L28933

 

MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) SCAN

 

10/01/2011

 

Indications and Limitations of Coverage and/or Medical Necessity

• The following indications may be covered for PET under certain circumstances.

o Details of Medicare PET coverage are discussed later in this policy. Unless otherwise indicated, the clinical conditions below are covered when PET utilizes FDG as the tracer.

• Clinical Condition (Effective Date) Coverage.

• Myocardial Viability (July 1, 2001 to September 30, 2002) Covered only following an inconclusive SPECT.

• Myocardial Viability (October 1, 2002) Primary or initial diagnosis prior to revascularization, or following an inconclusive SPECT.

• Perfusion of the heart using ammonia N-13* tracer (October 1, 2003) covered for noninvasive imaging of the perfusion of the heart.

• *Not FDG PET.

• General Conditions of Coverage for FDG PET

• Allowable FDG PET Systems:

o Definitions: For purposes of this section:

 “Any FDA approved” means all systems approved or cleared for marketing by the FDA to image radionuclides in the body.

 “FDA approved” means that the system indicated has been approved or cleared for marketing by the FDA to image radionuclides in the body.

 “Certain coincidence systems” refers to the systems that have all the following features.

  Crystal at least 5/8-inch thick.

 Techniques to minimize or correct for scatter and/or randoms.

 Digital detectors and iterative reconstruction.

 Scans performed with gamma camera PET systems with crystals thinner than 5/8-inch will not be covered by Medicare.

• In addition, scans performed with systems with crystals greater than or equal to 5/8-inch in thickness, but that do not meet the other listed design characteristics are not covered by Medicare.

• Allowable PET systems by covered clinical indication:

o Allowable Type of FDG PET System.

• Covered Clinical Condition (Prior to July 1, 2001)July 1, 2001 through December 31, 2001 (On or after January 1, 2002).

• Determination of myocardial viability only following an inconclusive SPECT (Not covered by Medicare)Full ring (FDA approved: Full ring Partial ring).

• Myocardial Viability Primary or initial diagnosis prior to revascularization (Continued coverage following an inconclusive SPECT is also allowed) (Not covered by Medicare)Not covered (Effective October 1, 2002, Full and partial ring).

• NOTE: PET is not covered for other diagnostic uses, and is not covered for screening (testing of patients without specific symptoms).

• Monitoring - Use of PET to monitor tumor response during the planned course of therapy (i.e. when no change in therapy is being contemplated) is NOT covered.

o Restaging only occurs after a course of treatment is completed, and this is covered, subject to the conditions above.

Coverage of PET Scans for Noninvasive Imaging of the Perfusion of the Heart

• A. Rubidium 82

• Rubidium 82 (Effective March 14, 1995)

o Effective for services performed on or after March 14, 1995, 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 Rubidium 82 (Rb 82) are covered, provided the requirements below are met:

 The PET scan, whether at rest alone, or rest with stress, is performed in place of, but not in addition to, a single photon emission computed tomography (SPECT).

 The PET scan, whether at rest alone or rest with stress, is used following a SPECT that was found to be inconclusive.

• In these cases, the PET scan must have been considered necessary in order to determine what medical or surgical intervention is required to treat the patient. (For purposes of this requirement, an inconclusive test is a test(s) whose results are equivocal, technically uninterpretable, or discordant with a patient's other clinical data and must be documented in the beneficiary's file.)

 For any PET scan for which Medicare payment is claimed for dates of services prior to July 1, 2001, the claimant must submit additional specified information on the claim form (including proper codes and/or modifiers), to indicate the results of the PET scan.

• The claimant must also include information on whether the PET scan was performed after an inconclusive noninvasive cardiac test.

• The information submitted with respect to the previous noninvasive cardiac test must specify the type of test performed prior to the PET scan and whether it was inconclusive or unsatisfactory.

• These explanations are in the form of special G codes used for billing PET scans using Rb 82. Beginning July 1, 2001, claims should be submitted with the appropriate codes.

• Ammonia N-13 (Effective October 1, 2003)

o Effective for services 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 requirements below are met:

 The PET scan, whether at rest alone, or rest with stress, is performed in place of, but not in addition to, a SPECT.

 The PET scan, whether at rest alone or rest with stress, is used following a SPECT that was found to be inconclusive.

  In these cases, the PET scan must have been considered necessary in order to determine what medical or surgical intervention is required to treat the patient.

• (For purposes of this requirement, an inconclusive test is a test whose results are equivocal, technically uninterpretable, or discordant with a patient's other clinical data and must be documented in the beneficiary's file.)

Coverage of FDG PET for Myocardial Viability

o Beginning July 1, 2001 through September 30, 2002, Medicare covers FDG PET for the determination of myocardial viability, following an inconclusive SPECT.

Limitations:

• In the event that a patient has received a single photon computed tomography test (SPECT) with inconclusive results, a PET scan may be covered.

