This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Effective Date: See below.

Summary of Article Changes:

• Group 19 effective 7/1/2022: added A9596- Gallium ga-68 gozetotide, diagnostic, (illuccix), 1 millicurie
• Group 14 effective 1/1/2021: added, "NOTE: The PI modifier must be billed with C79.81 along with one of the C50.XXX diagnosis codes listed below AND the KX modifier to attest the initial anti-tumor treatment strategy is for male and female breast cancer only when used in staging distant metastasis per NCD 220.6.17.2.B1a effective 1/1/2021."
• Groups 14, 16, 17, 19 effective 5/10/22: added, "PSMA-PET/CT or PSMA-PET/MRI with Gallium 68-ga Gozetotide/PSMA-11 may be used to screen patients for Pluvicto™ eligibility per NCCN Guidelines and SNMMI AUC."

Visit the National Coverage Determination (NCD) webpage to view the NCD coverage articles.

To access a complete list of CMS NCDs, visit the National Coverage Determinations (NCDs) Alphabetical Index.