Notes
1 Some Medicare contractors include anal cancer in their local coverage of “colorectal cancer”; for PET facilities served by those carriers, PET for subsequent treatment evaluation of anal cancer would be a covered indication.
2 PET is non-covered for initial staging of axillary lymph nodes in patients with breast cancer and of regional lymph nodes in patients with melanoma, but is covered for detection of distant metastatic disease in high-risk patients with breast cancer or melanoma..
3 PET is non-covered for “diagnosis” of breast cancer to evaluate a suspicious breast mass. However, PET is covered for initial treatment strategy evaluation of a patient with axillary nodal metastasis of unknown primary origin or in a patient with a paraneoplastic syndrome potentially caused by an occult breast cancer.
4 Patient must have prior CT or MRI negative for extrapelvic metastatic disease for PET to qualify as a covered indication for initial treatment strategy evaluation. Patients who do not qualify for this covered indication (e.g., because CT or MRI was not done or because either CT or MRI showed extrapelvic metastatic disease) can be entered on NOPR.
5 To qualify as a covered indication for subsequent treatment strategy evaluation, thyroid cancer must be of follicular cell origin and been previously treated by thyroidectomy and radioiodine ablation and the patient must have a serum thyroglobuilin > 10 ng/mL and a negative whole-body I-131 scan. Patients who do not qualify for this covered indication (e.g., because the tumor is of other than follicular cell origin, the thyroglobulin is not elevated, or I-131 whole-body imaging was not performed or is positive) can be entered on NOPR.
Important Note
The scientific evidence concerning the clinical utility of FDG-PET is generally less robust for cancers and indications that are currently covered by Medicare only in the NOPR than for cancers and indications that are currently covered without the requirement for clinical data submission to the NOPR. For this reason, Medicare has conditioned coverage of FDG-PET under the NOPR on the collection of clinical data. These data will be used to help determine the clinical utility of FDG-PET for conditionally covered cancers and indications. The billing physician remains responsible for documenting medical necessity, which is required for the coding and billing of both covered and NOPR-eligible PET studies. Eligibility for the NOPR does not constitute a clinical management recommendation for the use of PET for the conditionally covered cancers and indications, by either the Medicare program or NOPR investigators. Referring and interpreting physicians are thus advised to refer to the published literature to better understand the potential limitations of FDG-PET for NOPR-eligible uses.
General Note
PET imaging of the brain with CPT code 78608 for subsequent treatment strategy evaluation of any type of cancer is covered only under NOPR.
<<page 2
|
