Massachusetts health plans accept a standard one-page form for prior authorization of PET and PET/CT imaging. Ordering clinicians, usually in oncology, meet it when a plan or its radiology benefit manager requires approval before a scan. Developed by the Massachusetts Collaborative and adopted with the Division of Insurance Bulletin 2016-08 imaging forms, it asks for tumor type, radiotracer, biopsy confirmation, treatment history and the reason for the study.
The ordering clinician's office completes all five sections: member, ordering provider, facility, the exam request with CPT and ICD codes, and the cancer details in Section 5. The patient completes nothing.
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PET - PET CT Prior Authorization Form
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Section 5 asks for the tumor type and date of diagnosis, whether a biopsy confirmed the cancer, prior treatment (none, surgery alone or other), current or completed chemotherapy and radiotherapy, known metastatic disease, suspected recurrence or progression, and prior imaging results with dates.
Yes. The radiotracer choices include a sodium 18F fluoride PET/CT bone scan alongside standard FDG PET or PET/CT imaging, and an Other option for a tracer described in the space provided. The ordering clinician also enters the CPT and ICD codes in Section 4.