TL;DR: CMS retired NCD 220.6.10 for FDG PET breast cancer coverage and replaced it with NCD 220.6.17. Billing teams should confirm all FDG PET breast cancer claims reference the current NCD section before submitting.
The Centers for Medicare & Medicaid Services updated NCD 297 on January 9, 2026, marking a formal administrative change to how the FDG PET breast cancer coverage policy is documented in the NCD Manual. The old section — 220.6.10 — has been retired and replaced by section 220.6.17, which has been the operative NCD for FDG PET breast cancer billing since April 3, 2009. This policy does not list specific CPT or HCPCS codes, but it directly affects any oncology or radiology billing team submitting FDG PET claims for breast cancer indications under Medicare.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | FDG PET for Breast Cancer (Replaced with Section 220.6.17) — RETIRED |
| Policy Code | NCD 297 |
| Change Type | Modified |
| Effective Date | January 9, 2026 (retirement formal; operative replacement effective April 3, 2009) |
| Impact Level | Low — administrative retirement, not a clinical coverage change |
| Specialties Affected | Oncology, Radiology, Nuclear Medicine |
| Key Action | Confirm all FDG PET breast cancer claims cite NCD 220.6.17, not the retired 220.6.10 |
CMS FDG PET Breast Cancer Coverage Criteria and Medical Necessity Requirements 2026
Here's the real issue with this update: the clinical coverage policy for FDG PET in breast cancer didn't change on January 9, 2026. It changed in 2009. CMS is now formally removing the old section 220.6.10 from the NCD Manual and pointing everyone to 220.6.17, which has governed FDG PET breast cancer billing for over 15 years.
If your team has been billing correctly, you've been working off 220.6.17 already. But if anyone on your team — or in your clearinghouse's edits — still references 220.6.10, that reference is now officially dead. The NCD Manual no longer contains that section.
For the actual medical necessity criteria governing FDG PET for breast cancer, you need to pull NCD 220.6.17 directly from the CMS Medicare Coverage Database. That section — not 220.6.10 — is the live coverage policy. Medical necessity determinations for FDG PET breast cancer claims are governed entirely by 220.6.17 as of April 3, 2009.
The cross-reference in the retired section points to the broader PET Scans NCD at §220.6. If your billing guidelines for FDG PET breast cancer don't already cite §220.6 and §220.6.17, update them now.
Coverage Indications at a Glance
Because NCD 220.6.10 has been retired and replaced — and because NCD 297 as documented here contains no independent clinical criteria — the coverage indications table reflects the administrative status of this policy change, not a new set of clinical rules.
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| FDG PET for breast cancer — all indications under section 220.6.10 | Retired | None listed in NCD 297 | All coverage criteria now governed by NCD 220.6.17 |
| FDG PET for breast cancer — all indications under section 220.6.17 | Active (since April 3, 2009) | See NCD 220.6.17 and §220.6 | This is the operative section for medical necessity and reimbursement determinations |
The policy data for NCD 297 does not include specific CPT, HCPCS, or ICD-10 codes. For code-level guidance, refer directly to NCD 220.6.17.
CMS FDG PET Breast Cancer Billing Guidelines and Action Items 2026
This is an administrative retirement, not a clinical pivot. But administrative sloppiness causes claim denial just as fast as a missed prior authorization. Here's what to do.
| # | Action Item |
|---|---|
| 1 | Audit your internal policy reference documents before February 15, 2026. Any internal policy document, LCD reference sheet, or payer policy tracker that cites NCD 220.6.10 as the governing section for FDG PET breast cancer billing needs to be updated to reflect NCD 220.6.17. The effective date for this retirement is January 9, 2026. Don't let an outdated reference create a documentation gap during an audit. |
| 2 | Pull NCD 220.6.17 and confirm your billing team has read it. NCD 297 does not contain independent coverage criteria. The medical necessity rules for FDG PET breast cancer live entirely in 220.6.17 and the broader §220.6 PET Scans NCD. If your team hasn't reviewed 220.6.17 recently, do it now — especially if you have new staff who joined after 2009. |
| 3 | Check your clearinghouse and claims editing software. Some editing tools reference NCD section numbers in their logic. Confirm that any rule tied to NCD 220.6.10 has been updated or retired in your system. A stale reference in your edits won't protect you from a claim denial — it may actually trigger one. |
| 4 | Review your prior authorization workflows for FDG PET breast cancer claims. Prior authorization requirements for FDG PET under Medicare can vary by Medicare Administrative Contractor. This policy change doesn't alter those requirements, but it's a good trigger to verify your MAC's current prior auth rules for breast cancer PET imaging. Contact your MAC directly if you're unsure. |
| 5 | Update your FDG PET breast cancer billing guidelines documentation. Any written billing guidelines your practice or revenue cycle team uses for FDG PET should cite §220.6 and §220.6.17 as the governing NCDs. Remove any reference to 220.6.10. This protects you in an audit and keeps your team from chasing a retired policy. |
| 6 | Don't expect a reimbursement change from this update. This is not a coverage expansion or restriction. Reimbursement rates for FDG PET breast cancer claims under Medicare are unchanged by this retirement. If you've seen claim denial activity recently on these claims, the cause is elsewhere — check your 220.6.17 compliance, not this retirement notice. |
| 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 Breast Cancer Under NCD 297
The policy data for NCD 297 does not list specific CPT, HCPCS, or ICD-10 codes. This is consistent with the administrative nature of the change — NCD 297 is a retirement and cross-reference notice, not a new coverage determination with its own code set.
For the codes that govern FDG PET breast cancer billing under Medicare, go directly to NCD 220.6.17 and the §220.6 PET Scans NCD in the CMS Medicare Coverage Database. Those documents contain the operative CPT and HCPCS codes for FDG PET breast cancer reimbursement.
Do not attempt to bill FDG PET breast cancer claims using 220.6.10 as a reference point. That section no longer exists in the NCD Manual.
A Note on the Broader §220.6 PET Scans NCD
CMS structured its PET scan NCDs as a parent-child system. Section §220.6 is the parent — it governs PET scan coverage across indications. The subsections (220.6.1 through 220.6.17 and beyond) govern specific indications, including breast cancer.
When 220.6.10 was the active breast cancer section, it functioned as the specific medical necessity authority for that indication. When CMS moved breast cancer coverage to 220.6.17 in 2009, 220.6.10 became a legacy reference. This January 2026 update formally removes it from the manual rather than leaving it as a ghost section.
This matters for FDG PET billing because your documentation needs to align with the live hierarchy. Cite §220.6 as the parent NCD and §220.6.17 as the breast cancer-specific authority. Any MAC-level local coverage determination for PET imaging in your region should also be reviewed alongside the NCD — MAC-level LCDs can add criteria on top of the NCD floor.
If you bill FDG PET for breast cancer across multiple states or MAC jurisdictions, check each MAC's LCD. The NCD sets the national floor for medical necessity; your MAC may have additional requirements that affect prior authorization, documentation, or claim submission.
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