Medicare Coverage Indications
PET scans have been approved for reimbursement under Medicare for the following:
Cancers and indications that are reimbursable by Medicare are NOT eligible for entry in the NOPR. Cancers and indications that are specifically excluded for Medicare reimbursement are also not eligible for entry in the NOPR.
C = covered – Not eligible for entry in the NOPR
NC = non-covered nationally – Not eligible for entry in the NOPR
NOPR = covered only with entry in the NOPR
|
Indications |
Initial Treatment Strategy |
Subsequent Treatment Strategy |
|
(formerly Diagnosis and Initial Staging) |
(includes Treatment Monitoring, Restaging and Detection of Suspected Recurrence) |
Lip, Oral Cavity, and Pharynx (140-149) |
C |
C |
Esophagus (150) |
C |
C |
Stomach (151) |
C |
NOPR |
Small Intestine (152) (for carcinoid, see Neuroendocrine tumor below) |
C |
NOPR |
Colon (153) and Rectum (154) |
C |
C |
Anus (154) (Considered distinct from rectum; see footnote 1) |
C |
NOPR (1) |
Liver and intrahepatic bile ducts (155) |
C |
NOPR |
Gallbladder & extrahepatic bile ducts (156) |
C |
NOPR |
Pancreas (157) |
C |
NOPR |
Retroperitoneum and peritoneum (158) |
C |
NOPR |
Nasal cavity, ear, and sinuses (160) |
C |
C |
Larynx (161) |
C |
C |
Lung, non-small cell (162) |
C |
C |
Lung, small cell (162) |
C |
NOPR |
Pleura (163) |
C |
NOPR |
Thymus, heart, mediastinum (164) |
C |
NOPR |
Bone/cartilage (170) |
C |
NOPR |
Connective/other soft tissue (171) |
C |
NOPR |
Melanoma (172) (Nasopharyngeal, ocular and vulvar/vaginal melanomas are coded based on those anatomic locations; PET not covered for regional nodal staging – see footnote 2) |
C / NC (2) |
C |
Non-melanoma skin (173) |
C |
NOPR |
Female breast (174) (PET not covered for diagnosis of breast masses or for axillary nodal staging – see footnotes 2 and 3) |
C / NC (2,3) |
C |
Male breast (175) (PET not covered for diagnosis of breast masses or for axillary nodal staging – see footnotes 2 and 3) |
C / NC (2,3) |
C |
Kaposi's sarcoma (176) |
C |
NOPR |
Uterus, unspecified (179) |
C |
NOPR |
Cervix (180) (PET not covered for diagnosis of cervical cancer – see footnote 4) |
C / NC (4) |
C |
Placenta (181) |
C |
NOPR |
Uterus, body (182) |
C |
NOPR |
Ovary (183.0) |
C |
C |
Uterine adnexa (183.2-183.9) |
C |
NOPR |
Other and unspecified female genitalia (184) |
C |
NOPR |
Prostate (185) |
NC |
NOPR |
Testis (186) |
C |
NOPR |
Penis and other male genitalia (187) |
C |
NOPR |
Bladder (188) |
C |
NOPR |
Kidney and other urinary tract (189) |
C |
NOPR |
Eye (190) |
C |
NOPR |
Primary Brain (191) |
C |
NOPR |
Other and unspecified nervous system (192) |
C |
NOPR |
Thyroid (193) (Covered for subsequent treatment strategy only if specific requirements met – see footnote 5; otherwise NOPR) |
C |
C / NOPR (5) |
Other endocrine glands and related structures (194) |
C |
NOPR |
Metastatic cancer / unknown primary origin (196-199) |
C |
NOPR |
Lymphoma (200-202) |
C |
C |
Myeloma (203) |
C |
C |
Leukemia (204-208) |
NOPR |
NOPR |
Neuroendocrine tumor (209) |
C |
NOPR |
All other solid tumors |
C |
NOPR |
All Other cancers not listed herein |
NOPR |
NOPR |
ClinicalTrials.gov Identifier NCT00868582 Version: February 18, 2010
Notes
1 Some Medicare contractors include anal cancer in their local coverage of “colorectal cancer”; for PET facilities served by those carriers, PET for subsequent treatment evaluation of anal cancer would be a covered indication.
2 PET is non-covered for initial staging of axillary lymph nodes in patients with breast cancer and of regional lymph nodes in patients with melanoma, but is covered for detection of distant metastatic disease in high-risk patients with breast cancer or melanoma..
3 PET is non-covered for “diagnosis” of breast cancer to evaluate a suspicious breast mass. However, PET is covered for initial treatment strategy evaluation of a patient with axillary nodal metastasis of unknown primary origin or in a patient with a paraneoplastic syndrome potentially caused by an occult breast cancer.
4 PET is non-covered for “diagnosis” of cervical cancer. However, PET is covered for initial staging of cervical cancer.
5 To qualify as a covered indication for subsequent treatment strategy evaluation, thyroid cancer must be of follicular cell origin and been previously treated by thyroidectomy and radioiodine ablation and the patient must have a serum thyroglobuilin > 10 ng/ml and negative whole-body I-131 scan. Patients who do not qualify for this covered indication (e.g., because the tumor is of other than follicular cell origin, the thyroglobulin is not elevated, or I-131 whole-body imaging was not performed or is positive) can be entered on NOPR.
IMPORTANT NOTE
- The scientific evidence concerning the clinical utility of FDG-PET is generally less robust for cancers and indications that are currently covered by Medicare only in the NOPR than for cancers and indications that are currently covered without the requirement for clinical data submission to the NOPR. For this reason, Medicare has conditioned coverage of FDG-PET under the NOPR on the collection of clinical data. These data will be used to help determine the clinical utility of FDG-PET for conditionally covered cancers and indications. The billing physician remains responsible for documenting medical necessity, which is required for the coding and billing of both covered and NOPR-eligible PET studies. Eligibility for the NOPR does not constitute a clinical management recommendation for the use of PET for the conditionally covered cancers and indications, by either the Medicare program or NOPR investigators. Referring and interpreting physicians are thus advised to refer to the published literature to better understand the potential limitations of FDG-PET for NOPR-eligible uses.
- The ICD-9-CM® codes in the table above are provided for reference purposes only and for guidance in completion of the cancer type on the pre-PET form for cases included in the NOPR. Each provider should refer to the coverage policy of its respective Medicare contractor to determine which ICD-9-CM® codes are indicative of medical necessity. Note also that, although PET is covered to aid in the diagnosis of strongly suspected cancers, claims submitted with the appropriate non-cancer ICD-9-CM® code(s) may not be paid without medical necessity appeal.
- PET imaging of the brain with CPT code 78608 is covered for those cancers and indications designated by “C” in the table above and is covered only under NOPR for those cancers and indications indicated by “NOPR” in the table above.
ClinicalTrials.gov Identifier NCT00868582 Version: February 18, 2010