Coverage for PET Scans for Dementia and Neurodegenerative

60.12 - Coverage for PET Scans for Dementia and Neurodegenerative Diseases (Rev. 12364; Issued: 11-16-23; Effective: 10-13-23; Implementation:12-19-23) Effective for dates of service on or after September 15, 2004, Medicare will cover Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scans for a differential diagnosis of fronto-temporal dementia (FTD) and Alzheimer's disease (AD) OR; its use in a CMS-approved practical clinical trial focused on the utility of FDG-PET in the diagnosis or treatment of dementing neurodegenerative diseases. Refer to Pub. 100-03, National Coverage Determination (NCD) Manual, section 220.6.13, for complete coverage conditions. A. NCD 220.6.13 - A/B Medicare Administrative Contractors (MACs) (A and B) Billing Requirements for PET Scan Claims for FDG-PET for the Differential Diagnosis of Fronto-temporal Dementia and Alzheimer’s Disease: Current Procedural Terminology (CPT) Code for PET Scans for Dementia and Neurodegenerative Diseases Contractors shall advise providers to use the appropriate CPT code from section 60.3.1 for dementia and neurodegenerative diseases for services performed on or after January 28, 2005. Diagnosis Codes for PET Scans for Dementia and Neurodegenerative Diseases The contractor shall ensure one of the following appropriate diagnosis codes is present on claims for PET Scans for AD: • ICD-10-CM is applicable, ICD-10 codes are: F03.90, F03.90 plus F05, G30.9, G31.01, G31.9, R41.2 or R41.3 Medicare contractors shall deny claims when submitted with an appropriate CPT code from section 60.3.1 and with a diagnosis code other than the range of codes listed above. Medicare contractors shall instruct providers to issue an Advanced Beneficiary Notice to beneficiaries advising them of potential financial liability prior to delivering the service if one of the appropriate diagnosis codes will not be present on the claim. The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This Claim Adjustment Reason Code (CARC)/Remittance Advice Remark Code (RARC) combination is compliant with CAQH CORE Business Scenario Three. -Group Code: PR (patient responsibility) (if claim is received with a GA modifier) otherwise CO (contractual obligation) -CARC: 11 -RARC: N/A -Medicare Summary Notice (MSN): 16.48 Provider Documentation Required with the PET Scan Claim Medicare contractors shall inform providers to ensure the conditions mentioned in the NCD Manual, section 220.6.13, have been met. The information must also be maintained in the beneficiary's medical record: - Date of onset of symptoms, - Diagnosis of clinical syndrome (normal aging, mild cognitive impairment or MCI: mild, moderate, or severe dementia), - Mini mental status exam (MMSE) or similar test score, - Presumptive cause (possible, probably, uncertain AD), - Any neuropsychological testing performed, - Results of any structural imaging (MRI, CT) performed, - Relevant laboratory tests (B12, thyroid hormone), and, - Number and name of prescribed medications. B. NCD 220.6.20 - Billing Requirements for Beta Amyloid Positron Emission Tomography (PET) in Dementia and Neurodegenerative Disease. Effective October 13, 2023, as a result of the reconsideration of NCD 220.6.20, and under section 1862(a)(1)(A) of the Social Security Act, this NCD has been removed. Coverage determinations are now made by the MACs. See NCD 220.6.20 of the NCD Manual. Effective for claims with dates of service on and after September 27, 2013, thru October 12, 2023, Medicare will only allow coverage with evidence development (CED) for PET beta amyloid (also referred to as amyloid-beta (Aβ)) imaging (Healthcare Common Procedure Coding System (HCPCS) A9586) or (HCPCS Q9982) or (HCPCS Q9983) (one PET Aβ scan per patient). Effective for dates of service on or after September 27, 2013, thru October 12, 2023, contractors shall return as unprocessable/return to provider claims for PET Aβ imaging, through CED during a clinical trial, not containing the following: • Condition code 30, and value code D4 (FI only) • Modifier Q0 as appropriate • ICD-10 dx code Z00.6 (in either the primary/secondary position) • A PET HCPCS code (78811 or 78814) • At least one diagnosis code from the table below, And one of these additional diagnoses is required in addition to Z00.6 F03.90 Unspecified dementia without behavioral disturbance F03.91 Unspecified dementia with behavioral disturbance F01.50 Vascular dementia without behavioral disturbance F01.51 Vascular dementia with behavioral disturbance F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance G31.01 Pick's disease G31.09 Other frontotemporal dementia G31.85 Corticobasal degeneration G31.83 Dementia with Lewy bodies G31.84 Mild cognitive impairment, so stated R41.1 Anterograde amnesia R41.2 Retrograde amnesia R41.3 Other amnesia (amnesia NOS, memory loss NOS) and • Aβ HCPCS code A9586 or Q9982 or Q9983. MSN, RARC and CARC Codes Contractors shall return as unprocessable claims for PET Aβ imaging using the following messages: -CARC 4 – the procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. -RARC N519 - Invalid combination of HCPCS modifiers. Contractors shall line-item deny claims for PET Aβ, HCPCS code A9586 or Q9982 or Q9983, where a previous PET Aβ, HCPCS code A9586 or Q9982 or Q9983 is paid in history using the following messages: -CARC 149: “Lifetime benefit maximum has been reached for this service/benefit category.” -RARC N587: “Policy benefits have been exhausted”. -MSN 20.12: “This service was denied because Medicare only covers this service once a lifetime.” Spanish Version: “Este servicio fue negado porque Medicare sólo cubre este servicio una vez en la vida.” -Group Code: PR, if a claim is received with a GA modifier -Group Code: CO, if a claim is received with a GZ modifier