Appendix E - National Coverage Determinations Manual / Positron Emission Tomography FDG for Oncologic Conditions 220.6.17

Why This Topic Matters

Coverage policy for FDG PET affects whether claims are payable, whether evidence development requirements apply, and how cancer-related imaging services are documented and reported. Understanding the policy scope helps practices and facilities align billing workflows with Medicare requirements and identify when local contractor discretion or research-based coverage may apply.

Article Sections

1. General

   Introduces the CMS reconsideration of FDG PET coverage for oncologic conditions and the broader policy context for Medicare coverage review.

2. Framework

   Describes the revised coverage framework and its effective date, including the shift from the earlier multi-category structure to a two-part approach.

3. Initial Anti-tumor Treatment Strategy

   Addresses Medicare coverage for FDG PET used to inform initial treatment strategy, including the broader policy approach, stated exceptions, and related coverage limitations.

4. Subsequent Anti-tumor Treatment Strategy

   Summarizes Medicare coverage for FDG PET used after initial treatment, including the research-based coverage pathway and study requirements described by CMS.

5. Synopsis of New Framework

   Provides an overview table of coverage categories by tumor type under the revised framework and notes the article’s review status.