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Download Positron Emission Tomography (PET) Scans
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Payment Policies Positron Emission Tomography (PET) Scans Policy Harvard Pilgrim reimburses contracted providers for positron emission tomography (PET) scans performed on FDAapproved equipment at contracted facilities and PET imaging centers. Harvard Pilgrim’s PET is managed through an arrangement with National Imaging Associated (NIA). For additional information, see Harvard Pilgrim’s Outpatient Advanced Imaging Authorization policy. Policy Definition A PET scan is a non-invasive diagnostic imaging procedure that assesses the level of metabolic activity of various normal and abnormal (malignant) organ systems of the human body. A positron camera is used to produce cross-sectional tomographic images obtained from positron emitting, radioactive tracer substances that are administered intravenously to the patient. Prerequisite(s) HMO/POS/PPO Authorization is required for non-emergency, outpatient advanced imaging services. Ordering physicians are required to contact NIA to initiate the request. (Refer to Outpatient Advanced Imaging Authorization for specific requirements.) Connecticut Open Access HMO Note: For the Connecticut Open Access HMO product, no referral is required to see a contracted specialist. Harvard Pilgrim Reimburses 1 HMO/POS/PPO Harvard Pilgrim reimburses PET scans for covered indications. See provider billing section for a complete list of covered CPT, HCPCS and diagnosis codes. Brain PET scan Known Brain Tumor/Cancer • Follow-up on known brain tumor post surgery and/or after treatment recently completed. • Known brain tumor/cancer and has new signs or symptoms indicative of a reoccurrence of cancer. Epilepsy refractory seizures • Pre-surgical evaluation for refractory seizures (seizures continue to occur despite treatment). Heart PET scan • Evaluation of myocardial viability prior to possible percutaneous or surgical revascularization if: - Previous SPECT/MPI imaging for viability is inadequate; and - Patient has severe left ventricular dysfunction (LVEF ≤ 35%). • Evaluation in patient with suspected or known Coronary Artery Disease. - To qualify for PET perfusion scan done either at rest or with pharmacologic stress, the patient must meet criteria for indicated nuclear cardiac imaging/myocardial perfusion study, and - Patient had a previous inadequate SPECT/MPI imaging due to inadequate findings, technical difficulties with inter- pretation, or discordant results with previous clinical data. PET Scans Brain PET Scan • Initial treatment strategy (initial staging) differentiating between tumors and from treatment related issue necrosis Breast PET Scan (For known cancer/tumor. Not for R/O, screening or surveillance.) • Initial staging of patient with known (diagnosed) breast cancer for distant metastasis when conventional imaging studies (such as CT, MRI or ultrasound) are inconclusive. Harvard Pilgrim Health Care—Provider Manual (continued) H.244 December 2016 Payment Policies Positron Emission Tomography Scans (cont.) • Re-staging of known (diagnosed) breast cancer patient with local regional recurrence or distant metastasis. • Evaluate known (diagnosed) breast cancer patient’s response to treatment initiated within the last 8 weeks and course of treatment completed. • Evaluate known (diagnosed) breast cancer patient’s response to treatment initiated longer than 8 weeks ago, treatment is completed and no PET scans obtained after treatment. Cervical PET Scan (for known cancer/tumor—not for R/O, screening or surveillance) • Initial staging of known (diagnosed) cervical cancer/tumor when conventional imaging studies (such as CT, MRI or ultrasound) are inconclusive. • Follow up study (re-staging) for known (diagnosed) cervical cancer/tumor who has recently completed a course of treatment. • Known (diagnosed) cervical cancer/tumor and has new signs or symptoms indicative of a reoccurrence of cancer. (Re-staging.) Colorectal PET scan (for known cancer/tumor—not for R/O, screening or surveillance) • Initial staging for known (diagnosed) colorectal cancer/tumor when conventional imaging studies (such as CT, MRI or ultrasound) are inconclusive. • Follow up study (re-staging) for known (diagnosed) colorectal cancer/tumor who recently completed a course of treatment. • Known (diagnosed) colorectal cancer/tumor and has new signs or symptoms indicative of a reoccurrence of cancer. (Re-staging.) (Can approve if previous imaging study was performed less than 6 weeks earlier.) • Known (diagnosed) colorectal cancer/tumor and has a rising CEA. Esophageal PET Scan (for known cancer/tumor—not for R/O, screening or surveillance) • Initial staging of known (diagnosed) esophageal cancer/tumor when conventional imaging studies (such as CT, MRI or ultrasound) are inconclusive. • Evaluate known (diagnosed) esophageal cancer/tumor patient’s response to treatment initiated within the last 8 weeks