FDG PET NCD Coverage Contradictions Raise Confusion

In a small saga that has played out over the course of the year, transmittal 10838 released by the Centers for Medicare & Medicaid Services (CMS) on June 8th caused confusion and contradicted previous information released regarding the retirement of the National Coverage Determination (NCD) for 18F-FDG PET for infection and inflammation.

According to stakeholders, the transmittal ran contrary to a previously released transmittal in December 2020. This December transmittal had announced the retirement of the National Coverage Determination (NCD) for 18FFDG PET for infection and inflammation, which was stated effective as of January 1, 2021. Without the NCD, coverage determinations for PET for infection and inflammation are decisions made under the authority of local Medicare Administrative Contractors (MACs).

In a news release, the Society of Nuclear Medicine and Molecular Imaging (SNMMI), noted that “Removal of this NCD from 2008 was accomplished after many discussions and sharing of guidelines and literature by the SNMMI, together with our sister societies ACR and ASNC. This effort and CMS decision opened up a path to reimbursement that ultimately will improve care for patients.” The June transmittal showed that CMS released an updated list of nationally covered and non-covered ICD-10-CM indications for a variety of NCDs. However, in that transmittal, ICD-10-CM codes for some osteomyelitis and fever of unknown origin codes were listed as nationally noncovered under the cited NCD for infection and inflammation that was previously retired.

Because the policies are contractual and obligatory for MACS, the indications specified in the transmittal would not be covered by local MACS. Naturally, this information stood in direct contrast to the interpretation of the January 1, 2021, infection, and inflammation NCD retirement.

Stakeholders like SNMMI and experts sought clarification from CMS and worked to come to an overall understanding about the intent of the confusing information, which brought forth results. In a recent update, SNMMI announced that:

“On August 2, 2021, CMS revoked the non-covered codes issued under its June transmittal. Transmittal 10927 now reflects that in the absence of an NCD, and coverage determinations will now be made by the MACs, without further coding restrictions.”

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Information Sources:

https://s3.amazonaws.com/rdcms-snmmi/files/production/public/R10838NCD.pdf

https://www.snmmi.org/NewsPublications/News- Detail.aspx?ItemNumber=37176

https://www.cms.gov/files/document/r10927ncd.pdf