PET scan orders: best practices for oncologic conditions

Avoid insurance claim denials on cancer PET scans

CMS guidelines for Medical Necessity coverage of PET scans (specifically around oncologic conditions), are complex. And because coders are not allowed to use a diagnosis other than the diagnosis listed on the order, at times these PET scans are denied by payors when they could have been paid as meeting Medical Necessity based on the patient’s complete clinical picture.

Please consider this advice:

• When ordering a PET scan for a history of cancer, Medical Necessity is not met unless a second diagnosis documenting an active cancer or abnormal radiological finding is also listed.
• When ordering a PET scan for an oncologic condition, be sure to reference any bone metastases or pathological fractures (and specify that they are pathological fractures due to neoplasms/in neoplastic disease) as secondary diagnoses as this may assist in meeting Medical Necessity.
• PET is nationally non-covered for initial staging of regional lymph nodes in patients with Melanoma.
• PET is nationally non-covered for initial diagnosis and/or staging of axillary lymph nodes in patients with breast cancer.
• PET is nationally non-covered for initial diagnosis of cervical cancer related to initial anti-tumor treatment strategy.
• “The use of PET in the diagnosis of lymphoma, esophageal and colorectal cancers, as well as in melanoma, should be rare. PET is not covered for other diagnostic uses, and is not covered for screening (testing of patients without specific signs and symptoms of disease).”*
• “Use of PET to monitor tumor response during the planned course of therapy (i.e., when no change in therapy is being contemplated) is not covered.”*

*From the Medicare Claims Processing Manual CH 13 —Radiology Services and Other Diagnostic Procedures

For further reference:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c13.pdf