FDG PET for Refractory Seizures — NCD 294 | CMS Coverage Update

TL;DR: The Centers for Medicare & Medicaid Services modified NCD 294 governing FDG-PET coverage for refractory seizures, with a policy review date of January 9, 2026. This policy does not list specific CPT or HCPCS codes, so billing teams need to cross-reference the general PET scan NCD (§220.6) to confirm correct code use.

CMS FDG-PET Refractory Seizure Coverage Criteria and Medical Necessity Requirements 2026

The CMS FDG-PET refractory seizures coverage policy under NCD 294 has a narrow, specific scope. Medicare covers FDG-PET for pre-surgical evaluation only, and only when the purpose is to localize a focus of refractory seizure activity. That single sentence defines both the coverage and the limit.

If your team bills FDG-PET for any other seizure-related indication — monitoring treatment response, general workup, or follow-up imaging — that claim does not meet medical necessity under this policy. The Centers for Medicare & Medicaid Services drew a hard line at pre-surgical evaluation, and it has not moved since the NCD's original review in June 2001.

The prior authorization question comes up here often. NCD 294 does not specify a prior authorization requirement on its face. But your Medicare Administrative Contractor may have local rules that apply. Check with your MAC before assuming a clean prior auth pathway, especially for high-cost imaging like FDG-PET.

The referring physician owns the documentation burden. The policy states clearly that documentation showing the coverage criteria are met must be maintained in the beneficiary's medical record. This is not optional, and it is not your department's job to generate it — but it is your job to confirm it exists before billing.

Medical necessity documentation for FDG-PET refractory seizure billing needs to show three things: the patient has refractory seizures, surgery is being considered, and the scan is intended to localize the seizure focus. If any of those elements are missing from the chart, your claim is exposed.

CMS FDG-PET Refractory Seizures Exclusions and Non-Covered Indications

NCD 294 is short, but its exclusions are clear. Coverage applies only to pre-surgical evaluation. Everything else is out.

Post-surgical imaging is not covered under this NCD. Diagnostic workup for new-onset seizures is not covered. Monitoring seizure activity in patients who are not surgical candidates is not covered. If the patient's chart does not reflect active pre-surgical planning, the medical necessity argument falls apart at audit.

This is one of those policies where the coverage language is simple, but the claim denial risk is high. Billing teams get into trouble when they assume "refractory seizures" is enough to justify the scan. It is not. The scan has to be tied specifically to pre-surgical localization.

Coverage Indications at a Glance

CMS FDG-PET Refractory Seizures Billing Guidelines and Action Items 2026

The policy's effective date is January 9, 2026. Here is what your team should do now.

If your practice runs a high volume of epilepsy surgery evaluations, loop in your compliance officer before the effective date. The policy is straightforward on paper, but high-volume FDG-PET billing against a narrow NCD is exactly the kind of pattern that draws post-payment review.

CPT, HCPCS, and ICD-10 Codes for FDG-PET Refractory Seizures Under NCD 294

Covered CPT Codes (When Selection Criteria Are Met)

The policy data for NCD 294 does not list specific CPT or HCPCS codes. This is not unusual for older NCDs — the code-level detail lives in the cross-referenced PET Scans NCD at §220.6. Your FDG-PET refractory seizure billing codes must be pulled from that document.

For FDG-PET refractory seizure billing, check NCD §220.6 and your MAC's current billing instructions under Transmittal 527 of the Medicare Claims Processing Manual. That transmittal is the claims processing reference CMS cites directly in NCD 294.

Do not assume that codes valid for other PET indications automatically apply here. Confirm code applicability specifically for the pre-surgical seizure localization indication before updating your charge capture.

Key ICD-10-CM Diagnosis Codes

NCD 294 does not list specific ICD-10-CM codes. Your diagnosis coding must support the clinical scenario described in the NCD: refractory seizures with pre-surgical evaluation as the purpose of the scan. Work with your coding team and clinical documentation to confirm the diagnosis codes on the claim accurately reflect that clinical picture.

What the 2026 Policy Review Means for Billing Teams

This policy has not been substantively changed since June 2001. The January 9, 2026 review date signals CMS looked at it again — but the coverage criteria remain unchanged.

The real issue here is not what changed. The real issue is whether your team has been billing this correctly all along. A policy review like this is CMS putting the NCD back on the radar. That often precedes audit activity, even when the coverage language itself doesn't shift.

FDG-PET for refractory seizures is a high-cost service. Medicare reimbursement for PET imaging is significant, and the coverage policy is narrow. That combination is exactly what recovery audit contractors look for. A clean chart, a clear pre-surgical evaluation purpose, and the right code from NCD §220.6 are your best defenses.

The billing guidelines here are simple. The documentation requirements are simple. The exposure comes from teams that don't treat a narrow coverage policy with the discipline it requires.