Insurance and Appeals
Medicare covers PET/CT scans during the initial treatment strategy (diagnosis or staging) for all solid tumors with the exception of prostate cancer. As well, the majority of cancers are also covered in the subsequent treatment strategy (treatment monitoring and restaging) including non-small cell lung, breast, colorectal, esophageal, head and neck, ovarian, cervical and some thyroid cancers as well as lymphoma, melanoma and myeloma. Any cancers which are not yet covered in the subsequent treatment strategy may be reimbursed through a program called the National Oncologic PET Registry (NOPR).
While many commercial insurances set their coverage guidelines in accordance with Medicare, others make these determinations independently. In the event that a scan is denied by a particular insurance company, PET Imaging will offer clinical support to help validate the need for the PET/CT. An insurance company may consider overturning a denial if it is documented that PET/CT is likely to:
- Offer greater accuracy relative to conventional imaging
- Alter patient care in a significant number of patients
- Allow the avoidance of unnecessary surgeries or procedures
- Replace 3-4 conventional imaging tests with a single scan
- Save the costs and side effects associated with ineffective therapy through early identification of non-responders
Should you have a patient whose PET/CT has been denied, please contact PET Imaging for additional clinical support.
