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Reminder for Avoiding Claim Denials for Positron Emission Tomography Scans
Background
It has been noted that a high volume of PET scan claims falling between the CPT code range 78811–78816 are being denied upon original claim submission due to a nonspecific diagnosis code for cancer being used.
It’s imperative that providers are coding the diagnosis to the highest level of specificity known. By coding the beneficiaries’ specific cancer diagnosis, claims will likely not be denied for this reason and subsequently not have to go through the appeals process.
CMS continues to nationally cover one Fluorodeoxyglucose (18F) (FDG) PET study for beneficiaries who have cancers that are biopsy proven or strongly suspected based on other diagnostic testing when the beneficiary’s treating physician determines that the FDG PET study is needed to determine the location and/or extent of the tumor for the following therapeutic purposes related to the initial anti-tumor treatment strategy:
- to determine whether or not the beneficiary is an appropriate candidate for an invasive diagnostic or therapeutic procedure; or
- to determine the optimal anatomic location for an invasive procedure; or
- to determine the anatomic extent of tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor.
Effective for claims with dates of service on and after 6/11/2013, the chart below summarizes national FDG PET coverage for oncologic conditions:
| FDG PET for Cancers Tumor Type |
Initial Treatment Strategy (formerly “diagnosis” and “staging") |
Subsequent Treatment Strategy (formerly “restaging” and “monitoring response to treatment” |
|---|---|---|
| Colorectal | Cover | Cover |
| Esophagus | Cover | Cover |
| Head and Neck (not thyroid, CNS) | Cover | Cover |
| Lymphoma | Cover | Cover |
| Non-small cell lung | Cover | Cover |
| Ovary | Cover | Cover |
| Brain | Cover | Cover |
| Cervix | Cover with exceptions * | Cover |
| Small cell lung | Cover | Cover |
| Soft tissue sarcoma | Cover | Cover |
| Pancreas | Cover | Cover |
| Testes | Cover | Cover |
| Prostate | Noncovered | Cover |
| Thyroid | Cover | Cover |
| Breast (male and female) | Cover with exceptions * | Cover |
| Melanoma | Cover with exceptions * | Cover |
| All other solid tumors | Cover | Cover |
| Myeloma | Cover | Cover |
| All other cancers not listed | Cover | Cover |
*Cervix: Nationally noncovered for the initial 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 noncovered for initial diagnosis and/or 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: Nationally noncovered for initial staging of regional lymph nodes. All other indications for initial anti-tumor treatment strategy for melanoma are nationally covered.
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Revised 8/28/2024