PSMA PET scans using 18F-DCFPyL were approved by the FDA on May 27, 2021. Commercial production commenced shortly thereafter and several PET scan facilities such as PET Imaging Institute of South Florida have been performing PSMA PET scans ever since.
All PET scans are billed utilizing two codes — one for the scan itself, the other for the tracer injected into the patient. CMS provided dedicated billing codes for the PSMA tracers as follows: Pylarify on January 1, 2022, Illuccix on July 1, 2022, and Locametz on October 1, 2022. With dedicated billing codes for those tracers, CMS also provided reimbursement for those tracers.While third-party insurance companies are not obligated to reimburse for those tracers, they often follow Medicare, and as a result, many have been adding these PSMA tracers to their formulary as accepted codes and providing reimbursement for their use. However, their acceptance tends to lag behind Medicare by anywhere from 3-12 months, depending on the insurer, although some may never reimburse for those tracers. Remember that determination of insurance coverage is specific to your individual history, needs, coverage, and insurance plan.In ALL cases where reimbursement is not covered (or when an authorization is denied) by your insurer, you should reach out directly and ask for a special case to be made. There is not a guarantee of coverage, but it is possible that you and/or your physician may be able to convince your insurer to cover the scan AND the tracer cost.Patients without insurance coverage (or when an authorization is denied) can choose to pay cash for the scan. We offer a reduced price for the scan charge of $1,000 with an addition charge for invoice cost of the PSMA tracer, which may be up to $5,000, depending on tracer sourced. Please note, as a contracted facility with most medical insurance carriers, we are obligated to abide by contractual insurance guidelines. Therefore, our cash price offer can only be extended to those patients who do not have coverage.Contact us at our PSMA Fax Hotline: (954) 607-6757 or email to: firstname.lastname@example.org for further details.