About this policy
CMS NCA document | source_status=Closed | review_type=3rd Recon | public_comment_open=False | document_id=CAG-00181R3
Coverage indications
The Centers for Medicare and Medicaid Services (CMS) was asked to reconsider the April 3, 2009 NCD provision at Section 220.6.17 of the National Coverage Determinations (NCD) Manual, described below, that established an absolute frequency limitation of only one FDG PET study for the noted purposes. "CMS will cover only one FDG PET study for beneficiaries who have solid tumors that are biopsy proven or strongly suspected based on other diagnostic testing 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." After careful review, CMS believes that the current absolute restriction is not supported by the available evidence and therefore will amend 220.6.17 of the National Coverage Determinations Manual: the NCD will be changed to remove the current absolute restriction of coverage to ‘only one’ FDG PET scan to determine the location and/or extent of the tumor for the therapeutic purposes related to the initial treatment strategy as described above CMS will continue to nationally cover one FDG PET scan to determine the location and/or extent of the tumor for the therapeutic purposes related to the initial treatment strategy as described above; and local Medicare administrative contractors will have discretion to cover (or not cover) within their jurisdictions any additional FDG PET scan for the therapeutic purposes related to the initial treatment strategy as described above. For any individual beneficiary the usefulness of any additional FDG PET scan for initial treatment planning might be affected by the beneficiary’s specific medical problem, the availability of results of other diagnostic tests and the expertise of the interpreting physician. We believe in such situations that our local administrative contractors, who may more readily obtain this information, can make these determinations about any additional FDG PET scan for initial treatment planning within their jurisdictions. We do not believe that a national coverage determination is the most appropriate way to address coverage for any additional FDG PET scans for the therapeutic purposes related to the initial treatment strategy at this time.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
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