Medicare Covered Clinical Conditions, HCPCS/CPT Codes and Descriptions for FDG PET— Dedicated FDG PET Scanners Only
| Covered clinical condition | Code | Code description |
|---|---|---|
| Single Pulmonary Nodule (SPN) | ||
| Characterization of single pulmonary nodules following CT, lesion not to exceed 4 cm | G0125 | PET imaging; regional or whole body; single pulmonary nodule |
| Lung Cancer–Non Small Cell | ||
| Diagnosis | G0210 | PET imaging whole body; diagnosis; lung cancer, non-small cell |
| Staging | G0211 | PET imaging whole body; initial staging; lung cancer, non-small cell |
| Restaging | G0212 | PET imaging whole body; restaging; lung cancer, non-small cell |
| Colorectal Cancer | ||
| Diagnosis | G0213 | PET imaging whole body; diagnosis; colorectal cancer |
| Staging | G0214 | PET imaging whole body; initial staging; colorectal cancer |
| Restaging | G0215 | PET imaging whole body; restaging; colorectal cancer |
| Melanoma (not covered for evaluating regional nodes) | ||
| Diagnosis | G0216 | PET imaging whole body; diagnosis; melanoma |
| Staging | G0217 | PET imaging whole body; initial staging; melanoma |
| Restaging | G0218 | PET imaging whole body; restaging; melanoma |
| Non-covered indications | G0219 | PET imaging whole body; melanoma, for non-covered indications |
| Lymphoma | ||
| Diagnosis | G0220 | PET imaging whole body; diagnosis; lymphoma |
| Staging | G0221 | PET imaging whole body; initial staging; lymphoma |
| Restaging | G0222 | PET imaging whole body; restaging; lymphoma |
| Head and Neck Cancer (excluding CNS and thyroid cancers) | ||
| Diagnosis | G0223 | PET imaging whole body or regional; diagnosis; head and neck cancer |
| Staging | G0224 | PET imaging whole body or regional; initial staging; head and neck cancers |
| Restaging | G0225 | PET imaging whole body or regional; restaging; head and neck cancers |
| Esophageal Cancer | ||
| Diagnosis | G0226 | PET imaging whole body; diagnosis; esophageal cancer |
| Staging | G0227 | PET imaging whole body; initial staging; esophageal cancer |
| Restaging | G0228 | PET imaging whole body; restaging; esophageal cancer |
| Pre-surgical evaluation of refractory seizures | G0229 | PET imaging; metabolic brain imaging for pre-surgical evaluation of refractory seizures |
| Myocardial Viability | G0230 | PET imaging; metabolic assessment for myocardial viability following an inconclusive SPECT study |
| Myocardial Viability | 78459 | PET imaging; metabolic evaluation for determination of myocardial viability as a primary or initial diagnostic study prior to revascularization |
| Breast Cancer | ||
| Diagnosis (not covered) | G0252 | PET imaging; for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g. initial staging of axillary lymph nodes), not covered by Medicare |
| Staging/restaging | G0253 | PET imaging for breast cancer; staging/restaging, of local regional recurrence or distant metastases, i.e., staging/restaging after or prior to course of treatment |
| Evaluation of response to treatment | G0254 | PET imaging for breast cancer; evaluation of response to treatment, performed during course of treatment |
| Thyroid Cancer | ||
| Restaging | G0296 | PET imaging; for restaging of previously treated thyroid cancer of follicular cell origin following negative I-131 whole body scan |