Insurance and Billing·

• Medicare does pay for PET scans and follows a strict medical necessity policy.
• Blue Shield pays and also has a medical necessity policy.
• Tufts does pay and does not have a medical necessity policy tied to reimbursement.
• Harvard Pilgrim does pay and does not have a medical necessity requirement, however, prior authorization must be obtained by NIA.
• Mass Health does pay for this procedure and payment is based on an individual consideration basis at the present time.

For the above carriers, the following conditions are covered for diagnosis, staging and restaging:

Breast Cancer
Colon Cancer
Esophageal Cancer
Head & Neck Cancer
Heart
Lung Cancer
Lymphoma
Melanoma
Single Pulmonary Nodule
Thyroid Cancer
Seizures
Alzheimer's Disease / Fronto-Temporal Dementia

Diagnosis: PET is covered only in clinical situations in which the PET results may assist in avoiding an invasive diagnostic procedure, or in which the PET results may assist in determining the optimal anatomical location to perform an invasive diagnostic procedure. In general, for most solid tumors, a tissue diagnosis is made prior to the performance of PET scanning. PET scans following a tissue diagnosis are performed for the purpose of staging not diagnosis. Therefore, the use of PET in the diagnosis of lymphoma, esophageal, and colorectal cancers as well as in melanoma should be rare.

Staging and or Restaging: PET is covered in clinical situations in which:

1. The stage of the cancer remains in doubt after completion of a standard diagnostic workup, including conventional imaging (computed tomography, magnetic resonance imaging, or ultrasound). The use of PET would also be considered reasonable and necessary if it could potentially replace one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical management of the patient.
2. The clinical management of the patient would differ depending on the stage of the cancer identified. PET will be covered for restaging after the completion of treatment for the purpose of detecting residual disease, for detecting suspected recurrence or to determine the extent of a known recurrence. Use of PET would also be considered reasonable and necessary if it could potentially replace one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical management of the patient.

Monitoring: The use of PET to monitor tumor response during the planned course of therapy (i.e. when no change in therapy is being contemplated) is not covered. Restaging only occurs after a course of treatment is completed, and this is covered, subject to the conditions above.

OVERVIEW of MEDICAL CRITERIA for PET SCANNING

BREAST CANCER

• PET imaging for breast cancer, staging/restaging of local regional recurrence or distant metastases, i.e. staging/restaging after or prior to course of treatment
• PET imaging for breast cancer, evaluation of response to treatment, performed during course of treatment

COLORECTAL

• PET imaging whole body; diagnosis; colorectal cancer.
• PET imaging whole body; initial staging; colorectal cancer
• PET imaging whole body; restaging; colorectal cancer

ESOPHAGEAL CANCER

• PET imaging whole body; diagnosis; esophageal cancer
• PET imaging whole body; initial staging; esophageal cancer
• PET imaging whole body; restaging; esophageal cancer

HEAD & NECK CANCER

• PET imaging whole body or regional; diagnosis; head and neck cancer; excluding thyroid and CNS cancers.
• PET imaging whole body or regional; initial staging; head and neck cancer; excluding thyroid and CNS cancers.
• PET imaging whole body or regional; restaging; head and neck cancer; excluding thyroid and CNS cancers.

HEART

• PET imaging; metabolic assessment for myocardial viability following inconclusive SPECT study. Heart muscle imaging determination of myocardial viability as primary or initial diagnosis prior to revascularization

LUNG CANCER

• PET imaging whole body; diagnosis; lung cancer; non-small cell.
• PET imaging whole body; initial staging; lung cancer; non-small cell.
• PET imaging whole body; restaging; lung cancer; non-small cell.

LYMPHOMA

• PET imaging whole body; diagnosis; lymphoma
• PET imaging whole body; initial staging; lymphoma
• PET imaging whole body; restaging; lymphoma

MELANOMA

• PET imaging whole body; diagnosis; melanoma
• PET imaging whole body; initial staging; melanoma
• PET imaging whole body; restaging; melanoma

SINGLE PULMONARY NODULE

• PET imaging whole body for regional single pulmonary nodule (not to exceed 4 cm.)

THYROID CANCER

• PET imaging for restaging of recurrent or residual thyroid cancers of follicular origin that have been previously treated by thyroidectomy of radioiodine ablation and have a serum thyroglobulin greater than 10 mg/ml and negative I-131 whole body scan.

SEIZURES

• PET imaging for pre-surgical evaluation of refractory seizures

ALZHEIMER’S DISEASE / FRONTO-TEMPORAL DEMENTIA

• Recent diagnosis of dementia
• Documented cognitive decline of at least 6 months
• Comprehensive documented clinical evaluation prior to PET imaging
  Medical history
  Assessment of daily living activities
  Physical & mental status exam
  Cognitive scales or neuropsychological testing
  Laboratory tests
  MRI or CT

DEFINITIONS

Diagnosis
Assists in optimal anatomic localization prior to invasive diagnostic procedures

Staging
Stage of cancer remains in doubt after completion of standard diagnostic work-up.
Potentially replaces one or more imaging techniques
Clinical management of the patient would differ depending on the stage of cancer.

Restaging
Detection of residual disease after completion of a course of treatment
Detection/ assessment of recurrence

COMMON CANCERS NOT COVERED FOR PET IMAGING