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.
