PET coverage extended

Medicare patients who have been treated for prostate cancer and other solid tumors will continue to have access to PET scans to guide subsequent therapy.

Physicians, patients and medical imaging companies talked the CMS out of virtually ending payment for post-treatment PET scans.

In March, the agency proposed stopping coverage for post-treatment scans for prostate cancer and a limit of one scan for other cancers, looking to rein in imaging with questionable value. Instead, Medicare will cover three scans ordered to help guide subsequent anti-tumor treatment. The CMS will allow local Medicare administrative contractors to determine coverage for additional scans.

Gail Rodriguez, executive director of the Medical Imaging & Technology Alliance, issued a statement calling the decision “a step in the right direction in ensuring access to critical imaging procedures for patients with cancer.”

The technology involves injecting F-18 fluorodeoxyglucose (FDG) into the blood so the scan can identify signs of cancer metastasis. Dr. Robert Barr, chairman of the American Society of Neuroradiology's Health Policy Committee, said in an e-mail that the CMS' change of course “represents progress; FDG PET is a necessary tool for physician decisionmaking.”

The CMS also lifted the “coverage with evidence development,” or CED, requirement in effect since Medicare started paying for the tests in 2005. The rule meant Medicare would cover FDG PET scans post-treatment only if providers supplied data and tracked outcomes in the National Oncologic PET Registry.

An analysis from consulting firm Avalere Health showed that 97% of public comments—or 195 out of 201 filed—explicitly opposed the CMS' proposal to limit scans. Of those commenters, 170 were from individual providers. America's Health Insurance Plans endorsed the coverage restrictions.

“This is a win for a lot of the commenters because it's better to have the assurance at the national level that more than one is covered rather than leave it at the hands of local contractors,” Jenny Gaffney, a senior manager at Avalere, told Modern Healthcare. “This provides assurance that if a patient needs a second or third scan, then they will” be covered, she continued. Gaffney added that the decision to lift the CED requirement is a big win, too, because the CMS acknowledged that after eight years, enough data had been collected to show that these scans were necessary.

“There is hope for other technologies that find themselves in similar situations where their coverage has been confined to CED,” Gaffney said, adding that if evidence collected is robust, then the CMS might reconsider their CED requirements.

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