March 1, 2021
In 2008, CMS decided that PET imaging for infection and inflammation would not be covered for reimbursement. This National Coverage Determination (NCD) was based on the limited data available at that time.
From 2018-2020, SNMMI leadership, staff and consultants held multiple meetings with the CMS Coverage and Analysis group, presenting a much larger body of data in an effort to have the NCD removed.
As a result, in December 2020 CMS retired the NCD, effective January 1, 2021. Removal of the 2008 NCD opens up a path to reimbursement, which ultimately will improve care for patients.
In the absence of an NCD, coverage determinations for PET for infection and inflammation are now made at the discretion of local Medicare Administrative Contractors (MACs).
This is an exciting development for patients and physicians across the U.S. PET is an effective way—often the best way—to understand certain infections and inflammatory conditions and to provide earlier and better-informed diagnoses. in fact, it has become the standard of care for a number of conditions. Yet until now, reimbursement has not been available, severely limiting its use.
SNMMI, ASNC, ACNM and ACR are now meeting with local Medicare Administrative Contractors (MACs) to provide education and information about the new policy and ensure coverage at the local level.
SNMMI will soon approve appropriate use criteria for use of PET for infection and inflammation. In addition, a new workgroup has been formed to create appropriate use criteria for use of PET to diagnose fever of unknown origin.
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