DATE
NAME
PRACTICE NAME
ADDRESS 1
ADDRESS 2
CITY/STATE/ZIP
Dear [NAME OF REFERRING PHYSICIAN],
The ____________ PET/CT imaging team is pleased to share with you recent changes and
expansion in 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) on subsequent PET scans
for oncologic purposes.
There were three specific elements of this decision:
1. CMS is ending 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 has 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) used to guide
subsequent management of anti-tumor treatment strategy after completion of initial anti-tumor
therapy 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 indications and reimbursement please see the
attached chart. To review clinical appropriateness for specific patients, or to schedule a PET/CT
exam, please call us at XXXXXXX. Monday through Friday, X: 00 a.m. to X: 00 p.m.
As always, we look forward to serving you and your patients at ___________________.
Sincerely,
Medical Director, PET/CT Services
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