Centers for Medicare & Medicaid Services

Content Section

Publication Number

100-3

Manual Section Number

220.6.8

Version Number

Effective Date of this Version

1/28/2005

Implementation Date

4/18/2005

Benefit Category

Diagnostic Tests (other)

Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

The identification of patients with partial loss of heart muscle movement or hibernating myocardium is important in selecting candidates with compromised ventricular function to determine appropriateness for revascularization. Diagnostic tests such as FDG PET distinguish between dysfunctional but viable myocardial tissue and scar tissue in order to affect management decisions in patients with ischemic cardiomyopathy and left ventricular dysfunction.

Indications and Limitations of Coverage

1. FDG PET is covered for the determination of myocardial viability following an inconclusive single photon emission computed tomography (SPECT) test from July 1, 2001, through September 30, 2002. Only full ring PET scanners are covered from July 1, 2001, through December 31, 2001. However, as of January 1, 2002, full and partial ring scanners are covered.

2. Beginning October 1, 2002, Medicare covers FDG PET for the determination of myocardial viability as a primary or initial diagnostic study prior to revascularization, or following an inconclusive SPECT. Studies performed by full and partial ring scanners are covered.

Limitations: In the event a patient receives a SPECT test with inconclusive results, a PET scan may be covered. However, if a patient receives a FDG PET study with inconclusive results, a follow up SPECT test is not covered.

Documentation that these conditions are met should be maintained by the referring physician in the beneficiary's medical record, as is normal business practice.

(This NCD last reviewed September 2002.)

Cross Reference

See NCDs for PET Scans (§220.6) and SPECT (§220.12).

Transmittal Number

Transmittal Link

http://www.cms.hhs.gov/transmittals/downloads/R31NCD.pdf

Revision History

04/2005 - Removed text from PET Scans NCD (§220.6) and created a separate NCD. Effective date 01/28/05. Implementation date 04/18/05. (TN 31) (CR 3741)

Claims Processing Instructions

TN 527 (Medicare Claims Processing Manual)

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.