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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 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:
&#9642; Date of onset of symptoms;
&#9642; Diagnosis of clinical syndrome (normal aging; mild cognitive impairment (MCI); mild,
moderate or severe dementia);
&#9642; Mini mental status exam (MMSE) or similar test score;
&#9642; Presumptive cause (possible, probable, uncertain AD);
&#9642; Any neuropsychological testing performed;
&#9642; Results of any structural imaging (MRI or CT) performed;
&#9642; Relevant laboratory tests (B12, thyroid hormone); and,
&#9642; Number and name of prescribed medications.
You can find this rule in the 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.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.