PET
Will My Insurance Cover a PET Scan?

Medicare Approved Indications for PET Effective October 1, 2002 — Medicare-Approved Indications for PET Appropriate Indications for PET — Not Covered by Medicare

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Medicare and insurance coverage for PET examinations are limited to specific clinical indications. TRA billing staff will work with your referring physician to complete the required pre-exam authorization process.

Please see Private Pay Policy

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Medicare Approved Indications for PET:

Single Pulmonary Nodule — for evaluation of a solitary pulmonary nodule (SPN)

• SPN must be less than or equal to 4 cm.
  
  
• If the nodule is indeterminate on CT and no previous films document stability over 2 or more years, PET recommended next.

Lung Cancer — Non-Small Cell — diagnosis, staging and re-staging of non-small cell lung cancer

• Requires histologic documentation of NSCLC.
  
  
• CT scan of the chest will also be required if not already done.
  
  
• PET not needed if distant metastases are already documented.

Esophageal Cancer — diagnosis, staging, re-staging

Colorectal Cancer — diagnosis, staging, re-staging

• Must have documented abnormally elevated or rising CEA level.
  
  
• Recommend to confirm recurrent colorectal cancer or to determine the extent of recurrent disease if this will impact therapeutic decisions.

Lymphoma (Lymphoma or Hodgkins Disease) — diagnosis, staging, re-staging

• Recommended baseline evaluation prior to or at initiation of therapy.
  
  
• Recommend for the re-staging after completion of treatment.
  
  
• Recommend for re-staging disease if relapse is suspected.

Melanoma— diagnosis, staging, re-staging; not covered for regional lymph node evaluation

• Recommended in any patient who is being considered for surgical treatment of melanoma.
  
  
• Recommended to evaluate for possible recurrence.
  
  
• Not used solely for evaluation of regional lymph nodes.

Head + Neck Cancers (excluding CNS and thyroid cancer) — diagnosis, staging, re-staging

Myocardial Viability

• Metabolic assessment for myocardial viability following inconclusive SPECT.

Refractory Seizures

• Metabolic brain imaging for pre-surgical evaluation refractory seizures.

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Effective October 1, 2002 — Medicare-Approved Indications for PET include:

Breast Cancer — While Medicare coverage of PET scans will include breast cancer, coverage will not include PET scans used to make an initial diagnosis of breast cancer. Medicare will cover PET scans used for breast cancer when:

• There is a need for more information about the cancer's location or size ("staging" or "re-staging").
  
  
• There is a need to distinguish scar tissue from potential malignancy (cancerous tissue).
  
  
• There is concern that the cancer may have spread ("metastasized").
  
  
• The physician wants to monitor the patient's response to treatment to see if the cancer is responding when a change in treatment is being considered.

For more information about PET and breast cancer see Kim's Story.   (PDF 258K)

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Appropriate Indications for PET — not covered by Medicare:

Thyroid Carcinoma

• Useful in select cases to identify extent of recurrent disease.

Carcinoma of the Cervix

• Recommended in patients being considered for open surgical treatment

Differentiation of Recurrent Brain Tumor form Radiation Necrosis

• Recommended in cases where distinguishing post-radiation necrosis from recurrent tumor of the brain is necessary

Alzheimer's Disease

• Useful in diagnosis or ruling out Alzheimer's disease in its early stages.

Seizures

• Helpful in confirming the location of seizure foci of the brain in surgical candidates.

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