TL;DR: The Centers for Medicare & Medicaid Services retired the umbrella NCD 211 for Positron Emission Tomography (PET) scans effective January 1, 2022, with this policy update formally documented under revision 11892 (effective April 10, 2023) and carrying forward into 2026 billing guidance. Coverage authority for PET indications not addressed by a specific NCD under section 220.6 now sits with your Medicare Administrative Contractor — not CMS nationally.
This is a structural shift that billing teams still get wrong three years in. If your organization bills PET scans for oncologic or non-oncologic indications that don't fall under a named NCD in section 220.6, your coverage policy is now a local determination — meaning your MAC's local coverage determinations (LCDs) and local coverage articles govern reimbursement, not a single national rule. The policy does not list specific CPT or HCPCS codes because the retired NCD operated as an umbrella; the codes themselves are addressed within the individual NCDs under section 220.6 that remain in force.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Centers for Medicare & Medicaid Services (CMS) |
| Policy | Positron Emission Tomography (PET) Scans — RETIRED |
| Policy Code | NCD 211 (Section 220.6) |
| Change Type | Modified (Umbrella NCD Retirement Formally Documented) |
| Effective Date | January 1, 2022 (Revision 11892 effective April 10, 2023; policy key 211-v7 updated March 7, 2026) |
| Impact Level | High |
| Specialties Affected | Nuclear Medicine, Radiology, Oncology, Neurology, Cardiology, Internal Medicine |
| Key Action | Identify every PET indication your practice bills and confirm whether it falls under a surviving section 220.6 NCD or now requires MAC-level LCD review before submitting claims |
CMS PET Scan Coverage Criteria and Medical Necessity Requirements 2026
The short version: CMS no longer has one national rule that governs whether PET scans are covered under Medicare. The umbrella NCD under section 220.6 was retired effective January 1, 2022.
What replaced it depends entirely on the specific indication you're billing. If a PET indication is addressed by one of the surviving NCDs under section 220.6 — think specific oncologic uses that CMS has historically addressed at the national level — those coverage determinations remain intact. MACs cannot alter coverage for indications that still carry an NCD. That protection is explicit in the policy language.
For every PET indication not covered by a surviving section 220.6 NCD, your Medicare Administrative Contractor now makes the medical necessity determination under section 1862(a)(1)(A) of the Social Security Act. That's the provision requiring that services be "reasonable and necessary." In practice, this means your MAC's LCD — and any associated billing article — is now your coverage policy for those indications.
This matters because MACs don't all agree. A PET indication that your MAC covers without prior authorization today might require it if your MAC revises its LCD. Billing teams that assumed CMS retired the umbrella NCD and nothing else changed are the ones seeing claim denials they don't understand.
The policy does not list specific CPT or HCPCS codes directly — no codes are enumerated in NCD 211 itself. Applicable PET codes are embedded in the individual NCDs under section 220.6 that remain active. If you're trying to confirm whether a specific PET claim is covered under Medicare in 2026, you have to trace the indication to either a surviving section 220.6 NCD or your MAC's LCD.
Coverage Indications at a Glance
The table below reflects the structural framework established by the NCD 211 retirement. Because the policy document does not enumerate specific indications within the umbrella NCD itself — those live in the individual NCDs under section 220.6 — this table maps the coverage authority rather than individual clinical indications.
| Indication Category | Coverage Status | Authority | Notes |
|---|---|---|---|
| PET indications with a surviving specific NCD under section 220.6 | Covered (per existing NCD terms) | CMS National | MACs cannot alter these; coverage criteria unchanged from respective NCD |
| PET indications previously non-covered under a section 220.6 NCD | Not Covered | CMS National | Non-covered NCD designations also remain in force; MACs cannot override |
| PET indications NOT addressed by any section 220.6 NCD — oncologic | MAC Determination | Local (MAC LCD) | Coverage varies by contractor jurisdiction; check your MAC's current LCD |
| PET indications NOT addressed by any section 220.6 NCD — non-oncologic | MAC Determination | Local (MAC LCD) | Same MAC-level authority; prior auth requirements vary by MAC |
If you're uncertain which category a specific PET indication falls into for your patient population, that's not a billing team judgment call alone. Loop in your compliance officer before March 7, 2026 reporting deadlines, or before submitting claims under any assumption about coverage status.
CMS PET Scan Billing Guidelines and Action Items 2026
This is where most billing teams have left money on the table — or triggered avoidable denials — since 2022. The NCD retirement didn't come with a billing playbook. Here's how to build one now.
| # | Action Item |
|---|---|
| 1 | Audit every PET indication in your charge capture against the surviving section 220.6 NCDs. Pull your MAC's published list of active LCDs and map each PET indication your practice bills to either an active NCD or an LCD. If you haven't done this since January 2022, do it now. The policy change is three years old, but the 2026 revision to policy key 211-v7 is a signal to verify your current workflow reflects the post-retirement reality. |
| 2 | Contact your MAC directly to confirm which PET indications it covers locally. Your MAC's website publishes its active LCDs. Search by procedure or by the relevant HCPCS/CPT codes embedded in the surviving section 220.6 NCDs. Do not assume your prior authorization workflow covers all PET indications the same way — local determinations often have different prior auth requirements than national ones did. |
| 3 | Update your denial management protocols to flag MAC-level denials on PET claims separately from NCD-based denials. Denials citing section 1862(a)(1)(A) on PET claims post-2022 are MAC decisions, not national coverage decisions. Your appeals process for those claims goes through the MAC, not through an NCD coverage framework. Train your billing team on that distinction before it costs you on a round of appeals. |
| 4 | Review the SPECT cross-reference (NCD section 220.12) if your practice bills both PET and SPECT imaging. The policy explicitly cross-references the SPECT NCD. If you're billing both modalities for similar indications, confirm that the SPECT NCD hasn't been similarly retired or modified in a way that affects your claims. |
| 5 | Flag any PET claims billed under non-oncologic indications for MAC LCD verification. Non-oncologic PET use was always narrower under the old national framework. Post-retirement, those indications are fully local determinations — and the reimbursement landscape across MACs for non-oncologic PET is not uniform. If your MAC hasn't published a clear LCD for a non-oncologic PET indication you bill, that's a prior authorization conversation to have before the claim goes out. |
| 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 (policy key 211-v7) does not enumerate specific CPT, HCPCS, or ICD-10 codes. This is consistent with the nature of the retirement — the umbrella NCD operated as a framework that deferred code-level specificity to the individual NCDs under section 220.6.
To identify the exact codes governing a specific PET indication under Medicare coverage policy in 2026, you need to:
- Reference the individual surviving NCDs under section 220.6 — each contains the applicable codes for its covered indication
- Check your MAC's active LCDs for PET indications now governed locally — LCDs will list covered HCPCS codes and any applicable ICD-10-CM diagnosis codes required for medical necessity
Billing a PET claim without confirming the applicable code set against either a surviving section 220.6 NCD or your MAC's LCD is the fastest path to a claim denial. There is no single national code table for PET coverage anymore — that's the direct consequence of the umbrella NCD retirement.
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