78459 – Myocardial imaging, positron emission tomography (PET), metabolic evaluation
Coverage of PET Scans for PET Scan for Thyroid Cancer.
For services furnished on or after October 1, 2003, Medicare covers the use of FDG PET for thyroid cancer only for restaging of recurrent or residual thyroid cancers of follicular cell origin that have previously been treated by thyroidectomy and radioiodine ablation and have a serum thyroglobulin > 10ng/ml and negative I-131 whole body scan.
Coverage of PET Scans for Perfusion of the Heart Using Ammonia N-13
Effective for service performed on or after October 1, 2003, PET scans performed at rest or with pharmacological stress used for noninvasive imaging of the perfusion of the heart for the diagnosis and management of patients with known or suspected coronary artery disease using the FDA-approved radiopharmaceutical ammonia N-13 are covered, provided the following requirements are met.
Coverage for PET Scans for Dementia and Neurodegenerative Diseases
Effective for dates of service on or after September 15, 2004, Medicare will cover FDG
PET scans for a differential diagnosis of fronto-temporal dementia (FTD) and
Alzheimer’s disease OR; its use in a CMS-approved practical clinical trial focused on the
utility of FDG-PET in the diagnosis or treatment of dementing neurodegenerative
diseases. Refer to Pub. 100-03, NCD Manual, section 220.6.13, for complete coverage
conditions and clinical trial requirements and section 60.15 of this manual for claims
A. Carrier and FI Billing Requirements for PET Scan Claims for FDG-PET for the Differential Diagnosis of Fronto-temporal Dementia and Alzheimer’s Disease:
– Procedure Code for PET Scans for Dementia and Neurodegenerative Diseases
Contractors shall advise providers to use the appropriate Procedure code from section 60.3.1
for dementia and neurodegenerative diseases for services performed on or after January 28, 2005.
– Diagnosis Codes for PET Scans for Dementia and Neurodegenerative Diseases
The contractor shall ensure one of the following appropriate diagnosis codes is present on claims for PET Scans for AD:
– 290.0, 290.10 – 290.13, 290.20 – 290, 21, 290.3, 331.0, 331.11, 331.19, 331.2,
Medicare contractors shall use an appropriate Medicare Summary Notice (MSN) message such as 16.48, “Medicare does not pay for this item or service for this condition” to deny claims when submitted with an appropriate Procedure code from section 60.3.1 and with a diagnosis code other than the range of codes listed above. Also, contractors shall use an appropriate Remittance Advice (RA) such as 11, “The diagnosis is inconsistent with the procedure.”
Medicare contractors shall instruct providers to issue an Advanced Beneficiary Notice to beneficiaries advising them of potential financial liability prior to delivering the service if one of the appropriate diagnosis codes will not be present on the claim.
Provider Documentation Required with the PET Scan Claim
Medicare contractors shall inform providers to ensure the conditions mentioned in the
NCD Manual, section 220.6.13, have been met. The information must also be maintained in the beneficiary’s medical record:
– Date of onset of symptoms;
– Diagnosis of clinical syndrome (normal aging, mild cognitive impairment or
MCI: mild, moderate, or severe dementia);
– Mini mental status exam (MMSE) or similar test score;
– Presumptive cause (possible, probably, uncertain AD);
– Any neuropsychological testing performed;
– Results of any structural imaging (MRI, CT) performed;
– Relevant laboratory tests (B12, thyroid hormone); and,
– Number and name of prescribed medications.
Billing Requirements for PET Scans for Specific Indications of Cervical Cancer for Services
Contractors shall accept claims for these services with the appropriate Procedure code listed in
section 60.3.1. Refer to Pub. 100-03, section 220.6.17, for complete coverage guidelines for this new PET oncology indication. The implementation date for these Procedure codes will be April 18, 2005. Also see section 60.17, of this chapter for further claims processing instructions for cervical cancer indications.
Billing Requirements for PET Scans for Non-Covered Indications
For services performed on or after January 28, 2005, contractors shall accept claims with the following HCPCS code for non-covered PET indications:
– G0235: PET imaging, any site not otherwise specified
Short Descriptor: PET not otherwise specified
Type of Service: 4
NOTE: This code is for a non-covered service.