Medicare

CMS National Coverage

Effective June 11, 2013, The Centers for Medicare and Medicaid Services (CMS) ended the National Oncologic PET Registry (NOPR) which previously provided Medicare coverage for FDG PET imaging under the Coverage with Evidence Development (CED) program.

 

The new National Coverage Policy for Oncologic PET/CT imaging expanded covered indications.  The policy also defined the number of scans that will be covered for a patient, per cancer.  The National Coverage Policy allows one (1) scan for initial treatment strategy (diagnosis/initial staging) and up to three (3) scans per patient, per cancer for subsequent scans.

 

  • One (1) initial scan for treatment strategy (diagnosis or initial staging)

  • Three (3) subsequent scans per specific cancer type

  • Medical necessity needs to be documented for four (4) or more scans.  Scans for routine surveillance will not be covered without a documented change in patient condition.

  

CMS Local Coverage

NCPIC will perform PET scans beyond the three (3) subsequent scans covered by the National Coverage Policy.  These scans will be covered by the Local Medicare contractor as long as the scans are determined to be medically necessary.  At the time the scan is ordered, NCPIC requests a short statement from the referring physician describing the reason the scan is medically necessary.

  

NOTE:  When there is a NEW cancer diagnosis, a new count for initial and subsequent scans becomes effective.

 

View a table of the Expanded PET/CT Coverage, effective June 11, 2013.

 

*The Centers for Medicare and Medicaid Services (CMS) decides coverage for PET/CT scans through a National Coverage Determination (NCD) section 220.6.  The coverage policy is the same nationwide.