0010 - Cardiac Positron Emission Tomography Scans: Medical Necessity and Documentation Requirements

Issue Name
0010 - Cardiac Positron Emission Tomography Scans: Medical Necessity and Documentation Requirements
Date
Review Type
Complex
Provider Type
Laboratory/Ambulance; Outpatient Hospital; Professional Services
MAC Jurisdiction
JN

Description

Documentation will be reviewed to determine if Cardiac PET Scans meet Medicare coverage criteria, meet applicable coding guidelines, and/or are medically reasonable and necessary.

Affected Code(s)

78459, 78491, 78492, A9526, A9555, A9552, A9597, A9598

Applicable Policy References

1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor;  and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
4. 42 CFR §405.986- Good Cause for Reopening  
5. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests
6. Medicare National Coverage Determination (NCD) Manual: Chapter 1, Part 4- Coverage Determinations, Section 220.6.1- PET for Perfusion of the Heart
7. Medicare National Coverage Determination (NCD) Manual: Chapter 1, Part 4- Coverage Determinations, §220.6.8- FDG PET for Myocardial Viability
8. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §50- Nuclear Medicine
9. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §60- Positron Emission Tomography (PET) Scans- General Information
10. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §60.9- Coverage of PET Scans for Myocardial Viability
11. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §60.11- Coverage of PET Scans for Perfusion of the Heart Using Ammonia N-13
12. Medicare Program Integrity Manual, Chapter 13- Local Coverage Determinations, §13.5.4- Reasonable and Necessary Provisions in LCDs
13. First Coast LCD L36209- Cardiology – non-emergent outpatient testing: exercise stress test, stress echo, MPI SPECT, and cardiac PET, Effective 10/01/2015; Revised 10/01/2019
14. Annual American Medical Association: CPT Manual, Coding Guidelines
15. Annual ICD-9-CM Manual, Coding Guidelines
16. Annual HCPCS Manual, Coding Guidelines