and course of treatment completed. • Evaluate known (diagnosed) esophageal cancer/tumor patient’s response to treatment initiated longer than 8 weeks ago, course of treatment is completed and no PET scan obtained after treatment. • Physical, laboratory and/or evidence of recurrent esophageal cancer/tumor. Head and Neck PET Scan • R/O head and/or neck cancer/tumor. • R/O head and/or neck cancer with evidence of mets or other tumor in the body. • R/O head and/or neck cancer in a tumor that has been clinically apparent and persistent in the head and/or neck region. Known (diagnosed) Head and/or Neck Cancer/tumor (for known cancer/tumor—not for R/O, screening or surveillance) • Initial staging of known (diagnosed) head and/or neck cancer/tumor when conventional imaging studies (such as CT, MRI or ultrasound) are inconclusive. • Known (diagnosed) head and/or neck cancer with history of cancer surgery, chemotherapy or radiation therapy and has new signs or symptoms indicative of a reoccurrence of cancer. • Known (diagnosed) head and/or neck cancer with history of cancer surgery, chemotherapy or radiation therapy and evaluation for possible presence of residual tumor after treatment completed. • Follow up study (re-staging) for known (diagnosed) head and/or neck cancer who has completed treatment. Lung PET Scan (for known cancer/tumor—not for R/O, screening or surveillance) • Initial staging of known (diagnosed) lung cancer/tumor when conventional imaging studies (such as CT, MRI or ultrasound) are inconclusive. • Follow up study (re-staging) for known (diagnosed) lung cancer/tumor who has recently completed a course of treatment. • Known (diagnosed) lung cancer and has new signs or symptoms indicative of a reoccurrence of cancer. Lymphoma PET Scan (for known cancer/tumor—not for R/O, screening or surveillance) • Initial staging of known (diagnosed) lymphoma when conventional imaging studies (such as CT, MRI or ultrasound) are inconclusive. Harvard Pilgrim Health Care—Provider Manual (continued) H.245 December 2016 Payment Policies Positron Emission Tomography Scans (cont.) • Follow up study (re-staging) for known (diagnosed) lymphoma who has recently completed treatment. • Known (diagnosed) lymphoma and has new signs or symptoms indicative of a reoccurrence of cancer. Melanoma PET scan (for known cancer/tumor—not for R/O, screening or surveillance) • Initial staging of known (diagnosed) melanoma when conventional imaging studies (such as CT, MRI or ultrasound) are inconclusive. • Follow-up study (re-staging) for known (diagnosed) melanoma who has recently completed treatment. • Known (diagnosed) melanoma and has new signs or symptoms indicative of a reoccurrence of cancer. Myeloma PET Scan • Initial treatment strategy (diagnosis) of solid tumors that are biopsy proven or strongly suspected based on other diagnostic testing to determine the location and/or extent of the tumor for the following therapeutic purposes related to the initial treatment strategy: - To determine if patient is an appropriate candidate for an invasive diagnostic or therapeutic procedure, or - To determine the optimal anatomic location for an invasive procedure, or - To determine the anatomic extent of the tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor. • Subsequent treatment strategy (monitoring response to treatment when a change in treatment is anticipated) for known (diagnosed) myeloma for patient who has recently completed treatment. • Subsequent treatment strategy (restaging) for known (diagnosed) myeloma and has new signs or symptoms indicative of a reoccurrence of cancer. Ovarian PET Scan • Initial treatment strategy (diagnosis) of solid tumors that are biopsy proven or strongly suspected based on other diagnostic testing to determine the location and/or extent of the tumor for the following therapeutic purposes related to the initial treatment strategy: - To determine if patient is an appropriate candidate for an invasive diagnostic or therapeutic procedure, or - To determine the optimal anatomic location for an invasive procedure, or - To determine the anatomic extent of the tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor. • Subsequent treatment strategy (monitoring response to treatment when a change in treatment is anticipated) for known (diagnosed) ovarian cancer for patient who has recently completed treatment. • Subsequent treatment strategy (restaging) for known (diagnosed) ovarian cancer and has new signs or symptoms indicative of a reoccurrence of cancer. Pancreatic PET Scan • Initial treatment strategy (diagnosis) of solid tumors that are biopsy proven or strongly suspected based on other diagnostic testing to determine the location and/or extent of the tumor for the following therapeutic purposes related to the initial treatment strategy: - To determine if patient is an appropriate candidate for an invasive diagnostic or therapeutic procedure, or - To determine the optimal anatomic location for an invasive procedure, or - To determine the