PET Access Program Policy

The Ontario PET Access Program considers requests on a case-by-case basis to fund PET scans for patients who may benefit, but who do not meet the eligibility criteria for funding under any other programs.

For funding to be granted, the patient must satisfy all eligibility criteria in this policy.

To be considered for funding:

• The patient must have valid OHIP coverage
• The requested PET imaging product (e.g., FDG) must be available in Canada
• If the PET scan is requested solely to determine patient suitability for a therapy (e.g., drugs, radionuclide therapy etc.), the therapy must be publicly funded
• Compared to other available tests, the majority of experts must agree that a PET scan is safer for the patient and/or will provide more benefit to the patient.

Before Applying to the Ontario PET Access Program

• You must have the patient’s express consent.
• Review the indications to be sure the patient is not eligible under insured services or the PET Registry. Any requests to the PET Access Program normally considered under those programs will be redirected.

Criteria for PET Access Review

The PET Access Program considers the following criteria to evaluate requests submitted by a referring physician.

Evidence

• Some literature supports the use of PET scans under these clinical circumstances.
• There is demonstration of improved test performance (i.e., greater sensitivity and specificity) over standard anatomical imaging, OR identification of disease beyond the extent defined by anatomical imaging.
  
  Note: Indications not funded due to lack of evidence are not considered unless the application includes new evidence to support the use of PET under these clinical circumstances.

Diagnostic alternatives

• There are inconclusive results from standard diagnostic tests.

Funding alternatives

• The patient must not be eligible for a scan under insured services, or qualify for inclusion in the PET Registry.

Clinical impact

• The patient may avoid unnecessary invasive interventions (e.g., exploratory surgery) or treatment due to the use of a PET scan.
  AND/OR
• The clinical management may change based on the PET scan results.

The referring physician must describe the clinical impact and implications on clinical management.

Assessment Review Process

Submissions must meet all of the criteria that apply before the assessment review can take place.

A 3‐person expert panel considers requests on a case‐by‐case basis. The panel typically includes a radiologist, a nuclear medicine physician and a disease specialist (usually an oncologist). If the panel cannot reach a decision, the request will automatically be sent to an alternate panel for consideration.

PET Scans Ontario staff adjudicate certain requests for indications that:

• have been approved by the Ministry of Health and Long‐Term Care but have not yet been implemented
  OR
• were originally part of a ministry funded PET Registry that has closed, and are pending a formal ministry review

Outcomes

PET Scans Ontario requires healthcare facilities to submit outcomes data for approved PET scans. We collect and assess this data for program planning and management purposes.

See the Privacy section for information about our authority to collect personal health information for health system management and planning.

Request for a Repeat PET Scan

Requests for repeat scans must meet the usual criteria for PET Access Program review (i.e., the PET scan is expected to change clinical management; not intended for surveillance).

Resubmissions, Reassessments and Appeals

If a request for a PET scan is not approved, the referring physician can submit a request for a resubmission, a reassessment or an appeal. For information on the eligibility criteria, filing process and review process, download the PET Access Program Resubmission, Reassessment and Appeals Policy.