Oncology Imaging Guideline Addendum

This policy covers PET/CT imaging (CPT 78815) using specified radiotracers — including newly added 64Cu‑DOTATATE (DETECTNET) and 68Ga‑DOTA‑TOC — as well as 18F‑FDG, 68Ga‑DOTATATE (NETSPOT), 11C‑Choline, and 18F‑Fluciclovine for evaluation of malignancies such as low‑grade neuroendocrine tumors, medullary thyroid cancer, prostate cancer, and pediatric oncology indications. Coverage is radiotracer‑ and indication‑specific: the planned tracer must be stated for medical‑necessity review, only listed tracers are supported (others such as 68Ga‑PSMA‑11, 18F‑NaF, 18F‑fluoroestradiol and unlisted isotopes are not covered), SSR tracer PET/CT is appropriate when performed after inconclusive CT/MRI, and surveillance imaging must follow the policy’s specified timing/frequency.

"This section is updated to include new radiotracers ${ }^{64} \mathrm{Cu}$ DOTATATE (DETECTNET ${ }^{\circledR}$ ) and ${ }^{68}$ Ga-DOTA-TOC when PET/CT is indicated for low grade neuroendocrine t..."