Does Medicaid Cover PET Scans?

A Positron Emission Tomography (PET) scan is an imaging test that visualizes organ and tissue function and metabolism. Unlike structural imaging, PET scans use a small amount of radioactive tracer to detect diseased cells that absorb more tracer. This aids early detection and monitoring of conditions like cancers, heart disease, and brain disorders. Medicaid may cover PET scans, but coverage is not automatic and depends on specific conditions.

Medicaid Coverage Criteria for PET Scans

Medicaid coverage for PET scans requires “medical necessity,” meaning the scan is needed for diagnosis, staging, or monitoring of a specific medical condition. A physician’s order and justification are always necessary. Medicaid considers PET scans medically necessary when results can help avoid invasive procedures or guide their optimal location, such as when cancer staging remains uncertain after conventional imaging like CT, MRI, or ultrasound.

PET scans are often covered for oncologic conditions, such as non-small cell lung cancer, colorectal cancer, lymphoma, melanoma, and esophageal cancer, for diagnosis, staging, and restaging. They can determine cancer spread before treatment or check for recurrence. Coverage also extends to non-oncologic conditions, like evaluating myocardial viability or localizing seizure activity in refractory epilepsy.

Prior authorization is a prerequisite for Medicaid coverage of PET scans in most states, requiring approval before the scan.

Navigating the Approval Process

The prescribing physician’s office typically initiates the structured process for obtaining Medicaid approval for a PET scan. Once medical necessity is determined, staff prepare and submit a prior authorization request to the state Medicaid agency or its contractor. This submission requires detailed medical documentation to support the need for the scan, including:

Patient’s primary and any relevant secondary diagnoses with corresponding ICD codes
Summary of the most recent medical evaluation and physical exam findings
Laboratory and pathology reports
Prior imaging results pertinent to the condition
Comprehensive treatment plan outlining past or planned therapies

Many state Medicaid programs use online portals or third-party radiology benefits management companies to review prior authorization requests. Physician offices typically use these platforms or submit forms directly. After submission, a waiting period follows for review against medical necessity criteria. Additional information or clarification may be requested from the physician during this review.

Upon approval, an authorization number or confirmation is issued, essential for billing Medicaid. Some state guidelines specify a timeframe for the scan after authorization, such as within 30 days. Failure to obtain approval before the scan can result in non-coverage by Medicaid.

State-Specific Differences in Coverage

Each state administers its Medicaid program, leading to variations in coverage policies and prior authorization requirements for services like PET scans. While federal guidelines provide a framework, each state’s Medicaid agency, and sometimes managed care organizations, establish specific rules, clinical criteria, and administrative procedures. Some states might have particular lists of covered conditions or different documentation standards.

State-level differences mean a PET scan covered in one state may not be covered under the same circumstances in another. Some states contract with specific entities for radiology prior authorizations, while others manage requests directly.

To determine exact coverage policies, individuals can visit their state’s official Medicaid website, which typically provides detailed provider manuals and administrative codes outlining covered services and prior authorization rules. Contacting the state Medicaid agency directly or consulting with their healthcare provider’s billing department are also effective ways to obtain specific, current information. Healthcare providers are generally familiar with their state’s Medicaid program authorization processes and criteria.

Understanding Denials and Appeals

Medicaid may deny a PET scan request. Common reasons for denial include insufficient documentation, incomplete prior authorization requests, or the service not meeting state coverage criteria. For example, if medical records do not show less invasive tests were inconclusive, or if the scan is deemed experimental, coverage may be denied.

If a PET scan request is denied, Medicaid beneficiaries have the right to appeal. The appeal process typically begins with an internal review by the Medicaid agency or its contractor, re-evaluating the request with additional information. This often involves submitting further medical records, a detailed letter of support from the physician, or clarification regarding the patient’s condition and treatment plan. Adhere to specified deadlines for filing appeals, commonly 30 to 90 days from the denial notice.

If the internal review upholds the denial, beneficiaries can request a fair hearing, a formal administrative proceeding. During a fair hearing, an impartial officer reviews the case and hears testimony from the beneficiary or their representative, the physician, and Medicaid agency representatives. To strengthen an appeal, provide comprehensive medical records, including detailed physician notes, pathology reports, and prior imaging results that underscore medical necessity.