PET for Perfusion of the Heart — NCD 292 | CMS Coverage Update

TL;DR: The Centers for Medicare & Medicaid Services modified NCD 292, the national coverage determination governing cardiac PET perfusion imaging, with an updated policy date of January 9, 2026. Here's what billing teams need to know.

This CMS cardiac PET perfusion coverage policy has been in place since 1995 — but the January 2026 modification gives billing teams a reason to review their workflows now. NCD 292 in the Medicare system covers PET scans using two FDA-approved radiopharmaceuticals: Rubidium 82 (Rb 82) and Ammonia N-13. The policy does not list specific CPT or HCPCS codes in its current form, so you'll need to cross-reference your MAC's local billing guidance for code-level detail.

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Quick-Reference Table

Field	Detail Copy
Payer	CMS (Centers for Medicare & Medicaid Services)
Policy	PET for Perfusion of the Heart — NCD 292
Policy Code	NCD 292
Change Type	Modified
Effective Date	2026-01-09
Impact Level	Medium
Specialties Affected	Cardiology, Nuclear Medicine, Radiology
Key Action	Audit your PET perfusion claims to confirm the PET-replaces-SPECT or post-inconclusive-SPECT rule is documented before billing Medicare

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CMS Cardiac PET Perfusion Coverage Criteria and Medical Necessity Requirements 2026

NCD 292 covers cardiac PET perfusion imaging under a specific two-path structure. Your team needs to understand this structure before submitting any claim.

Path 1: PET in place of SPECT. CMS covers a PET scan — whether at rest alone or rest with pharmacological stress — when it replaces a SPECT entirely. The PET scan cannot be billed in addition to a SPECT. It must substitute for it.

Path 2: PET after an inconclusive SPECT. CMS also covers the PET scan when a prior SPECT came back inconclusive. "Inconclusive" has a precise definition here: the SPECT results were equivocal, technically uninterpretable, or discordant with the patient's other clinical data. That determination must be documented in the patient's file. No documentation, no coverage.

Both paths apply only to patients with known or suspected coronary artery disease. That's the core medical necessity gate. If the indication isn't CAD — documented and supported in the chart — you have a denial risk.

The CMS cardiac PET perfusion coverage policy covers two radiopharmaceuticals. Rubidium 82 (Rb 82) has been covered since March 14, 1995. Ammonia N-13 has been covered since October 1, 2003. If your facility uses a different tracer, that tracer is not covered under this NCD.

For Path 2 claims, the documentation must also show that the PET scan was considered necessary to determine what medical or surgical intervention the patient requires. That's a higher bar than just ordering a follow-up scan. Your clinical documentation needs to make that case explicitly.

Prior authorization is not explicitly required under this NCD as written. That said, your Medicare Administrative Contractor may have additional local coverage determination requirements layered on top of NCD 292. Check with your MAC before assuming prior auth isn't a factor for your region.

Reimbursement under this policy depends on correct code selection and documentation of which path applies. Without clear path documentation in the chart, your billing team has no foundation to support the claim.

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CMS Cardiac PET Perfusion Exclusions and Non-Covered Indications

The CMS cardiac PET perfusion coverage policy is narrow by design. If the claim doesn't fit cleanly into one of the two covered paths, it's not covered.

The biggest exclusion is billing PET in addition to SPECT. If both scans are performed and billed together, Medicare will not cover the PET scan under this NCD. This comes up more often than it should. Train your ordering workflow to flag cases where both scans are ordered concurrently.

Any tracer other than Rb 82 or Ammonia N-13 falls outside this coverage policy. PET perfusion using other radiopharmaceuticals is not addressed by NCD 292 and would not be covered under this determination.

Inconclusive SPECT documentation gaps are a soft exclusion. The policy technically allows PET after an inconclusive SPECT — but if the patient file doesn't document that the SPECT was inconclusive and why, the claim has no support. A claim denial in this scenario isn't a coverage issue. It's a documentation issue that your team can prevent.

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Coverage Indications at a Glance

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CMS Cardiac PET Perfusion Billing Guidelines and Action Items 2026

The modification date is January 9, 2026. Review your workflows against these action items now.

Copy Action Items

If you're not sure how your payer mix or your MAC's LCD interacts with NCD 292, loop in your compliance officer before the effective date of January 9, 2026.

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CPT, HCPCS, and ICD-10 Codes for Cardiac PET Perfusion Under NCD 292

The current NCD 292 policy document does not list specific CPT or HCPCS codes. This is a known limitation of how this NCD is published by CMS.

For cardiac PET perfusion billing, your code selection depends on your MAC's local billing guidelines and the current Medicare fee schedule. Contact your Medicare Administrative Contractor directly for the applicable codes in your jurisdiction.

Cross-Referenced CMS Policies

NCD 292 cross-references two related national coverage determinations. Both are relevant to cardiac PET perfusion billing and should be reviewed alongside this policy:

Policy	Reference Copy
PET Scans — General	NCD §220.6
SPECT	NCD §220.12

Review both cross-referenced NCDs before finalizing your cardiac imaging billing guidelines. The SPECT NCD (§220.12) is especially relevant because NCD 292's coverage rules depend on the relationship between PET and SPECT in the clinical workflow.

A Note on Historical Billing Codes

The policy references special G codes that were used for PET scans billed with Rb 82 for dates of service prior to July 1, 2001. Those G codes are no longer applicable. Current claims should use standard coding per your MAC's current instructions.

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