorization requests and claims align with the detailed indication-specific criteria outlined in this policy.
Action Required
By May 15, 2026: Billing team must implement prior authorization protocols for all PET imaging requests submitted to Excellus BlueCross BlueShield. Update billing software and intake forms to capture required documentation for each clinical scenario: (1) Cardiac PET perfusion - document equivocal SPECT results or post-transplant status; (2) Cardiac sarcoidosis - document MRI contraindications, equivocal MRI results, or documented extracardiac sarcoidosis; (3) Spinal infection - document fever, IV drug use history, recent infection, immunocompromised status, or abnormal imaging findings; (4) Bone infection - document equivocal MRI/CT and multifocal or hardware-related infection; (5) Mediastinal lymphadenopathy - document lymph nodes ≥15mm with no explainable disease; (6) Pulmonary nodules - confirm solid nodule ≥8mm (exclude ground glass opacities); (7) PVD/aortic infection - document equivocal CT-angiography and confirm Indium-111/Gallium-67 not performed. DENY claims for: spine PET for routine spinal disorders/fusions/failed back surgery (non-neoplastic), pelvic PET for erectile dysfunction, PET/CT for Gaucher disease evaluation, or 3D rendering (CPT 76376/76377) billed with PET imaging. Update encounter templates to ensure providers document specific medical necessity criteria. Communicate policy restrictions to ordering providers. Non-compliance will result in claim denials for services not meeting criteria.