PET/CT Insurance Coverage Information

Reimbursement Issues

Most insurance companies pay for clinically indicated PET procedures. To be clinically indicated, the PET scan must be potentially beneficial in providing information supportive of a diagnosis or monitoring certain conditions. Click here for an overview by MD Buyline for what is approved, what is under consideration, and actual payment amounts.

Many insurance companies have coverage policies for certain clinical situations where PET scans have been proven to be useful. Since PET is a growing field, the data sometimes does not catch up with the payers coverage policy, so just because the indication is not on the standard coverage list does not mean that the insurance company will not pay for a clinically indicated PET scan.

When the scan is in the process of being pre-authorized, it is a good idea for the physician to provide clinical information to the insurance company, including articles that support the use of PET for that indication. Many coverage policies are local, so it is important to determine the coverage policies from the major payers in your area.

We participate with most health insurance plans. The field of PET has been emerging into clinical diagnostic medicine and is approved by many insurance carriers for coverage.

Patients are responsible for deductibles, co-payments and remaining balances. Payment is expected when services are rendered and all patients are responsible to supply an insurance card and a referral from their Primary Care Physician (if needed).

Please contact our office with questions regarding insurance and coverage for PET scans.

Medicare Coverage

PET scans have been approved for reimbursement under Medicare for the following:

Source: Section 50-36 of the CMS Coverage Manual and CMS Decision Memoranda #CAG-00094A and #CAG-00098N

Private Insurance - Reimbursement for PET scan indications

Most private insurance companies cover the same indications as Medicare covers. Private insurance companies may cover additional indications. In either case, it is prudent to check with your insurance company prior to having a PET scan. The cost for the PET scan has three components: (1) the FDG radiopharmaceutical, (2) the actual scan, and (3) the professional physician who reads/interprets the scan.

Self-Payment Plan

If private insurance does not cover PET and the patient is not a candidate for Medicare, they may want to self-fund the PET scan. Please call us for information about payment arrangements.