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Positron Emission Tomography (PET) Oncologic Applications - (Effective Date - 2026-10-15) 6.01.29
Excellus BlueCross BlueShield·Oncology, Radiation Oncology, Radiology +2 more·Radiology (x-rays) & Imaging
Effective date
Oct 15, 2026
We identified it
Jul 16, 2026
Summary
Excellus BlueCross BlueShield has issued a comprehensive PET oncologic applications policy (effective October 15, 2026) that establishes medical necessity criteria for FDG PET/CT imaging across 30+ cancer types. The policy specifies when PET imaging is covered for initial staging, restaging/recurrence, and surveillance, with notably restrictive guidance on surveillance imaging for most cancers and specific requirements for documentation of clinical scenarios (e.g., inconclusive conventional imaging, isolated metastatic lesions amenable to surgical resection). Billing teams must update authorization workflows and documentation requirements to align with these cancer-specific criteria.
Action Required
By October 15, 2026: (1) Billing and prior authorization teams must implement cancer-type-specific medical necessity screening for all PET imaging requests, cross-referencing the 30+ cancer-specific criteria sections in policy 6.01.29 before approving claims. (2) Update the billing system and EMR encounter templates to prompt providers to document the specific clinical scenario justifying PET (e.g., 'Stage III disease', 'inconclusive conventional imaging', 'candidate for surgical resection of isolated metastasis', 'postoperative rising CEA/LFT'). (3) Deny or request additional documentation for any PET requests that do not meet the defined criteria—particularly surveillance imaging in asymptomatic patients with no clinical/laboratory evidence of disease, which is not routinely medically necessary for most cancer types per this policy. (4) Train revenue cycle and prior authorization staff on the distinction between covered indications (initial staging, restaging with inconclusive imaging, recurrence) and non-covered indications (routine surveillance, asymptomatic follow-up). (5) Establish an internal reference guide mapping CPT/HCPCS PET codes to the cancer-type criteria in sections A–Z of the policy. Failure to align authorizations with this policy will result in claim denials and rework.