Expanded Coverage of PET Scans

Expanded Coverage of PET Scans Effective for Services on or After July 1, 2001

See the Medicare National Coverage Determinations Manual, section 220.6, for specific coverage criteria for PET Scans. Coverage is expanded for PET scans to include the following effective July 1, 2001:

•  Scans performed with dedicated full-ring scanners will be covered. Gamma camera systems with at least a 1 inch thick crystal are eligible for coverage in addition to those already approved by CMS (FDA approved);

• The provider must maintain on file the doctor’s referral and documentation that the procedure involved:
o Only FDA approved drugs and devices and,
o Did not involve investigational drugs, or procedures using investigational drugs, as determined by the FDA;


• The ordering physician is responsible for certifying the medical necessity of the study according to the conditions. The physician must have documentation in the beneficiary’s medical record to support the referral supplied to the PET scan provider.

The following is a brief summary of the expanded coverage as of July 1, 2001:

• PET is covered for diagnosis, initial staging and restaging of non-small cell lung cancer (NSCLC).

• Usage of PET for colorectal cancer has been expanded to include diagnosis, staging, and restaging.

• Usage of PET for the initial staging, and restaging of both Hodgkin’s and non-Hodgkin’s disease.

• Usage of PET for the diagnosis, initial staging, and restaging of melanoma. (PET Scans are NOT covered for the evaluation of regional nodes.)

• Medicare covers PET for the diagnosis, initial staging, and restaging of esophageal cancer.

• Usage of PET for Head and Neck Cancers. (PET scans for head and neck cancer is NOT covered for central nervous system or thyroid cancers.)

• Usage of PET following an inconclusive single photon emission computed tomography (SPECT) only for myocardial viability. In the event that a patient has received a SPECT and the physician finds the results to be inconclusive, only then may a PET scan be ordered utilizing the proper documentation.

• Usage of PET for pre-surgical evaluation for patients with refractory seizures.

NOTE: Effective January 1, 2002, the definitions of HCPCS Codes G0210 through G0230 have been updated to properly reflect the type of PET scanner used.


POSITRON EMISSION TOMOGRAPHY (PET) SERVICES

Effective 4/1/2015, Medicaid is carving out the cost of the radioactive tracer from the PET scan global fee. Medicaid will reimburse for the professional/technical administrative component of a PET scan and separate reimbursement will be made for the PET scan tracer. To receive reimbursement for only the professional component (facility based services only), see modifier -26 Professional Component.

78459 Myocardial imaging, positron emission tomography (PET), metabolic evaluation

78491 Myocardial imaging, positron emission tomography (PET), perfusion, single study at rest or stress

78492 multiple studies at rest and/or stress

78608 Brain imaging, positron emission tomography (PET), metabolic evaluation

78609 perfusion evaluation

78811 Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)

78812 skull base to mid-thigh

78813 whole body

78814 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)

78815 skull base to mid-thigh

78816 whole body

(Report 78811-78816 only once per imaging session)