Description
Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) is covered only in clinical situations in which PET results may assist in avoiding an invasive diagnostic procedure, or in which the PET results may assist in determining the optimal location to perform an invasive procedure. PET would also be considered reasonable and necessary when clinical management of the patient would differ depending on the staging of the cancer identified, and in clinical situations in which the stage of the cancer remains in doubt after completing a standard diagnostic workup or it is expected that conventional imaging study information is insufficient for clinical management of the patient. Medical records will be reviewed to determine if the utilization of FDG PET studies for initial anti-tumor treatment strategy are medically necessary according to Medicare coverage indications.
Affected Code(s)
78608, 78811, 78812, 78813, 78814, 78815, 78816, A9552
Applicable Policy References
1. Social Security Act (SSA), Title XVIII - Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A) - Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII - Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefit
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980 - Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b) - Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c) - Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986 - Good Cause for Reopening
7. 42 CFR §411.15 - Particular Services Excluded from Coverage, (k) - Any Services Not Reasonable and Necessary
8. National Coverage Determination Manual, Ch. 1, Part 4, §220.6.17 Positron Emission Tomography (PET) (FDG) for Oncologic Conditions
9. Medicare Claims Processing Manual, Ch. 13 - Radiology Services and Other Diagnostic Procedures, §60 – Positron Emission Tomography (PET) Scans - General Information; §60.1 - Billing Instructions, (D)- Post-Payment Review for PET Scans; §60.3.1 - Appropriate CPT Codes Effective for PET Scans for Services Performed on or After January 28, 2005; §60.3.2 - Tracer Codes Required for Positron Emission Tomography (PET) Scans; §60.7 - Expanded Coverage of PET Scans Effective for Services on or After July 1, 2001
10. Medicare Claims Processing Manual, Ch. 13 – Radiology Services and Other Diagnostic Procedures, §60.16. A-Billing and Coverage Changes for PET Scans Effective for Services on or After April 3, 2009 https://www.cms.gov/medicare/coverage/determinationprocess/downloads/petforsolidtumorsoncologicdxcodesattachment_NCD220_6_17.pdf
11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
12. Noridian LCA A54666: Billing and Coding Positron Emission Tomography Scans Coverage. Effective date 10/01/2015; Revised date 10/01/2023; Retired date 10/01/2023
13. Noridian LCA A54668: Billing and Coding Positron Emission Tomography Scans Coverage. Effective date 10/01/2015; Revised date 10/01/2023; Retired date 10/01/2023
14. Novitas LCA A53132: Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Oncologic Conditions. Effective date 10/01/2015; Revised date 10/01/2021; Retired date 03/24/2022
15. First Coast Service Options, Inc LCA A58826: Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Oncologic Conditions. Effective date 04/01/2021; Revised date 10/01/2021; Retired date 03/24/2022
16. ICD-10-CM Diagnosis Codebook
17. AMA CPT Codebook
18. HCPCS Level II Codebook