Insurance and Billing

Most insurance companies pay for clinically indicated PET scan procedures. To be clinically indicated the procedure must be potentially beneficial in providing information supportive of a diagnosis or monitoring conditions. It is prudent to check with the insurance company prior to the PET scan for coverage.

• Private Insurance
• Medicare
• National Oncologic PET Registry (NOPR)
  
• Medicaid

PRIVATE INSURANCE
Coverage for PET scans varies widely, and should be pre-determined on an individual basis. The referring physician's office is responsible for obtaining prior authorization and providing proof of medical necessity for any PET scan.

The cost for the PET scan is broken into three components: (1) the FDG
radiopharmaceutical, (2) the PET scan, and (3) the professional fee for the radiologist who interprets the scan.

Patients are responsible for deductibles, co-payments and remaining balances. All patients are responsible for supplying their insurance card on the day of the PET scan.

If private insurance does not cover the PET scan, the patient may choose to self-pay the procedure. Please call our billing department about payment arrangements.

MEDICARE
The Centers for Medicare and Medicaid Services (CMS) coverage policies for PET indications are decided at a national level and are documented in a National Coverage Determination (NCD), section 220.6 Medicare Covered Indications.

In April 2009, CMS announced a new coverage policy for oncology PET scans. Under the new policy, CMS expanded coverage for the use of PET for initial treatment strategy evaluation, formerly diagnosis and initial staging of patients with nearly all cancer types, and allowed the use of PET for subsequent treatment stratcgy evaluation (formerly restaging, detection of suspected recurrence and treatment monitoring for an expanded number of cancer types).

NATIONAL ONCOLOGIC PET REGISTRY (NOPR)
The National Oncologic PET Registry (NOPR) was developed in response to the Centers for Medicare and Medicaid Services (CMS) proposal to expand coverage for FDG PET to include cancers and indications not presently eligible for Medicare reimbursement. Medicare reimbursement for these cancers is available if the patient's referring physician and the imaging center submit data to a clinical registry to assess the impact of PET on cancer patient management. The NOPR implements this registry for CMS.

The NOPR is sponsored by the Academy of Molecular Imaging (AMI) and is managed by the American College of Radiology (ACR) through the American College of Radiology Imaging Network. Also, endorsed by the American College of Radiology (ACR), the American Society for Clinical Oncology (ASCO), and the Society for Nuclear Medicine (SNM).

MEDICAID
Medicaid will pay for PET scans, based on medical necessity as determined by a patient's primary care physician. North Shore P.E.T. Imaging Center does not accept out of state Medicaid.