• Beginning October 1, 2002, Medicare will cover FDG PET for the determination for 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.

o However, if a patient received a FDG PET study with inconclusive results, a follow-up SPECT is not covered.

Limitations:

• In the event that a patient receives a SPECT with inconclusive results, a PET scan may be performed and covered by Medicare. However, a SPECT is not covered following a FDG PET with inconclusive results.

 

 

CPT/HCPCS Codes

 

 

78459 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC EVALUATION

78491 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; SINGLE STUDY AT REST OR STRESS

78492 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; MULTIPLE STUDIES AT REST AND/OR STRESS

A9526 NITROGEN N-13 AMMONIA, DIAGNOSTIC, PER STUDY DOSE, UP TO 40 MILLICURIES

A9555 RUBIDIUM RB-82, DIAGNOSTIC, PER STUDY DOSE, UP TO 60 MILLICURIES

 

 

ICD-9 Codes that Support Medical Necessity

 

 

The following ICD-9 codes are applicable to Procedure codes 78459, 78491 and 78492 only:

 

 

411.0 POSTMYOCARDIAL INFARCTION SYNDROME

411.81 ACUTE CORONARY OCCLUSION WITHOUT MYOCARDIAL INFARCTION

412 OLD MYOCARDIAL INFARCTION

413.1 PRINZMETAL ANGINA

414.00 CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL NATIVE OR GRAFT

414.01 CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY

414.02 CORONARY ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT

414.03 CORONARY ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT

414.06 CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY OF TRANSPLANTED HEART

414.07 CORONARY ATHEROSCLEROSIS OF BYPASS GRAFT (ARTERY) (VEIN) OF TRANSPLANTED HEART

414.10 ANEURYSM OF HEART (WALL)

414.11 ANEURYSM OF CORONARY VESSELS

414.12 DISSECTION OF CORONARY ARTERY

414.19 OTHER ANEURYSM OF HEART

414.3 CORONARY ATHEROSCLEROSIS DUE TO LIPID RICH PLAQUE

414.4 CORONARY ATHEROSCLEROSIS DUE TO CALCIFIED CORONARY LESION

414.8 OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE

426.2 LEFT BUNDLE BRANCH HEMIBLOCK

426.3 OTHER LEFT BUNDLE BRANCH BLOCK

426.4 RIGHT BUNDLE BRANCH BLOCK

426.50 BUNDLE BRANCH BLOCK UNSPECIFIED

426.51 RIGHT BUNDLE BRANCH BLOCK AND LEFT POSTERIOR FASCICULAR BLOCK

426.52 RIGHT BUNDLE BRANCH BLOCK AND LEFT ANTERIOR FASCICULAR BLOCK

426.53 OTHER BILATERAL BUNDLE BRANCH BLOCK

426.54 TRIFASCICULAR BLOCK

426.6 OTHER HEART BLOCK

427.31 ATRIAL FIBRILLATION

428.0 CONGESTIVE HEART FAILURE UNSPECIFIED

428.1 LEFT HEART FAILURE

428.20 UNSPECIFIED SYSTOLIC HEART FAILURE

428.21 ACUTE SYSTOLIC HEART FAILURE

428.22 CHRONIC SYSTOLIC HEART FAILURE

428.23 ACUTE ON CHRONIC SYSTOLIC HEART FAILURE

428.30 UNSPECIFIED DIASTOLIC HEART FAILURE

428.31 ACUTE DIASTOLIC HEART FAILURE

428.32 CHRONIC DIASTOLIC HEART FAILURE

428.33 ACUTE ON CHRONIC DIASTOLIC HEART FAILURE

428.40 UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.41 ACUTE COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.42 CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.43 ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.9 HEART FAILURE UNSPECIFIED

 

 

Documentation Requirements

• Documentation that the required conditions (as indicated in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy) for each of the FDG PET scan’s performed has been met, must be maintained by the referring physician in the beneficiary’s medical record. PET scan facilities must keep patient record information on file for each Medicare patient for whom such a PET scan claim is made.

• The medical record must include standard information (e.g., age, sex, and height) along with any annotations regarding body size or type that indicates the need for a PET scan to determine the patient’s condition.

• Documentation containing medical necessity of procedures in addition to testing results such as images and reports must be maintained.

Treatment Logic

• PET is a noninvasive diagnostic imaging procedure that assesses the level of metabolic activity and perfusion in various organ systems of the human body.

• A positron camera (tomograph) is used to produce cross-sectional tomographic images, which are obtained from positron emitting radioactive tracer substances (radiopharmaceutical) such as FDG (2-{flourine-18}-fluoro-2-dexoy-D-glucose) that are usually administered intravenously to the patient.

Sources of Information and Basis for Decision

 

FCSO LCD 29231, Myocardial Imaging, Positron Emission Tomography (PET) Scan, 10/01/2011. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

 

AMA CPT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

LCD L28933 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) SCAN