Outline
Insurance Issues Overview
General |
This manual is based primarily on Medicare PET coverage guidelines in effect as of 2002. Most insurance companies follow Medicare guidelines when determining their own coverage. Some insurance companies require PET scans to be preauthorized. P> Mississippi Valley PET Imaging Center will assist your office staff in determining the insurer's PET coverage policies and will work on behalf of the patient to obtain coverage. To assist us, we ask that you submit a copy of the patient's insurance card (front and back) at the time the order is placed. With this information we can immediately begin working to determine coverage. Remember: many insurance companies will expand coverage to otherwise non-covered diagnoses when the physician believes it is in the best interest of the patient to have the exam. Top of Page |
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Medicare |
No Pre-Authorization Required, but must meet diagnosis guidelines. Pre-payment Audits: Medicare may perform pre-payment audits
of claims for PET scans at a higher rate than most other claims. During
this, Mississippi Valley PET Imaging Center will call the referring
physician office and ask for appropriate documentation (written proof
of condition, stage, etc., prior to providing payment for services). |
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Blue Cross - Blue Shield (Wellmark) |
No Pre-Authorization Required, but must meet diagnosis guidelines generally similar to Medicare - see Appendix 1 Individual Consideration: |
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John Deere Health Plan |
Requires Pre-Authorization - see form in Appendix 2 Information required by John Deere during preauthorization:
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Specific Insurance Information by Disease Entity
General Medicare Requirements for Use of PET in Malignancies
| Brain for Dementia/Alzheimer's | Medicare does not cover as of May 2002 |
| Brain for Refractory Seizures | Covered for pre-surgical evaluation only |
| Breast Cancer |
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| Cardiac | Initial Study to determine Myocardial Viability |
| Cardiac | Myocardial Viability covered only following inconclusive SPECT |
| Colorectal Cancer | Determine location of tumors if rising CEA level suggests recurrence |
| Colorectal Cancer | Diagnosis, staging, and restaging |
| Esophageal Cancer | Diagnosis, staging, and restaging |
| Head and Neck Cancers Excluding CNS and Thyroid |
Diagnosis, staging, and restaging |
| Lung Cancer (Non-Small Cell) | Diagnosis, staging, and restaging |
| Lung Cancer (Solitary Pulmonary Nodules, SPNs) | Characterization |
| Lymphoma | Diagnosis, staging, and restaging |
| Melanoma | Evaluating recurrence prior to surgery as an alternative to Gallium scan |
| Melanoma | Diagnosis, staging, and restaging. Not covered for evaluating regional lymph nodes. |
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Specific Medicare Guidelines for Use of PET by Cancer/Disease Type
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| Brain Imaging | ||
| Refractory Seizures | Medicare covers FDG-PET only for the purpose or pre-operative localization of a focus of refractory seizure activity. | |
| Dementia / Alzheimer's | Medicare does NOT cover PET for Dementia or Alzheimer's disease. | |
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| Breast Cancer | Medicare covers FDG-PET in the staging and restaging of breast cancer. | |
| Medicare covers FDG-PET as an adjunct to standard imaging modalities for: | ||
| Staging: Medicare will cover PET for Breast Cancer patients with distand metastases. | ||
| Restaging: Medicare will cover PET for Breast Cancer patients with locoregional recurrence or metastasis. | ||
| Monitoring Tumor Response: Medicare will cover PET as an adjunct to standard imaging modalities for monitoring tumor response to treatment for women with locally advanced and metastatic breast cancer. | ||
Uses NOT approved:
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| Cardiac Imaging | Medicare covers FDG-PET as an initial study to determine myocardial viability and following an inconclusive spect study. | |
| Myocardial Viability Ref: #CAG-00098N - Coverage Decision February 20, 2002 Myocardial metabolic imaging is a tool used to optimize the selectino of patients for revascularization and potentially the reversal of left ventricular dysfunction with improved patient outcomes PET using 18F-fluorodeoxyglucose (FDG) as a tracer to study glucose metabolism in the heart and orther organs is advocatged by an increasing number of clinicians. FDG-PET imaging is used to measure myocardial cell metabolism. An area of ischemic viable myocardial wall will show a mismatch between blood flow and metabolism as measureed by the tracer. Regions showing deficits in both perfusion and FDG uptake can be considered dear regions (scar). Conversely, an area showing a defect in blood flow but with preserved FDG uptake is said to show a blood flow-metabolism mismatch and is considered still viable and a candidate for revascularization. |
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| Initial Study | Both SPECT or FDG-PET are reasonable and necessary as a primary or initial diagnostic study for determining myocardial viability prior to revascularization. | |
| Following Inconclusive SPECT | PET continues to be reasonable and necessary following inconclusive SPECT. | |
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| Colorectal Cancer | Medicare covers FDG-PET to diagnose, stage, and restage colorectal cancer. Additionally, FDG-PET is covered where there is a rising level of carcinoembryonic antigen (CEA). | |
