Molecular Imaging Program

Information for Physicians

Clinically Indicated FDG-PET/CT Scans

The ordering and performance of clinical FDG-PET/CT scans is complicated due to insurance coverage, reimbursement issues related to Medicare beneficiaries, and whether the patient is participating in an IRB approved clinical trial. The majority of these clinical PET/CT scans are performed in the Huntsman Cancer Hospital on the 3rd floor. If the patient is on a research study where the FDG-PET/CT scans are part of an approved IRB study and standard of care they are most often performed in the Center for Quantitative Cancer Imaging. This is due to the fact that the patient is on a research study and the PET/CT acquisition parameters are often defined and the FDG uptake time may defined. In addition, the images are often sent for central review and additional post-processing may be required per the study protocol.

Medicare and FDG-PET/CT
On June 11, 2013, the Center for Medicare and Medicaid Services (CMS) issued a final decision memorandum http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=263 regarding FDG PET which calls for the end of the prospective data collection requirements under Coverage with Evidence Development (CED) for all oncologic indications for FDG-PET. Please note that this decision applies to the FDG-PET registry (NOPR-2009) only. Effective June 12, 2013, the NOPR-2009 registry will no longer accept new case registrations. The following table is a summary of the current Medicare coverage for FDG-PET

Effective for claims with dates of service on and after June 11, 2013, the chart below summarizes national FDG PET coverage for oncologic conditions:

FDG PET for Solid Tumors and Myeloma

Tumor Type

Initial Treatment Strategy
(formerly “diagnosis” & “staging”)

Subsequent Treatment Strategy
(formerly “restaging” and “monitoring response to treatment”)

Colorectal

Cover

Cover

Esophagus

Cover

Cover

Head and Neck (not thyroid or CNS)

Cover

Cover

Lymphoma

Cover

Cover

Non-small cell lung

Cover

Cover

Ovary

Cover

Cover

Brain

Cover

Cover

Cervix

Cover with exceptions *

Cover

Small cell lung

Cover

Cover

Soft tissue sarcoma

Cover

Cover

Pancreas

Cover

Cover

Testes

Cover

Cover

Prostate

Non-cover

Cover

Thyroid

Cover

Cover

Breast (male and female)

Cover with exceptions *

Cover

Melanoma

Cover with exceptions *

Cover

All other solid tumors

Cover

Cover

Myeloma

Cover

Cover

All other cancers not listed

Cover

Cover

*Cervix: Nationally non-covered for the initial diagnosis of cervical cancer related to initial anti-tumor treatment strategy. All other indications for initial anti-tumor treatment strategy for cervical cancer are nationally covered.
*Breast: Nationally non-covered for initial diagnosis and/or staging of axillary lymph nodes. Nationally covered for initial staging of metastatic disease. All other indications for initial anti-tumor treatment strategy for breast cancer are nationally covered.
*Melanoma: Nationally non-covered for initial staging of regional lymph nodes. All other indications for initial anti-tumor treatment strategy for melanoma are nationally covered.

Scheduling an FDG-PET/CT Scan

To schedule a clinical FDG-PET/CT scan, please follow the procedures as outlined below.

MEDICARE PATIENTS:

  • Please fax the scheduling request form along with the Medicare patient information sheet to (801) 585-2314. If within the university system use the online PET ordering system.

COMMERCIAL INSURANCE PATIENTS:

  • Many commercial insurance carriers require pre-authorization for PET scans. Generally clinic notes and /or history and physicals are needed when requesting pre-authorization and or certification of coverage. This information is typically only available from the referring physician.

If you have any questions, please call Huntsman Cancer Institute's financial counseling at (801) 587-4038.

Thank you for your cooperation. Should you have any questions please feel free to contact HCI pre-authorization contact at (801) 587-4038.