How to get a pet scan covered by insurance?
- Tony Dean
Part B – Because Part B of Medicare covers medically necessary services, such as outpatient treatments, PET scans may be covered as diagnostic, non-laboratory tests. For coverage, the test must be ordered by a physician and be medically necessary. This online tool provided by the National Coverage Determination (NCD) for PET Scans can be used to determine whether a condition qualifies as medically necessary.
Does a PET scan reveal the cancer’s stage?
A PET scan is a positron emission tomography examination. PET scan is a type of test that may be utilized in the treatment of cancer. It may be performed alongside a CT scan. If so, doctors refer to this as a PET-CT scan. However, you may also hear it referred to as a PET scan.
- A PET-CT scan is a method for detecting and determining the stage of certain cancers.
- The stage of a cancer describes its location and whether it has spread.
- Doctors also determine the stage of the cancer and how it is affecting the body’s functions.
- Nowing the stage of cancer allows you and your physician to select the most effective treatment.
Additionally, it helps your doctor predict your likelihood of recovery.
Cancer – Cancer cells show up as bright spots on PET scans because they have a higher metabolic rate than do normal cells. PET scans can be helpful for: Diagnosing cancer determining if your cancer has spread Checking the effectiveness of a cancer treatment Finding a recurrence of cancer PET scans must be carefully interpreted because noncancerous conditions can mimic cancer and certain cancers do not appear on PET scans.
Why do insurance companies refuse to cover PET scans?
By Kerry Scannell CCS, CPC, specialist in coding denials – PET scans for oncologic conditions are covered under the Medical Necessity policy of the Centers for Medicare & Medicaid Services (CMS). And because coders are not permitted to use a diagnosis other than the one listed on the order, these PET scans are sometimes denied by payors when they could have been covered as Medically Necessary based on the patient’s full clinical picture.
Please consider the following: Medical Necessity is not met when ordering a PET scan for a cancer history unless a second diagnosis documenting an active cancer or abnormal radiological finding is also listed. When ordering a PET scan for an oncologic condition, be sure to list any bone metastases or pathological fractures (and specify that they are pathological fractures due to neoplasms/in neoplastic disease) as secondary diagnoses, as this may help demonstrate Medical Necessity.
PET is not covered nationally for the initial staging of regional lymph nodes in Melanoma patients. PET is not covered nationally for the initial diagnosis and/or staging of axillary lymph nodes in breast cancer patients. PET is not covered nationally for the initial diagnosis of cervical cancer associated with the initial antitumor treatment strategy.
“PET should be utilized infrequently for the diagnosis of lymphoma, esophageal, and colorectal cancers, as well as melanoma. PET is not covered for other diagnostic uses or screening (testing patients without specific disease symptoms).” * PET monitoring of tumor response during the planned course of therapy (i.e., when no change in therapy is planned) is not covered.
*From the Medicare Claims Processing Manual, Chapter 13 —Radiological Services and Other Diagnostic Procedures For additional information, please visit http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1 Part4.pdf. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c13.pdf
What cancer does a PET scan not detect?
Is PET useful for all cancers? – Although PET CT detects the majority of cancers, there are a few exceptions. The most significant of these would be stomach cancer (signet cell type). In such instances, conducting this test would be unnecessary. However, there are cancers that can be detected extremely sensitively, such as lymphoma, GIST, etc. Your physician will inform you of its usefulness.