CMS Revokes Coding Barriers for 18F FDG PET Infection and Inflammation NCD Retirement

August 3, 2021

Yesterday brought some great news about coverage of 18F-FDG PET for osteomyelitis and fever of unknown origin.

In December 2020, the Centers for Medicare and Medicaid Services (CMS) retired the National Coverage Determination (NCD) for 18F-FDG PET for infection and inflammation, effective January 1, 2021. 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). 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. 

On June 8, 2021, CMS published the updated lists of nationally covered and non-covered ICD-10-CM indications for the various NCDs. Unexpectedly, the ICD-10-CM codes for some osteomyelitis and fever of unknown origin codes were listed as nationally non-covered in this Transmittal 10838 under the infection and inflammation NCD that was retired. The information in this transmittal was contrary to our understanding of the January 1, 2021, retirement of the infection and inflammation NCD. Since the transmittal was binding on the MACS, those indications are not currently being covered by local MACs.

Since June, SNMMI has been working with CMS to clarify, potentially reverse, and obtain more information for our members regarding this unanticipated and conflicting information in the transmittal. The result yielded great news. 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.