FDG PET for Lymphoma (Replaced with Section 220.6.17) - RETIRED | CMS Coverage Update

Summary: The Centers for Medicare & Medicaid Services modified its FDG PET for Lymphoma coverage policy, retiring the standalone policy and replacing it with Section 220.6.17, effective May 15, 2026. Here's what billing teams need to know before that date.

This change affects how Medicare covers fluorodeoxyglucose positron emission tomography — FDG PET — for lymphoma staging, restaging, and treatment monitoring. The original standalone policy is now retired. Coverage guidance lives exclusively under the consolidated Section 220.6.17 of the National Coverage Determinations manual. The policy does not list specific CPT or HCPCS codes, so billing teams should cross-reference their current charge capture against the active NCD language directly.

CMS FDG PET for Lymphoma Coverage Criteria and Medical Necessity Requirements 2026

The CMS FDG PET for lymphoma coverage policy has always been one of the more nuanced imaging NCDs. CMS has covered FDG PET for lymphoma under specific medical necessity criteria for years — but that coverage language was scattered across multiple policy documents. Consolidating it under Section 220.6.17 is CMS's way of housekeeping, but it's not a neutral administrative act for your billing team.

Here's what matters: the underlying coverage criteria for FDG PET in lymphoma haven't necessarily changed in clinical substance, but the governing document has. Any internal billing guidelines, payer correspondence templates, or prior authorization workflows your team built around the retired policy need to be updated to reference Section 220.6.17. If your MAC or internal compliance tracking system still points to the old policy, you're working from a retired document. That's a documentation risk on audit.

FDG PET for lymphoma staging and restaging has been a covered Medicare benefit when medical necessity criteria are met — specifically, when the scan is expected to affect patient management. CMS requires that FDG PET be used as a replacement for, or in addition to, conventional imaging when it changes the treatment plan. Coverage historically applied to initial staging, restaging after treatment, and monitoring for suspected recurrence. Section 220.6.17 governs all of this now.

Prior authorization isn't typically required under Medicare FFS for FDG PET in lymphoma, but your Medicare Advantage contracts are a different story. If your patient population includes significant MA volume, verify each plan's prior auth requirements independently — they're not bound by the FFS NCD, even though many use it as a baseline for their own coverage policy language.

The medical necessity documentation burden here is real. Your ordering physicians need to clearly document why FDG PET — rather than CT or conventional imaging — is the appropriate study. "Lymphoma staging" alone doesn't support medical necessity. The documentation should reflect that the PET result will change management. Auditors look for this, and claim denial rates for inadequately documented PET claims remain elevated across oncology practices.

CMS FDG PET for Lymphoma Exclusions and Non-Covered Indications

The retired policy — and the Section 220.6.17 framework that replaces it — has never covered FDG PET for lymphoma as a routine surveillance tool in asymptomatic patients post-treatment. That distinction matters.

CMS draws a clear line between restaging (covered, when medical necessity is documented) and routine surveillance scanning after a confirmed complete remission with no clinical suspicion of recurrence (not covered). If your physicians are ordering follow-up PETs on asymptomatic lymphoma patients at fixed intervals post-treatment, those claims are exposed. The coverage policy requires a clinical reason tied to management change — not a calendar.

Coverage also does not extend to FDG PET when ordered purely for prognostic purposes without documented treatment management implications. CMS's position is that imaging reimbursement requires a clear tie to clinical decision-making. If the scan won't change what the physician does, it doesn't meet medical necessity under this framework.

Coverage Indications at a Glance

The policy does not list specific CPT or HCPCS codes. Cross-reference Section 220.6.17 directly for code-level guidance.

CMS FDG PET Lymphoma Billing Guidelines and Action Items 2026

The retirement of the standalone FDG PET for Lymphoma policy isn't a soft change. It's a hard cutover. Before May 15, 2026, your team needs to complete the following:

If your practice has high FDG PET volume in oncology or hematology, loop in your compliance officer before the effective date. The shift to Section 220.6.17 is a good trigger to do a broader audit of your PET billing practices.

CPT, HCPCS, and ICD-10 Codes for FDG PET Lymphoma Under Section 220.6.17

The policy data for this change does not list specific CPT, HCPCS, or ICD-10 codes. CMS has not enumerated specific codes within the retirement notice or the replacement section reference provided.

For authoritative code-level guidance, go directly to Section 220.6.17 of the Medicare National Coverage Determinations Manual. Your MAC's website is also the right place to find any associated local coverage determination that maps specific codes to the NCD criteria.

For reference, FDG PET billing for oncology indications typically involves PET procedure codes that your nuclear medicine or radiology billing team uses under the existing CMS oncology PET framework. Do not assume that any codes you were billing under the retired policy are automatically valid under Section 220.6.17 without confirming against the current NCD text. That confirmation step protects your reimbursement and your audit exposure.