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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that an FDG PET scan is considered reasonable and necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both Alzheimer's disease (AD) and Frontotemporal dementia (FTD). These patients have been evaluated for specific alternate neurodegenerative diseases or other causative factors, but the cause of the clinical symptoms remains uncertain.
The following additional conditions must be met before an FDG PET scan will be covered:
a. The patient's onset, clinical presentation, or course of cognitive impairment is such that FTD is suspected as an alternative neurodegenerative cause of the cognitive decline. Specifically, symptoms such as social disinhibition, awkwardness, difficulties with language, or loss of executive function are more prominent early in the course of FTD than the memory loss typical of AD;
b. The patient has had a comprehensive clinical evaluation (as defined by the American Academy of Neurology encompassing a medical history from the patient and a well-acquainted informant (including assessment of activities of daily living), physical and mental status examination (including formal documentation of cognitive decline occurring over at least 6 months) aided by cognitive scales or neuropsychological testing, laboratory tests, and structural imaging such as magnetic resonance imaging (MRI) or computed tomography (CT);
c. The evaluation of the patient has been conducted by a physician experienced in the diagnosis and assessment of dementia;
d. The evaluation of the patient did not clearly determine a specific neurodegenerative disease or other cause for the clinical symptoms, and information available through FDG PET is reasonably expected to help clarify the diagnosis between FTD and AD and help guide future treatment;
e. The FDG PET scan is performed in a facility that has all the accreditation necessary to operate nuclear medicine equipment. The reading of the scan should be done by an expert in nuclear medicine, radiology, neurology, or psychiatry, with experience interpreting such scans in the presence of dementia;
f. A brain single photon emission computed tomography (SPECT) or FDG PET scan has not been obtained for the same indication. (The indication can be considered to be different in patients who exhibit important changes in scope or severity of cognitive decline, and meet all other qualifying criteria listed above and below (including the judgment that the likely diagnosis remains uncertain.) The results of a prior SPECT or FDG PET scan must have been inconclusive or, in the case of SPECT,
difficult to interpret due to immature or inadequate technology. In these instances, an FDG PET scan may be covered after one year has passed from the time the first SPECT or FDG PET scan was performed.)
g. The referring and billing provider(s) have documented the appropriate evaluation of the Medicare beneficiary. Providers should establish the medical necessity of an FDG PET scan by ensuring that the following information has been collected and is maintained in the beneficiary medical record:
o Date of onset of symptoms;
o Diagnosis of clinical syndrome (normal aging; mild cognitive impairment (MCI); mild, moderate or severe dementia);
o Mini mental status exam (MMSE) or similar test score;
o Presumptive cause (possible, probable, uncertain AD);
o Any neuropsychological testing performed;
o Results of any structural imaging (MRI or CT) performed;
o Relevant laboratory tests (B12, thyroid hormone); and,
o Number and name of prescribed medications.
All other uses of FDG PET for patients with a presumptive diagnosis of dementia-causing neurodegenerative disease (e.g., possible or probable AD, clinically typical FTD, dementia of Lewy bodies, or Creutzfeld-Jacob disease) for which CMS has not specifically indicated coverage continue to be noncovered. You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, FDG PET for Dementia and Neurodegenerative Diseases (220.6.13).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.