CPT code 78816 covers positron emission tomography (PET) imaging for limited area or whole body, with concurrently acquired CT for attenuation correction and anatomical localization. PET/CT is primarily used for oncologic evaluation and is subject to strict prior authorization requirements.
PET/CT is one of the most heavily prior-authorized imaging studies due to its high cost. All major insurers require PA, and clinical documentation must clearly demonstrate that the study will change c... Always verify requirements with the specific insurer and plan.
PET/CT is primarily used for cancer diagnosis, staging, restaging, and treatment response monitoring. Common oncologic indications include lung cancer, lymphoma, melanoma, head and neck cancers, esophageal cancer, and colorectal cancer. Limited non-oncologic uses include cardiac viability assessment and certain infectious/inflammatory conditions.
PET/CT is one of the most heavily prior-authorized imaging studies due to its high cost. All major insurers require PA, and clinical documentation must clearly demonstrate that the study will change clinical management. Most insurers follow CMS National Coverage Determination (NCD) criteria for PET/CT approval.
Note: PA requirements vary by specific plan and member. Always verify requirements with the insurer before scheduling.
Clearly state the oncologic indication and how PET/CT will inform treatment decisions.
Include pathology results confirming the cancer diagnosis.
Document why conventional imaging (CT, MRI) is insufficient to answer the clinical question.
For treatment response monitoring, document the treatment protocol and timeline.
Reference CMS NCD criteria for the specific cancer type. Most insurers follow these guidelines.
For non-oncologic PET indications (cardiac, infection), additional documentation is typically needed.
Greenlight Medical detects when CPT 78816 requires prior auth, assembles all documentation automatically, and submits to the correct payer portal. No manual lookups, no phone calls, no faxes.
See Greenlight in ActionYes, PET/CT (CPT 78816) requires prior authorization from virtually all insurers, including Traditional Medicare. It is one of the most heavily scrutinized imaging studies due to its cost. Complete oncologic documentation is essential for approval.
CMS and most commercial insurers approve PET/CT for nearly all solid tumors and lymphomas for initial staging, restaging, and treatment response monitoring. Specific approved indications include lung cancer, lymphoma, melanoma, head and neck cancers, esophageal cancer, colorectal cancer, breast cancer, and many others.
PET/CT prior authorizations typically take 3-7 business days for standard review. Given the oncologic urgency, many insurers offer expedited review (24-72 hours) when clinical urgency is documented. Greenlight Medical prioritizes PET/CT PA submissions and ensures complete documentation for fastest approval.