1. Effective for services performed on or after October 1, 2003, Medicare covers the use of FDG PET for thyroid cancer only for 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 performed.
2. Effective for services performed on or after January 28, 2005, Medicare only covers FDG PET for diagnosis, other staging and restaging, restaging of medullary cell tumors, and monitoring response to treatment as "coverage with evidence development".
Medicare shall notify providers and beneficiaries where these services can be accessed, as they become available, via the following:
Requirements: PET is covered in any/all of the following circumstances:
A. Diagnosis: PET is covered only in clinical situations in which: (1) the PET results may assist in avoiding an invasive diagnostic procedure, or (2) the PET results may assist in determining the optimal anatomical location to perform an invasive diagnostic procedure. In general, for most solid tumors a tissue diagnosis is made prior to the performance of PET scanning. PET scans following a tissue diagnosis are generally performed for staging rather than diagnosis.
B. Staging and/or Restaging: PET is covered for staging in clinical situations in which: (1)(a) the stage of the cancer remains in doubt after completion of a standard diagnostic workup, including conventional imaging (computed tomography, magnetic resonance imaging, or ultrasound), or (1)(b) the use of PET could potentially replace one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical management of the patient, and (2) clinical management of the patient would differ depending on the stage of the cancer identified.
PET is covered for restaging after completion of treatment for the purpose of: (1) detecting residual disease, (2) detecting suspected recurrence, (3) determining the extent of a known recurrence, or (4) potentially replacing one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical management of the patient.
C. Monitoring Response to Treatment: PET is covered for monitoring response to treatment when a change in therapy is anticipated.
Documentation that these conditions are met should be maintained by the referring physician in the beneficiary's medical record, as is normal business practice.
(This NCD last reviewed March 2005.)
