CMS Pub. 100-04, ch. 32, § 60.12

Effective for dates of service on or after September 15, 2004, Medicare will cover FDG PET scans for a differential

diagnosis of fronto-temporal dementia (FTD) and Alzheimer's disease 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, NCD Manual, section 220.6.13, for complete coverage conditions and clinical trial

requirements and section 60.15 of this manual for claims processing information.

A. A/B MAC (A and B) Billing Requirements for PET Scan Claims for FDG-PET for the Differential Diagnosis of

Fronto-temporal Dementia and Alzheimer’s Disease:

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 CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.

Group Code: PR (if claim is received with a GA modifier) otherwise CO

CARC: 11

RARC: N/A

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. Billing Requirements for Beta Amyloid Positron Emission Tomography (PET) in Dementia and

Neurodegenerative Disease:

Effective for claims with dates of service on and after September 27, 2013, Medicare will only allow coverage with

evidence development (CED) for Positron Emission Tomography (PET) beta amyloid (also referred to as amyloid-beta (Aβ)) imaging (HCPCS A9586) or (HCPCS Q9982) or (HCPCS Q9983) (one PET Aβ scan per patient).

Note: Please note that effective January 1, 2014 the following code A9599 will be updated in the IOCE and

HCPCS update. This code will be contractor priced.

Note: Please note that effective January 1, 2018 the following code A9599 is end-date.

Medicare Summary Notices, Remittance Advice Remark Codes, and Claim Adjustment Reason Codes

Effective for dates of service on or after September 27, 2013, 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

• CD-10 dx code Z00.6 (in either the primary/secondary position)

• A PET HCPCS code (78811 or78814)

• At least, one Dx 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)

Contractors shall return as unprocessable claims for PET Aβ imaging using the following

messages:

-Claim Adjustment Reason Code 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.

Remittance Advice Remark Code 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