Summary: The Centers for Medicare & Medicaid Services modified its FDG PET coverage policy for cancer indications not previously specified, effective May 15, 2026, retiring the standalone policy and replacing it with Section 220.6.17. Here's what billing teams need to do before that date.
This change closes a long-standing Medicare coverage pathway that many oncology and nuclear medicine billing teams have relied on for FDG PET claims outside of the explicitly listed tumor types. The retired policy is replaced by Section 220.6.17 of the Medicare National Coverage Determinations Manual. The policy does not list specific CPT, HCPCS, or ICD-10 codes in the available data — but that doesn't reduce the urgency. If your team bills FDG PET for any cancer indication, this affects your reimbursement and claim denial risk starting May 15, 2026.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | FDG PET for All Other Cancer Indications Not Previously Specified — RETIRED, Replaced with Section 220.6.17 |
| Policy Code | N/A |
| Change Type | Modified (Retirement and Replacement) |
| Effective Date | May 15, 2026 |
| Impact Level | High |
| Specialties Affected | Nuclear Medicine, Oncology, Radiology, Hematology/Oncology, Radiation Oncology |
| Key Action | Audit all FDG PET claims billed under the catch-all cancer indication pathway and confirm coverage under Section 220.6.17 before May 15, 2026 |
CMS FDG PET Coverage Criteria and Medical Necessity Requirements 2026
The core issue here is consolidation. CMS is retiring the catch-all NCD that covered FDG PET for cancer types not explicitly addressed elsewhere in Medicare policy. That coverage now lives entirely under Section 220.6.17 of the NCD Manual.
For years, the "all other cancer indications" NCD functioned as a safety valve. When a provider ordered FDG PET for a tumor type not listed in the named-indication policies, this coverage policy provided a path to reimbursement — subject to the Coverage with Evidence Development (CED) framework. That framework required claims to be tied to a CMS-approved registry or clinical trial. That requirement was not optional, and many claim denials over the years stemmed from providers missing that step.
Section 220.6.17 now absorbs and governs this territory. What that means in practice: the medical necessity criteria, CED requirements, and coverage conditions that previously applied under the retired policy now exist within a single consolidated framework. The Centers for Medicare & Medicaid Services has made this a structural change, not just a renaming exercise.
If you've been billing FDG PET under the assumption that the old policy's rules still apply, verify that assumption against Section 220.6.17 now. Don't wait until May 14 to figure out whether your workflows still hold up.
The medical necessity bar for FDG PET under Medicare has always been stringent. CMS requires that the scan be used for one of three purposes: diagnosis, staging, or restaging of a cancer. Management decisions — like whether to continue or change treatment — also fall within covered use in certain contexts. But "ordered by an oncologist" is not, by itself, sufficient to establish medical necessity under Medicare billing guidelines.
Prior authorization is not universally required for FDG PET under Medicare fee-for-service, but Medicare Advantage plans vary significantly. If your patient population includes MA enrollees, check each plan's prior authorization requirements separately. This retirement of the old policy is a signal that MA plans may update their own policies in response — watch for that through Q3 2026.
CMS FDG PET Exclusions and Non-Covered Indications
The policy data provided does not include a specific exclusions list from the retired NCD or Section 220.6.17. However, based on the structure of Medicare's FDG PET coverage framework, there are well-established non-covered scenarios your billing team should keep in mind.
FDG PET ordered solely for screening — without a confirmed or strongly suspected cancer diagnosis — is not covered. Medicare does not cover PET scans as a general cancer screening tool.
Repeat scans for restaging where clinical documentation does not support a change in the patient's condition represent a high-risk area for claim denial. CMS reviewers and Medicare Administrative Contractors look closely at whether the ordering provider documented a clinical question that the PET scan was intended to answer.
Claims submitted without documentation tying the scan to an approved registry or clinical trial — when Coverage with Evidence Development conditions apply — will not be reimbursed. This has been a consistent audit finding for years. The consolidation into Section 220.6.17 does not eliminate CED requirements; it may sharpen them.
If you're uncertain how the exclusion criteria in Section 220.6.17 map to your current billing patterns, loop in your compliance officer before May 15, 2026.
