The Physician or a designated representative (Physician Assistant or Oncologic Nurse) must complete all relevant questions and sign this form to process PET preauthorization requests. This form is intended to document medical necessity for health plan benefit coverage, while obviating need for additional contacts in the majority of the cases. Please be advised that PET can requests are subject to diagnosis, indication and other requirements and benefit limitations of the patient’s health plan.
Presence of calcification and any known malignant neoplasm: THYROID CANCER ONLY
Check all that apply:
Specify thyroid tumor type:
Negative I-131 Whole Body Scan
Follicular Cell Origin Tumors:
S/P Radioiodine Ablation Therapy
Medullary Thyroid Cancer
Other Thyroid Malignancies (e.g., Lymphoma)
YES Please identify all sites of known metastatic disease:
Primary Site: Brain
NO Is this study being requested to avoid an invasive procedure or identify an optimal anatomic location for a biopsy? Lymph Node Metasteses?:
Serum Thyroglobulin level >10ng/ml
ALL OTHER TUMORS / NEOPLASMS (please specify): Metastatic Disease?
Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
ONCOLOGIC PET SCAN
DOCUMENTATION: Date of Diagnosis:
DIAGNOSIS OF TUMOR:
Has the tumor diagnosis been confirmed through tissue sampling?: INITAL STAGING OF TUMOR
Date of Diagnosis: Completion Date:
RESTAGING TUMOR after completion of treatment, for one of the following: For detection of RESIDUAL DISEASE For detection of suspected TUMOR RECURRENCE Clinical findings (i.e. unexplained weight loss, fever, pain) and/or labs (i.e. tumor markers) suggestive of tumor progression or recurrence: Chemotherapy Radiation
The patient is on the:
Are the patient's treatments complete?:
Chemotherapy and Radiation
total treatment cycle. YES
Is a change in treatment being considered based upon the PET scan results?
If yes, what new treatment is being contemplated?: SURVEILLANCE IN AN ASYMPTOMATIC PATIENT NATIONAL ONCOLOGIC PET REGISTRY (NOPR) PROGRAM PARTICIPATION OTHER FDA-APPROVED CLINCIAL TRIAL OTHER RESEARCH PROTOCOL
IS THE PATIENT IN REMISSION?:
If "YES" how long?:
PRIOR IMAGING: Please provide results from the most recent imaging for: CT
HAS THE PATIENT UNDERGONE PRIOR ONCOLOGIC SURGERY?:
NO Please explain:
ANY ADDITIONAL INFORMATION RELATED TO THE PET IMAGING REQUEST MAY BE INCLUDED HERE:
Signature of Physician or designated representative (physician assistant; oncologic nurse) - required:
Fax Form and any relevant Progress Notes back to 800-610-0050 as soon as possible. Copyright 2007, American Imaging Management, Inc. All Rights Reserved.
ONCOLOGIC PET SCAN
ONCOLOGIC PET SCAN PET SCAN Request Date:
Date of Service:
PET / CT FUSION
MEMBER/PATIENT INFORMATION Mem...