Below is a summary of all covered PET scan conditions, with effective dates.
NOTE: The G codes below except those a # can be used to bill for PET Scan services through January 27, 2005. Effective for dates of service on or after January 28, 2005, providers must bill for PET Scan services using the appropriate Procedure codes. See section 60.3.1. The G codes with a # can continue to be used for billing after January 28, 2005 and these remain non-covered by Medicare. (NOTE: PET Scanners must be FDA-approved.)
Conditions Coverage Effective Date ****HCPCS/Procedure code
*Myocardial perfusion imaging (following previous 3/14/95
PET G0030-G0047) single study, rest or stress
(exercise and/or pharmacologic) G0030
*Myocardial perfusion imaging (following previous 3/14/95
PET G0030-G0047) multiple studies, rest or stress
(exercise and/or pharmacologic) G0031
*Myocardial perfusion imaging (following rest SPECT, 3/14/95
78464); single study, rest or stress
(exercise and/or pharmacologic) G0032
*Myocardial perfusion imaging (following rest 3/14/95
SPECT 78464); multiple studies, rest or stress
(exercise and/or pharmacologic) G0033
*Myocardial perfusion (following stress SPECT 3/14/95
78465); single study, rest or stress
(exercise and/or pharmacologic) G0034
*Myocardial Perfusion Imaging (following stress 3/14/95
SPECT 78465); multiple studies, rest or stress
(exercise and/or pharmacologic) G0035
*Myocardial Perfusion Imaging (following coronary 3/14/95
angiography 93510-93529); single study, rest or stress
(exercise and/or pharmacologic) G0036
*Myocardial Perfusion Imaging, (following coronary 3/14/95
angiography), 93510-93529); multiple studies, rest
or stress (exercise and/or pharmacologic) G0037
*Myocardial Perfusion Imaging (following stress 3/14/95
planar myocardial perfusion, 78460); single study,
rest or stress (exercise and/or pharmacologic) G0038
*Myocardial Perfusion Imaging (following stress 3/14/95
planar myocardial perfusion, 78460); multiple studies,
rest or stress (exercise and/or pharmacologic) G0039
*Myocardial Perfusion Imaging (following stress 3/14/95
echocardiogram 93350); single study, rest or stress
(exercise and/or pharmacologic) G0040
*Myocardial Perfusion Imaging (following stress 3/14/95
echocardiogram, 93350); multiple studies, rest or stress
(exercise and/or pharmacologic) G0041
*Myocardial Perfusion Imaging (following stress 3/14/95
nuclear ventriculogram 78481 or 78483); single
study, rest or stress (exercise and/or pharmacologic) G0043
*Myocardial Perfusion Imaging (following stress nuclear 3/14/95
ventriculogram 78481 or 78483); multiple studies,
rest or stress (exercise and/or pharmacologic) G0042
*Myocardial Perfusion Imaging (following stress ECG, 3/14/95
93000); single study, rest or stress (exercise and/or
pharmacologic) G0044
*Myocardial perfusion (following stress ECG, 93000), 3/14/95
multiple studies; rest or stress (exercise and/or
pharmacologic) G0045
*Myocardial perfusion (following stress ECG, 93015), 3/14/95
single study; rest or stress (exercise and/or
pharmacologic) G0046
*Myocardial perfusion (following stress ECG, 93015); 3/14/95
multiple studies, rest or stress (exercise and/or
pharmacologic) G0047
PET imaging regional or whole body; single pulmonary nodule 1/1/98 G0125
Lung cancer, non-small cell (PET imaging whole body) 7/1/01
Diagnosis, Initial Staging, Restaging G0210 ,G0211, G0212
Colorectal cancer (PET imaging whole body) 7/1/01
Diagnosis, Initial Staging, Restaging G0213, G0214,G0215
Melanoma (PET imaging whole body) 7/1/01
Diagnosis, Initial Staging, Restaging G0216, G0217, G0218
Melanoma for non-covered indications 7/1/01 #G0219
Lymphoma (PET imaging whole body) 7/1/01
Diagnosis, Initial Staging, Restaging G0220, G0221, G0222
Head and neck cancer; excluding thyroid and 7/1/01
CNS cancers (PET imaging whole body or regional)
Diagnosis, Initial Staging, Restaging G0226, G0227, G0228
Metabolic brain imaging for pre-surgical evaluation 7/1/01
of refractory seizures
Diagnosis, Initial Staging, Restaging G0229
Metabolic assessment for myocardial viability 7/1/01
following inconclusive SPECT study G0230
Recurrence of colorectal or colorectal metastatic 1/1/02
cancer (PET whole body, gamma cameras only) G0231
Staging and characterization of lymphoma (PET whole 1/1/02
body, gamma cameras only) G0232
Recurrence of melanoma or melanoma metastatic 1/1/02
cancer (PET whole body, gamma cameras only) G0233
Regional or whole body, for solitary pulmonary 1/1/02
nodule following CT, or for initial staging of
non-small cell lung cancer (gamma cameras only) G0234
Non-Covered Service 1/28/05
PET imaging, any site not otherwise specified #G0235
Non-Covered Service
Initial diagnosis of breast cancer and/or surgical 10/1/02
planning for breast cancer (e.g., initial staging of
axillary lymph nodes), not covered (full- and partial-ring
PET scanners only) #G0252
Breast cancer, staging/restaging of local regional 10/1/02
recurrence or distant metastases, i.e., staging/restaging
after or prior to course of treatment (full- and
partial-ring PET scanners only) G0253
Greast cancer, evaluation of responses to treatment, 10/1/02
performed during course of treatment
(full- and partial-ring PET scanners only) G0254
Myocardial imaging, positron emission tomography 10/1/02
(PET), metabolic evaluation) 78459
Restaging or previously treated thyroid cancer of 10/1/03
follicular cell origin following negative I-131
whole body scan (full- and partial-ring PET scanner only) G0296
Tracer Rubidium**82 (Supply of Radiopharmaceutical 10/1/03
Diagnostic Imaging Agent)
(This is only billed through Outpatient Perspective
Payment System, OPPS.) (A/B MACs (B) must use
HCPCS Code A4641). Q3000
***Supply of Radiopharmaceutical Diagnostic Imaging 01/1/04 A9526
Agent, Ammonia N-13***
Conditions Coverage Effective Date ****HCPCS/Procedure code
PET imaging, brain imaging for the differential 09/15/04
diagnosis of Alzheimer’s disease with aberrant
features vs. fronto-temporal dementia
