Most payers reimburse for clinically indicated positron emission tomography (PET) and PET/ computed tomography (CT) procedures. To be clinically indicated, the procedure must be potentially beneficial in providing information supportive of a diagnosis or monitoring certain conditions.
Generally, most private insurance companies cover the same indications as Medicare, although some may cover more indications and some may cover fewer indications. Private payers can have wide variations in coverage policies, covering criteria and procedures.
Radiology benefit managers (RBMs) are widely used by private payers to determine the appropriateness of ordering imaging procedures based on patients’ clinical indications (signs, symptoms or diagnoses) and treatment monitoring.
RBMs typically work to implement the payer’s prior-authorization process. Authorization of outpatient services before the performance of an imaging study is often required for payment. It is critical that referring physicians submit the appropriate clinical information in the authorization request.
It is appropriate for the imaging center to be allowed to participate in the prior-authorization process. The knowledge and expertise of radiology providers in both the clinical and technological aspect of healthcare can aid the referring physician in selecting the most important study for patients based on the clinical knowledge that is shared between providers.
Claims appeals can be initiated by a provider if there is a disagreement with a decision. Typically if a formal appeal is filed, a peer-to-peer discussion about the decision will take place.