Government Relations
GR News
November 12, 2009
CMS Posts Final Decision on FDG-PET for Cervical Cancer Staging Effective November 10th, 2009
On November 10, 2009, the Centers for Medicare and Medicaid Services (CMS) posted a final decision memorandum for FDG-PET for initial staging of cervical cancer. CMS has concluded that the evidence is adequate to determine that the results of FDG-PET imaging for initial staging of beneficiaries diagnosed with cervical cancer are used by the treating physician to make meaningful changes in therapeutic management and improve health outcomes, and thus are reasonable and necessary.
Therefore, CMS will cover only one FDG-PET for staging for beneficiaries who have biopsy proven cervical cancer when the beneficiary’s treating physician determines that the FDG-PET study is needed to determine the location and/or extent of the tumor for the following therapeutic purposes related to the initial treatment strategy:
- To determine whether or not the beneficiary is an appropriate candidate for an invasive diagnostic or therapeutic procedure; or
- To determine the optimal anatomic location for an invasive procedure; or
- To determine the anatomic extent of tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor.
CMS believes that there is no credible evidence that the results of FDG-PET imaging are useful to make the initial diagnosis of cervical cancer, and therefore do not improve health outcomes, and thus are not reasonable and necessary. Therefore CMS will noncover FDG-PET for this indication.
This decision is final, and effective November 10, 2009. It is the opinion of the Society of Nuclear Medicine that claims for initial staging of cervical cancer can be submitted without any need for administrative delay. Cervical cancer initial staging (PI modifier) was already covered, and only had to be done under NOPR if CT or MRI was not done first, or if done and showed evidence of extrapelvic metastatic disease. Hence, we believe that as of today, any claim submitted with CPT codes 78811-16, PI modifier, and ICD-9 code 180.0-180.9 should be paid. In the unlikely event that FDG-PET was performed for diagnosis of cervical cancer, for claims date of service (DOS) November 10, 2009 or after, the claim would have to be submitted with HCPCS code G0235 (and would not be paid for this now noncovered service).