| Medicare covers FDG-PET for colorectal carcinomas for diagnosis, staging, and restaging. New medical evicence supports the use of FDG-PET as a useful tool in determining the presence of hepatic/extrahepatic metastased in the primary staging of colorectal carcinoma prior to selecting a treatment regimen. Use of FDG-PET is also supported in evaluating recurrent colorectal cancer beyond the limited presentation of a rising CEA level where the patient presents clinical signs or symptoms of recurrence. | ||
| Diagnosis | PET is covered 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 th 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 colorectal cancdrs should be rare. | |
| Staging and/or Restaging | PET is covered in clinical situations in which: (a) the stage of teh cancer remains in doubt after completion of a standard diagnostic workup, including conventional imaging (computed tomography, magnetic resonance imaging, or ultrasound); -or- (b) the use of PET would also be considered reasonable and necessary if ti could potentially replace one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical manangement of the patient, -and- (c) 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 inusfficient for the clinical management of the patient. |
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| Rising CEA Levels | Medicare covers FDG-PET for patients with recurrent colorectal carcinomas, which are suggested by rising levels of the biochemical tumor marker CEA. | |
| Frequency Limitations | Whole body PET scans for assessment of recurrence of colorectal cancer cannot be ordered more frequently than once every 12 months unless medical necessity documentation supports a separate re-evaluation of CEA within this period. | |
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| Esophageal Cancer | Medicare covers FDG-PET to diagnose, stage, and restage esophageal cancer. Medical evidence is present to support the use of FDG-PET in pre-surgical staging of esophageal cancer. | |
| 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 esophageal cancers should be rare. |
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| Staging and/or Restaging | PET is covered in clinical situations in which: (a)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) -or- (b)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, -and- (c)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. |
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| Head and Neck Cancers | Medicare covers FDG-PET to diagnose, stage, and restage head and neck cancers. | |
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Cancers of the Central Nervous System (CNS) and thyroid are not covered. The head and neck cancers encompass a diverse set of malignancies of which the majority is squamous cell carcinoma. Patients may present with metastases to cervical lymph nodes but conventional forms of diagnostic imaging fail to identify the primary tumor. Patients that present with cancer of the head and neck are left with two options either to have a bilateral neck dissection and/or bilateral radiation with random biopsies. PET scanning attempts to reveal the site of primary tumor to prevent the adverse effects of random biopsies or unneeded radiation. |
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| 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. | |
| Staging and/or Restaging | PET is covered in clinical situations in which: (a)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) -or- (b)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, -and- (c)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. PET scans for head and neck cancers do NOT include covereage for CNS or thyroid cancers. |
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| Lung Cancer | Medicare covers FDG-PET to diagnose, stage, and restage non-small cell lung cancer | |
| Medicare covrs regional FDG-PET scans. The primary purpose of such characterization should be to determine the likelihood of malignancy in order to plan future management and treatment for the patient. | ||
| Requirements | There must be evidence of primary tumor. Claims
for regional PET chest scans to characterize SPNs should include evidence
of the initial detection of a primary lung tumor, usually by computed
tomography (CT). This should include, but is not restricted to, a report
on the results of such CT or other detection method, indicating an indeterminate
or possibly malignant lesion, not exceeding four centimeters (cm) in diameter. PET scan claims must include the results of concurrent thoracic CT (as noted above) , which is necessary for anatomic information, in order to ensure that the PET scan is properly coordinated with other diagnostic modalities. In cases of serial evaluation of SPNs using both CT and regional PET chest scanning, such PET scans will not be covered if repeated within 90 days following a negative PET scan. NOTE: A tissue sampling procedure (TSP) is not routinely covered in the case of a negative PET scan for characterization of SPNs, since the patient is presumed not to have a malignant lesion, based upon the PET scan results. When there has been a negative PET, the provider must submit additional information with the claim to support the necessity of a TSP, for review by the Medicare contractor. |
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| Diagnosis | PET is covered 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. |
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| Staging and/or Restaging | PET is covered in clinical situations in which
