(Medicare Claims Processing Manual)

Contractors shall advise providers to use the appropriate CPT code from section 60.3.1 for covered breast cancer indications for services performed on or after January 28, 2005.  NOTE:  The NCD Manual contains a description of coverage.  FDG Positron Emission Tomography is a minimally invasive diagnostic procedure using positron camera [tomograph] to measure the decay of radioisotopes such as FDG.  The CMS determined that the benefit cate gory for the requested indications fell under 1861(s)(3)  of the Act diagnostic service.  60.9 - Coverage of PET Scans for Myocardial Viability  (Rev.10881; Issued: 08- 06-2021; Effective: 09- 07-2021; Implementation: 09- 07- 2021)     FDG PET is covered for the determination of myocardial viability following an inconclusive single photon computed tomography test (SPECT) from July 1, 2001, through September 30, 2002. Only full ring scanners are covered as the scanning medium for this service from July 1, 2001, through December 31, 2001. However, as of January 1, 2002, full and partial ring scanners are covered for myocardial viability following an inconclusive SPECT.  Beginning October 1, 2002, Medicare will cover FDG PET for the determination of myocardial viability as a primary or initial diagnostic study prior to revascularization, and will continue to cover FDG PET when used as a follow -up to an inconclusive SPECT. However, if a patient received a FDG PET study with inconclusive results, a follow -up SPECT is not covered. FDA full and partial ring PET scanners are covered. In the event that a patient receives a SPECT with inconclusive results, a PET scan may be perfor med and covered by Medicare. However, a SPECT is not covered following a FDG PET with inconclusive results. See the Medicare National Coverage Determinations Manual, Section 220.6 for specific frequency limitations for Myocardial Viability following an inconclusive SPECT.  Documentation that these conditions are met should be maintained by the referring provider as part of the beneficiarys medical record.    HCPCS Code for PET Scan for Myocardial Viability    78429- Myocardial imaging, positron emission tomography (PET), metabolic evaluation study, single study; with concurrently acquired computed tomography transmission scan  78432- Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study, dual radiotracer;   78433- Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study, dual radiotracer; with concurrently acquired computed tomography transmission scan   78459 -  Myocardial imaging, positron emission tomography (PET), metabolic evaluation   60.10 - Coverage of PET Scans for PET Scan for Thyroid Cancer  (Rev. 527, Issued: 04- 15-05, Effective: 01 -28-05, Implementation: 04- 18-05)  For services furnished on or after October 1, 2003, Medicare covers the use of FDG PET for thyroid cancer only for restaging of recurrent or residual thyroid cancers of folliculark cell origin that have previously been treated by thyroidectomy and radioiodine ablation and have a serum thyroglobulin > 10ng/ml and negative I -131 whole body scan.  Contractors shall advise providers to use the appropriate CPT code from section 60.3.1 for thyroid cancer for services performed on or after January 28, 2005.   60.11 - Coverage of PET Scans for Perfusion of the Heart Using Ammonia N- 13 (Rev. 223, Issued: 07- 02-04) (Effective/Implementation: Not Applicable)  Effective for service performed on or after October 1, 2003, PET scans performed at rest or with pharmacological stress used for noninvasive imaging of the perfusion of the heart for the diagnosis and management of patients with known or suspected coronary artery disease using the FDA -approved radiopharmaceutical ammonia N -13 are covered, provided the following requirements are met.  60.12 - Coverage for PET Scans for Dementia and Neurodegenerative Diseases  (Rev. 12364; Issued: 11- 16-23; Effective: 10 -13-23; Implementation:12- 19-23)  Effective for dates of service on or after September 15, 2004, Medicare will cover Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET)  scans for a differential diagnosis of fronto- temporal dementia (FTD) and Alzheimer's disease (AD) OR; its use in a CMS -approved practical clinical trial focused on the utility of FDG -PET in the diagnosis or treatment of dementing neurodegenerative diseases.  Refer to Pub. 100-03, National Coverage Determination (NCD)  Manual, section 220.6.13, for complete coverage conditions.   A.  NCD 220.6.13 -  A/B Medicare Administrative Contractors (MACs)  (A and B) Billing Requirements for PET Scan Claims for FDG -PET for the Differential Diagnosis of Fronto- temporal Dementia and Alzheimers Disease:   Current Procedural Terminology (CPT) Code for PET Scans for Dementia and Neurodegenerative Diseases   Contractors shall advise providers to use the appropriate CPT code from section 60.3.1 for dementia and neurodegenerative diseases for services performed on or after January 28, 2005.  Diagnosis Codes for PET Scans for Dementia and Neurodegenerative Diseases   The contractor shall ensure one of the following appropriate diagnosis codes is present on claims for PET Scans for AD:    ICD-10-CM is applicable, ICD -10 codes are:  F03.90, F03.90 plus F05, G30.9, G31.01, G31.9, R41.2 or R41.3  Medicare contractors shall deny claims when submitted with an appropriate CPT code from section 60.3.1 and with a diagnosis code other than the range of codes listed above.  