REIMBURSEMENT

CURRENT MEDICARE POLICY

PET scans performed at rest or with pharmacological stress used for non-invasive imaging of the perfusion of the heart for the diagnosis and management of patients with known or suspected coronary artery disease using the FDA‐approved radiopharmaceutical Rubidium 82 (Rb-82) are covered, provided the requirements below are met:
 

The PET scan, whether at rest alone, or rest with stress, is performed in place of, but not in addition to, a single photon emission computed tomography (SPECT); or

​

The PET scan, whether at rest alone or rest with stress, is used following a SPECT that was found to be inconclusive.  In these cases, the PET scan must have been considered necessary in order to determine what medical or surgical intervention is required to treat the patient. (For purposes of this requirement, an inconclusive test is a test(s) whose results are equivocal, technically uninterpretable, or discordant with a patient’s other clinical data and must be documented in the beneficiary’s file.)

Any PET scan for which Medicare payment is claimed for dates of services prior to July 1, 2001, the claimant must submit additional specified information on the claim form (including proper codes and/or modifiers), to indicate the results of the PET scan. The claimant must also include information on whether the PET scan was performed after an inconclusive non-invasive cardiac test. The information submitted with respect to the previous non-invasive cardiac test must specify the type of test performed prior to the PET scan and whether it was inconclusive or unsatisfactory. These explanations are in the form of special G codes used for billing PET scans using Rb 82. Beginning July 1, 2001, claims should be submitted with the appropriate codes."

​

APPROVED CARDIAC PET TRACERS

Approval of PET radiotracers for clinical cardiac application by the U.S. Food and Drug Administration (FDA) in 1989 and 2000, followed by reimbursement of their use for myocardial perfusion (1995) and viability (2001) imaging by the Centers for Medicare and Medicaid Services (CMS) (see below), were important first steps toward clinical success. In recent years, continuous improvement of scanner systems, commercial marketing of the tracers fluorodeoxyglucose (FDG) and rubidium-82(82Rb), and increasing availability of the technique, mostly due to its tremendous success in oncology, have all contributed to a rapid growth of PET for clinical cardiac imaging. Today, many leading nuclear cardiology institutions run high-through put PET programs and create further evidence for its clinical usefulness. Large sample-size studies and randomized trials are underway or have been published.