Why MA Plans Denies PET/CT Scan
Staging not appropriate for tumor type
Follow-up scan too soon after treatment
Diagnosis does not meet NCD criteria
Know Medicare Advantage's Criteria
Medicare Advantage plans must cover all services covered by Original Medicare (CMS NCDs and LCDs) but may require prior auth. Plans use various criteria including InterQual, MCG, and proprietary guidelines.
Key policies to know:
- Must cover all services covered by Original Medicare
- Can require prior authorization not required by Original Medicare
- CMS NCDs and LCDs serve as coverage floor
- Organization determinations must be issued within 14 days (72 hours for expedited)
MA Plans's Specific Approach to PET/CT Scan
Applicable Policy
CMS NCD 220.6.17 (FDG PET for Oncology)
How MA Plans Typically Denies This
MA plans must cover all PET indications covered by the CMS NCD. Some MA plans require prior auth even for NCD-covered indications, which is allowed, but they cannot deny if criteria are met.
Your Strategy for This Payer
This is your strongest argument: CMS NCD 220.6.17 covers virtually all oncologic PET indications. If your indication is covered, the MA plan has no basis for denial.
Key Phrase to Use on the Call
"This PET/CT is covered under CMS NCD 220.6.17 for [specific indication]. The MA plan is required to cover all services covered by Original Medicare, and this meets NCD criteria."
Building Your Medical Necessity Argument
Reference the specific NCD indication being met
Document how PET results will change management
Note prior imaging results that are insufficient
Cite NCCN guideline recommendation for PET at this stage
P2P Call Tips for MA Plans
Cite the relevant CMS NCD or LCD -- MA plans cannot deny what Medicare covers
If the service has a CMS NCD, that trumps the MA plan's internal criteria
Reference CMS regulations on MA coverage obligations
Request expedited determination if clinical urgency exists
Guidelines to Reference
- CMS National Coverage Determination for FDG PET
- NCCN Guidelines by cancer type
Relevant CPT Codes
Specialty: Oncology / Pulmonology
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