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Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography

Positron emission tomography (PET) using 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) may be considered medically necessary in:
The assessment of select patients with epileptic seizures who are candidates for surgery (see Policy Guidelines section)

The diagnosis of chronic osteomyelitis.

The use of FDG-PET for all other miscellaneous indications is investigational, including, but not limited to:

Central Nervous System Diseases

Autoimmune disorders with central nervous system manifestations, including:

Behçet syndrome

lupus erythematosus

Cerebrovascular diseases, including:

arterial occlusive disease (arteriosclerosis, atherosclerosis)

carotid artery disease

cerebral aneurysm

cerebrovascular malformations (arteriovenous malformation and Moya-Moya disease)

hemorrhage

infarct

ischemia

Degenerative motor neuron diseases, including:

amyotrophic lateral sclerosis

Friedreich ataxia

olivopontocerebellar atrophy

Parkinson disease

progressive supranuclear palsy

Shy-Drager syndrome

spinocerebellar degeneration

Steele-Richardson-Olszewski syndrome

Tourette syndrome

Demyelinating diseases, such as multiple sclerosis

Developmental, congenital, or inherited disorders, including:

adrenoleukodystrophy

Down syndrome

Huntington chorea

kinky-hair disease (Menkes disease)

Sturge-Weber syndrome (encephalofacial angiomatosis) and the phakomatoses

Miscellaneous

chronic fatigue syndrome

sick building syndrome

posttraumatic stress disorder

Nutritional or metabolic diseases and disorders, including:

acanthocytosis

hepatic encephalopathy

hepatolenticular degeneration

metachromatic leukodystrophy

mitochondrial disease

subacute necrotizing encephalomyelopathy

Psychiatric diseases and disorders, including:

affective disorders

depression

obsessive-compulsive disorder

psychomotor disorders

schizophrenia

Pyogenic infections, including:

aspergillosis

encephalitis

Substance abuse, including the central nervous system effects of alcohol, cocaine, and heroin

Trauma, including brain injury and carbon monoxide poisoning

Viral infections, including:

HIV/AIDS

AIDS dementia complex

Creutzfeldt-Jakob disease

progressive multifocal leukoencephalopathy

progressive rubella encephalopathy

subacute sclerosing panencephalitis

Mycobacterium infection

Migraine

Anorexia nervosa

Assessment of cerebral blood flow in newborns

Vegetative vs locked-in syndrome

Pulmonary Diseases

Adult respiratory distress syndrome

Diffuse panbronchiolitis

Emphysema

Obstructive lung disease

Pneumonia

Musculoskeletal Diseases

Spondylodiscitis

Joint replacement follow-up

Other

Giant cell arteritis

Vasculitis

Vascular prosthetic graft infection

Inflammatory bowel disease

Sarcoidosis

Fever of unknown origin

Inflammation of unknown origin.

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