[INSERT DATE]
[INSERT NAME]
[INSERT PRACTICE NAME]
[INSERT ADDRESS 1]
[INSERT ADDRESS 2]
[INSERT CITY/STATE/ZIP]
Dear [INSERT NAME OF REFERRING PHYSICIAN],
The [INSERT IMAGING CENTER NAME] PET/CT imaging team would like to clarify any
questions you may have regarding oncologic PET/CT coverage.
On June 11, 2013, the Centers for Medicare and Medicaid Services (CMS) issued a final decision
memorandum on Positron Emission Tomography (PET) for Solid Tumors.1 This decision
memorandum was in response to the request of the National Oncologic PET Registry (NOPR) to
lift the requirement for Coverage with Evidence Development (CED) for NOPR-covered FDG PET
indications on subsequent PET scans for oncologic purposes.
There were three specific elements of this decision:
1. CMS ended the requirement for CED for FDG PET for oncologic indications. This removes the
requirement for prospective data collection by the NOPR for those cancers or cancer types that
had been covered under CED.
2. CMS determined that three FDG PET scans are nationally covered when used to guide
subsequent management of anti-tumor treatment strategy after completion of initial anticancer
therapy. Coverage of any additional FDG PET scans (that is, beyond three) for subsequent
management will be determined by local Medicare Administrative Contractors.
3. CMS will nationally cover FDG PET when used to guide subsequent anti-tumor treatment
strategy of prostate cancer.
To find out more information regarding PET/CT coverage and reimbursement, please see the
attached chart.
In addition, we would like to clarify several points:

Effective for claims with dates of service on or after June 11, 2013, The National
Coverage Determination allows and considers “medically necessary and appropriate”
four (4) FDG PET scans per patient per unique diagnosis. This includes (1) initial
treatment strategy (ITS), formerly known as “diagnosis” and “staging” and three (3)
subsequent treatment strategy (STS), formerly “restaging” and “monitoring response to
treatment” for the same cancer diagnosis. Coverage for additional ITS and/or STS exams
is determined and controlled by the regional Medical Administrative Contractors (MAC).

The MACs are NOT limiting reimbursement to three (3) STS scans, but are requiring
documentation of medical necessity for STS PET scans beyond (3). Cases of payment
beyond (3) STS PET have been documented by customers.

Modifiers “PI” for ITS and “PS” for STS remain and a “KX” modifier should be used on
STS scans beyond 3. (Please note: these modifiers are current as of the date of this
letter. However, modifiers may change. You should always verify with your local MAC.)

The only exception to the above frequency is with dx 185.0, prostate cancer, which is not
covered for initial treatment strategy. Therefore, all PI modifiers for 185.0 would be
denied and PS modifiers would follow the same frequency as other cancer dx codes.

Scans performed prior to 6/11/13 do NOT count in the CMS limit.

Ensure PET scan requests contain sufficient clinical history from the patient charts to document
medical necessity.
A few additional points:

18F

None of these restrictions apply to non-Medicare or commercially insured patients.
NaF (Sodium Fluoride) PET Bone Scans continue to accrue under CED via NOPR and other
clinical trials.
To review clinical appropriateness for specific patients, or to schedule a PET/CT exam, please
call us at [INSERT PHONE NUMBER]. Monday through Friday, X: 00 a.m. to X: 00 p.m.
As always, we look forward to serving you and your patients at [INSERT IMAGING CENTER
NAME].
Sincerely,
[INSERT NAME AND TITLE]
The following table is taken from Appendix C of the National Coverage Determination2 for FDG
PET for oncologic conditions effective June 11, 2013
Tumor Type
Colorectal
Esophagus
Head and Neck (not thyroid
or CNS)
Lymphoma
Non-small cell lung
Ovary
Brain
Cervix
Small cell lung
Soft tissue sarcoma
Pancreas
Testes
Prostate
Thyroid
Breast (male and female)
Melanoma
All other solid tumors
Myeloma
All other cancers not listed
Covered
Covered
Subsequent Treatment
Strategy
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered with exceptions*
Covered
Covered
Covered
Covered
Non-covered
Covered
Covered with exceptions*
Covered with exceptions*
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Initial Treatment Strategy
Initial Treatment Strategy (ITS) was formerly diagnosis and initial staging. One PET scan is nationally
covered by Medicare with additional scans covered at the discretion of each local Medicare Administrative
Contractor.
Subsequent Treatment Strategy (STS) was formerly treatment monitoring, restaging and detection of
suspected recurrence. Three PET scans are covered by Medicare with additional scans covered at the
discretion of each local Medicare Administrative Contractor.
*Cervix: Nationally non-covered for the initial diagnosis of cervical cancer related to initial anti-tumor
treatment strategy. All other indications for initial anti-tumor treatment strategy for cervical cancer are
nationally covered.
*Breast: Nationally non-covered for initial diagnosis and/or staging of axillary lymph nodes. Nationally
covered for initial staging of metastatic disease. All other indications for initial anti-tumor treatment strategy
for breast cancer are nationally covered.
*Melanoma: Nationally non-covered for initial staging of regional lymph nodes. All other indications for initial
anti-tumor treatment strategy for melanoma are nationally covered.
Reference:
1. Final Decision Memorandum on Positron Emission Tomography (PET) for Solid Tumors (CAG-00191R4)
http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=263
2. Final Decision Memorandum on Positron Emission Tomography (PET) for Solid Tumors (CAG-00191R4).
Appendix C. http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=263