Coverage Indications at a Glance
The policy data does not provide a specific indication-by-indication breakdown for the retired policy or Section 220.6.17. The table below reflects the general framework that CMS has historically applied to FDG PET coverage for cancer indications, based on the structure of Medicare's NCD framework. Confirm specific indications against Section 220.6.17 directly.
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Named cancer types with explicit NCD coverage | Covered | See individual NCDs | Governed by separate named-indication policies, not this retired NCD |
| Cancer types not previously specified — CED-eligible | Covered with Conditions | Not listed in available data | Must be enrolled in CMS-approved registry or trial; now governed by Section 220.6.17 |
| Diagnosis / initial staging | Covered (when criteria met) | Not listed in available data | Medical necessity documentation required |
| Restaging after treatment | Covered (when criteria met) | Not listed in available data | Must document clinical change or decision point |
| Cancer screening without confirmed diagnosis | Not Covered | Not listed in available data | Not an approved FDG PET indication under Medicare |
| Staging without CED compliance (where required) | Not Covered | Not listed in available data | Claims without registry enrollment will be denied |
CMS FDG PET Billing Guidelines and Action Items 2026
This is where the work is. The retirement of a policy and its replacement with a new section is exactly the kind of change that creates billing gaps — not because the coverage changed dramatically, but because teams keep following the old workflow after the structure underneath it shifted.
| # | Action Item |
|---|---|
| 1 | Pull Section 220.6.17 now. Download the current version of the NCD Manual Section 220.6.17 from CMS.gov. Read it against your current FDG PET billing guidelines and identify any gaps before May 15, 2026. Don't rely on summaries — read the source. |
| 2 | Audit claims billed under the "all other indications" pathway. Identify every FDG PET claim your team submitted in the last 12 months that was coded under the catch-all cancer indication framework. Verify those claims had proper CED documentation. If they didn't, assess your retroactive exposure before this policy change draws auditor attention. |
| 3 | Update your charge capture and order entry workflows. If your EHR or billing system references the retired policy anywhere — in templates, order sets, or billing rules — update those references to Section 220.6.17. Stale policy references are a common source of claim denial that's entirely preventable. |
| 4 | Confirm CED registry enrollment for applicable patients. If you're billing FDG PET for cancer indications that require Coverage with Evidence Development, verify that each patient is enrolled in an approved registry or clinical trial. Document that enrollment in the claim file. This is not new — but the consolidation into Section 220.6.17 is a good forcing function to audit your current compliance. |
| 5 | Check Medicare Advantage plan policies for downstream changes. MA plans often update their own coverage policies in response to CMS NCD changes. Contact your top MA payers and ask whether they're updating their FDG PET coverage policy in response to this retirement. Do this before May 15, 2026 — not after your first denial. |
| 6 | Brief your ordering physicians. Oncologists and nuclear medicine physicians need to know that medical necessity documentation standards haven't loosened under the new structure. If anything, consolidation creates more scrutiny. The clinical question the PET scan is answering must be explicit in the order and the chart. |
| 7 | Talk to your compliance officer if you have volume exposure. If FDG PET represents significant revenue for your practice or facility, this is not a change to handle informally. Have your compliance officer review your current billing guidelines against Section 220.6.17 and document that review before the effective date. |
| 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 FDG PET Under the Retired CMS Cancer Indication Policy
The policy data provided does not list specific CPT, HCPCS, or ICD-10 codes for this policy change. Do not assume code applicability based on this post alone.
FDG PET billing typically involves a small set of well-known codes, but the correct codes depend on the specific indication, scanner type, and clinical context. Section 220.6.17 in the NCD Manual is your authoritative source for which codes are covered and under what conditions.
To get the definitive code list:
- Review Section 220.6.17 of the Medicare NCD Manual directly at CMS.gov
- Check with your Medicare Administrative Contractor for any local coverage determination guidance that applies in your region
- Use the CMS Coverage Database to search for FDG PET and confirm all applicable policy sections
Your MAC is the right contact if you have questions about how the transition from the retired policy to Section 220.6.17 affects claims in your specific jurisdiction. Local coverage determination guidance from your MAC may add criteria or documentation requirements beyond what the NCD specifies.
Get the Full Picture
Track this policy across versions, search 1,500+ policies by CPT code, and get real-time alerts when any payer changes coverage.