Medicare Coverage

Reimbursement for PET/CT studies is available for Medicare beneficiaries directly through the Medicare program or through the Coverage with Evidence Development/ National Oncologic PET Registry (NOPR) program. PET/CT studies are reimbursed for use with the radiopharmaceuticals 18F-Fluordeoxyglucose, generally referred to as FDG, and 18F-Sodium Fluoride (NaF). Medicare and NOPR reimbursement for studies with each of these radiopharmaceuticals is discussed below.

Cancers and Indications utilizing FDG for PET/CT studies are eligible for reimbursement through Medicare or through the National Oncologic PET Registry (NOPR)

For a table listing both Medicare and NOPR-covered indications for FDG-PET/CT, click here.

Cancers and indications that are directly reimbursable by Medicare are NOT eligible for entry in the NOPR. Cancers and indications that are specifically excluded from Medicare reimbursement are also not eligible for entry in the NOPR.

Cancers and Indications utilizing 18F- Sodium Fluoride (NaF) for PET/CT Bone Scans are eligible for reimbursement only through the National Oncologic PET Registry (NOPR)

Effective February 7, 2011, PET/CT bone scans utilizing the radiopharmaceutical 18F- Sodium Fluoride (NaF) are covered for Medicare beneficiaries through the Coverage with Evidence Development/National Oncologic PET Registry (NOPR) program for the detection of bone metastases.

18F-Sodium Fluoride (NaF) PET/CT bone scans are an important tool for detecting and evaluating metastatic bone cancer. These bone studies are particularly useful, since some of the most prevalent cancers are commonly associated with metastatic bone disease, such as breast and prostate cancer, as well as carcinoma of the thyroid, kidney, and lung. Examples of tumor type and ICD-9-CM codes for 18F-Sodium Fluoride (NaF) PET/CT bone studies are as follows:

Tumor Type	ICD-9-CM Codes
Lung	162.x
Female Breast	174.x
Prostate	185
Secondary malignant neoplasm of the bone	198.5
Metastatic Cancer of Unknown Origin of The Bone	199
Other cancer type	Provide ICD-9-CM code

Approved cancer indications for 18F- Sodium Fluoride PET/CT (NaF) bone scans include:

Initial Treatment Strategy (Diagnosis and Initial Staging)

Diagnosis of suspected osseous metastatic disease in patients without a pathologically proven diagnosis of cancer
Initial Staging of a newly diagnosed cancer

Subsequent Treatment Strategies
Restaging/Detection of Suspected Recurrence

Suspected new osseous metastasis as a site of recurrence or progression
Suspected progression of known osseous metastasis

Treatment Monitoring

Monitoring treatment response during systemic therapy
Monitoring Treatment Response during radiation therapy
Monitoring treatment response during COMBINED systemic therapy and radiation therapy

18F-Sodium Fluoride (NaF) PET/CT bone scans are currently reimbursable only for Medicare beneficiaries and only through the NOPR program.