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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 say that Item/Service Description

A. General

Medicare covers FDG Positron Emission Tomography (PET) scans for either the differential diagnosis of
frontotemporal dementia (FTD) and Alzheimer's disease (AD) under specific requirements; OR, its use in a
Centers for Medicare & Medicaid Services (CMS)-approved practical clinical trial focused on the utility of
FDG PET in the diagnosis or treatment of dementing neurodegenerative diseases. Specific requirements for
each indication are clarified below:

Indications and Limitations of Coverage

B. Nationally Covered Indications

1. FDG PET Requirements for Coverage in the Differential Diagnosis of AD and FTD

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 AD and 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:
Date of onset of symptoms;
Diagnosis of clinical syndrome (normal aging; mild cognitive impairment (MCI); mild, moderate or
severe dementia);
Mini mental status exam (MMSE) or similar test score;
Presumptive cause (possible, probable, uncertain AD);
Any neuropsychological testing performed;
Results of any structural imaging (MRI or CT) performed;
Relevant laboratory tests (B12, thyroid hormone); and,
Number and name of prescribed medications.

The billing provider must furnish a copy of the FDG PET scan result for use by CMS and its Medicare
Administrative Contractors upon request. These verification requirements are consistent with Federal
requirements set forth in 42 Code of Federal Regulations, section 410.32 generally for diagnostic x-ray tests,
diagnostic laboratory tests, and other tests. In summary, section 410.32 requires the billing physician and the
referring physician to maintain information in the medical record of each patient to demonstrate medical
necessity [410.32(d) (2)] and submit the information demonstrating medical necessity to CMS and/or its agents
upon request [410.32(d)(3)(I)] (OMB number 0938-0685).

2. FDG PET Requirements for Coverage in the Context of a CMS-approved Practical Clinical Trial Utilizing
a Specific Protocol to Demonstrate the Utility of FDG PET in the Diagnosis, and Treatment of
Neurodegenerative Dementing Diseases

An FDG PET scan is considered reasonable and necessary in patients with MCI or early dementia (in clinical
circumstances other than those specified in subparagraph 1) only in the context of an approved clinical trial that
contains patient safeguards and protections to ensure proper administration, use and evaluation of the FDG
PET scan.

The clinical trial must compare patients who do and do not receive an FDG PET scan and have as its goal to
monitor, evaluate, and improve clinical outcomes. In addition, it must meet the following basic criteria:
a. Written protocol on file;
b. Institutional Review Board review and approval;
c. Scientific review and approval by two or more qualified individuals who are not part of the research
team; and,
d. Certification that investigators have not been disqualified.

C. Nationally Non- Covered Indications

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 Creutzfeldt-Jakob
disease) for which CMS has not specifically indicated coverage continue to be noncovered.

You can find this information in Medicare's National Coverage Determination (NCD) for 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.