Archive
API

National Coverage Determination (NCD)

Positron Emission Tomography (PET) Scans

220.6

Expand All | Collapse All

Tracking Information

Publication Number
100-3
Manual Section Number
220.6
Manual Section Title
Positron Emission Tomography (PET) Scans
Version Number
4
Effective Date of this Version
04/03/2009
Ending Effective Date of this Version
03/07/2013
Implementation Date
10/30/2009
Implementation QR Modifier Date

Description Information

Benefit Category
Diagnostic Tests (other)


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

Positron Emission Tomography (PET) is a minimally invasive diagnostic imaging procedure used to evaluate metabolism in normal tissue as well as in diseased tissues in conditions such as cancer, ischemic heart disease, and some neurologic disorders. A radiopharmaceutical is injected into the patient that gives off sub-atomic particles, known as positrons, as it decays. PET uses a positron camera (tomograph) to measure the decay of the radiopharmaceutical. The rate of decay provides biochemical information on the metabolism of the tissue being studied.

NOTE: This manual section 220.6 lists all Medicare-covered uses of PET scans. Except as set forth below in cancer indications listed as "Coverage with Evidence Development," a particular use of PET scans is not covered unless this manual specifically provides that such use is covered. Although this section 220.6 lists some non-covered uses of PET scans, it does not constitute an exhaustive list of all non-covered uses.

(This NCD last reviewed March 2009.)
Indications and Limitations of Coverage
 
Cross Reference
See NCD for SPECT (§220.12).
Claims Processing Instructions

Transmittal Information

Transmittal Number
120
Coverage Transmittal Link
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R120NCD.pdf
Revision History

10/2009 - This change request rescinds and replaces Transmittal 106, dated September 18, 2009. The effective date has been changed to April 3, 2009, and the implementation date has been changed to October 30, 2009. Business Requirements (BR) 6632.6.1 and 6632.6.2 have been revised to clarify that they are subsets of BR 6632.6 and are specific to CED. All other information remains the same. (TN 108) (CR6632)

Transmittal 108, dated October 16, 2009, is being rescinded and replaced with Transmittal 120. This transmittal restores language that was inadvertently removed from section 220.6. This transmittal also updates section 220.6.17, per Transmittal 110, Change Request 6753, dated December 18, 2009. All other information remains the same.(TN 120) (CR6632)

09/2009 - CMS is adopting a coverage framework that replaces the four-part diagnosis, staging, restaging and monitoring response to treatment categories with a two-part framework that differentiates FDG PET imaging used to inform the initial antitumor treatment strategy from other uses related to guiding subsequent antitumor treatment strategies after the completion of initial treatment. CMS is making this change for all NCDs that address coverage of FDG PET for all oncologic conditions. Effective date 04/06/2009 Implementation date 10/19/2009. (TN 106) (CR6632)

04/2005 - Covered as an adjunct test for detection of pre-treatment metastases (i.e., staging) in newly diagnosed cervical cancer subsequent to conventional imaging that is negative for extra-pelvic metastasis. For all remaining indications that are subject of this NCD, as well as other indications for cervical cancer not specifically mentioned, covered only when providers are participating in, and patients are enrolled in, an approved FDG PET clinical study, or an FDG PET clinical trial meeting FDA category B IDE exemption status. Effective date 01/28/2005. Implementation date 4/18/2005. (TN 31) (CR 3741)

06/2003 - Expanded coverage for noninvasive imaging of perfusion of heart using FDA-approved Ammonia N-13 tracer, and restaging of recurrent or residual thyroid cancers of follicular cell origin that have been previously treated by thyroidectomy and radioiodine ablation and have a serum thyroglobulin >10ng/ml and negative I-131 whole body scan. Also maintained national noncoverage determinations for all uses of FDG-PET for soft tissue sarcoma and dementia and neurogenerative diseases. Effective and implementation dates 10/01/2003. (TN 171) (CR 2687)

05/2002 - Provided coverage for breast cancer and broader coverage for myocardial viability. Effective and implementation dates 10/01/2002. (TN 156) (CR 2138)

11/2001 - Clarified types of allowable PET scanners. Effective and implementation dates 01/01/2002. (TN 147) (CR 1886) Reduction in coverage announced in Federal Register, 66 FR 58741.

04/2001 - Expanded coverage to include diagnosis and staging/restaging of non-small cell lung cancer, esophageal cancer, colorectal cancer, lymphoma, melanoma, head and neck cancers, myocardial viability, and refractory seizures. Effective and implementation dates July 1, 2001. (TN 136) (CR 1603)

04/1999 - Added coverage for evaluation of recurrent colorectal cancer in patients with rising levels of carcinoembryonic antigen, staging of lymphoma (both Hodgkins and non-Hodgkins) when PET scan substitutes for gallium scan, and detection of recurrent melanoma. Effective July 1, 1999. (TN 113) (CR 861)

02/1999 - Added coverage for characterization of solitary pulmonary nodules and initial staging of lung cancer. Effective date 1/1/1998. (TN 106)

05/1995 - Provided limited coverage for use in noninvasive imaging of perfusion of heart for diagnosis and management of patients with known or suspected coronary artery disease. Effective date 03/14/1995. (TN 76)
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Positron Emission Tomography (PET) Scans - RETIRED 7 04/10/2023 - N/A View
Positron Emission Tomography (PET) Scans 6 01/01/2022 - 04/10/2023 View
Positron Emission Tomography (PET) Scans 5 03/07/2013 - 01/01/2022 View
Positron Emission Tomography (PET) Scans 4 04/03/2009 - 03/07/2013 You are here
PET Scans 3 01/28/2005 - 04/03/2009 View
PET Scans 2 10/01/2003 - 01/28/2005 View
PET Scans 1 10/01/2002 - 10/01/2003 View
CPT Copyright Statement
CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
Submit Feedback/Ask a Question