Medicare contractors shall instruct providers to issue an Advanced Beneficiary Notice to beneficiaries advising them of potential financial liability prior to delivering the service if one of the appropriate diagnosis codes will not be present on the claim .  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This Claim Adjustment Reason Code (CARC)/Remittance Advice Remark Code (RARC)  combination is compliant with CAQH CORE Business Scenario Three.   -Group Code: PR (patient responsibility)  (if claim is received with a GA modifier) otherwise CO (contractual obligation)  -CARC: 11  -RARC: N/A  -Medicare Summary Notice (MSN):  16.48   Provider Documentation Required with the PET Scan Claim   Medicare contractors shall inform providers to ensure the conditions mentioned in the NCD Manual, section 220.6.13, have been met.  The information must also be maintained in the beneficiary's medical record:   - Date of onset of symptoms, - Diagnosis of clinical syndrome (normal aging, mild cognitive impairment or MCI: mild, moderate, or severe dementia),  - Mini mental status exam (MMSE) or similar test score,  - Presumptive cause (possible, probably, uncertain AD),  - Any neuropsychological testing performed,  - Results of any structural imaging (MRI, CT) performed, - Relevant laboratory tests (B12, thyroid hormone), and, - Number and name of prescribed medications.  B. NCD 220.6.20 -  Billing Requirements for Beta Amyloid Positron Emission Tomography (PET) in Dementia and Neurodegenerative Disease.   Effective October 13, 2023, as a result of the reconsideration of NCD 220.6.20, and under section 1862(a)(1)(A) of the Social Security Act, this NCD has been removed. Coverage determinations are now made by the MACs. See NCD 220.6.20 of the NCD Manual.  Effective for claims with dates of service on and after September 27, 2013, thru October 12, 2023, Medicare will only allow coverage with evidence development (CED) for PET beta amyloid (also referred to as amyloid -beta (A)) imaging (Healthcare Common Procedure Coding System (HCPCS)  A9586) or (HCPCS Q9982) or (HCPCS Q9983)  (one PET A scan per patient).  Effective for dates of service on or after September 27, 2013, thru October 12, 2023, contractors shall return as unprocessable/return to provider claims for PET A imaging, through CED during a clinical trial, not containing the following:    Condition code 30, and value code D4 (FI  only)   Modifier Q0 as  appropriate   ICD-10 dx code Z00.6 (in either the primary/secondary position)   A PET HCPCS code (78811 or 78814)   At least one diagnosis code from the table  below,   And one of these additional diagnoses is required in addition to Z00.6   F03.90  Unspecified dementia without behavioral disturbance  F03.91  Unspecified dementia with behavioral disturbance  F01.50  Vascular dementia without behavioral disturbance  F01.51  Vascular dementia with behavioral disturbance  F02.80  Dementia in other diseases classified elsewhere without behavioral disturbance  F02.81  Dementia in other diseases classified elsewhere with behavioral disturbance  G31.01  Pick's disease  G31.09  Other frontotemporal dementia  G31.85  Corticobasal degeneration  G31.83  Dementia with Lewy bodies  G31.84  Mild cognitive impairment, so stated  R41.1  Anterograde amnesia  R41.2  Retrograde amnesia  R41.3  Other amnesia (amnesia NOS, memory loss NOS)   and  A HCPCS code A9586 or Q9982 or Q9983.    MSN, RARC and CARC Codes   Contractors shall return as unprocessable claims for PET A imaging using the following messages:   -CARC  4  the procedure code is inconsistent with the modifier used or a required modifier is missing.   Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.  -RARC  N519 -  Invalid combination of HCPCS modifiers.   Contractors shall line -item deny claims for PET A, HCPCS code A9586 or Q9982 or Q9983, where a previous PET A, HCPCS code A9586 or Q9982 or Q9983 is paid in history using the following messages:   -CARC 149: Lifetime benefit maximum has been reached for this service/benefit  category.   -RARC N587: Policy benefits have been exhausted.   -MSN 20.12: This service was denied because Medicare only covers this service once a lifetime.   Spanish Version: Este servicio fue negado porque Medicare slo cubre este servicio una vez en la  vida.   -Group Code: PR, if a claim is received with a GA modifier   -Group Code: CO, if a claim is received with a GZ  modifier   60.13 - Billing Requirements for PET Scans for Specific Indications of Cervical Cancer for Services Performed on or After January 28, 2005  (Rev. 1888; Issued: 01- 06-10, Effective date:  11 -10-09; Implementation Date:  01 -04-10)  Contractors shall accept claims for these services with the appropriate CPT code listed in section 60.3.1.  Refer to Pub. 100- 03, section 220.6.17, for complete coverage guidelines for this new PET oncology indication.  The implementation date for these CPT codes will be April 18, 2005.  Also see section 60.17, of this chapter for further claims processing instructions for cervical cancer indications.   60.14 - Billing Requirements for PET Scans for Non -Covered Indications  (Rev. 527, Issued: 04- 15-05, Effective: 01 -28-05, Implementation: 04- 18-05)  For services performed on or after January 28, 2005, contractors shall accept claims with the following HCPCS code for non- covered PET indications:    -  G0235:  PET imaging, any site not otherwise specified  Short Descriptor:  PET not otherwise specified  Type of Service:  4  NOTE:   This code is for a non- covered service.