(a)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) -or- (b)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. -and- (c)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. |
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| Lymphoma | Medicare covers FDG-PET to diagnose, stage, and restage Lymphoma. | |
| 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 should be rare. | |
| Staging and/or Restaging | PET is covered in clinical situations in which: (a)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) -or- (b)(b)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, -and- (c)(c)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. |
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| Melanoma | Medicare covers FDG-PET to diagnose, stage, and restage Malignant Melanoma. | |
| 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 should be rare. | |
| Staging and/or Restaging | PET is covered in clinical situations in which: (a)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) -or- (b)(b)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, -and- (c)(c)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. |
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| Note: | PET scanning is NOT covered for the evaluation of regional lymph nodes. | |
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Wellmark BCBS of Iowa/South Dakota PET Policy as of April 2002
Section: Radiology
Policy#: Rad03
Reviewed: March 2002
| Description | Positrons are atomic particles released by radioactive materials. PET scanning differs from CT (computer tomography) or MR (magnetic resonance imaging), because PET gives information about the function of an area of the body, rather than just taking a picutre of it. |
When services are covered: Positron Emission Tomography is considered a covered benefit for the following conditions:
| Lung Cancer | ||
| Patients with a solitary pulmonary nodule. | ||
| Patients in whom chest x-ray and CT scans cannot distinguish between benign and malignant disease | ||
| Patients in whom test results will change management. | ||
| Initial staging of lung cancer. | ||
| Diagnosis, staging, and restaging of lung cancer of the Non-small Cell varities | ||
| Recurrent Colorectal Cancer | ||
| Determining location of colorectal cancer is rising CEA (carcinoembryonic antigen) level suggests recurrence. | ||
| As a technique to detect and assess resectability of hepatic or extrahepatic metastases of colorectal cancer | ||
| Diagnosis, staging, and restaging of colorectal cancer. | ||
| Lymphoma and Hodgkins Disease | ||
| Dignosis, staging, and restaging lymphoma only when used as an alternative to gallium scan or lymphangiogram | ||
| Melanoma | ||
| Identification of extra nodal metastases at initial staging or during follow-up after treatment for melanoma as an alternative to gallium scans. | ||
| Diagnosis, staging, and restaging of melanoma(Not covered for evaluating regional nodes | ||
| Pancreatic Cancer | ||
| When medically necessary to evaluate benign or malignant status of questionable pancreatic cancer not answered by other imaging techniques such as CT scan, ERCP, or ultrasonography | ||
| Complex Partial Seizures | ||
| Patient has failed medical treatment. | ||
| Presurgical evaluation of refractory seizures. | ||
| Heart Imaging | ||
| Diagnosed or suspected coronary artery disease. | ||
| Not a routine screening test. | ||
| Determination of myocardial viability only following an inconclusive SPECT (myocardial perfusion study) | ||
| Head and Neck | ||
| Diagnosis, staging, and restaging of head and neck cancers excluding CNS and thyroid cancers. | ||
| Esophageal Cancer | ||
| Diagnosis, staging, and restaging of cancer of the esophagus. | ||
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When services are NOT covered:PET is NOT a covered benefit for any condition other than those listed above, including, but not limited to the following conditions:
| Brain Imaging | ||
| Autoimmune disorders with CNS manifestations Cerebrovascular diseases Degenerative motor neuron diseases Dementias Demyelinating diseases Developmental, congenital, or inherited disorders Demyelinating disease such as mulitple sclerosis |
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| Cancers | ||
| Brain tumor diagnosis or grading Breast Colorectal cancer: PET scanning is considered investigational to asses the presence of scarring vs. local bowel recurrence in patients with previously resected colorectal cancer. Liver Melanoma: PET scanning is considered investigational at a technique to deteck regional lymph node metastases in patients with clinically localized malanome who are candidates to undergo sentinel lympyh node biopsy Ovarian Parathyroid Thyroid |
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| Nutritional or metabolic diseaes and disorderss | ||
| Psychiatric diseases and disorders | ||
| Pyogenic and viral infections | ||
| Substance abuse | ||
| Trauma | ||
| Migraines | ||
| Pulmonary Diseases | ||
| IF the service is excluded from the member benefit certificate or it is determined to be NOT MEDICALLY NECESSARY. | ||
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Individual Consideration: |
Medical policies are written based on the available medical scientific
literature. For some policies there may be unique circumstances which
require special consideration. In those circumstances providers may submit
relevant clinical information for payment consideration to: Medical Review Station 2 636 Grand Ave. DesMoines, IA 50309 |
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| Updated March 8, 2004 |