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FROM:           PAUL SWATSENBARG, Deputy Administrator

                        Division of Medicaid



Effective October 1, 2001, Idaho Medicaid will adopt specific sections of coverage criteria that have been established by Cigna Medicare in regards to Positron Emission Tomography Scans (PET Scans).  As of October 1, 2001, Idaho Medicaid will now review the following tests for Prior Authorization:


            Solitary Pulmonary Nodule

            Non-Small Cell Lung Cancer

            Colorectal or Colorectal Metastatic Cancer


            Melanoma or Metastatic Melanoma

            Head and Neck Cancers (excluding CNS and Thyroid)

            Esophageal Cancer


The following corresponding G-codes will be considered covered codes as of October 01, 2001:


G0125 G0210 G0211 G0212 G0213 G0214 G0215 G0216 G0217 G0218

G0219 G0220 G0221 G0222 G0223 G0224 G0224 G0225 G0226 G0227 G0228



A Prior Authorization Request form is included with this information release.  Please submit all Prior Authorization requests to the Idaho Medicaid Medical Director for review.  For billing purposes, Idaho Medicaid will require providers to utilize the HCPCS G-codes that have been created by Medicare for the purpose of the billing of PET Scans.  Hospitals will need to use Revenue Code 404 with the appropriate G-code attached. 


At this time, Idaho Medicaid will not cover PET Scans for myocardial viability, breast/ovarian cancer, refractory seizures or other neurological disorders. 


For questions regarding Prior Authorization, please contact Esther Ussing at (208) 364-1835.  For coverage issues pertaining to PET Scans, please contact Colleen Osborn at  (208) 364-1923.


PET Scan Prior Authorization Request

Department of Health & Welfare

Division of Medicaid

Attention: Medical Director

Fax:  (208) 364-1811

Phone:  (208)  364-1835


Date: _________________________




Client Medicaid ID Number: ____________________________



Diagnosis Code:             __________________________________


*Previous CT Scan Result:   ______________________________


*Previous MRI Result:         ______________________________


Type of Requested Scan and

Appropriate HCPCS Billing Code:   ________________________


Requested Date-of-Service: ______________________________



Ordering Physician:        __________________________________


*Healthy Connections Physician:   _________________________



Request Completed by: __________________________________

Address:                          __________________________________


Phone:                              __________________________________

Medicaid Provider #:     __________________________________



Approved/Denied by:    ___________________________________

Address:                          ___________________________________


Phone:                  ___________________________________

Date of Authorization:  ___________________________________

Prior Authorization #:  ___________________________________



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