– Carrier and FI
Effective for services on or after January 28, 2005, contractors shall accept and pay for claims for PET scans for lung cancer, esophageal cancer, colorectal cancer, lymphoma, melanoma, head & neck cancer, breast cancer, thyroid cancer, soft tissue sarcoma, brain cancer, cervical cancer, ovarian cancer, pancreatic cancer, small cell lung cancer, and testicular cancer, as well as for neurodegenerative diseases and all other cancer indications not previously mentioned in this chapter, if these scans were performed as part of a CMS-approved clinical trial. (See Pub. 100-03, sections 220.6.2-220.6.7 and 220.6.10-220.6.15.)
Contractors shall also be aware that PET scans for all cancers not previously specified at Pub. 100-03, section 220.6.15, remain nationally non-covered unless performed in conjunction with a CMS-approved clinical trial.
– Carriers Only
Carriers shall pay claims for PET scans for beneficiaries participating in a CMS-approved clinical trial submitted with an appropriate Procedure code from 60.3.1 and the QR (Item or Service Provided in a Medicare Specified Study) modifier.
– FIs Only
In order to pay claims for PET scans on behalf of beneficiaries participating in a CMS-approved clinical trial, FIs require providers to submit claims with ICD-9 code V70.7 in the second diagnosis position on the CMS-1450 (UB-92), or the electronic equivalent, with the appropriate principal diagnosis code and an appropriate Procedure code from section 60.3.1. Effective for PET scan claims for dates of service on or after January 28, 2005, FIs shall accept claims with the QR modifier on other than inpatient claims.
