The patient’s medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See “Indications and Limitations of Coverage.”) This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
The patient’s medical record should include but is not limited to:
- Relevant medical history
- Physical examination findings
- Results of pertinent tests/procedures
- Imaging testing performed
- Rationale for decision for PET scan including rationale for PET scan over standard imaging modalities and why PET was necessary
- Results of PET scan
- Documentation in medical record of the role PET scan plays in clinical management
- In cases of fever of unknown fever curve with temperatures and documentation of ≥ 21 days since onset of fever and fevers in the 2 weeks prior to the study.
Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient and indicate the
reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will
The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, the reason for the tests, an interpretive report(s) and copies of images. The computerized image reconstruction data should also be maintained.
Documentation must be available to Medicare upon request.