PET scans have been approved for reimbursement under Medicare for the following:
| Clinical Condition
FDG-PET |
Coverage - is subject to additional guidelines set forth
below and in the conditions and requirements of the CMS
National Coverage Determination described below. |
|
| Breast Cancer1 | Staging, restaging, and monitoring response
to therapy |
|
| Colorectal Cancer | Diagnosis•, staging† and
restaging†† |
|
| Esophageal Cancer | Diagnosis•, staging† and restaging†† |
|
| Head
& Neck Cancers (excluding CNS and thyroid) |
Diagnosis•, staging† and
restaging†† |
|
| Lung Cancer (non-small cell) | Diagnosis•, staging† and restaging†† |
|
| Lymphoma | Diagnosis•, staging† and
restaging†† |
|
| Melanoma (excludes evaluation of regional nodes) |
Diagnosis•, staging† and
restaging†† |
|
| Myocardial Viablity2 | Primary or initial diagnosis,
or following an inconclusive
SPECT prior to revascularization |
|
| Refractory Seizures | Covered for pre-surgical
evaluation only |
|
| Solitary Pulmonary Module | Characterization of indeterminate single pulmonary nodule |
|
| Thyroid Cancer3 | Restaging |
|
| Cervical Cancer4 | Staging as an adjunct to conventional imaging | |
| Dementia5 | Differential diagnosis of fronto-temporal dementia
(FTD) and Alzheimer’s disease (AD) - or - CMS approved practical
clinical trial |
Approved Under the Following Conditions:
For all uses of PET relating to malignancies the following conditions apply:
For all uses of PET relating to malignancies the following conditions apply:
• Diagnosis: PET is covered only in clinical situations in which: (1) the PET results may assist in avoiding an invasive diagnostic procedure, or in which, (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. PET is not covered as a screening test (i.e. testing of patients without specific signs and symptoms of disease).
† Staging: 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 (CT), magnetic resonance imaging(MRI), or ultrasound), or (1)(b) if it 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.
†† Restaging: PET is covered for restaging: (1) after completion of treatment for the purpose of detecting residual disease, (2) for detecting suspected recurrence or metastasis, (3) to determine the extent of a known recurrence, or (4) if it 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. Restaging applies to testing after a course of treatment is completed, and is covered subject to the conditions above.
Monitoring: This refers to the use of PET to monitor tumor response to treatment during the planned course of therapy (i.e., when a change in therapy is anticipated).
1) Breast Cancer: Medicare covers FDG PET as an adjunct to standard imaging modalities for staging patients with distant metastasis, or restaging patients with locoregional recurrence or metastasis. Monitoring treatment of a breast cancer tumor when a change in therapy is contemplated is also covered as an adjunct to other imaging modalities.
2) Myocardial Viability: Medicare covers FDG PET for the determination of myocardial viability as a primary or initial diagnostic study prior to revascularization, or following an inconclusive SPECT. SPECT may not be used following an inconclusive PET scan.
3) Thyroid Cancer: 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.
4) Cervical Cancer: Medicare covers FDG-PET as an adjunct test for the detection of pre-treatment metastases (i.e. staging) in newly diagnosed cervical cancer subsequent to conventional imaging that is negative for extra-pelvic metastasis.
5) Dementia: Medicare covers FDG-PET scans for either the differential diagnosis of fronto-temporal dementia (FTD) and Alzheimer's disease (AD) under specific requirements. Medicare has established specific requirements for coverage of the differential diagnosis of FTD and AD. These requirements are detailed in the NCD for Dementia and Neurodegenerative Diseases (220.6.1) and summarized in the attached Coverage Policy document and the PET Request Form below.