anatomic extent of the tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor. Soft Tissue PET Scan • Initial treatment strategy (diagnosis) of solid tumors that are biopsy proven or strongly suspected based on other diagnostic testing to determine the location and/or extent of the tumor for the following therapeutic purposes related to the initial treatment strategy: - To determine if patient is an appropriate candidate for an invasive diagnostic or therapeutic procedure, or - To determine the optimal anatomic location for an invasive procedure, or - To determine the anatomic extent of the tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor. Harvard Pilgrim Health Care—Provider Manual (continued) H.246 December 2016 Payment Policies Positron Emission Tomography Scans (cont.) Solitary Pulmonary Nodule PET Scan (for a single nodule only—not for multiple nodules) Evaluate a solitary pulmonary nodule that is equal to or less than 4 cm in diameter evident on recent chest x-ray, CT or MRI (10mm = 1 cm). (PET appropriate for diagnosis of indeterminate or possibly malignant single lung lesion/nodule.) Thyroid PET Scan (for known cancer/tumor—not for R/O, screening or surveillance) Follow-up study (re-staging) for known (diagnosed) thyroid cancer/tumor and meets all of the following: • Evaluate response to surgical or radiation treatment. • Post treatment Iodine 131 uptake test was inconclusive. • No more than 2 PET scans since the initiation of therapy for thyroid cancer. Follow-up study (re-staging) for known (diagnosed) thyroid cancer/tumor for recurrent or residual thyroid cancer and meets all of the following: • Serum thyroglobulin levels above 10 ng/ml after surgical or radiation treatment. • Standard imaging tests have failed to localize metastasis or recurrent disease. Testicular PET Scan • Initial treatment strategy (diagnosis) of solid tumors that are biopsy proven or strongly suspected based on other diagnostic testing to determine the location and/or extent of the tumor for the following therapeutic purposes related to the initial treatment strategy: - To determine if patient is an appropriate candidate for an invasive diagnostic or therapeutic procedure, or - To determine the optimal anatomic location for an invasive procedure, or - To determine the anatomic extent of the tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor. All Other Solid Tumor Types PET Scan • Initial treatment strategy (diagnosis) of solid tumors that are biopsy proven or strongly suspected based on other diagnostic testing to determine the location and/or extent of the tumor for the following therapeutic purposes related to the initial treatment strategy: - To determine if patient is an appropriate candidate for an invasive diagnostic or therapeutic procedure, or - To determine the optimal anatomic location for an invasive procedure, or - To determine the anatomic extent of the tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor. Harvard Pilgrim Does Not Reimburse HMO/POS/PPO PET scans for non-covered indications. Claim submitted with non-covered indication will be denied as provider liable. This applies to professional component only (Modifier-26), technical component only (TC), or global services. Brain PET Scan • Brain PET—Evaluate suspected tumor (R/O Brain tumor/cancer) (Brain tumor/cancer must be diagnosed by other non PET imaging methods or procedures). • Brain PET—Evaluate suspected inflammation. • More than one PET requested post treatment and no other change in patient’s condition such as new signs or symptoms. (If more than one PET is requested post treatment, need PCR to discuss appropriate continued therapy and evaluation.) (EXCEPTION: Thyroid Cancer–refer to specific criteria.) • PET for diagnosis unless specifically identified as approvable criteria. • Any specific criteria where states must verify the information and unable to obtain specific information. • Any other criteria not identified as a covered indication. Heart PET Scan • More than one PET requested post treatment and no other change in patient’s condition such as new signs or symptoms. (If more than one PET is requested post treatment, need PCR to discuss appropriate continued therapy and evaluation.) (EXCEPTION: Thyroid Cancer–refer to specific criteria.) • PET for diagnosis unless specifically identified as approvable criteria. Harvard Pilgrim Health Care—Provider Manual (continued) H.247 December 2016 Payment Policies Positron Emission Tomography Scans (cont.) • Any specific criteria where states must verify the information and unable to obtain specific information. • Any other criteria not identified as a covered indication. PET Scans • For the initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes). • More than one PET requested post treatment and no other change in patient’s condition such as new signs or symptoms. (If more than one PET is requested post treatment, need PCR to discuss appropriate continued therapy and evaluation.) (EXCEPTION: Thyroid Cancer–refer