PET/CT Reimbursement

Ministry Saint Joseph's Hospital follows the requirements for reimbursement set by Medicare and Medicaid.  Although most insurance companies follow these same guidelines, it is recommended that people contact their private insurance companies with any concerns or questions regarding PET scan reimbursement requirements.

PET REIMBURSEMENT SUMMARY
As of April 2004
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Clinical
Conditions
Reimbursement
(with limitations)
Clinical Indication
Breast Cancer[i] Staging, restaging, & monitoring of treatment
  • Staging of patients with metastasis outside a localized region
  • Restaging localized region for metastasis
  • Evaluation of effectiveness of treatment
 Colorectal Cancer  Diagnosis, Staging, and Restaging
  • Indications for staging and restaging include rising CEA marker.
  • Stage of cancer remains in doubt after completion of a standard diagnostic work up Restaging after completion of treatment.
  • Clinical management would change, depending on the stage of the cancer identified
 Esophageal Cancer  Diagnosis, Staging, and Restaging
  • Pre-surgical staging to assess the extent of the disease
  • Stage of cancer remains in doubt after completion of a standard diagnostic work up
  • Restaging after completion of treatment.
  • Clinical management would change, depending on the stage of the cancer identified
 Head and Neck Cancer
 (excludes CNS and thyroid carcinoma)
 Diagnosis, Staging, and Restaging
  • Reveal the site of the primary tumor to prevent unnecessary random biopsies or unneeded radiation
  • Stage of cancer remains in doubt after completion of a standard diagnostic work up.
  • Restaging after completion of treatment.
  • Clinical management would change, depending on the stage of the cancer identified.
Lung Cancer
(Non-Small Cell)
Diagnosis, Staging, and Restaging
  • There must be evidence of a primary tumor which is pathologically confirmed
  • Evidence of a tumor on a current thoracic CT scan
  • Stage of cancer remains in doubt after completion of a standard diagnostic work up.
  • Restaging after completion of treatment.
  • Clinical management would change, depending on the stage of the cancer identified
Lymphoma Diagnosis, Staging, and Restaging [ii]
  • Can take the place of a Gallium scan
  • Stage of cancer remains in doubt after completion of a standard diagnostic work up
  • Restaging after completion of treatment.
  • Clinical management would change, depending on the stage of the cancer identified
Melanoma

Diagnosis, Staging, and Restaging

  • Cannot be used for the regional evaluation of nodes
  • Stage of cancer remains in doubt after completion of a standard diagnostic work up
  • Restaging after completion of treatment.
  • Clinical management would change, depending on the stage of the cancer identified
Cardiac Viability Primary or Initial diagnostic evaluation
  • Can be used as a primary or initial diagnostic exam prior to revascularization.
Seizure Disorders Pre-surgical Evaluation
  • Only for pre-surgical evaluation of seizure localization
Single Pulmonary Nodule (SPN) Single Nodule within the Lung
  • Purpose is to examine a single lung nodule and determine the likelihood of malignancy. [iii]
  • Stage of cancer remains in doubt after completion of a standard diagnostic work up
  • Restaging after completion of treatment.
  • Clinical management would change, depending on the stage of the cancer identified

Thyroid Cancer

Restaging
  • Recurrent or residual thyroid carcinoma of follicular cell orgin.[iv]

Medicare Definitions:

Diagnosis:

PET is covered only in clinical situations in which the PET results may assist in avoiding an invasive diagnostic procedure, or in which the PET results may assist in determining the optimal anatomical location to perform an invasive diagnostic procedure. In general, for most solid tumors, a tissue diagnosis is made prior to the performance of PET scanning. PET scans following a tissue diagnosis are performed for the purpose of staging, not diagnosis. Therefore, the use of PET in the diagnosis of lymphoma, esophageal, and colorectal cancers as well as in melanoma should be rare. PET is not covered for other diagnostic uses, and is not covered for screening (testing of patients without specific signs and symptoms of disease).

Staging and Restaging:

PET is covered in clinical situations in which 1) (a) the stage of the cancer remains in doubt after completion of a standard diagnostic work up, including conventional imaging (computed tomography, magnetic resonance imaging, or ultrasound) or (b) the use of PET would also be considered reasonable and necessary if it could potentially replace one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical management of the patient and 2) clinical management of the patient would differ depending on the stage of the cancer identified. PET will be covered for restaging after the completion of treatment for the purpose of detecting residual disease, for detecting suspected recurrence or to determine the extent of a known recurrence. Use of PET would also be considered reasonable and necessary if it could potentially replace one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical management of the patient.

Monitoring:

Use of PET to monitor tumor response during the planned course of therapy (i.e., when no change in therapy is being contemplated) is not covered except for breast cancer. Restaging only occurs after a course of treatment is completed, and this is covered, subject to the conditions above.

[i] Medicare continues to have a national non coverage determination for initial diagnosis and staging of axillary lymph nodes.Medicare covers FDG PET as an adjunct to other imaging modalities for staging patients with distant metastasis, or restaging patients with locoregional recurrence or metastasis. Monitoring treatment of a breast cancer tumor when a change in therapy is contemplated is also covered as an adjunct to other imaging modalities.

[ii] A PET scan will be allowed for restaging no sooner than 50 days following the last staging PET scan or Gallium scan, unless sufficient evidence is presented to the Medicare contractor that the restaging at an earlier date is medically necessary

[iii] When evaluation of a SPN using both CT and regional PET chest scanning, PET scans will not be covered if repeated within 90 days following a negative PET scan.

[iv] Patient must have treated by a thyroidectomy and radioiodine ablation.Must also have a serum thyroglobulin > 10 ng/ml and a negative I-131 wholebody.All other uses of PET is not covered

 

 
 
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