PET Scan and PET CT Fusion: Medical Coverage
PET scan, or Positron Emission Tomography, is a powerful tool for detecting several types of cancer. It is useful for the accurate detection of cancer spread in patients with an established diagnosis of cancer, or for the noninvasive evaluation of nodules detected by chest x-ray or CT. PET works by having the ability to detect sites of high metabolic activity. Since many cancers have significantly higher metabolism than normal tissues or noncancerous masses, PET allows sensitive detection of even small cancers.
PET-CT Fusion is a newer refinement of the technique that allows the most accurate correlation of anatomic information (from the CT) and metabolic information (from the PET scan) and helps to ensure the highest degree of accuracy for the exam.
PET and PET-CT Fusion are performed by SDI radiologists at St. Joseph's Diagnostic Center (main campus).
Want to learn more about PET scans, Click here for more information about PET-CT
| Solitary Pulmonary Nodules (SPNs) |
January 1, 1998 |
Characterization |
Lung Cancer
(Non Small Cell) |
January 1, 1998 |
Initial staging |
Lung Cancer
(Non Small Cell) |
July 1, 2001 |
Diagnosis, staging and restaging |
| Esophageal Cancer |
July 1, 2001 |
Diagnosis, staging and restaging |
| Colorectal Cancer |
July 1, 1999 |
Determining location of tumors if rising CEA level suggests recurrence |
| Colorectal Cancer |
July 1, 2001 |
Diagnosis, staging and restaging |
| Lymphoma |
July 1, 1999 |
Staging and restaging only when used as an alternative to Gallium scan |
| Lymphoma |
July 1, 2001 |
Diagnosis, staging and restaging |
| Melanoma |
July 1, 1999 |
Evaluating recurrence prior to surgery as an alternative to a Gallium scan |
| Melanoma |
July 1, 2001 |
Diagnosis, staging and restaging; Non-covered for evaluating regional nodes |
| Breast Cancer |
October 1, 2002 |
As an adjunct to standard imaging modalities for staging patients with distant metastasis or restaging patients with locoregional recurrence or metastasis; as an adjunct to standard imaging modalities for monitoring tumor response to treatment for women with locally advanced and metastatic breast cancer when a change in therapy is anticipated. |
| Head and Neck Cancers (excluding CNS and thyroid) |
July 1, 2001 |
Diagnosis, staging and restaging |
| Thyroid Cancer |
October 1, 2003 |
Restaging of recurrent or residual thyroid cancers of follicular cell origin that have been previously treated by thyroidectomy and radioiodine ablation and have a serum thyroglobulin >10ng/ml and negative I-131 whole body scan performed |
| Myocardial Viability |
July 1, 2001 to
September 30, 2002 |
Covered only following inconclusive SPECT |
| Myocardial Viability |
October 1, 2001 |
Primary or initial diagnosis, or following an inconclusive SPECT prior to revascularization. SPECT may not be used following an inconclusive PET scan |
| Refractory Seizures |
July 1, 2001 |
Covered for pre-surgical evaluation only |
| Perfusion of the heart using Rubidium 82* tracer |
March 14, 1995 |
Covered for noninvasive imaging of the perfusion of the heart |
| Perfusion of the heart using ammonia N-13* tracer |
October 1, 2003 |
Covered for noninvasive imaging of the perfusion of the heart |
*Not FDG-PET. |
Medicare expands PET coverage for cervical cancer
1/31/2005
The U.S. Centers for Medicare and Medicaid Services (CMS) said it will extend Medicare coverage for the use of an FDG-PET scan for staging newly diagnosed cervical cancer subsequent to conventional imaging that is negative for extrapelvic metastasis.
In addition to issuing a national coverage determination (NCD) for cervical cancer staging, the agency held that PET scans for brain, pancreatic, small-cell lung cancer (SCLC), ovarian, and testicular cancers are only reasonable and necessary when the provider and patients are participating in one to two types of prospective clinical studies.
According to CMS, these are:
- "A clinical trial of FDG-PET that meets the requirements of Food and Drug Administration (FDA) category B investigational device exemption (42 CFR 405.201) or;"
- "An FDG-PET clinical study that is designed to collect additional information at the time of the scan to assist in patient management. Qualifying clinical studies must ensure that specific hypotheses are addressed; appropriate data elements are collected; hospitals and providers are qualified to provide the PET scan and interpret the results; participating hospitals and providers accurately report data on all enrolled patients not included in other qualifying trials through adequate auditing mechanisms; and all patient confidentiality, privacy, and other federal laws must be followed."
- This policy is in keeping with all other indications for which CMS currently has a noncoverage determination. The proposed new coverage policy is available for viewing on the agency's Web site.
PET and PET-CT Fusion are performed at St. Joseph's Diagnostic Center.
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