Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan provided on October 19, 2020.
You asked the Plan to pay for the PET with CT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services were billed with a non-covered diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the PET scan. Our reviewer says that the documentation does support that the PET scan provided was medically reasonable and necessary. Our physician reviewer found the enrollee has a history of colon cancer. FDG-PET (fluorodeoxyglucose-positron emission tomography) scanning has become more popular in the imaging of colorectal cancer and is used in pretreatment staging, posttreatment follow-up, and surveillance. It achieves similar sensitivity and specificity compared with contrast-enhanced CT scanning. For certain indications, such as monitoring response to therapy, assessing for recurrence in patients with elevated carcinoembryonic antigen (CEA), assessing for hepatic metastases post partial hepatectomy, and differentiating local recurrence versus scar, small studies have shown incremental benefit over conventional diagnostic imaging. For now, the lack of larger studies and the higher costs of FDG-PET scanning prohibit more widespread adoption. The most commonly used radiotracer is fluorodeoxyglucose (FDG), a glucose analog that is taken up and trapped in cells. To differentiate tumor from background, FDG positron emission tomography (PET) relies on the increased glucose metabolism of tumor cells and calculates a semiquantitative measure of glucose uptake, also known as standard uptake value (SUV). With the advent of simultaneous CT scanning, PET scanning also improves both spatial resolution and anatomic localization of findings. Therefore, the enrollee met criteria for the services rendered.
Review of the file shows that the Plan states that the NCD has a list of covered diagnosis codes and any code not listed is not covered. While the NCD does have a list of covered diagnosis code, the NCD does not state that any code not listed is not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PET scan have been met. Therefore, we decided that the Plan has to pay for the positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan provided on October 19, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.