Reimbursement

What are the requirements?

All Oncology Studies

For all uses of PET/CT, excluding Rubidium 82 for perfusion of the heart, myocardial viability and refractory seizures, the following definitions apply:

Diagnosis: PET/CT is covered only in clinical situations in which the PET/CT results may assist in avoiding an invasive diagnostic procedure, or in which the PET/CT 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/CT scanning. PET/CT scans following a tissue diagnosis are generally performed for the purpose of staging, rather than diagnosis. Therefore, the use of PET/CT in the diagnosis of lymphoma, esophageal and colorectal cancers, as well as in melanoma, should be rare. PET/CT is not covered for screening (testing of patients without specific signs and symptoms of disease).

Staging: PET/CT is covered in clinical situations in which:
1a. The stage of the cancer remains in doubt after completion of a standard diagnostic workup, including conventional imaging (computed tomography, magnetic resonance imaging, or ultrasound) or Myocardial Perfusion Rest and stress imaging
1b. The use of PET/CT would also be considered reasonable and necessary 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 and,
2. Clinical management of the patient would differ depending on the stage of the cancer identified.

Restaging: PET/CT will be covered for restaging:
1. After the 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 conventionalm imaging studies when it is expected that conventional study information is to determine the extent of a known reccurence, or if the study information is insuffi cient 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.

Monitoring: Use of PET/CT to monitor tumor response to treatment during the planned course of therapy (i.e., when a change in therapy is anticipated).

Covered Indications: Cardiology

Myocardial Viability
Initial diagnosis or following
inconclusive SPECT

Myocardial Perfusion
Rest and stress imaging
Refractory Seizures
Pre-surgical evaluation

Covered Indications: Neurology

Alzheimer’s Disease & FTD
Differential diagnosis

Refractory Seizures
Pre-surgical evaluation