USPC - PET Scan

california_artist said:

That was such a huge site I typed in the section
Here's what that got me:
C. Regardless of any other terms or conditions, all uses of FDG PET scans, in order to be covered by the Medicare program, must meet the following general conditions prior to June 30, 2001:

•Submission of claims for payment must include any information Medicare requires to ensure the PET scans performed were: (a) medically necessary, (b) did not unnecessarily duplicate other covered diagnostic tests, and (c) did not involve investigational drugs or procedures using investigational drugs, as determined by the FDA.
•The PET scan entity submitting claims for payment must keep such patient records as Medicare requires on file for each patient for whom a PET scan claim is made.
Regardless of any other terms or conditions, all uses of FDG PET scans, in order to be covered by the Medicare program, must meet the following general conditions as of July 1, 2001:

•The provider of the PET scan should maintain on file the doctor's referral and documentation that the procedure involved only FDA-approved drugs and devices, as is normal business practice.
•The ordering physician is responsible for documenting the medical necessity of the study and ensuring that it meets the conditions specified in the instructions. The physician should have documentation in the beneficiary's medical record to support the referral to the PET scan provider.
III. Covered Indications for PET Scans and Limitations/Requirements for Usage

For all uses of PET relating to malignancies the following conditions apply:

A. Diagnosis: PET is covered only in clinical situations in which: (1) the PET results may assist in avoiding an invasive diagnostic procedure, or in which (2) the PET results may assist in determining the optimal anatomical location to perform an invasive diagnostic procedure. In general, for most solid tumors, a tissue diagnosis is made prior to the performance of PET scanning. PET scans following a tissue diagnosis are generally performed for staging rather than diagnosis.

PET is not covered as a screening test (i.e., testing patients without specific signs and symptoms of disease).

B. Staging: PET is covered for staging in clinical situations in which: (1)(a) the stage of the cancer remains in doubt after completion of a standard diagnostic workup, including conventional imaging (computed tomography (CT), magnetic resonance imaging (MRI), or ultrasound), or (1)(b) it could potentially replace one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical management of the patient, and 2) clinical management of the patient would differ depending on the stage of the cancer identified.

C. Restaging: PET is covered for restaging: (1) after completion of treatment for the purpose of detecting residual disease, (2) for detecting suspected recurrence or metastasis, (3) to determine the extent of a known recurrence, or (4) if it could potentially replace one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical management of the patient. Restaging applies to testing after a course of treatment is completed, and is covered subject to the conditions above.

D. Monitoring: This refers to use of PET to monitor tumor response to treatment during the planned course of therapy (i.e., when a change in therapy is anticipated ).

NOTE: In the absence of national frequency limitations, contractors, should, if necessary, develop frequency requirements on any or all of the indications covered on and after July 1, 2001.

(This NCD last reviewed December 2004.)


Cross Reference
See NCD for SPECT (§220.12).

Claims Processing Instructions

•TN 527 (Medicare Claims Processing Manual)
•TN 628 (Medicare Claims Processing Manual)
•TN 1817 (Medicare Claims Processing)
•TN 1833 (Medicare Claims Processing)


Seems you should be covered under B and C

nancygt said:

Medicare update 2009
More up to date data from medicare guidelines-while most cancers are covered for initial scan for staging, monitoring is only covered for designated cancers. You can see they are doing another study but at present, uterine is not included. You can find many earlier posts about how frustrating this is since USPC has statistics and treatment protocols much more suimilar to ovarian that uterine.

Subsequent Anti-tumor Treatment Strategy
As part of its April 3, 2009, NCD, the CMS reviewed evidence on the use of FDG PET in the subsequent treatment strategy for patients with tumor types other than those seven indications currently covered without exception (breast, colorectal, esophagus, head and neck (non-CNS/thyroid), lymphoma, melanoma, and non-small cell lung).
As a result, CMS determined that the available evidence is adequate to determine that FDG PET imaging also improves physician decision making in the determination of subsequent treatment strategy in Medicare beneficiaries who have ovarian cancer, cervical cancer, and myeloma, improves health outcomes, and is thus reasonable and necessary under §1862(a)(1)(A) of the Act.
Therefore, effective for claims with dates of service on and after April 3, 2009, for tumor types other than breast, colorectal, esophagus, head and neck (non-CNS/thyroid), lymphoma, melanoma, non-small cell lung, ovarian, cervical, and myeloma, CMS has determined that the available evidence is not adequate to determine that FDG PET imaging improves physician decision making in the determination of subsequent anti-tumor treatment strategy or improves health outcomes in Medicare beneficiaries and thus is not reasonable and necessary under §1862(a)(1)(A) of the Act.
However, CMS has determined that the available evidence is sufficient to determine that FDG PET imaging for subsequent anti-tumor treatment strategy for all other tumor types other than the 10 indications noted above may be nationally covered as research under §1862(a)(1)(E) of the Act through CED.
Therefore, CMS will nationally cover a subsequent FDG PET study for all other tumor types other than the 10 indications noted above, when the beneficiary’s treating physician determines that the FDG PET study is needed to inform the subsequent anti-tumor
treatment

daisy366 said:

question
Does this mean that if our doctor requests a PET they will approve it?