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Coverage & Claim Submission for PET Scans

The Medicare National Coverage Determinations Manual (Pub. 100-03), chapter 1, section 220.6.17, describes coverage indications related to Positron Emission Tomography (PET) scans for the initial and subsequent staging of solid tumors and myeloma.

Medicare covers 3 PET scans when used to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy for the same diagnosis. CGS will review coverage of any additional PET scans (beyond 3) on a case-by-case basis.

Example: Each different cancer diagnosis is allowed:

  • 1 initial treatment strategy PET scan (with HCPCS modifier PI)
  • 3 subsequent treatment strategy PET scans (with HCPCS modifier PS).

Subsequent treatment strategy PET scans (with HCPCS modifier PS) for the same cancer diagnosis (number 4 or more) also require HCPCS modifier KX.

Note: A beneficiary's file may or may not contain a claim for initial treatment strategy (with HCPCS modifier PI). The existence or non-existence of an initial strategy claim has no bearing on the subsequent treatment strategy claim (with HCPCS modifier PS) frequency count.

When submitting claims for PET scans, please use the appropriate CPT code and modifier(s):

  • 78608 – Brain imaging, Positron emission tomography (PET); metabolic evaluation
  • 78811 – Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)
  • 78812 – Positron emission tomography (PET) imaging; skull base to mid-thigh
  • 78813 – Positron emission tomography (PET) imaging; whole body
  • 78814 – Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)
  • 78815 – Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh
  • 78816 – Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body
  • HCPCS modifier PI: PET to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing
  • HCPCS modifier PS: PET to inform of the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that a PET study is needed to inform subsequent anti-tumor strategy

References:

Published: 06.08.2026

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