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Medicare PET/CT Reimbursement for Oncology: What’s covered, what’s not

Posted By Digirad
August 16, 2018

PET/CT is a vital diagnostic imaging tool and is especially effective in revealing conditions such as cancer and brain disorders. When it comes to Medicare coverage, there are a number of misconceptions about PET/CT reimbursements.

In the majority of cases, PET/CT imaging is covered when clinically necessary, either as an initial treatment strategy or a subsequent treatment strategy.

Few exceptions apply to specific breast and cervical cancer, and melanoma diagnoses. The initial treatment of prostate cancer is the only non-covered event. Below is a consolidated reference chart that details PET/CT insurance reimbursement for specific conditions.

Tumor Type	Initial Treatment Strategy	Subsequent Treatment Strategy
Brain Cancer	✓	✓
Breast Cancer (female & male)	*CWE	✓
Cervical Cancer	*CWE	✓
Colorectal Cancer	✓	✓
Esophageal Cancer	✓	✓
Head & Neck Cancer (not thyroid or CNS)	✓	✓
Lymphoma	✓	✓
Melanoma	*CWE	✓
Myeloma	✓	✓
Non-Small Cell Lung Cancer	✓	✓
Pancreatic Cancer	✓	✓
Prostate Cancer	Non-covered	✓
Ovarian Cancer	✓	✓
Small Cell Lung Cancer	✓	✓
Soft Tissue Sarcoma	✓	✓
Testicular Cancer	✓	✓
Thyroid Cancer	✓	✓
All other solid tumors	✓	✓
All other cancers not listed	✓	✓

*CWE = Covered w/ exceptions

Cervical: Nationally non-covered for the 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 initial 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: Non-covered for initial staging of regional lymph nodes. All other indications for initial anti-tumor treatment strategy for melanoma are nationally covered.

Leukemia: Nationally covered under “all other cancers not listed.”

Prostate cancer (dx 185.0) 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 diagnosis codes.