Positron Emission Tomography (PET) Scans - RETIRED | CMS Coverage Update

Summary: The Centers for Medicare & Medicaid Services modified its Positron Emission Tomography (PET) Scans coverage policy, effective June 5, 2026, retiring the existing policy document. Here's what billing teams need to know before that date.

CMS PET scan coverage policy has long governed which oncologic, cardiac, and neurological indications qualify for Medicare reimbursement. The retirement of this policy signals a structural change in how CMS manages PET scan billing guidelines — and your team needs to understand what that means for claims submitted on or after June 5, 2026. This policy does not list specific CPT or HCPCS codes in the available data; work from your current charge capture and cross-reference the CMS coverage policy source directly.

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Quick-Reference Table

Field	Detail Copy
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 5, 2026
Impact Level	High
Specialties Affected	Oncology, Nuclear Medicine, Radiology, Cardiology, Neurology
Key Action	Audit all active PET scan billing workflows before June 5, 2026, and confirm which NCD or LCD now governs coverage for your indications

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CMS PET Scan Coverage Criteria and Medical Necessity Requirements 2026

The retirement of a CMS coverage policy doesn't mean coverage disappears. It means the document that housed the medical necessity criteria, coverage indications, and billing rules no longer exists as a standalone policy. What replaces it — and where — is the question your billing team needs to answer before June 5, 2026.

CMS manages PET scan coverage through a combination of National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) issued by Medicare Administrative Contractors (MACs). When a standalone policy like this one is retired, the controlling authority for medical necessity decisions shifts. That shift may go to an existing NCD, to your MAC's LCD, or to the Medicare Benefit Policy Manual. You need to know which one applies to your claims.

PET scans have historically required strong medical necessity documentation. Coverage has tied to specific cancer types, stages, and intended use — initial diagnosis versus restaging versus monitoring treatment response. That structure doesn't vanish when a policy retires, but the document you've been citing on appeal letters and prior authorization requests does.

Check with your compliance officer before the effective date of June 5, 2026. If your team routinely cites this CMS policy in appeals or prior auth submissions, you need a new source document ready to go.

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What "Retired" Actually Means for CMS PET Scan Billing

A policy retirement is different from a policy revision. A revision changes criteria. A retirement removes the document entirely from active status.

This matters for PET scan billing because retirement can mean a few things. CMS may be consolidating PET scan coverage under a broader NCD. It may be deferring more coverage decisions to MAC-level LCDs. Or it may be integrating the criteria into updated coverage determination infrastructure. None of these outcomes is inherently bad — but all of them require your billing team to act.

The real issue here is documentation. If your charge capture, superbill, or prior authorization workflow references this specific policy as the coverage authority, that reference breaks on June 5, 2026. Claims that cite a retired policy as medical necessity justification are denial bait.

Run a search of your payer correspondence templates, appeal letter boilerplates, and prior auth forms. Anywhere this policy appears as a citation, update it before June 5.

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CMS PET Scan Exclusions and Non-Covered Indications

Because no specific policy detail is available in the source data for this retirement, this section can't enumerate what CMS excluded under the retired document. That's not a gap you can leave open.

Pull the retired policy directly from the CMS source before June 5, 2026, and document the exclusions that applied. Your team needs that list for two reasons. First, if coverage moves to a MAC LCD, the exclusions may shift — some indications previously covered may no longer be, and vice versa. Second, if you've been billing on the edge of covered indications, the coverage policy transition is exactly when those claims start getting flagged.

For PET scans, the historically non-covered territory has included routine surveillance without evidence of recurrence, non-oncologic indications with insufficient evidence, and uses where a lower-cost imaging modality was considered adequate. Whether those exclusions carry forward under whatever replaces this policy depends on your MAC and the new controlling authority.

Talk to your MAC's provider relations team. Get the current LCD number for PET scans in your jurisdiction before the effective date.

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Coverage Indications at a Glance

Because no policy detail is available in the source data, this table reflects the general CMS PET scan coverage framework based on known NCD and LCD history. Verify each indication against the current controlling document in your jurisdiction before June 5, 2026. Do not rely on this table as a substitute for the actual coverage policy.

This table is a starting point, not a billing guide. The retired policy's specific criteria are what controlled claims before June 5, 2026. What controls after that date depends on CMS's replacement structure.

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CMS PET Scan Billing Guidelines and Action Items 2026

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If your practice has high PET scan volume — oncology, nuclear medicine, cardiology — loop in your compliance officer before June 5, 2026. The stakes on a misrouted coverage authority are real, and this is the kind of transition that creates audit exposure if it's not managed deliberately.

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CPT, HCPCS, and ICD-10 Codes for PET Scans Under This Policy

The available policy data for this retirement does not include specific CPT, HCPCS, or ICD-10 codes. Do not rely on this post for a definitive code list.

For accurate PET scan billing codes under the current Medicare coverage framework, cross-reference the following sources directly:

• Your MAC's active LCD for PET scans (search your MAC's website by procedure or specialty)
• The CMS NCD Manual for any applicable National Coverage Determinations
• The CMS Medicare Coverage Database, searchable by procedure type

PET scan billing has historically involved codes in the nuclear medicine and diagnostic imaging families. The specific codes that map to covered indications — and the diagnosis codes required to support medical necessity — are controlled by the LCD or NCD that replaces this retired policy. Using the wrong code pairing after the effective date is a fast path to claim denial and potential overpayment liability.

Your billing team should confirm the current active code set with your MAC before June 5, 2026. If your practice management system has a PET scan code list mapped to this retired policy, that mapping needs to be updated.

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