PET Procedures Covered by Insurance or Medicare

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PET Procedures Covered by Insurance or Medicare

Conditions Covered

Private insurance or Medicare typically covers PET (positron emission tomography) procedures for the following. Please inquire with your insurance company or with Medicare to verify coverage under your plan:

Cancers

  • Breast
  • Cervical
  • Colorectal
  • Esophageal
  • Head and neck
  • Lung cancer
  • Lymphoma
  • Melanoma
  • Ovarian
  • Thyroid

Non-Cancer Conditions:

Brain

  • Epilepsy
  • Alzheimers or Fronto-Temporal Dementia

Cardiac

  • Cardiac Perfusion
  • Cardiac Viability

Coverage for PET with F-18 Fluorodeoxyglucose (FDG) and PET with Sodium Fluoride F-18 (NaF-PET)

PET with F-18 Fluorodeoxyglucose (FDG)

Medicare reimbursement is available for PET with F-18 Fluorodeoxyglucose (FDG) to include cancers and indications not presently eligible for Medicare reimbursement. The National Oncologic PET Registry (NOPR) was developed in response to the Centers for Medicare and Medicaid Services (CMS) proposal to expand coverage for positron emission tomography (PET) with F-18 fluorodeoxyglucose (FDG). The CMS proposal indicated that Medicare reimbursement for these cancers could be obtained under the CMS coverage, if the patient's referring physician and the PET provider submitted data to a clinical registry to assess the impact of PET on cancer patient management.

Status Update

On April 3, 2009, CMS announced a new coverage policy for PET. Under this new policy, CMS expanded coverage for the use of PET for initial evaluation of patients with cancer to nearly all types of cancer and also allows for use of PET in subsequent treatment strategy evaluations for an expanded number of cancers. However, for many other cancers, the use of PET in subsequent treatment strategy evaluations will still be covered by CMS only if patients are enrolled in an approved clinical trial or registry. The NOPR sought and obtained CMS approval to continue its data collection to allow for coverage of PET scans performed for these cancers and indications. This continuing registry for FDG-PET is known as NOPR 2009.

PET with Sodium Fluoride F-18 (NaF-PET)

On February 26, 2010, CMS issued a decision memorandum regarding the use of PET with sodium fluoride F-18 (NaF-PET) for detection of bony metastasis. CMS concluded that the available evidence was sufficient to allow for NaF-PET coverage under coverage with evidence development. Again, the NOPR sought and obtained CMS approval to perform the necessary data collection in order to allow for coverage of NaF-PET scans performed for detection of bony metastases. This new registry, developed during 2010, is known as NOPR (NaF-PET) and began accepting patient registrations on January 31, 2011.

Patient Eligibility

Medicare beneficiaries (with Medicare as their primary insurance) who are referred for FDG-PET for those oncologic indications that are not currently reimbursable under Medicare or for NaF-PET to evaluate bony metastases are eligible to participate in the NOPR. The Indications table lists the cancers and indications that are accepted for FDG-PET in the NOPR 2009 registry.

Referring Physician's Responsibilities

The patient's referring physician must agree to complete pre- and post-PET data collection forms consisting of a few questions regarding the patient's planned management.

  • The Pre-PET Form must be completed by the referring physician and returned to the PET facility prior to the patient's PET scan. A blank Pre-PET Form for either the NOPR 2009 or the NOPR (NaF-PET) registry can be downloaded from the NOPR Web site and sent to the PET facility at the time of patient referral. If the form is not submitted with the referral, a patient-specific form will be e-mailed to the PET facility for delivery to the referring physician. The Pre-PET Form can be returned to the PET facility via FAX, mail, or hand delivery.

 

  • After the PET is performed, a patient-specific Post-PET Form for iether the NOPR 2009 or the NOPR (NAF-PET) registry will be sent to the referring physician for completion within 30 days. This form can also be returned to the PET facility via FAX, mail, or hand delivery.

 

Please Note: The case is eligible for CMS reimbursement only if the Pre-PET Form is completed and returned to the PET facility prior to the PET scans and the Post-PET Form is completed and returned within 30 days of the PET.

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