FDG PET for Myocardial Viability — NCD 298 | CMS Coverage Update

TL;DR: The Centers for Medicare & Medicaid Services modified NCD 298 governing FDG PET for myocardial viability, 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 code-level coverage.

Quick-Reference Table

CMS FDG PET Myocardial Viability Coverage Criteria and Medical Necessity Requirements 2026

The CMS FDG PET myocardial viability coverage policy under NCD 298 in the Medicare system has two distinct coverage pathways. Know which one applies to your patient before the claim goes out.

Pathway 1: Primary or initial diagnostic study. Beginning October 1, 2002, Medicare covers FDG PET as a primary study before revascularization. The patient does not need a prior SPECT to establish medical necessity. Both full ring and partial ring PET scanners are covered under this pathway.

Pathway 2: Following an inconclusive SPECT. If a patient had a single photon emission computed tomography (SPECT) study with inconclusive results, FDG PET is covered as a follow-up. This pathway has been in place since July 1, 2001. The scanner type limitation — full ring only — applied only through December 31, 2001. After January 1, 2002, both scanner types qualify.

The clinical rationale behind this coverage policy is specific. FDG PET distinguishes between dysfunctional but viable myocardial tissue — sometimes called hibernating myocardium — and scar tissue. That distinction directly drives management decisions for patients with ischemic cardiomyopathy and left ventricular dysfunction. CMS covers this test because it changes what happens to the patient, not just because it produces an image.

Medical necessity here centers on one question: does this patient have partial loss of heart muscle movement or hibernating myocardium that could respond to revascularization? If the clinical picture doesn't raise that question, neither coverage pathway applies.

Prior authorization is not explicitly required under NCD 298. But that doesn't mean documentation is optional. The referring physician must maintain records showing the clinical conditions are met. That documentation lives in the beneficiary's medical record. If your billing team ever needs to defend a claim, that's where the proof has to be.

CMS FDG PET Myocardial Viability Exclusions and Non-Covered Indications

There is one hard exclusion in this coverage policy, and it's asymmetric in a way that catches billing teams off guard.

If a patient gets a SPECT with inconclusive results, a follow-up FDG PET is covered. But the reverse is not true. If a patient gets an FDG PET with inconclusive results, a follow-up SPECT is not covered under Medicare.

This asymmetry isn't a minor technical point. It has real claim denial exposure. If your clinical team runs FDG PET first and gets an inconclusive read, then orders SPECT to try again, that SPECT claim will not survive Medicare review under NCD 298. Train your cardiology and nuclear medicine teams on this before it becomes a write-off.

The policy does not list any other categorical exclusions. There are no documented carve-outs by diagnosis code, patient age, or scanner model beyond the early 2001–2002 scanner type restrictions — which are now historical and don't affect current billing.

Coverage Indications at a Glance

CMS FDG PET Myocardial Viability Billing Guidelines and Action Items 2026

This policy has been stable since its last clinical review in September 2002, but the January 9, 2026 effective date on this modification means CMS touched it. Review your current workflows against these criteria now.

If the January 9, 2026 modification introduced wording changes you're not sure how to apply to your patient mix, loop in your compliance officer before submitting claims under the updated version.

CPT, HCPCS, and ICD-10 Codes for FDG PET Myocardial Viability Under NCD 298

Covered CPT Codes (When Selection Criteria Are Met)

NCD 298 does not list specific CPT or HCPCS codes. For FDG PET myocardial viability billing, you must reference the general PET scan NCD at §220.6 in the Medicare Coverage Database for the applicable procedure codes. Do not assume a code is covered under this NCD without verifying it against §220.6.

For SPECT billing referenced in coverage pathway 2, refer to NCD §220.12.

Not Covered / Experimental Codes

No specific "not covered" CPT or HCPCS codes are listed in NCD 298. The non-covered indication — SPECT following inconclusive FDG PET — would use SPECT procedure codes found under NCD §220.12. Submitting those codes after an inconclusive FDG PET will not meet medical necessity under NCD 298.

Key ICD-10-CM Diagnosis Codes

NCD 298 does not specify ICD-10-CM codes. Diagnosis codes for ischemic cardiomyopathy and left ventricular dysfunction are the clinically relevant diagnoses driving coverage. Work with your cardiology coders to confirm the ICD-10-CM codes on the claim reflect those conditions accurately. A mismatch between the diagnosis code and the clinical rationale documented in the referring note is a common reason these claims get flagged.