Updated Medicare Rebate for PET Scans [2019]

The last thing patients need when facing medical tests for cancer diagnosis is the uncertainty of whether or not their diagnostic procedures are covered under current Medicare regulations. 

With new guidelines taking effect November 1, 2019, here’s what you should know about what is covered by Medicare for PET scans.

What Is a PET Scan? 

PET is short for positron emission tomography, a technique that utilises a mildly radioactive drug to detect and visually identify areas of the body where cell activity is abnormally active. The scan offers a three-dimensional picture of what lies under the skin or within an organ. A PET scan is considered valuable because it helps to determine if and where a type of cancer may have migrated within the body.

Major cancer hospitals typically have the ability to perform PET scans, but they may not be readily available. If your medical professional orders a PET scan, the patient may have to travel to another location. 

The scans are normally performed on an outpatient basis in a facility that has a radiology or nuclear medicine department. Macquarie Medical Imaging, with two convenient locations, is fully accredited and approved to serve Medicare patients.

The Role of PET Scans in Cancer Detection and Treatment

The major benefits of a PET scan include:

  • Showing the location of a cancer
  • Aiding in the determination of size and stage of the cancer
  • Assessing whether a growth is malignant or benign
  • Deciding the best treatment for a cancer
  • Evaluating the effectiveness of treatment

Whole body PET scans (Image Source: Macquarie Medical Imaging)

Cancers and Stages Covered by Medicare for PET Scans

The updated Medicare Benefits Schedule Book, effective November 1, 2019, lists specific cancers for which PET scan coverage is authorised. It should be noted that prostate cancer is not one of the included diagnoses. Under Section 14, Nuclear Medicine Imaging, scans are included for the following classifications:

61523

  • Lung Cancer: An evaluation procedure of a “single pulmonary nodule“ that is unsuitable for traditional biopsy or which has proved difficult to assess by other means.
  • Fee: $953.00
  • Benefit: 75% = $714.75  85% = $868.30

61524

  • Breast Cancer: An assessment procedure for Stage III breast cancer in patients who are considered suitable for active therapeutic procedures.
  • Fee: $953.00
  • Benefit: 75% = $714.75  85% = $868.30

61525

  • Breast Cancer: An assessment to determine and evaluate the recurrence of a lump or to confirm the suspected spread of breast cancer in patients already undergoing treatment.
  • Fee: $953.00
  • Benefit: 75% = $714.75  85% = $868.30 

61529

  • Lung Cancer: A PET scan conducted in order to classify the stage of non-small-cell lung cancer in cases where surgery or radiotherapy is planned.
  • Fee: $953.00
  • Benefit: 75% = $714.75  85% = $868.30

61538

  • Brain Tumour: This authorises a brain scan that can be used to evaluate residual or recurrent brain tumours, during ongoing chemotherapy or following such therapy, in patients for whom further treatment has been recommended. 
  • Fee: $901.00
  • Benefit: 75% = $675.75  85% benefit is listed as $816.30.

61541

  • Colorectal Cancer: An evaluation scan, in cases where the cancer is believed to have recurred or spread.
  • Fee: $953.00
  • Benefit: 75% = $714.75  85% = $868.30

61533

  • Skin Cancer: After initial treatment, the PET scan will help determine if a malignant melanoma has spread or recurred.
  • Fee: $999.00
  • Benefit: 75% = $749.25  85% = $914.30

61565

  • Ovarian Cancer: For a woman who has been treated for cancer of the ovaries, this scan is instrumental in determining the extent of the suspected “residual, metastatic or recurrent“ ovarian cancer, before proceeding with additional treatment.
  • Fee: $953.00
  • Benefit: 75% = $714.75  85% = $868.30

61571

  • Cervical Cancer: The PET scan helps physicians further classify the stage and progression of uterine cancers, previously classified at FIGO Stage IB2 or greater, before continuing to radiation treatment or other procedures.
  • Fee: $953.00
  • Benefit: 75% = $714.75  85% = $868.30

61575

  • Uterine Cancer: This is another evaluation for patients with uterine cervical carcinoma. The scan is used for further staging in cases with confirmed local recurrence, and considered suitable for “salvage pelvic chemoradiotherapy or pelvic exenteration with curative intent.“
  • Fee: $953.00
  • Benefit: 75% = $714.75  85% = $868.30

61577

  • Oesophageal or GEJ Cancer: A diagnostic scan to determine the stage or progression of the cancer.
  • Fee: $953.00
  • Benefit: 75% = $714.75  85% = $868.30

61598

  • Head or Neck Cancers: Images to determine the extent of the cancer in patients whose biopsy results confirm such cancer, or to confirm suspected recurrence.
  • Fee: $953.00
  • Benefit: 75% = $714.75  85% = $868.30

61604

  • Head and Neck Cancer: Further testing for patients who have already received treatment for such cancer, with suspected recurrence.
  • Fee: $953.00
  • Benefit: 75% = $714.75  85% = $868.30

61610

  • Skin Cancer: A specific test to evaluate the spread of cancers from an unknown primary site involving the lymph nodes.
  • Fee: $953.00
  • Benefit: 75% = $714.75  85% = $868.30

61620

  • Hodgkin or Non-Hodgkin Lymphoma: To determine the stage of the newly diagnosed or yet-to-be-treated illness.
  • Fee: $953.00
  • Benefit: 75% = $714.75  85% = $868.30

61622

  • Hodgkin or Non-Hodgkin Lymphoma: Follow-up study to determine the effectiveness of initial or previous treatment, typically performed while treatment is ongoing or within three months after ending treatment.
  • Fee: $953.00
  • Benefit: 75% = $714.75  85% = $868.30

61628

  • Hodgkin or Non-Hodgkin Lymphoma: A whole body scan to determine the extent and staging of recurrent cancer.
  • Fee: $953.00
  • Benefit: 75% = $714.75  85% = $868.30

61632

  • Hodgkin or Non-Hodgkin Lymphoma: If a form of stem cell transplantation is considered following chemotherapy, the scan is used to determine the body’s response to previous treatment.
  • Fee: $953.00
  • Benefit: 75% = $714.75  85% = $868.30

61646

  • Bone Cancer and Specific Other Tumours: The scan is used to stage certain biopsy-confirmed cancers that are considered curable with treatment.
  • Fee: $999.00
  • Benefit: 75% = $749.25 85% = $914.30

61647

  • Stomach, Intestinal or Pancreatic Cancer: To determine the specific position and extent of any tumour suspected or confirmed anywhere along the gastrointestinal tract or pancreas.
  • Fee: $1,053.00
  • Benefit: 75% = $789.75 85% = $968.30

Schedule an Appointment

If you have been referred by your physician for a PET scan, it’s easy to make an appointment at either of two convenient MMI locations. Simply upload your referral form to proceed. 

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