Medicare Reimbursements
PET Imaging Procedures
(as of 10/01/2002)
G0125 Lung image (PET)
G0210 Dx lung ca
G0211 Initial lung
G0212 Restaging lung
G0213 Dx colorectal
G0214 Initial colorectal
G0215 Restaging colorectal
G0216 Dx melanoma
G0217 Initial melanoma
G0218 Restaging melanoma
G0220 Dx lymphoma
G0221 Initial lymphoma
G0222 Restaging lymphoma
G0223 Regional dx head
G0224 Regional initial head
G0225 Restaging head neck only
G0226 Dx esophageal
G0227 Initial esophageal
G0228 Restaging esophageal
G0229 Metabolic brain presurgical*
G0230 Myocardial viability post SPECT*
*regional procedure
78459 Metabolic heart presurgical
G0253 Staging / Restaging breast
G0254 Evaluate treatment response for breast
Medicare Frequency Limitations:
Lung SPN's: 90 days after negative PET
Esophageal: no frequency limitations noted
Colorectal: every 12 months, more frequently with
proper documentation (rising CEA)
Lymphoma: every 50 days
Melanoma: every 12 months
Head & Neck: no frequency limitations noted
Private Insurance Coverage:
There is no "standard" coverage by private insurance carriers,
and many have expanded coverage beyond CMS indications.
Private insurance coverage is on an case-by-case basis, with
almost all indications covered, with the exception of
“screening" PET scans.
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ICD-9 Codes That Support
Medical Necessity for Medicare
(as of 10/01/2002)
G0125, G0210, G0211, G0212: Lung Cancer
Malignant neoplasm of
162.2-162.9 Trachea, bronchus, and lung
793.1 Nonspecific abnormal findings on Radiologic and
other examination of lung field
G0213, G0214, G0215: Colorectal Cancer
Malignant neoplasm of
153.0-153.9 Colon
154.0-154.1 Rectosigmoid junction & rectum
G0216, G0217, G0218: Melanoma
172.0-172.9 Malignant melanoma of skin
G0220, G0221, G0222: Lymphoma
200.00-200.08 Reticulosarcoma
200.10-200.18 Lymphosarcoma
200.20-200.28 Burkitt's tumor or lymphoma
201.00-201.98 Hodgkin's disease
202.00-202.98 Other malignant neoplasms of lymphoid
& histiocytic tissue
G0223, G0224, G0225: Head & Neck Cancer
Malignant neoplasm of
140.0-140.9 Lip
141.0-141.9 Tongue
142.0-142.9 Major salivary glands
143.0-143.9 Gum
144.0-144.9 Floor of mouth
145.0-145.9 Other & unspecified parts of mouth
146.0-146.9 Oropharynx
147.0-147.9 Nasopharynx
148.0-148.9 Hypopharynx
149.0-149.9 Other and ill-defined sites within the lip,
oral cavity, and pharynx
195.0 Head, face, and neck
G0226, G0227, G0228: Esophageal Cancer
Malignant neoplasm of
150.0-150.9 Esophagus
G0229: Brain Presurgical
345.01 Generalized nonconvulsive epilepsy w/o mention of
intractable epilepsy
345.11 Generalized convulsive epilepsy w/o mention of
intractable epilepsy
G0253, G0254: Breast Cancer
174.0-174.9 Malignant neoplasm of female breast
175.0-175.9 Malignant neoplasm of male breast
Definition of Terms
- “Diagnosis” scans are done prior to tissue
confirmation of malignancy.
- "Initial Staging" is defined as PET scans that are
done after a tissue diagnosis of malignancy
and before initial treatment.
- "Restaging" is defined as a PET scan 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. Restaging
occurs only after a treatment course is
finished.
- PET is NOT covered for "monitoring tumor
response defined as a PET scan during the
course of therapy."
- PET is not covered for screening (testing of
patients without specific symptoms).
General Information
PET scans performed on patients who have recently undergone chemotherapy and/or radiation therapy is not recommended. However, special consideration will be given to therapy patients on a case-by-case basis.
PET scans are not available on an emergency basis, and a twenty-four (24) hour notice is necessary for delivery of isotopes.
Special considerations for diabetic patients:
&Mac183; Fasting blood sugar less than 200
&Mac183; First patient scheduled in the morning
&Mac183; Cardiac scans cannot be performed on diabetic patients
Frequency limitations will be set by local carriers in the absence of national guidelines.
Medicare Coverage Criteria
After 10/01/2002
Characterization of Solitary Pulmonary Nodules (SPN):
- SPNs must be no greater than 4cm in diameter
- Radiologic reports must show as indeterminate
or possibly malignant
- Tissue Sampling Procedure not routinely covered with
negative PET scans for SPN
- Has not had a PET scan within 90 days
Diagnosis, staging and restaging of lung cancer:
- Must maintain evidence of primary tumor
- Concurrent CT scan reports
- Diagnosis scans (before tissue confirmation) only covered when
PET may help avoid another procedure or determine optimal
location for biopsy
- Staging/restaging scans are covered only when:
&Mac183; Stage in doubt after standard work-up or if PET replaces test
in standard work-up; and
&Mac183; Clinical management of the patient would differ depending on
stage by PET
- Restaging scans will be covered for detecting residual disease,
suspected recurrence or determine extent of a known recurrence.
Diagnosis, staging and restaging of esophageal cancer and colorectal cancer, lymphoma, melanoma, and head/neck cancers:
- Diagnosis scans (before tissue confirmation) only covered when
PET may avoid another procedure or optimal localization a biopsy
- Staging/restaging scans are covered only when:
&Mac183; Stage in doubt after standard work-up or if it replaces test in standard work-up; or
&Mac183; Clinical management of t-e patient would differ depending on stage by PET
- Restaging scans will be covered for detecting residual disease,
suspected recurrence or determine extend of a known recurrence
FDG PET on patient with lymphoma:
- Policy appears as if the PET will be allowed every 50 days
FDG PET on patients with melanoma:
- PET scans will not be covered for t-e evaluation of regional nodes
FDG PET on patients with head and neck cancer:
- Excludes patients with thyroid cancer and Central Nervous System
(CNS) cancers
FDG limited coverage in refractory seizures:
- Pre-surgical evaluation to localize a focus of a seizure activity
FDG coverage for myocardial viability
- Following an inconclusive SPECT scan (G0230)
- For determination of myocardial viability as a primary or initial
diagnostic study prior to revascularization.
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