23 Miss. Code. R. 220-1.9

Current through December 10, 2024

Rule 23-220-1.9 - Positron Emission Tomography (PET) Scans

A. Effective July 1, 2013, Positron Emission Tomography (PET) scans must be prior authorized by the radiology UM/QIO as noted in Rule 1.2.

B. The Division of Medicaid covers one (1) fluorodeoxyglucose (FDG) PET scan for solid tumors, myeloma or lymphoma that are biopsy proven or strongly suspected based on other diagnostic testing for the following therapeutic purposes related to the initial treatment strategy to determine:

1. Whether or not the beneficiary is an appropriate candidate for an invasive diagnostic or therapeutic procedure,

2. Optimal anatomic location for an invasive procedure, or

3. The anatomic extent of a tumor when the recommended anti-tumor treatment reasonably depends on the extent of the tumor.

C. The Division of Medicaid covers PET scans for initial anti-tumor treatment strategy, formerly "diagnosis" and "staging", for the following oncologic conditions:

1. Thyroid cancer,

2. Non-small cell, lung cancer,

3. Colorectal cancer,

4. Melanoma,

5. Lymphoma,

6. Head and neck cancer, excluding thyroid and central nervous system,

7. Esophageal cancer,

8. Male and female breast cancer when used in staging distant metastasis,

9. Cervical cancer that is newly diagnosed following conventional imaging that is negative for extra-pelvic metastasis,

10. Ovarian cancer,

11. Testicular cancer,

12. Brain cancer,

13. Pancreatic cancer, or

14. Soft tissue carcinoma,

D. The Division of Medicaid does not cover PET scans for the initial anti-tumor treatment strategy, formerly "diagnosis" and "staging", for the:

1. Initial diagnosing of breast cancer or the initial staging of axillary nodes,

2. Initial diagnosing of cervical cancer,

3. Evaluation of regional lymph nodes in melanoma, or

4. Diagnosis of adenocarcinoma of the prostate.

E. The Division of Medicaid covers PET scans for subsequent anti-tumor treatment strategy, formerly "restaging" and "monitoring response to treatment", after the completion of the initial treatment course for the following oncologic conditions:

1. Breast cancer,

2. Colorectal cancer,

3. Esophageal cancer,

4. Head and neck (non-CNS/thyroid), excluding thyroid and central nervous system,

5. Lymphoma,

6. Melanoma,

7. Non-small cell lung cancer,

8. Thyroid cancer,

9. Ovarian cancer,

10.Cervical cancer, or

11. Myeloma.

F. The Division of Medicaid covers FDG-PET scans for refractory seizures only for pre-surgical evaluation of localization of a focus of refractory seizure activity.

G. The Division of Medicaid does not cover PET scans for chronic osteomyelitis, infection of hip arthroplasty, and fever of unknown origin.

23 Miss. Code. R. 220-1.9

Miss. Code Ann. § 43-13-121; 42 CFR §§431.10(e), 440.230(d).

Revised Rule 1.9. B. E. and added G. eff. 01/01/02014, Added to correspond with approved SPA 2013-007 (eff. 07/01/2013) eff. 07/01/2013.