Summary: The Centers for Medicare & Medicaid Services modified its FDG PET for Melanoma 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 do before that date.
This change consolidates CMS FDG PET imaging coverage for melanoma under the broader National Coverage Determination framework at Section 220.6.17. The standalone policy has been retired. If your oncology or nuclear medicine billing team uses FDG PET imaging codes for melanoma staging, restaging, or treatment monitoring, this structural shift affects how you document medical necessity and reference policy authority on your claims. The policy does not list specific CPT or HCPCS codes in the available data — but the clinical and billing implications of moving to a new NCD section are real and worth acting on now.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | FDG PET for Melanoma — Retired, Replaced by Section 220.6.17 |
| Policy Code | N/A |
| Change Type | Modified (Policy Retirement + Consolidation) |
| Effective Date | May 15, 2026 |
| Impact Level | Medium — structural change with documentation and reference implications |
| Specialties Affected | Oncology, Nuclear Medicine, Radiology, Surgical Oncology |
| Key Action | Update all internal policy references, LCD cross-references, and medical necessity documentation templates to cite Section 220.6.17 before May 15, 2026 |
CMS FDG PET for Melanoma Coverage Criteria and Medical Necessity Requirements 2026
The core issue here is a structural one. CMS is retiring a standalone FDG PET for melanoma coverage policy and folding it into Section 220.6.17 of the National Coverage Determinations manual. This is a consolidation move — the kind CMS makes when a procedure-specific policy matures enough to live within its broader imaging NCD framework rather than stand alone.
What this means for your billing team: any internal documentation, prior authorization request templates, or medical necessity denial appeal letters that cite the old standalone policy need to be updated. Citing a retired policy on a claim or appeal is a claim denial waiting to happen. CMS auditors and Medicare Administrative Contractors will expect references to the active coverage policy — Section 220.6.17 — not a retired predecessor.
Section 220.6.17 governs FDG PET imaging broadly under Medicare. Within that section, melanoma is one of the covered oncologic indications. The medical necessity standard for FDG PET under Medicare has historically required that the scan be used for one of the approved clinical purposes — staging, restaging, or monitoring treatment response — and that the ordering physician document why the scan is needed for that specific patient at that specific point in care.
FDG PET melanoma billing under Medicare has always required tight clinical documentation. That requirement doesn't soften with this change. If anything, it reinforces it. You now need to document medical necessity against the criteria in Section 220.6.17 — not the retired standalone policy.
The available policy data does not specify prior authorization requirements tied to this particular structural change. However, prior authorization for PET imaging is already required by many Medicare Advantage plans that wrap CMS guidance. Check your specific plan contracts if you're billing MA plans — don't assume that because CMS itself doesn't mandate prior auth for traditional Medicare FDG PET that your MA payers don't either.
CMS FDG PET for Melanoma Exclusions and Non-Covered Indications
The retired policy was not a blanket approval for all FDG PET imaging in melanoma patients. Coverage under CMS FDG PET policy has never extended to every clinical scenario involving melanoma. The consolidation into Section 220.6.17 doesn't change that.
FDG PET scans that are not tied to one of the recognized clinical indications — staging, restaging, or treatment monitoring — remain non-covered under Medicare. Surveillance scans ordered outside of a documented clinical need don't qualify. Screening use in patients without a confirmed diagnosis doesn't qualify either.
The policy data available does not enumerate specific excluded indications beyond what general NCD 220.6 framework guidance covers. If you're billing PET for melanoma in scenarios beyond the core staging and restaging indications, talk to your compliance officer before May 15, 2026. The retirement of the standalone policy and the move to Section 220.6.17 is a good moment to audit your current documentation practices — not just update a reference number.
Coverage Indications at a Glance
The policy data provided does not include a detailed indication-by-indication breakdown. The table below reflects what CMS FDG PET NCD framework guidance (Section 220.6 and its subsections) has historically covered for melanoma. Treat this as a reference orientation — not a substitute for reviewing Section 220.6.17 directly.
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Initial staging of confirmed melanoma | Covered (when medically necessary) | Not specified in available data | Documentation must establish clinical need for PET over conventional imaging |
| Restaging after treatment or recurrence | Covered (when medically necessary) | Not specified in available data | Physician must document clinical basis for restaging |
| Treatment response monitoring | Covered (when medically necessary) | Not specified in available data | Scan must be tied to active treatment decision-making |
| Surveillance without documented clinical indication | Not Covered | Not specified in available data | Routine surveillance without findings does not meet medical necessity |
| Screening in undiagnosed patients | Not Covered | Not specified in available data | FDG PET is not covered for cancer screening use |
CMS FDG PET for Melanoma Billing Guidelines and Action Items 2026
| # | Action Item |
|---|---|
| 1 | Update all internal policy references to Section 220.6.17 before May 15, 2026. Any template, checklist, or billing guide that cites the retired standalone FDG PET for Melanoma policy needs to be revised now. The effective date is firm — after May 15, 2026, the old policy is gone. |
| 2 | Audit your medical necessity documentation templates. Your templates for ordering FDG PET in melanoma patients should reference the coverage criteria in Section 220.6.17. If your templates were built around the retired policy's specific language, they may reference outdated criteria. Pull them, review them, and update them. |
| 3 | Check your denial appeal letter library. If your revenue cycle team has pre-built appeal letters that cite the former standalone CMS FDG PET melanoma coverage policy, those letters will undermine your appeals after May 15, 2026. Update them to cite Section 220.6.17 and make sure the clinical necessity language aligns with the active NCD. |
| 4 | Confirm how your Medicare Administrative Contractor handles Section 220.6.17 for melanoma. MACs can issue local coverage determinations that layer on top of NCD guidance. Check whether your MAC has a related LCD that addresses FDG PET for oncologic indications in your region. If it does, your billing team needs to understand how the MAC's LCD interacts with the updated NCD reference. |
| 5 | Review Medicare Advantage plan contracts for FDG PET prior authorization requirements. Traditional Medicare follows NCD 220.6.17 without a separate prior auth step for most FDG PET indications. Medicare Advantage plans are not bound by that same process. If you bill MA plans for FDG PET melanoma imaging, verify current prior authorization requirements with each payer before May 15, 2026. |
| 6 | Brief your nuclear medicine and oncology billing staff on the policy retirement. The clinical team may not notice this change at all — it looks administrative from the outside. But your billing team needs to know the reference has changed. A quick internal memo before the effective date prevents confusion when claims get audited. |
| 7 | If your volume of FDG PET melanoma claims is high, consider a pre-deadline claim sample audit. Pull 30 days of FDG PET melanoma claims, check the documentation, and verify medical necessity is being established correctly. Use that audit to catch documentation gaps before the transition date — not after. |
| 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 for Melanoma Under Section 220.6.17
The available policy data does not list specific CPT, HCPCS, or ICD-10 codes. Do not use this absence as a reason to skip code-level verification.
FDG PET billing involves a specific set of CPT codes for the PET scan itself, radiopharmaceutical supply codes, and diagnosis codes tied to melanoma. Those codes exist and are in active use — the policy document provided here simply does not enumerate them.
What to do: Pull the full text of Section 220.6.17 directly from the CMS NCD manual. Cross-reference it with your current charge capture to confirm which CPT codes your team uses for FDG PET and whether your ICD-10 diagnosis codes for melanoma align with the indication-level criteria in the updated section. If you're not sure which codes fall under this coverage policy after the retirement, ask your billing consultant or MAC before May 15, 2026.
This is not a case where you want to assume the codes haven't changed because the clinical procedure hasn't changed. Policy consolidations sometimes bring coding clarifications with them. Verify.
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