Appeal type: unknown
Decision: unknown

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 say that The Centers for Medicare and Medicaid Services (CMS) was asked by the National 
Oncologic PET Registry (NOPR) to reconsider section 220.6 of the National Coverage Determinations (NCD) 
Manual to end the prospective data collection requirements under Coverage with Evidence Development 
(CED) across all oncologic indications of FDG PET imaging. The CMS received public input indicating that 
the current coverage framework of prospective data collection under CED be ended for all oncologic uses of 
FDG PET imaging. 
 
1.      Framework 
 
Effective for claims with dates of service on and after June 11, 2013, CMS is adopting a coverage framework 
that ends the prospective data collection requirements by NOPR under CED for all oncologic uses of FDG PET 
imaging. CMS is making this change for all NCDs that address coverage of FDG PET for oncologic uses 
addressed in this decision. This decision does not change coverage for any use of PET imaging using 
radiopharmaceuticals NaF-18 (fluorine-18 labeled sodium fluoride), ammonia N-13, or rubidium-82 (Rb-82). 
 
CMS continues to believe that the evidence is adequate to determine that the results of FDG PET imaging are 
useful in determining the appropriate initial anti-tumor treatment strategy for beneficiaries with suspected 
cancer and improve health outcomes and thus are reasonable and necessary under 1862(a)(1)(A) of the Social 
Security Act (the Act). 
 
Therefore, CMS continues to nationally cover one 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. 
 
Indications and Limitations of Coverage 
 
    a. CMS continues to nationally cover FDG PET imaging for the initial anti-tumor treatment strategy for male 
and female breast cancer only when used in staging distant metastasis. 
    b. CMS continues to nationally cover FDG PET to determine initial anti-tumor treatment strategy for 
melanoma other than for the evaluation of regional lymph nodes. 
    c. CMS continues to nationally cover FDG PET imaging for the detection of pre-treatment metastasis (i.e., 
staging) in newly diagnosed cervical cancers following conventional imaging. 
 
C.1      Initial Anti-Tumor Treatment Strategy Nationally Non-Covered Indications 
 
    a. CMS continues to nationally non-cover initial anti-tumor treatment strategy in Medicare beneficiaries who 
have adenocarcinoma of the prostate. 
    b. CMS continues to nationally non-cover FDG PET imaging for diagnosis of breast cancer and initial 
staging of axillary nodes. 
    c. CMS continues to nationally non-cover FDG PET imaging for initial anti-tumor treatment strategy for the 
evaluation of regional lymph nodes in melanoma. 
  d. CMS continues to nationally non-cover FDG PET imaging for the diagnosis of cervical cancer related to 
initial anti-tumor treatment strategy. 
 
3.      Subsequent Anti-Tumor Treatment Strategy 
 
B.2.      Subsequent Anti-Tumor Treatment Strategy Nationally Covered Indications 
 
Three FDG PET scans are nationally covered when used to guide subsequent management of anti-tumor 
treatment strategy after completion of initial anti-cancer therapy. Coverage of more than three FDG PET scans 
to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy 
shall be determined by the local Medicare Administrative Contractors. 
 
4.      Synopsis of Coverage of FDG PET for Oncologic Conditions 
 
You can find this information in Medicare's National Coverage Determination (NCD) for Positron Emission 
Tomography (FDG) for Oncologic Conditions (220.6.17). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.