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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: 
- 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). 
 
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.