Medicare Coverage

Cancers and Indications Covered Under the National Oncologic PET Registry

For this NOPR table formatted as a pdf file, click here (200 kb).

∆ = Covered under the PET Registry
C = Nationally covered indication, PET Registry not needed
NC = Not eligible for entry in the PET Registry—nationally non-covered indication
NA = Not Applicable

Indications (ICD-9)	Diagnosis	Initial Staging	Treatment Monitoring	Restaging/ Suspected Recurrence
Lip, Oral Cavity, and Pharynx (140-149)	C	C	∆	C
Esophagus (150)	C	C	∆	C
Stomach (151)	∆	∆	∆	∆
Small Intestine (152)	∆	∆	∆	∆
Colon (153) and Rectum (154)	C	C	∆	C
Anus (154)	∆(1)	∆(1)	∆	∆(1)
Liver and intrahepatic bile ducts (155)	∆	∆	∆	∆
Gallbladder & extrahepatic bile ducts (156)	∆	∆	∆	∆
Pancreas (157)	∆	∆	∆	∆
Retroperitoneum and peritoneum (158)	∆	∆	∆	∆
Nasal cavity, ear, and sinuses (160)	C	C	∆	C
Larynx (161)	C	C	∆	C
Lung, non-small cell (162)	C	C	∆	C
Lung, small cell (162)	∆	∆	∆	∆
Pleura (163)	∆	∆	∆	∆
Thymus, heart, mediastinum (164)	∆	∆	∆	∆
Bone/cartilage (170)	∆	∆	∆	∆
Connective/other soft tissue (171)	∆	∆	∆	∆
Melanoma of skin (172)	C	C(2)	∆	C
Female breast (174)	NC(3)	C(2)	C	C
Male breast (175)	NC(3)	C(2)	C	C
Kaposi's sarcoma (176)	∆	∆	∆	∆
Uterus, unspecified (179)	∆	∆	∆	∆
Cervix (180)	∆	C(4)	∆	∆
Uterus, body (182)	∆	∆	∆	∆
Ovary and uterine adnexa (183)	∆	∆	∆	∆
Prostate (185)	∆	∆	∆	∆
Testis (186)	∆	∆	∆	∆
Penis and other male genitalia (187)	∆	∆	∆	∆
Bladder (188)	∆	∆	∆	∆
Kidney and other urinary tract (189)	∆	∆	∆	∆
Eye (190)	∆	∆	∆	∆
Primary Brain (191)	∆	∆	∆	∆
Thyroid (193)	∆	∆	∆	C(5)
Lymphoma (200-202)	C	C	∆	C
Myeloma (203)	∆	∆	∆	∆
Leukemia (204-208)	∆	∆	∆	∆
Solitary Pulmonary Nodule	C	NA	NA	NA
Other or not listed	∆	∆	∆	∆

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 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.

NOTES:
1. Some Medicare carriers include anal cancer in their coverage of "colorectal cancer"; for PET facilities served by those carriers, PET for anal cancer diagnosis, initial staging, or restaging/suspected recurrence would be a covered indication.

2. Does not cover initial staging for axillary lymph nodes for breast cancer patients and regional lymph nodes for melanoma patients

3. PET is non-covered for "Diagnosis" of breast cancer to evaluate a suspicious breast mass. However, a patient with suspected breast cancer is eligible for entry in NOPR for the indications (1) "Diagnosis: Unknown Primary Site" in a patient with axillary nodal metastasis but no evident primary breast cancer by conventional evaluation and (2) "Diagnosis: Paraneoplastic Syndrome".

4. Patient must have prior CT or MRI negative for extrapelvic metastatic disease to qualify as a covered indication. Patients who do not qualify for covered indication (e.g., because CT or MRI not done or because either showed extrapelvic metastatic disease) can be entered on NOPR.

5. To qualify as a covered indication thyroid cancer must be of follicular cell origin and been previously treated by thyroidectomy and radioiodine ablation and have a serum thyroglobuilin > 10ng/ml and negative I-131 whole body scan. Patients who do not qualify for covered indication (e.g., because tumor of other than follicular cell origin or thryoglobulin not elevated) can be entered on NOPR.

The following table presents Medicare-approved indications for PET scans in cardiology and neurology as of January 30, 2005.

Clinical Condition	Coverage
CARDIOLOGY
Myocardial Viability	Primary or initial diagnosis, or following an inconclusive SPECT prior to revascularization. SPECT may not be used following an inconclusive PET scan.
NEUROLOGY
Refractory Seizures	Covered for pre-surgical evaluation only.
Alzheimer’s Disease	Alzheimer’s Disease versus Fronto-Temporal Dementia. Differential diagnosis of Alzheimer’s Disease and fronto-temporal dementia, where patient has had a recent diagnosis of dementia, cognitive decline for six months, and a standard clinical evaluation, yet a diagnosis of AD remains uncertain.