PET Scans, Alzheimers & Coding
Recently a friend of mine on Facebook asked me:
“PET scan prcocedure 78608–billed with DX code 331.0 Alzeimhers Medicare is denying the claim as not medically necessary…why bc as per Medicare policies and guidelines its a valid dx code to be billed with the proc code…pls advise!!”
After a bit of searching we found that the procedure is considered not medically necessary.
The latest update I found regarding the above mentioned procedure can be found here: http://www.anthem.com/medicalpolicies/policies/mp_pw_a050587.htm
From the above document, updated 10/01/2011:
Investigational and Not Medically Necessary:
“All other uses of PET scan with or without PET/CT fusion, other than as set forth above, are considered investigational and not medically necessary including, but not limited to, the following:
Malignancies that do not meet the criteria in the Medically Necessary sections above;
Interim PET scanning to evaluate response to treatment during a course of treatment; (Note: Interim PET scanning****** is not considered restaging.)
Screening for any malignancies in an individual not yet diagnosed with cancer, other than as described in the criteria for “Solitary Pulmonary Nodule” above;
Surveillance***** of asymptomatic individuals, except for Ewing Sarcoma (without abnormal physical findings, lab tests, or other imaging findings related to malignancy recurrence) after completion of therapy for malignancy;
Alzheimer’s disease and other dementias (e.g., multi-infarct dementia, fronto-temporal dementia);
Cerebrovascular disease, (e.g., carotid artery disease, aneurysms, arteriovascular malformations, ischemic cerebrovascular disease or assessment of arterial vasospasm subsequent to subarachnoid hemorrhage).
******Interim PET Scanning: a PET scan obtained during a course of treatment, for example after the 3rd of a planned 6 cycles of chemotherapy. This type of imaging may be done to evaluate the initial response to the treatment. This is different from a PET scan done during a course of treatment when prompted by new signs or symptoms or for a different diagnosis.”
Do you agree with this post? Please share your comments if you have a different approach to best work this claim.
