• WIS Articles
• WIS Presentations
• Ask A Radiologist

Now into its second year, NOPR has become a major tool in Medicare’s fight against cancer.

The National Oncologic PET/CT Registry (NOPR) has been a tremendous success through the first 18 months of data collection. Over 65,000 patients have been scanned to date – this reinforces the goal that the NOPR will make possible a more accurate assessment of the actual influence of PET/CT on patient management across a wide spectrum of cancer indications. By linking access to PET/CT for virtually all Medicare beneficiaries to the collection of clinically valuable evidence, the NOPR represents the cutting edge coverage determinations for the future.

The NOPR has provided a unique clinical trial tool to enhance our cancer detection capabilities for your Medicare patients utilizing PET/CT imaging. All types of cancer (except breast) are now covered under the NOPR for diagnosis, and all are also covered for staging, recurrence and response to treatment. Many of your peers now use the NOPR regularly to greatly expand the diagnostic information available in the fight against cancer for indications not previously covered by Medicare.

The following table outlines the top ten cancers scanned with PET/CT on NOPR patients through the first 18 months of the NOPR study and the top ten sites/indications of those patients.

Please read the attached information carefully and call me at 206-618-2364 if you have any additional questions, or need further explanation on how to schedule a patient for a PET/CT scan under the NOPR coverage. We look forward to providing expanded PET/CT diagnostic imaging for your patients.
- Gary Beneze, Program Director – PET/CT Imaging

Coverage Matrix – National Oncological PET Registry

Cancers and indications that are currently reimbursable by Medicare are NOT eligible for entry in the NOPR. Cancers and indications that are specifically excluded for Medicare reimbursement are also not eligible for entry in the NOPR.

IMPORTANT NOTE: The scientific evidence concerning the clinical utility of FDG-PET is generally less robust for cancers and indications that are currently covered by Medicare only in the NOPR than for cancers and indications that are currently covered without clinical data submission to the NOPR. For this reason, Medicare has conditioned coverage of FDG-PET under the NOPR on the collection of clinical data. These data will be used to help determine the clinical utility of FDG-PET for conditionally covered cancers and indications. The billing physician remains responsible for documenting medical necessity, which is required for the coding and billing of both covered and NOPR-eligible PET studies. Eligibility for the NOPR does not constitute a clinical management recommendation for the use of PET for the conditionally covered cancers and indications, by either the Medicare program or NOPR investigators. Referring and interpreting physicians are thus advised to refer to the published literature to better understand the potential limitations of FDG-PET for NOPR-eligible uses.

Cancers and Indications Eligible for Entry in the NOPR

E = Eligible for Entry in NOPR
C = Not Eligible for Entry in NOPR - nationally covered indication currently.
NC = Not Eligible for Entry in NOPR - nationally non-covered indication currently.
NA = Not Applicable

NOTES:

1. Some Medicare carriers include anal cancer in their coverage of "colorectal cancer." For PET facilities served by those carriers, PET for anal cancer diagnosis, initial staging, or restaging/suspected recurrence would be a covered indication.
2. Does not cover initial staging for axillary lymph nodes for breast cancer patients and regional lymph nodes for melanoma patients
3. PET is non-covered for "Diagnosis" of breast cancer to evaluate a suspicious breast mass. However, a patient with suspected breast cancer is eligible for entry in NOPR for the indications (1) "Diagnosis: Unknown Primary Site" in a patient with axillary nodal metastasis but no evident primary breast cancer by conventional evaluation and (2) "Diagnosis: Paraneoplastic Syndrome".
4. Patient must have prior CT or MRI negative for extrapelvic metastatic disease to qualify as a covered indication. Patients who do not qualify for covered indication (e.g., because CT or MRI not done or because either showed extrapelvic metastatic disease) can be entered on NOPR.
5. To qualify as a covered indication thyroid cancer must be of follicular cell origin and been previously treated by thyroidectomy and radioiodine ablation and have a serum thyroglobulin > 10ng/ml and negative I-131 whole body scan. Patients who do not qualify for covered indication (e.g., because tumor of other than follicular cell origin or thyroglobulin not elevated) can be entered on NOPR.

GENERAL NOTE:

PET imaging of the brain with CPT code 78608 for diagnosis, initial staging, treatment monitoring, or restaging/suspected recurrence of any type of cancer is covered only under NOPR.