Insurers and appropriateness criteria impose restrictions

-- by James Brice

In an ideal world, radiology works for its patients as it did for the five subjects of this story. They had easy access to diagnostic imaging¹s most advanced techniques either because they were willing to pay the hefty price for a PET scan, or because they were associated with a major medical center that was equipped with the technology.

Most healthcare consumers, however, do not live in an ideal world. Their reality includes the dictates of managed care and the Health Care Financing Administration. According to the rules of the game that typically apply, it would be unlikely that Ray Lunt could receive a PET scan to satisfy his curiosity about the status of his apparently healthy heart. Medicare does cover rubidium-82 PET studies of symptomatic patients, but many physicians still consider the procedure experimental.

Medicare payment policy, which is the standard that many private insurers follow, has since January 1998 covered FDG PET of solitary pulmonary nodules, the condition that afflicted Rita Rovazzi. However, Rovazzi¹s physician would be more likely to prescribe a spiral CT pulmonary study because it is considerably less expensive than PET imaging.

In the real world, Dan Hutchinson probably would qualify for Medicare reimbursement for a PET scan to diagnose his Hodgkin¹s lymphoma. The federal program has paid for this procedure since July 1999. But Robert Young might have had difficulty finding a private insurer to cover PET scanning to diagnose his colorectal cancer. Medicare pays for FDG PET only to examine for recurrent colorectal cancer in patients with rising levels of carcinoembryonic antigen.

The American College of Radiology¹s appropriateness criteria are also instructive. Although a major revision of the criteria will be published between the writing of this article and the time the magazine goes to press, the criteria that applied until May largely discouraged the use of PET. For acute chest pain, PET ranked behind 12 other modalities. The criteria noted that the technology is expensive and probably not indicated in the workup of a patient with suspected myocardial ischemia.

The panel that evaluated the appropriateness of diagnostic options for solitary pulmonary nodules could not come to a consensus regarding FDG PET, other than noting that F-18 FDG PET may be useful in differentiating focal pulmonary abnormalities from malignancy. For the diagnostic workup of palpable breast masses, the criteria offer only diagnostic mammography, sonography, and pneumocystography for suspected intracystic masses that were not seen with ultrasound.

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