TL;DR: The Centers for Medicare & Medicaid Services retired the umbrella NCD 211 for PET scans effective January 1, 2022, shifting coverage decisions for most PET indications to Medicare Administrative Contractors. Here's what billing teams need to know now.
This policy update — officially logged as NCD 211 v7 with an effective date of March 7, 2026 — formalizes the retirement of the overarching CMS PET scan coverage policy under section 220.6. Coverage authority for oncologic and non-oncologic PET uses not governed by a separate NCD now sits with your MAC, not with a national determination. This policy does not list specific CPT or HCPCS codes, which is itself a signal your billing team needs to act on.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS |
| Policy | Positron Emission Tomography (PET) Scans — RETIRED |
| Policy Code | NCD 211 (section 220.6) |
| Change Type | Modified |
| Effective Date | 2026-03-07 |
| Impact Level | High |
| Specialties Affected | Nuclear medicine, oncology, radiology, neurology, cardiology |
| Key Action | Identify your MAC and pull their current local coverage determinations for all PET indications you bill |
CMS PET Scan Coverage Criteria and Medical Necessity Requirements 2026
The real issue here is what "retired umbrella NCD" actually means for your claims. It does not mean PET coverage disappeared. It means the national rule that governed PET broadly no longer exists. What replaced it is a patchwork of local coverage determinations set by each MAC — and those vary.
The CMS PET scan coverage policy under NCD 211 originally sat as an umbrella over all PET indications. Under it, specific sub-NCDs within section 220.6 covered oncologic indications, non-oncologic indications like cardiac and neurological applications, and the registry-based coverage pathway. Those sub-NCDs still stand. Your MAC cannot change coverage for indications already locked in under a current 220.6 NCD.
Where your team needs to pay attention is everything outside those remaining 220.6 NCDs. For any PET indication not explicitly addressed by a surviving NCD, your MAC now makes the call. That means medical necessity criteria, documentation requirements, and prior authorization rules will differ depending on which MAC covers your jurisdiction. What Novitas allows, NGS may not.
PET scan billing under this structure requires you to know two things before submitting a claim: whether the indication has an active NCD, and if not, what your MAC's LCD says. Skipping either step is how you generate a claim denial that takes months to resolve.
CMS PET Scan Coverage at a Glance
This table reflects the structure CMS established when it retired NCD 211. The remaining 220.6 sub-NCDs govern specific indications. Everything else falls to MAC discretion.
| Indication Category | Status | Coverage Authority | Notes |
|---|---|---|---|
| Oncologic PET indications with active 220.6 sub-NCD | Covered (per existing NCD) | CMS national | MACs cannot alter coverage for these indications |
| Non-oncologic PET indications with active 220.6 sub-NCD | Covered (per existing NCD) | CMS national | MACs cannot alter coverage for these indications |
| Oncologic PET indications NOT in a 220.6 sub-NCD | Determined by MAC | Medicare Administrative Contractor | Check your MAC's LCD; no national rule applies |
| Non-oncologic PET indications NOT in a 220.6 sub-NCD | Determined by MAC | Medicare Administrative Contractor | Check your MAC's LCD; no national rule applies |
| PET indications previously non-covered under 220.6 | Non-covered (status unchanged) | CMS national | Retirement did not flip previously non-covered indications to covered |
Cross-reference: CMS also directs billing teams to SPECT coverage under NCD section 220.12 for related nuclear medicine imaging.
What the NCD 211 Retirement Actually Means for Reimbursement
This change hurts billing teams more than it helps them. A national coverage determination gives you predictability. Every Medicare patient, every jurisdiction — the rule is the same. MAC-level local coverage determinations fragment that. You now have to track LCD policies from your specific contractor, and those policies update on their own schedule.
The reimbursement question is real. When coverage is MAC-determined, so is the medical necessity standard your documentation has to meet. A claim that passes muster under one MAC's LCD may fail under another's. If your practice has locations in multiple MAC jurisdictions, you may be running two different documentation protocols for the same PET indication.
PET scan billing guidelines under this structure also mean your prior authorization process may change. Some MACs require prior authorization for PET indications they cover through an LCD. Others don't. Check your MAC's requirements before you assume the pre-retirement process still applies.
CMS PET Scan Billing Guidelines and Action Items 2026
The effective date on this policy version is March 7, 2026. If your billing team hasn't already adjusted your workflows to the MAC-authority model — which technically took effect January 1, 2022 — you're overdue. Here's what to do now.
| # | Action Item |
|---|---|
| 1 | Identify your MAC and pull every active LCD covering PET scans. Go to the CMS Coverage Database and filter by your MAC. Download current LCDs for all PET indications you bill. This is your new source of truth for medical necessity criteria on any indication without a 220.6 NCD. |
| 2 | Audit your charge capture against surviving 220.6 sub-NCDs. List every PET indication your practice bills. For each one, confirm whether it falls under an active NCD in section 220.6 or whether it's now MAC-determined. This split defines two different documentation and billing tracks. |
| 3 | Update your prior authorization workflow by indication. Some PET indications under MAC LCDs require prior authorization. Others don't. Don't assume the old NCD-era rules still apply. Call your MAC or check their LCD documentation articles for current prior auth requirements. |
| 4 | Review your medical necessity documentation templates. LCD-based medical necessity criteria are often more specific — and more stringent — than NCD criteria were. Pull your MAC's LCD language and update your physician documentation templates to match. A claim denial for insufficient medical necessity documentation is preventable if the template captures what the LCD requires. |
| 5 | Flag any PET indication that previously relied solely on the umbrella NCD. If you were billing a PET indication that wasn't in a specific 220.6 sub-NCD and assumed the umbrella NCD covered it, that coverage pathway is gone. Verify your MAC has an LCD for that indication. If they don't, coverage may simply not exist — and billing it risks denial and potential overpayment liability. |
| 6 | Set a calendar reminder to check MAC LCD updates quarterly. Unlike NCDs, MACs update LCDs on their own schedule. There's no single effective date to track. Build a quarterly review into your revenue cycle calendar so you catch LCD changes before they generate surprise denials. |
If you bill PET across multiple MAC jurisdictions, loop in your compliance officer before March 15, 2026 to map each jurisdiction's LCD requirements. The exposure from jurisdiction-to-jurisdiction variation is significant.
| 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 NCD 211
The policy data for NCD 211 v7 does not list specific CPT or HCPCS codes. That absence is meaningful. Under the retired umbrella structure, CPT codes for PET scans are now governed either by the surviving 220.6 sub-NCDs or by your MAC's LCD billing guidelines — not by this umbrella NCD.
CMS does not publish a centralized code list under NCD 211 because the policy's function is structural, not granular. It transfers coverage authority, not specific code coverage.
What this means for your billing team:
- PET scan CPT codes (including codes for FDG and non-FDG PET, PET/CT combinations, and perfusion studies) are covered or non-covered based on the specific sub-NCD or MAC LCD that governs each indication.
- You must look up applicable codes within each surviving 220.6 sub-NCD or your MAC's LCD documentation articles.
- ICD-10-CM diagnosis codes that support medical necessity are likewise defined at the sub-NCD or LCD level, not here.
Do not bill PET claims based on NCD 211 as a standalone coverage authority. It no longer functions that way. Route your code-level questions to the specific NCD or LCD that covers the clinical indication you're billing.
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