Summary: The Centers for Medicare & Medicaid Services modified its Positron Emission Tomography (PET) Scans coverage policy, effective June 10, 2026, retiring the existing national policy framework. Here's what billing teams need to do before that date.
CMS PET scan coverage policy has governed reimbursement for nuclear medicine imaging across oncology, cardiology, and neurology for years. The retirement of this policy — without a direct replacement named in the record — creates real uncertainty for practices and facilities billing PET scans to Medicare. This policy does not list specific codes in the available data, which makes your own code audit more important, not less.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | Positron Emission Tomography (PET) Scans — RETIRED |
| Policy Code | N/A |
| Change Type | Modified (Retired) |
| Effective Date | June 10, 2026 |
| Impact Level | High |
| Specialties Affected | Oncology, Nuclear Medicine, Cardiology, Neurology, Radiology |
| Key Action | Confirm which NCD or LCD now governs your PET scan claims before June 10, 2026 |
CMS PET Scan Coverage Policy Retirement: What It Means in 2026
When a CMS coverage policy gets retired, it doesn't always mean coverage disappears. It often means coverage authority shifts — from a national-level policy to Medicare Administrative Contractor (MAC)-level Local Coverage Determinations (LCDs), or to another National Coverage Determination (NCD) that absorbs the indications.
That distinction matters enormously for your billing team.
If your MAC now governs PET scan coverage in your region, your medical necessity criteria, documentation requirements, and prior authorization rules may differ from what you've been following. And if you're billing across multiple jurisdictions, you may be operating under different rules in different states starting June 10, 2026.
The real issue here is that a policy retirement creates a gap — even a temporary one — where the rules aren't obvious. Claims filed after the effective date without the right supporting coverage determination behind them are prime candidates for claim denial. Get ahead of this now.
CMS PET Scan Coverage Criteria and Medical Necessity Requirements 2026
PET scan billing under Medicare has always been tightly tied to medical necessity. CMS has historically required specific clinical indications — diagnosis staging, restaging, monitoring treatment response, or detecting recurrence — before approving reimbursement.
The retirement of this coverage policy doesn't eliminate medical necessity requirements. It relocates them.
With the national policy retired, your MAC's LCD for PET scans becomes your primary reference for coverage criteria. Different MACs have published LCDs covering PET scans for specific cancer types, cardiac viability assessment, and neurological conditions including Alzheimer's disease evaluation. If your MAC hasn't published an updated LCD to replace this retired national policy, contact them directly — don't assume the prior criteria still apply without confirmation.
For oncology specifically, CMS has long covered PET scans for diagnosis, staging, and restaging across a wide range of solid tumors. Cardiac PET imaging for myocardial viability has had separate coverage pathways. Neurological PET — particularly amyloid imaging — has been subject to its own NCD framework. Each of these clinical areas may now fall under different coverage authority after June 10, 2026.
Prior authorization requirements for PET scans vary by MAC and by the specific clinical indication. Some Medicare Advantage plans have added prior auth requirements that don't exist in traditional Medicare. If your patients are on Medicare Advantage, confirm those plan-level requirements separately — this retirement applies to traditional Medicare policy, not Medicare Advantage.
The bottom line: your billing team can't rely on institutional memory of what CMS covered under this retired policy. Get the current LCD in writing before June 10, 2026.
Coverage Indications at a Glance
Because this policy does not include specific code data in the available record, and the retirement means coverage authority shifts rather than coverage ending outright, the table below reflects general PET scan indication categories and their likely post-retirement status. Confirm each with your MAC's LCD.
| Indication | Status After Retirement | Relevant Codes | Notes |
|---|---|---|---|
| Oncology — diagnosis, staging, restaging | Likely MAC LCD-governed | Confirm with your MAC | Was broadly covered under prior NCD framework |
| Cardiac myocardial viability | Likely MAC LCD-governed | Confirm with your MAC | May fall under separate cardiac imaging NCD |
| Neurological — Alzheimer's/amyloid imaging | May have separate NCD | Confirm with your MAC | Subject to coverage with evidence development historically |
| Infection/inflammation imaging | Coverage status uncertain | Confirm with your MAC | Was limited under prior policy; verify MAC LCD |
| General screening (no clinical indication) | Not covered | N/A | Medical necessity required; no change expected here |
This table is based on general CMS PET scan coverage history, not the retired policy's specific text. Verify every row against your MAC's current LCD before billing.
