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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 Caveats Regarding Use of Oncologic PET: 1. "Watchful waiting" does not constitute a "therapy." After an Initial Therapy Strategy PET, further PET restaging is not justified unless treatment has been given or unless a significant change in patient status suggests progression/transformation of disease. 2. Routine modalities (e.g., diagnostic CT, bone scintigraphy, MRI) should be employed before PET if the clinical decision to be made is likely to be answered by those modalities, such as: If there is specific clinical suspicion of involvement of an organ or region, documentation of a single site of involvement is necessary/sufficient for clinical decision making, and documentation of additional disease would not change patient management (imaging should be targeted to the area/organ of concern); If the major site of clinical concern is one that is typically poorly imaged by FDG-PET, such as: If the clinical concern is brain involvement (use MRI, or contrast-enhanced CT, if patient cannot undergo MRI); If the clinical concern is within the urinary tract consider CT, ultrasonography, or MRI. If the patient's tumor is known to be poorly FDG avid; If disease is reasonably assumed to be limited to an organ or system generally well imaged by other modalities (e.g., bone scintigraphy for disease limited to skeleton). 3. PET should be employed instead of or before conventional imaging if: Available data suggest that PET is likely to obviate additional advanced imaging tests or invasive procedures or is likely to be more accurate than other modalities in detection or characterization of lesions that would change patient management; Patient has contrast allergy or other contraindication to contrast administration that renders other modalities less effective; Patient is being monitored for known disease that either has been previously shown to be better characterized on PET than on other modalities or has been shown to be adequately FDG-avid for follow-up with PET and was not previously imaged with other modalities (e.g., bone metastases well visualized on previous PET and either not as well visualized on bone scintigraphy or bone scintigraphy not done). 4. Special care should be taken to avoid conditions that may promote false-positive or false-negative FDG PET studies. Although clinical circumstances sometimes warrant modification of these guidelines, if clinically feasible, routine follow-up PET imaging should be delayed: For at least three weeks after chemotherapy; For at least 8-12 weeks following radiation therapy, unless the clinical question involves a site outside the field of radiation; Until resolution or near-resolution of acute infectious or inflammatory processes that may mimic or mask active tumor; At least one week after short-acting marrow stimulants and three weeks after long-acting marrow stimulants. 5. Incidental findings are common on PET/CT studies, and further follow-up of such findings should be tempered by clinical circumstances and patient prognosis: Reasonable efforts should be made to obtain previous imaging studies to evaluate for chronicity of indeterminate findings before ordering follow-up imaging studies or interventions; Clinical impact should be assessed in the individual patient (e.g., a potentially malignant thyroid nodule may be of little overall significance in a patient with advanced metastatic disease). You can find this information in Medicare's Local Coverage Determination (LCD): Multiple Imaging in Oncology (L35391).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.