| Disease Category |
Clinical Indications |
Covered by Medicare |
| Breast Cancer |
- Staging (not reliable for axillary nodal involvement)
- Evaluate suspected local and/or distant metastasis (inconclusive diagnostic imaging studies, lab studies)
- Radiation therapy planning
- Monitor response to treatment
|
Yes
Initial staging for distant metastases
Staging and re-staging locoregional recurrence or distant metastases
Evaluate response to treatment |
| Colorectal Cancer |
- Initial staging prior to surgery
- Restaging post treatment
- Restaging for rising CEA levels
- Restage when other imaging studies are inconclusive
- Differentiation of presacral post surgical change vs. recurrent tumor
- Restage when abnormal physical exam or clinical symptoms of recurrence
- Re-evaluation after radiofrequency ablation of hepatic colorectal metastases
- Radiation therapy planning
|
Yes
Diagnosis*
Staging
Restaging
Monitoring covered under clinical trials protocols
(*CMS guidelines state that PET would rarely be used in the diagnosis of colorectal cancer) |
| Esophageal Cancer |
- Initial staging to evaluate local extent of disease and/or identify distant metastasis prior to scheduled surgery
- Radiation therapy planning
- Re-stage for suspected recurrence
|
Yes
Diagnosis*
Staging
Restaging
Monitoring covered under clinical trials protocols
(*CMS guidelines state that PET would rarely be used in the diagnosis of esophageal cancer) |
Head & Neck Cancer
(Excluding CNS and thyroid) |
- Detection of unknown primary
- Identify an appropriate site for biopsy
- Staging of neck nodes
- Staging outside of the head & neck
- Radiation therapy planning
- Differentiation of post surgical change from recurrent tumor
- Exclusion of lesions that appear suspicious on other imaging modalities
|
Yes
Diagnosis
Staging
Restaging
Monitoring covered under clinical trials protocols |
| Lung Cancer |
- Distinguish malignant from benign pulmonary nodule(s)
- Biopsy localization information
- Mediastinal nodal staging
- Staging for extrathoracic metastases
- Radiation therapy planning
- Re-stage to detect recurrent disease or residual tumor following definitive therapy
- Differentiation of postsurgical change from recurrent tumor
|
Yes
Diagnosis*
Staging
Restaging
Monitoring covered under clinical trials protocols
(*PET is also covered to evaluate a solitary (single) pulmonary nodule, indeterminate on CT and > 4 cm – see indication Solitary Pulmonary Nodule) |
| Lymphoma |
- Initial staging to determine extent of disease prior to chemotherapy
- Biopsy localization information
- Radiation therapy planning for Hodgkin’s
- Restage to evaluate response to treatment
- Differentiation of residual soft tissue (scar) vs. tumor
|
Yes
Diagnosis*
Staging
Restaging
(*CMS guidelines state that PET would rarely be used in the diagnosis of lymphoma) |
Melanoma
(Excludes the evaluation of regional nodes) |
- Initial staging to determine extent of disease prior to scheduled treatment (not covered for evaluation of regional nodes)
- Restage to evaluate response to treatment
- Restage to detect recurrence
|
Yes
Diagnosis*
Staging
Restaging
Monitoring covered under clinical trials protocols
(*CMS guidelines state that PET would rarely be used in the diagnosis of melanoma; CMS does not cover PET for evaluation of regional nodes when there is not suspicion for more extensive disease) |
| Thyroid Cancer |
- Re-staging patients with suspected recurrence in thyroid cancers of follicular cell origin, post surgery or I 131 ablation with > 10 ng/ml serum thyroglobulin level and negative I 131 whole body scan
|
Yes
Diagnosis, other staging, restaging, and monitoring covered under clinical trials protocols
(CMS covers PET for patients who have been treated for thyroid cancer of follicular cell origin (either surgically or with I 131) and have thymoglobulin level > 10 ng/ml and a negative I 131 WB scan) |
| Cardiac Viability |
- Initial staging to determine myocardial viability from infracted tissue when patients are being evaluated for revascularization or transplant
|
Yes
Staging
(PET is covered when the patient has had an inclusive SPECT study and effective 10.01.03 PET can be used as a first line study instead of a SPECT study) |
| Seizure Disorders |
- Staging to evaluate seizure focus prior to scheduled surgery
|
Yes
(Pre-surgical evaluation) |
Solitary Pulmonary Nodule
(A PET scan for SPN may be repeated after 90 days following a negative PET scan) |
- Evaluation of an indeterminate single/solitary lung nodule < 4 cm identified by CXR or CT
- Evaluation of a lung nodule that shows an interval increase in size following a negative PET scan > 90 days prior
|
Yes
(CMS covers a PET scan for an indeterminate SPN by CT and when the single/solitary nodule is < 4cm) |
| Brain Cancer |
- Differentiation of radiation necrosis vs. residual/recurrent tumor
|
No
Covered under clinical trials protocols |
| Ovarian Cancer |
- Staging prior to surgery
- Restaging when CA-125 levels are increasing
- Radiation therapy planning
|
No
Covered under clinical trials protocols |
| Cervical Cancer |
- Staging prior to surgery (particularly good for evaluating paraaortic lymph nodes)
- Evaluating response to therapy
|
Yes
Staging as adjunct to conventional imaging Diagnosis, other staging, restaging, and monitoring covered under clinical trials protocols
(CMS has proposed coverage for the detection of pre-treatment metastases in newly diagnosed cervical cancer, after negative conventional imaging) |
| Alzheimer’s Disease |
- Differentiation between AD, normal aging and neuropsychiatric conditions
- Differentiation between AD and other dementia
- Detect AD at its earliest stages
|
Yes
(PET is covered for the differential diagnosis of AD with atypical features vs. fronto-temporal dementia) |