CMS PET Scan Billing Guidelines and Action Items 2026
| # | Action Item |
|---|---|
| 1 | Identify your MAC's current LCD for PET scans before June 10, 2026. Go to the CMS Coverage Database and filter by your MAC. Find the active LCD governing PET scans in your jurisdiction. If no LCD exists, contact your MAC's provider outreach team directly. |
| 2 | Audit your charge capture for all PET scan CPT codes. This policy does not list specific codes in the available data, but PET scan billing codes haven't changed — your charge master still carries them. Cross-reference every code against the new coverage authority to confirm which indications remain billable and which require updated documentation. |
| 3 | Update your medical necessity documentation templates. The criteria your coders and physicians have been using may reflect the retired national policy. Pull your MAC's LCD criteria and rebuild your documentation checklist to match. This is the step most teams skip — and the one that generates claim denials six months later. |
| 4 | Confirm prior authorization requirements with each payer. For traditional Medicare, check your MAC. For Medicare Advantage plans, contact each plan separately. Prior auth rules for PET scans have been tightening, and a policy retirement is the kind of event that prompts plan-level updates. |
| 5 | Flag any PET scan claims submitted after June 10, 2026, for early monitoring. Set a 30-day watch on denial rates for PET scan claims after the effective date. If you see a spike, you need to know immediately — not at your next monthly billing review. |
| 6 | Loop in your compliance officer now. If your practice or facility bills high PET scan volume, the retirement of a national coverage policy is a material compliance event. Your compliance officer should know about this change, review your updated billing guidelines, and sign off on the transition plan before June 10, 2026. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for PET Scans Under This Policy
This policy does not list specific CPT, HCPCS, or ICD-10 codes in the available policy data. Do not rely on this post for a definitive code list.
For PET scan billing under Medicare after the effective date of June 10, 2026, get your code-level coverage guidance directly from your MAC's LCD. The CMS Coverage Database at cms.gov/medicare-coverage-database is the authoritative source.
What we can tell you: PET scan CPT codes have historically lived in the nuclear medicine and diagnostic radiology sections of the CPT code set. Your MAC's LCD will specify which codes are covered, which require additional documentation, and which indications are excluded. Don't bill off memory or prior-year superbills after this retirement.
If you need a full code reference, pull the LCD directly and map it to your charge master. That's the only list that matters after June 10, 2026.
What This Retirement Actually Signals
Policy retirements at the national level aren't random housekeeping. They usually signal one of three things: CMS is consolidating coverage authority under a newer NCD, coverage is shifting to MAC-level LCDs, or CMS is updating the underlying evidence review.
For PET scans, the third option is worth watching. CMS has been reassessing coverage with evidence development (CED) requirements for certain PET indications — particularly neurological imaging. A retirement can precede a new NCD with updated clinical criteria, tighter documentation requirements, or expanded coverage for newly approved indications.
Watch the CMS Coverage Database for new NCD activity on PET scans through the rest of 2026. If a replacement policy publishes, it may include coding changes, new medical necessity criteria, or revised prior authorization pathways. Your billing team needs to be ready to update again on short notice.
This is the part of PET scan billing that catches practices off guard. The clinical team orders the scan, the patient gets imaged, and the billing team submits the claim — all before anyone checked whether the coverage policy had changed. That workflow breaks down when a retirement creates a policy gap. Build the coverage check into your pre-authorization workflow now.
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