Lack of reimbursement has been a stumbling block to expanded clinical use of PET, especially in the field of oncology, where its potential is greatest.
The economic picture brightened considerably late last year when the Health Care Financing Administration approved broad coverage of PET for diagnosis, staging, and restaging of six different malignancies: non-small cell lung cancer, esophageal cancer, colorectal cancer, lymphoma, melanoma, and head and neck cancers exclusive of central nervous system and thyroid tumors. At the same time, HCFA left the door open to future expansion of coverage in cases where “the biochemical evidence is relevant to the new indication” (J Nuc Med 2001;42:11N-12N). The expanded indications go into effect in July.
HCFA also referred coverage of PET studies for breast cancer and Alzheimer’s disease to its Medicare coverage advisory committee diagnostic imaging panel, which was scheduled to review the matter in May. Additionally, the panel will review evidence supporting potential expansion of PET’s indication for assessment of myocardial viability. The late-year decisions followed HCFA’s implementation last year of a reimbursement system for approved outpatient PET oncology procedures.
Prior to the relative flurry of activity last year, HCFA had restricted reimbursement for PET to limited applications related to evaluation of myocardial perfusion and viability, evaluation of indeterminate solitary pulmonary nodules, and initial staging of non-small cell lung cancer. The new coverage is spurring development of more outpatient centers, as radiologists foresee greater opportunities for economic viability.
Even some institutional PET facilities have had difficulty passing financial muster. The in-house PET facility at Emory University had been losing about $200,000 a year until improved image quality and greater physician recognition of PET’s clinical potential increased the demand for scanning. This turned a deficit into a $1 million annual profit, said Dr. John Bremner, director of the PET center.
The recent HCFA actions could set the stage for even broader coverage of PET studies. A strong case can be made for using PET to evaluate prostate, breast, and thyroid cancers, said Dr. Stephen Larson, chief of nuclear medicine at Memorial Sloan-Kettering Cancer Center. Some insurers already reimburse for selected PET studies that have not been approved for Medicare reimbursement.
“On a case-by-case basis, insurance companies will reimburse for procedures that are justified and perceived to be in the best interest of patient management,” Larson said. “Medicare has been a little slow to follow suit.”
© 2001 CMP Media, LLC.
6/1/01, Issue # 2306, page P12.
