All PlansCoverageHigh impact
Positron Emission Tomography (PET) - Non-Oncologic Applications 6.01.07
Excellus BlueCross BlueShield·Cardiology, Pulmonology, Orthopedics +3 more·Radiology (x-rays) & Imaging
Effective date
May 15, 2026
We identified it
Jun 20, 2026
Summary
New policy defines specific medical necessity criteria for PET/CT scans in non-oncologic applications across multiple body systems including cardiac, chest, spine, and musculoskeletal conditions. The policy establishes when PET imaging is medically appropriate versus investigational or not appropriate, with detailed indication-specific requirements.
Action Required
Before May 15, 2026: Billing team must review all PET/CT orders for non-oncologic conditions against new medical necessity criteria. Update prior authorization processes to verify patients meet indication-specific requirements (e.g., lymph node size >10mm for sclerosing mesenteritis, equivocal MRI results for cardiac sarcoidosis). Stop billing CPT codes 76376 and 76377 (3D rendering) with PET imaging as policy explicitly prohibits this combination. Train staff on new coverage limitations including that spine PET/CT for routine spinal disorders is not covered and pelvic PET for erectile dysfunction is investigational.