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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 Medicare covers FDG PET for only pre-surgical evaluation for the purpose of localization of a focus of refractory seizure activity. You can find these rules in the Medicare National Coverage Determinations Manual, Section 220.6.9. The rules state that the following are covered indications of FDG PET in the diagnosis or treatment of dementing neurodegenerative diseases:
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 1 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.
You can find these rules in the Medicare National Coverage Determinations Manual, Section 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.