Commonly Requested Items for Pre-Service Review of Positron Emission Tomography (PET) Scanning

Blue Cross Blue Shield of North Dakota (BCBSND) would like to provide additional information to help facilitate a quicker, more efficient pre-service review of positron emission tomography (PET) scans.
To assist with the review of PET scans, in addition to the most recent clinical notes, BCBSND is requesting the following information be submitted in the initial request:
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  • CPT code(s) for radiotracer to be used for this PET scan.
    • Types of radiotracers that need a CPT code include, but are not limited to:
    • Gallium 68-prostate-specific membrane antigen and piflufolastat fluorine-18
    • Carbon 11 choline and fluorine 18 fluciclovine
    • Fluorine 18 fluorodeoxyglucose
    • Other_________________
    • Date of last PET scan (if applicable) __________________

*Required: Clinical note showing past results of PET scan
Breast cancer diagnosis specific PET scan requests: mammogram, ultrasound of breast and breast MRI are NOT considered advanced imaging when looking for metastasis of this specific diagnosis — chest MRI/or CT of chest are needed for this type of review.

  • Clinical note ordering the PET scan
  • Preliminary treatment plan (including last date of treatment if currently being treated)
  • Pathology result

More information regarding PET scan criteria, can be found in the oncologic applications of positron emission tomography scanning policy

For additional questions, please contact the applicable Customer Contact Center phone number listed on the back of the member ID card.