June 14_Updated July 1: CMS released its
decision on June 11 expanding coverage for FDG-PET. The CMS ruling will change current reimbursement practices in several important ways:
Coverage of PET for treatment monitoring expanded The CMS ruling expands coverage for FDG-PET scans following initial anti-tumor therapy to at least three scans. Coverage of additional scans will be subject to determinations made by local Medicare Administrative Contractors.
NOPR reporting requirements eliminated Previously, PET sites were required to report data related to PET scanning and patient management to the National Oncologic PET Registry (NOPR) in order to receive reimbursement. The June 11 decision eliminates this reporting requirement for FDG-PET exams.
Decision clarifies coverage of PET/MRI Finally, CMS also explicitly stated in its decision memo that this coverage determination applies to hybrid PET/MRI scans as well as PET/CT. As CMS reimbursement for PET/MRI imaging was previously unclear, this determination may encourage PET/MRI adoption.
Coverage expansion likely to impact PET demand With scan volume increases projected, demand for PET studies will likely be even greater. To meet this demand, hospitals will want to evaluate their current capacity and market dynamics to assess whether their current PET offerings will be able to meet future demand.
Alliance HealthCare Radiology (“Alliance Radiology”) is glad to assist with evaluation of your capacity needs. Please reach out to your Account Development Director for prompt assistance or call our Resource Center at 800.544.3215. To read the full CMS National Decision, click decision.
Summary of FDG-PET Coverage for Oncologic Conditions.
Effective for claims with dates of service on and after June 11, 2013, the chart below summarizes national FDG PET coverage for oncologic conditions:
FDG PET for Solid Tumors and Myeloma Tumor Type | Initial Treatment Strategy
(formerly “diagnosis” & “staging”) | Subsequent Treatment Strategy
(formerly “restaging” and “monitoring response to treatment”) |
|---|
| Colorectal | Cover | Cover |
| Esophagus | Cover | Cover |
| Head and Neck (not thyroid or CNS) | Cover | Cover |
| Lymphoma | Cover | Cover |
| Non-small cell lung | Cover | Cover |
| Ovary | Cover | Cover |
| Brain | Cover | Cover |
| Cervix | Cover with exceptions * | Cover |
| Small cell lung | Cover | Cover |
| Soft tissue sarcoma | Cover | Cover |
| Pancreas | Cover | Cover |
| Testes | Cover | Cover |
| Prostate | Non-cover | Cover |
| Thyroid | Cover | Cover |
| Breast (male and female) | Cover with exceptions * | Cover |
| Melanoma | Cover with exceptions * | Cover |
| All other solid tumors | Cover | Cover |
| Myeloma | Cover | Cover |
| All other cancers not listed | Cover | Cover |
*Cervix: Nationally non-covered for the initial diagnosis of cervical cancer related to initial anti-tumor treatment strategy. All other indications for initial anti-tumor treatment strategy for cervical cancer are nationally covered. *Breast: Nationally non-covered for initial diagnosis and/or staging of axillary lymph nodes. Nationally covered for initial staging of metastatic disease. All other indications for initial anti-tumor treatment strategy for breast cancer are nationally covered. *Melanoma: Nationally non-covered for initial staging of regional lymph nodes. All other indications for initial anti-tumor treatment strategy for melanoma are nationally covered.
