For services on or after August 8, 2011, see policy N-215 or N-216, as appropriate.

Positron emission tomography, also called PET imaging or a PET scan, is a diagnostic examination/technique which produces a three dimensional image or map of functional processes in the body. This image is produced when a radioactive substance, commonly known as a radiopharmaceutical imaging agent is administered through an existing intravenous line or inhaled as a gas. 

Generally, the Medicare program covers PET scans in clinical situations when the results of the PET may assist in avoiding an invasive diagnostic procedure or when determining the best anatomical location to perform an invasive diagnostic procedure. PET scans are not covered as screening tests and should only be used to test patients with specific signs and symptoms of disease.

For more specific PET scan coverage indications and limitations, refer to the National Coverage Determination (NCD) information on the CMS Web site. NCDs can be viewed in their entirety on the CMS Web site at:  http://www.cms.hhs.gov/coverage

IOM references can be viewed on the CMS Web site at: http://www.cms.hhs.gov/manuals/cmsindex.asp

PET cardiac perfusion imaging
Cardiac perfusion for noninvasive imaging for the diagnosis and management of patients with known suspected coronary artery disease is covered provided the following requirements are indicated in the patient’s medical record:

• the PET scan, whether performed at rest or rest with stress, is performed in place of but not in addition to a single photon emission computed tomography (SPECT); or 
• the PET scan, whether at rest alone or rest with stress, is used following a SPECT that was found to be inconclusive. In this scenario, the PET scan must have been considered necessary in order to determine what medical or surgical intervention is required to treat the patient.

Services provided for conditions not included in the "Diagnosis Codes" section of this policy will be considered not medically necessary. Effective January 26, 2009, a provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

NOTE:

For additional information and coverage criteria for cardiac PET imaging, refer to Medicare Advantage Medical Policy Bulletin R-5 (Radionuclide Cardiovascular Imaging).

Documentation Requirements

Document the medical necessity of services being performed in the patient’s medical record (responsibility of the ordering physician).

Do not unnecessarily duplicate other covered diagnostic tests.

Use only Food and Drug Administration (FDA) approved drugs and devices to image radionuclides in the body. 

Ensure that these diagnostic tests are always performed by (or under the general supervision of) a qualified physician licensed to administer radioactive materials.

The PET scan entity submitting claims for payment (often not the ordering physician) must keep patient records on file for each patient for whom a PET scan claim is made.

In addition to selecting the correct Current Procedural Terminology (CPT) code for the PET scan performed, it is also important to use the correct Health Care Procedure Coding System (HCPCS) code to report the use of radiopharmaceutical diagnosis imaging agents.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Use radiotracer codes A9555 (Rubidium RB-82) or A9526 (Ammonia N-13) with procedure codes 78491 and 78492. 

Use radiotracer code A9552 (FDG) with CPT codes 78459, 78608, or 78811-78816.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Online Manual Publication 100-3 - Medicare National Coverage Determinations (NCD), Chapter 1, Section 220.6

Use of these codes does not guarantee reimbursement. The patient's medical record must document that the coverage criteria in this NCD have been met.

Please note, this is not an exhaustive list of all national coverage; it only represents national coverage to which this contractor has assigned CPT/HCPCS codes and associated ICD-9 codes.

CPT code 78459 and HCPCS codes A9526, and A9552

CPT codes 78608, 78811, 78812, 78813, 78814, 78815, 78816 and HCPCS code A9552