PET Initial Treatment Strategy (Diagnostic/Staging) Subsequent Treatment (Restaging/Monitoring) 78811 Limited Explain (Limited): 78812 Skull Base to Mid-Thigh 78813 Whole Body 78608 Brain Metabolic Evaluation Diagnostic CT with PET Head Neck Chest Abdomen Pelvis   PET Cardiac Stress (Rubidium) PET Cardiac Viability (FDG) 78492 Myocardial PET Perfusion - Multiple Study   PET Procedures Covered by Medicare: Alzheimer's Disease (Once in a lifetime) Esophageal Carcinoma Myocardial Viability FDG PET/CT Breast Carcinoma Head & Neck Carcinoma Non-Small Cell Lung Carcinoma Cervical Carcinoma Lymphoma Solitary Pulmonary Nodule Colorectal Carcinoma Malignant Melanoma Thyroid Carcinoma Carcinoma Procedures Covered Under the National PET Registry: (Medicare Patients Only) - call the center for participation and additional forms Anus (154) Kidney & Other Unrinary Tract (189) Penis and other male genitalia (187) Bladder (188) Larynx (161) Primary Brain (191) Bone Cartilage (170) Leukemia (204-208) Prostate (185) Breast - Female (174) Lip, Oval Cavity & Pharynx (140-149) Pleura (163) Breast - Male (175) Liver and intrahepatic bile ducts (155) Retroperitoneum and peritoneum(158) Cervix (180) Lung, small cell (162) Small intestines(152) Colon (153) & Rectum (154) Melanoma of skin (172) Stomach (151) Connective / Other Soft Tissue (171) Myeloma (203) Testis (186) Esophogus (150) Nasal cavity, ear and sinuses (160) Thymus, heart, mediastinum (164) Eye (190) Uterus, unspecified (179) Thyroid (193) Gallbladder & Extrahepatic bile ducts (156) Ovary and uterine adnexa(183) Uterus, body (182) Kaposi's Sarcoma (176) Pancreas (157) Other Explain (Other):   Patient Name Phone D.O.B. Diagnosis / Symptoms Desired Appointment Time & Date To optimize coronary images, IV Beta Blockers may be used to obtain heart rates of 55-65. Is there any reason that we should avoid using Beta Blockers on your patient? Yes No Allergic To Iodine DM CKD Known Arrhythmia Pacemaker Asthma Known Allergies     For Contrast Studies:     Creatinine BUN Date Referring Physician Full Name (in lieu of signature) Copies Sent to Date   Phone Fax Email

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Westside Medical Associates of Los Angeles

Copyright ©2013 Westside Medical Imaging
64-Slice CT Scan, Body, Heart, and Vascular Imaging in Southern California
99 N La Cienega Blvd. • Suite 103 • Beverly Hills, CA • 310.623.1150