CMS NCD 298 Update: FDG PET for Myocardial Viability Coverage Rules Explained
CMS has modified NCD 298, the National Coverage Determination governing FDG PET imaging for myocardial viability—a critical policy for cardiology practices, nuclear medicine departments, and the revenue cycle teams that support them. This update, effective March 12, 2026, reaffirms and clarifies the coverage framework that determines when Medicare will pay for FDG PET scans used to assess whether dysfunctional heart muscle is viable or scarred. If your facility performs cardiac PET imaging or bills for revascularization workups, here's what you need to know.
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | FDG PET for Myocardial Viability |
| Policy Code | NCD 298 |
| Change Type | Modified |
| Effective Date | 2026-03-12 |
| Impact Level | Medium |
| Specialties Affected | Cardiology, Nuclear Medicine, Cardiovascular Surgery, Radiology |
| Key Action | Verify that FDG PET claims are documented as either a primary study prior to revascularization or a follow-up to an inconclusive SPECT—and confirm that inconclusive PET results are not triggering unbillable follow-up SPECT orders. |
What NCD 298 Actually Covers: FDG PET and Myocardial Viability Under Medicare
Fluorodeoxyglucose (FDG) PET imaging for myocardial viability is used to distinguish between two very different clinical situations: heart muscle that is dysfunctional but still alive (hibernating myocardium), and heart muscle that has been permanently replaced by scar tissue. That distinction matters enormously—patients with viable but hibernating myocardium may benefit significantly from revascularization, while those with predominantly scar tissue may not.
The Centers for Medicare & Medicaid Services covers FDG PET for this indication under NCD 298, and the policy establishes two clear pathways to coverage:
- As a primary or initial diagnostic study prior to revascularization
- Following an inconclusive SPECT (single photon emission computed tomography) test
Both pathways have been in place since October 1, 2002, and the modified policy maintains this structure. Full ring and partial ring PET scanners are covered under both pathways.
CMS Medicare Coverage Criteria for FDG PET Myocardial Viability Studies
Medical necessity under NCD 298 hinges on patient presentation and the sequence of diagnostic workup. The policy targets patients with ischemic cardiomyopathy and left ventricular dysfunction—specifically those with partial loss of heart muscle movement who are being evaluated as candidates for revascularization.
For billing purposes, the clinical picture needs to support one of two scenarios:
Scenario A — Primary Study: The FDG PET is ordered as the first-line imaging study to assess viability before a revascularization decision is made. No prior SPECT is required. Documentation should establish compromised ventricular function and the clinical rationale for revascularization evaluation.
Scenario B — Post-Inconclusive SPECT: A SPECT was performed and returned inconclusive results. FDG PET is then ordered to resolve the diagnostic question. The referring physician's medical record must document that the SPECT was inconclusive—not simply that a SPECT was performed.
Documentation requirements under this NCD sit with the referring physician, not just the imaging facility. The medical record should clearly reflect which pathway applies and why the study was ordered. This is a common audit vulnerability—imaging centers sometimes have strong internal documentation while the referring physician's chart is sparse.
The Coverage Limitation Billing Teams Get Wrong: SPECT After PET
NCD 298 includes a limitation that catches facilities off guard. The policy is explicit: if a patient receives an FDG PET study with inconclusive results, a follow-up SPECT test is not covered by Medicare.
This is a one-way street. An inconclusive SPECT can lead to a covered PET. An inconclusive PET does not lead to a covered SPECT. Billing a SPECT following an inconclusive FDG PET will result in a denial, and appealing that denial without understanding this policy limitation wastes everyone's time.
This sequencing rule should be built into your order review workflow. If a provider is ordering SPECT after an inconclusive PET for the same viability question, the billing team needs to flag that before the claim goes out—not after the remittance comes back.
Historical Context: Scanner Types and the 2001–2002 Coverage Timeline
The policy's historical provisions are worth understanding for any retrospective billing or compliance work, though they have no practical impact on current claims:
- July 1, 2001 – December 31, 2001: Coverage existed only as a follow-up to inconclusive SPECT, and only full ring PET scanners were covered.
- January 1, 2002 – September 30, 2002: Both full and partial ring scanners became covered, still only as a SPECT follow-up.
- October 1, 2002 – present: Coverage expanded to include FDG PET as a primary or initial study prior to revascularization, with both scanner types covered.
The current policy, last clinically reviewed in September 2002, has remained substantively stable on the coverage criteria—though this 2026 modification reflects CMS's ongoing administrative review process.
Cross-Referenced CMS Policies Your Team Should Know
NCD 298 doesn't exist in isolation. CMS directs readers to two related NCDs that govern the broader imaging context:
- NCD §220.6 — PET Scans: The overarching PET coverage policy, which governs FDG PET across multiple indications including oncology and neurology.
- NCD §220.12 — SPECT: The coverage determination for single photon emission computed tomography, directly relevant given NCD 298's sequencing rules.
Claims processing instructions are governed by Transmittal 527 of the Medicare Claims Processing Manual. If your billing system has custom payer rules built around cardiac PET, verify they align with both NCD 298 and §220.6.
| 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 |
Affected Codes
The policy document for NCD 298 does not list specific CPT or HCPCS codes. Billing teams should reference the Medicare Coverage Database directly and consult with your MAC (Medicare Administrative Contractor) to confirm the applicable procedure codes for FDG PET myocardial viability studies in your region. Cross-referencing NCD §220.6 (PET Scans) may also yield relevant code-level guidance.
No ICD-10 diagnosis codes are specified in the NCD 298 policy document. Clinical documentation should support diagnoses consistent with ischemic cardiomyopathy and left ventricular dysfunction to establish medical necessity.
What Your Billing Team Should Do
| # | Action Item |
|---|---|
| 1 | Audit your FDG PET claim sequence now. Pull the last 90 days of cardiac PET claims and flag any where a SPECT was billed after an inconclusive FDG PET for the same patient and same indication. Identify any that are at risk for audit or recoupment. |
| 2 | Update your order intake process to capture the clinical pathway. Add a field or checkbox to your pre-authorization or order review workflow that confirms whether the FDG PET is being ordered as (a) a primary study prior to revascularization or (b) a follow-up to an inconclusive SPECT. This documentation requirement falls on the referring physician's record—build a process to request it before imaging occurs. |
| 3 | Educate referring physicians on the inconclusive SPECT documentation standard. "Inconclusive" must be explicit in the chart note—not implied. Work with your cardiology and nuclear medicine liaisons to ensure the referring physician's documentation uses language that maps clearly to the NCD 298 coverage criteria. |
| 4 | Review your MAC's local guidance. Since NCD 298 doesn't enumerate specific CPT codes, confirm with your Medicare Administrative Contractor which procedure codes they expect for FDG PET myocardial viability studies and whether any local coverage determinations (LCDs) supplement this NCD in your region. |
| 5 | Flag the March 12, 2026 effective date in your policy tracking system. If your facility has payer-specific billing rules or charge description master entries tied to cardiac PET, verify they reflect the modified policy as of that date. |
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