CMS Releases Final PET NCD

April 6, 2009

CMS Releases Final PET NCD

CMS NCD

On Friday, April 3, 2009, the Centers for Medicare & Medicaid Services (CMS) released their final PET Coverage Decision. Importantly, CMS finalizes the two main components of the proposed decision. First, CMS has expanded coverage for the use of PET for the initial treatment strategy (formerly diagnosis and initial staging) evaluation of patients with cancer to nearly all cancer types and also to allow for PET in subsequent treatment strategy (formerly restaging, detection of suspected recurrence, and treatment monitoring) evaluations for an additional number of cancers. Second, CMS will continue to restrict subsequent treatment strategy evaluation for most cancers and finalized the proposed new framework of-initial treatment and subsequent treatment.

As CMS proposed in January, CMS finalized and will cover one FDG PET study for patients who have solid tumors that are biopsy proven or strongly suspected based on diagnostic testing when the patient’s physician determines FDG PET is essential for determining the location and/or extent of the tumor. This is an expansion of coverage for FDG PET scans for all cancer types, with a few exceptions, beyond those currently covered - breast, cervix, colorectal, esophageal, head and neck, lymphoma, melanoma, and non-small cell lung Furthermore, the final policy expands coverage by covering the subsequent treatment strategy, in addition to the initial diagnosis for all the nine currently covered cancers, as well as ovarian and myeloma. For all other cancers, PET coverage for subsequent treatment strategy evaluation requires participation in an approved Coverage with Evidence Development (CED) program, such as NOPR.

Read a detailed NOPR memo to providers

CMS also mentions in the final policy that there will be two new modifiers accompanying the revised coverage parameters. While information has not been published yet, the SNM will have further details on these modifiers well before the July 2009 implementation date.

Furthermore, the SNM will clarify new billing instructions for those cancers that are specifically non-covered for the initial treatment strategy evaluation. For the following cancer types/indications, there are specific codes for some. G0219 PET imaging whole body; melanoma for non-covered indications should be for assessing regional lymph nodes in melanoma. Submit G0235 PET imaging, any site, not otherwise specified for the diagnosis of prostate cancer and initial staging of newly diagnosed prostate cancer. Finally, G0252 PET imaging, full & partial-ring PET scanner only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes) should be coded when diagnosing and axillary nodal staging breast cancer.

The SNM will be hosting a 90 minute webinar titled: Changes to PET Coverage: Including a Review of the NOPR Sequel on April 27, 2009 to help providers understand the final PET NCD and new NOPR requirements.

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