PET Procedures Approved for Medicare Reimbursement
F-18 labeled fluorodeoxyglucose (FDG) PET has been determined to be safe and effective for the evaluation of malignancy in patients with known or suspected abnormalities found by other testing modalities, or in patients with existing diagnoses of cancer. Provided the scans are performed using a camera approved or cleared for marketing by the FDA to image radionuclides in the body, the claims for payment must include any information Medicare requires to assure that the PET scans performed
1. were medically necessary,
2. did not unnecessarily duplicate other covered diagnostic tests and
3. did not involve investigational drugs or procedures using investigational drugs, as determined by the FDA
The PET scan entity submitting claims for payment must keep such patient records as Medicare requires on file for each patient for whom a PET scan claim is made. HCFA has ruled to have Medicare coverage for service
- performed after March 14, 1995 for PET scans using Rubidium 82 and related tests for noninvasive imaging of perfusion of the heart
- performed on or after January 1, 1998, for characterization of solitary pulmonary nodules (SPNs) and for the initial staging of lung cancer with FDG, and
- performed after July 1, 1999 for determining the location of recurrent colorectal tumor as evidence by rising levels of carcinoembryonic antigen (CEA), to stage and re-stage lymphoma when used as an alternative to gallium scanning, and for evaluating recurrence of melanoma prior to surgery as an alternative to gallium scanning
- performed after July 1, 2001 for the diagnosis, staging, and restaging of non- small cell lung cancer, lymphoma, colorectal cancer, melanoma, esophageal cancer, head and neck cancer (excluding CNS cancer), locating seizure focus in presurgical candidates, and FDG myocardial viability after an equivocal SPECT cardiac study.
The necessary documentation required by Medicare to be kept for patients that will be billed for one of the above mentioned covered indications as well as the modifiers and codes to use can be obtained from the local Medicare agency for each state. If you have any questions concerning Medicare coverage for PET procedures specifically performed at Wake Forest University Baptist Medical Center, please call 336-716-5600 or email us at petctr@wfubmc.edu .