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Home » Nuclear Medicine/PET » PET Reimbursement Guide
PET Reimbursement Guide
In addition to private insurance reimbursing for most cancer indications, the table below summarizes the present Medicare coverage:

 

ONCOLOGY INDICATIONS
CPT CODES
 
Diagnosis, Staging, Restaging   Diagnosis:
Colorectal Cancer 78812

- PET result may assist in avoiding an invasive diagnostic procedure or

    -PET results may assist in determining the optimal anatomical location to perform an invasive diagnostic procedure
    Staging:
Esophageal Cancer 78812 -The stage of the cancer is in doubt after the completion of a standard diagnostic workup including conventional imaging or
    -PET 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
Head and Neck Cancer
(Excludes CNS and thyroid cancers)

 

78812 -The clinical management of the patient will differ depending on the stage of the cancer identified
    Restaging:
Lymphoma 78812 -After completion of treatment for the purpose of detecting residual disease or
    -For detecting suspected recurrence or metastasis or
    -To determine the extent of known recurrence or
Melanoma (Not covered for the evaluation of regional nodes) 78813 -PET 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
     
Staging, Restaging, Monitoring   -Staging patients with distant metastasis or restaging patients with locoregional recurrence or metastasis as an adjunct to other imaging modalities
Breast Cancer 78812 -Monitoring tumor response to treatment for locally advanced and metastatic breast cancer when a change in therapy is anticipated as an adjunct to other imaging modalities
    --Limitation: Diagnosis of breast cancer and initial staging of axillary lymph nodes not covered by Medicare
     
Restaging    
Thyroid Cancer 78812 -Restaging of recurrent or residual thyroid cancers of follicular cell origin that have been previously treated by thyroidectomy and radioiodine ablation and have serum thyroglobulin >10ng/ ml and a negative I-131 whole body scan
     
Staging    
Cervical Cancer 78812 -The detection of metastasis during the pre-treatment management phase (i.e. staging) in patients with newly diagnosed and locally advanced cervical cancer with no extra-pelvic matastsis on conventional imaging (CT, MRI)
     
Characterization   -Evidence of the initial detection of a primary lung tumor by CT
Single Pulmonary Nodules (SPNs) 78812 -CT results indicate an ideterminate or possibly malignant lesion not exceeding 4cm in diameter
    -Frequency Limitation: Serial evaluation of SPN's with PET not covered if repeated within 90 days following a negative PET scan
NEUROLOGY INDICATIONS
CPT CODES
 
Refractory Seizures 78608 -Pre-surgical evaluation for the purpose of localization of a focus of refractory seizure activity
     
Alzheimer's Disease 78608 -Differential diagnosis of fronto-temporal dimentia (FTD) and Alzheimer's diease (AD) under specific requirements (please refer to separate coverage criteria guide for AD)
     
Brain Imaging, PET, Metabolic Evaluation 78608  

Medicare is considering expanding coverage to include certain indications for the following cancers:
  • Brain
  • Testicular
  • Small Cell Lung
  • Cervical
  • Pancreatis