Knowledge Base Article

CMS recently released a revised CR 6753 (Transmittal 1888  and Transmittal 110) concerning the coverage of PET scans for cervical cancer.  The National Coverage Determination (NCD) was revised effective for claims with dates of service on and after November 10, 2009 to allow coverage of one initial FDG PET study for staging in beneficiaries who have biopsy-proven cervical cancer.  The PET study is covered when it is needed to determine the location and/or extent of the tumor for the following therapeutic purposes related to initial strategy:

• To determine whether or not the beneficiary 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.

The NCD also determined that there is no credible evidence that PET imaging is useful in making initial diagnosis of cervical cancer or in improving health outcomes; therefore, CMS continues to non-cover FDG PET for the initial diagnosis of cervical cancer related to initial treatment strategy.

FDG Pet imaging for initial staging of cervical cancer related to initial treatment strategy was previously covered under the Coverage with Evidence Development (CED) prospective data collection requirements.  This CR removes the CED requirements; NOPR data reporting is no longer necessary and the –Q0 modifier is no longer necessary on claims for FDG PET services for cervical cancer.

Claims for FDG PET for cervical cancer billed to inform initial treatment must include all the following or they will “return to provider.

• PET or PET/CT CPT code (78608, 78811, 78812, 78813, 78814, 78815, or 78816), and
• -PI modifier (PET Tumor initial treatment strategy), and
• ICD-9 cervical cancer diagnosis code.

For more information, please see the Transmittals listed above or view the MLN Matters Article.  The implementation date of this CR was January 4, 2010.