Most insurance companies pay for clinically indicated PET and PET/CT procedures. To be clinically indicated, the procedure must be potentially beneficial in providing information supportive of a diagnosis or monitoring certain conditions.
Generally, most private insurance companies cover the same indications as Medicare, although some may cover more indications and some may cover fewer indications. Private payers can have wide variations in coverage policies, coverage criteria or procedures. The referring physician and the imaging center work together to verify specific local coverage guidelines and to obtain pre-authorization prior to performing the scan.
Patients are responsible for deductibles, co-payments and remaining balances. Payment is expected when services are rendered and all patients are responsible to supply an insurance card and a referral from their primary care physician (if needed).
Click here to view a list of clinical indications that have historically been covered by some private payers.
If private insurance does not cover the PET or PET/CT scan, and Medicare is not an option, the patient may CHOOSE to self-fund the procedure. Please call us for information about payment arrangements.
Please contact our office with questions regarding insurance and coverage for PET scans.
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The Centers for Medicare and Medicaid Services (CMS) coverage policies for PET and PET/CT indications are decided at a national level and are documented in a National Coverage Determination (NCD), section 220.6 Medicare Covered Indications.
In April 2009, CMS announced a new coverage policy for oncologic PET scans. Under this new policy, CMS expanded coverage for the use of PET for initial treatment strategy evaluation (formerly diagnosis and initial staging) of patients with nearly all cancer types, and allowed the use of PET for subsequent treatment strategy evaluations (formerly restaging, detection of suspected recurrence and treatment monitoring) for an expanded number of cancer types.
Click here to view CMS Decision Memo for Solid Tumors (CAG-00181R)
Click here to view a brief recap and table of Medicare coverage for oncologic uses of FDG PET, effective November, 2009.
Click here to view a Billing and Reimbursement Quick Reference Guide
For general Medicare information, Medicare enrollees can access all aspects of the Medicare program at http://www.medicare.gov/ or by calling Medicare at 800-633-4227.
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National Oncologic PET Registry (NOPR)
The National Oncologic PET Registry (NOPR) was developed in response to the Centers for Medicare and Medicaid Services (CMS) proposal to expand coverage for FDG PET to include cancers and indications not presently eligible for Medicare reimbursement. Medicare reimbursement for these cancers is available if the patient's referring physician and the imaging provider submit data to a clinical registry to assess the impact of PET on cancer patient management. The NOPR implements this registry for CMS.
The NOPR is sponsored by the Academy of Molecular Imaging (AMI) and is managed by the American College of Radiology (ACR) through the American College of Radiology Imaging Network (ACRIN).
The NOPR is endorsed by the American College of Radiology (ACR), the American Society for Clinical Oncology (ASCO), and the Society for Nuclear Medicine (SNM).
Learn more about the National Oncologic PET Registry (NOPR) by visiting the web site: www.cancerpetregistry.org.
Click here to view a chart of cancers and indications eligible for entry into the NOPR
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This information provided by PETNET Solutions is based on published guidelines and on our experience. It is provided for general information only, as a service and at no charge to our customers. It is based on information found in published CMS National Coverage documents, but is not all-inclusive. We believe that the information set forth herein is generally accurate; however, we cannot provide assurance that it is complete, accurate or current. Always check with your local insurance carriers, as coverage may vary by region. The referring physician is responsible for pre-authorization and providing proof of medical necessity for any PET scan. PETNET Solutions and its representatives hereby expressly disclaim any and all liability for claims, including bodily injury or death, arising from any reliance on the information set forth herein.