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Cancers and indications that are reimbursable by Medicare are NOT
eligible for entry in the NOPR. Cancers and indications that are
specifically excluded for Medicare reimbursement are also not eligible
for entry in the NOPR.
IMPORTANT NOTE: The scientific evidence concerning the clinical utility
of FDG-PET is generally less robust for cancers and indications that are
currently covered by Medicare only in the NOPR than for cancers and
indications that are currently covered without clinical data submission
to the NOPR. For this reason, Medicare has conditioned coverage of
FDG-PET under the NOPR on the collection of clinical data. These data
will be used to help determine the clinical utility of FDG-PET for
conditionally covered cancers and indications. The billing physician
remains responsible for documenting medical necessity, which is required
for the coding and billing of both covered and NOPR-eligible PET
studies. Eligibility for the NOPR does not constitute a clinical
management recommendation for the use of PET for the conditionally
covered cancers and indications, by either the Medicare program or NOPR
investigators. Referring and interpreting physicians are thus advised
to refer to the published literature to better understand the potential
limitations of FDG-PET for NOPR-eligible uses.
CANCERS AND INDICATIONS ELIGIBLE FOR ENTRY IN THE NOPR
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= |
Eligible for Entry in NOPR |
| C |
= |
Not Eligible for Entry in NOPR - nationally covered indication. |
| NC |
= |
Not Eligible for Entry in NOPR - nationally non-covered indication. |
| NA |
= |
Not Applicable |
| Lip, Oral Cavity, and Pharynx (140-149) |
C |
C |
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C |
| Esophagus (150) |
C |
C |
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C |
| Stomach (151) |
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| Small Intestine (152) |
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| Colon (153) and Rectum (154) |
C |
C |
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C |
| Anus (154) |
1 |
1 |
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1 |
| Liver and intrahepatic bile ducts (155) |
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| Gallbladder & extrahepatic bile ducts (156) |
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| Pancreas (157) |
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| Retroperitoneum and peritoneum (158) |
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| Nasal cavity, ear, and sinuses (160) |
C |
C |
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C |
| Larynx (161) |
C |
C |
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C |
| Lung, non-small cell (162) |
C |
C |
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C |
| Lung, small cell (162) |
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| Pleura (163) |
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| Thymus, heart, mediastinum (164) |
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| Bone/cartilage (170) |
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| Connective/other soft tissue (171) |
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| Melanoma of skin (172) |
C |
C2 |
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C |
| Female breast (174) |
NC3 |
C2 |
C |
C |
| Male breast (175) |
NC3 |
C2 |
C |
C |
| Kaposi's sarcoma (176) |
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| Uterus, unspecified (179) |
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| Cervix (180) |
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C4 |
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| Uterus, body (182) |
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| Ovary and uterine adnexa (183) |
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| Prostate (185) |
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| Testis (186) |
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| Penis and other male genitalia (187) |
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| Bladder (188) |
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| Kidney and other urinary tract (189) |
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| Eye (190) |
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| Primary Brain (191) |
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| Thyroid (193) |
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C5 |
| Lymphoma (200-202) |
C |
C |
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C |
| Myeloma (203) |
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| Leukemia (204-208) |
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| Solitary Pulmonary Nodule |
C |
NA |
NA |
NA |
| Other or not listed |
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NOTES:
- Some Medicare carriers include anal cancer in their coverage of "colorectal cancer"; for PET facilities served by those carriers, PET for anal cancer diagnosis, initial staging, or restaging/suspected recurrence would be a covered indication.
- Does not cover initial staging for axillary lymph nodes for breast cancer patients and regional lymph nodes for melanoma patients
- PET is non-covered for "Diagnosis" of breast cancer to evaluate a suspicious breast mass. However, a patient with suspected breast cancer is eligible for entry in NOPR for the indications (1) "Diagnosis: Unknown Primary Site" in a patient with axillary nodal metastasis but no evident primary breast cancer by conventional evaluation and (2) "Diagnosis: Paraneoplastic Syndrome".
- Patient must have prior CT or MRI negative for extrapelvic metastatic disease to qualify as a covered indication. Patients who do not qualify for covered indication (e.g., because CT or MRI not done or because either showed extrapelvic metastatic disease) can be entered on NOPR.
- To qualify as a covered indication thyroid cancer must be of follicular cell origin and been previously treated by thyroidectomy and radioiodine ablation and have a serum thyroglobuilin > 10ng/ml and negative I-131 whole body scan. Patients who do not qualify for covered indication (e.g., because tumor of other than follicular cell origin or thryoglobulin not elevated) can be entered on NOPR.
GENERAL NOTE:
PET imaging of the brain with CPT code 78608 for diagnosis, initial
staging, treatment monitoring, or restaging/suspected recurrence of any
type of cancer is covered only under NOPR.
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