PET Scan Requirements for Medicare

Position emission tomography, or more commonly known as PET scans, search for metabolic activity and perfusion in the patient's body. Many doctors order PET scans for patients who have been diagnosed with a form of cancer, and the tests help them determine the severity of the patients' condition.



Doctors billing for PET scans performed on Medicare patients must follow proper protocol to ensure that their claims are paid in a timely manner.

Initial Treatment

• The Centers for Medicare and Medicaid Services, or CMS, use national guidelines to determine how PET scans are to be covered. The National Coverage Determination was updated in 2009 to include the initial treatment strategy information. The scans could now be used for more diagnostic purposes. Before the change, doctors had to make a formal diagnosis and then determine the stage the cancerous condition had spread throughout the body. The doctor would also have to conduct multiple clinical studies. The new stipulation allows for a quicker results because doctors can proceed with their own strategy evaluations without having to collect several study results.

  CMS only allows PET scans that do not unnecessarily duplicate other covered diagnostic tests. The tests must also not involve experimental drugs or procedures that have not been approved by the U.S. Food and Drug Administration. The PET scan must also have either been approved or cleared by the FDA for marketing to image radionuclides in the body. This approval assumes the system has been cleared to be safe and ready to use.

  Medicare does not cover PET scans that are performed with gamma camera systems with crystal thinner than 58 inches.

Billing and Reporting

• Billing Medicare for PET scans requires one indication and a simple applicable code. Since 1995, the CMS issued if first coverage decision on the PET scan technology by allowing Medicare to cover the scans for more indications, including lung, skin and breast cancers.

  While the PET scan plays a vital role in figuring out the initial treatment, diagnosis and staging of most solid tumors, doctors must report any data collected from PET scans that are used to monitor the progress of treatment or remission of cancer in some designated areas. This is because scientific evidence is not as strong in showing that PET scans are useful for all types of cancer.

  Doctors must also follow a requirement stating that providers must collect clinical information about how the scans affected the doctors' treatment decisions. The doctors gather and place this information through the National Oncologic PET Registry.

Special Procedures

• Medicare covers PET scan surgical evaluations for patients who develop nonresponsive seizures through medications, but only after rigorously defined conditions are met. The patient record has to determine medical necessity. The record must show a history of the nonresponsive seizures in correlation with the medical therapy treatments. A provider who submits claims for payment for these procedures must have these records on file before the claim can be paid.