The U.S. Centers for Medicare and Medicaid Services (CMS) has released instructions regarding the processing of claims for certain FDG-PET studies for solid tumors.
The information covers the processing of claims in light of the June 11, 2013, final decision to end the coverage with evidence development (CED) requirement for certain studies, according the Society of Nuclear Medicine and Molecular Imaging (SNMMI).
Medicare contractors are instructed to cover one FDG-PET scan for initial antitumor treatment strategy and three scans when used to guide subsequent antitumor treatment strategy, after completion of initial therapy for the same cancer diagnosis.
The system begins on July 1, 2014; however, if contractors become aware of past FDG-PET studies for the same cancer diagnosis, such as via the appeal process, they are allowed to count earlier studies dating back to June 11, 2013.
If providers perform more than one initial treatment strategy or more than three subsequent treatment strategy FDG-PET studies for the same cancer indication, they should ensure that these studies are medically necessary and are not being provided for screening or surveillance.