to specific criteria.) • Ovarian CA (slow growing tumor and slow FDG uptake. PET not valuable in slow growing tumors). • Kidney or bladder tumors (since FDG excreted in high concentration, will cover the tumor when imaging these areas). • R/O Breast Cancer. - Positron Emission Mammography PEM • PET for diagnosis unless specifically identified as reimbursable criteria. • Any specific criteria where states must verify the information and unable to obtain specific information. • Any other criteria not identified as a covered indication. Member Cost-Sharing Services subject to applicable member out-of-pocket cost (e.g., copayment, coinsurance, deductible). Provider Billing Guidelines and Documentation Coding2 Harvard Pilgrim will not reimburse professional component only (Modifier-26), technical component only (TC), or global services for non-covered indications. Claim will be denied as provider liable. Brain PET—CPT/HCPCS and ICD-9/ICD-10 Covered Indications CPT/HCPCS Description 78609 Brain imaging, positron emission tomography (pet); perfusion evaluation 78608 Brain imaging, positron emission tomography (pet); metabolic evaluation ICD-9 Covered Indications ICD-10 Covered Indications Heart PET – CPT/HCPCS and ICD-9/ICD-10 Covered Indications CPT/HCPCS Description 78492 Myocardial imaging, positron emission tomography (pet), perfusion; multiple studies at rest and/or stress 78491 Myocardial imaging, positron emission tomography (pet), perfusion; single study at rest or stress 78459 Myocardial imaging, positron emission tomography (pet), metabolic evaluation ICD-9 Covered Indications ICD-10 Covered Indications Harvard Pilgrim Health Care—Provider Manual (continued) H.248 December 2016 Payment Policies Positron Emission Tomography Scans (cont.) PET Scans – CPT/HCPCS and ICD-9 Covered Indications CPT/HCPCS Description 78811 Positron emission tomography (pet) imaging; limited area (e.g., chest, head/neck) 78812 Positron emission tomography (pet) imaging; skull base to mid-thigh 78813 Positron emission tomography (pet) imaging; whole body 78814 Positron emission tomography (pet) with concurrently acquired computed tomography (ct) for attenuation correction and anatomical localization imaging; limited area (e.g., chest, head/neck) 78815 Positron emission tomography (pet) with concurrently acquired computed tomography (ct) for attenuation correction and anatomical localization imaging; skull base to mid-thigh 78816 Positron emission tomography (pet) with concurrently acquired computed tomography (ct) for attenuation correction and anatomical localization imaging; whole body ICD-9 Covered Indications ICD-10 Covered Indications PET Scans–CPT/HCPCS Not Covered for any Indication HCPCS Description G0252 Pet imaging, full and partial-ring pet scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g. initial staging of axillary lymph nodes) G0235 Pet imaging, any site, not otherwise specified G0219 Pet imaging whole body; melanoma for non-covered indications Related Policies Outpatient Advanced Imaging Policy PUBLICATION HISTORY 01/15/10 revised policy—effective 04/01/10 06/15/10 update to covered and non-covered indications 10/15/10 added covered diags resulting from 10/01/10 ICD-9 release updates 01/15/11 coding update; update to covered indications effective 01/15/11 for guideline 02/15/11 minor edits for clarity 10/15/11 update to covered indications effective 01/01/12 for guideline 01/01/12 removed First Seniority Freedom information from header 01/15/12 added covered diags 10/01/11 ICD-9 release update; update to covered indication PET Cardiac eff 04/01/12 for guideline 04/15/12 minor updates for clarity 10/15/12 added diag 793.19 as payable 01/15/13 update to covered indications effective 04/01/13 for guideline 12/15/13 annual review; no changes 06/15/14 added Connecticut Open Access HMO referral information to prerequisites 12/15/14 annual review; removed ICD-9 codes that are no longer reimbursed effective 04/01/13; administrative edits 07/15/15 ICD-10 coding update 12/15/15 annual review, added Positron Emission Mammography PEM as non-covered 12/15/16 annual review, no changes 1This policy applies to the products of Harvard Pilgrim Health Care and its affiliates—Harvard Pilgrim Health Care of Connecticut, Harvard Pilgrim Health Care of New England, and HPHC Insurance Company—for services performed by contracted providers. Payment is based on member benefits and eligibility, medical necessity review, where applicable, and provider contractual agreement. Payment for covered services rendered by contracted providers will be reimbursed at the lesser of charges or the contracted rate. (Does not apply to inpatient per diem, DRG, or case rates.) HPHC reserves the right to amend a payment policy at its discretion. CPT and HCPCS codes are updated annually. Always use the most recent CPT and HCPCS coding guidelines. 2The table may not include all provider claim codes related to PET imaging. Harvard Pilgrim Health Care—Provider Manual H.249 December 2016
