Gail Rodriguez, Executive Director, MITA

For centuries, the inner workings of the human brain have eluded the world’s scientists and physicians. Now, advances in neuroimaging techniques can address previously unanswered questions about how the brain functions and how distressing and costly diseases such as Alzheimer’s and Parkinson’s develop and progress. Innovations in diagnostic imaging, such as computed tomography (CT), positron emission tomography (PET), molecular imaging and the hybrid modality of PET and magnetic resonance (MR), can identify the causes of a stroke, rule out Alzheimer’s and correctly diagnose Parkinson’s. They offer the potential to detect disease and the ability to explore the brain’s frontier. Increasing access to these technologies will improve health and save lives while lowering healthcare costs.


Stroke is the fourth leading cause of death in the United States, killing 130,000 people annually, and is a leading cause of disability for those who survive. Today, CT can reveal the cause of stroke, assess its severity and determine whether a patient requires hospitalization. Knowing whether a stroke was caused by a blood clot is crucial, since clot-busting drugs can worsen symptoms - or kill - if a stroke has other causes. Time is also of the essence, given that most stroke patients arrive at the hospital after the “golden hour” - the window of time in which treating a patient for a severe injury most greatly increases the chance of survival. Having a portable CT in the ambulance offers a potential solution to this problem; a randomized clinical 

 found this approach reduced the time between the emergency call to therapy decision 

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The clinical benefits of CT to patients are measurable and contribute to improved outcomes. We now know that there are economic advantages as well. According to one 

, using CT to assign degrees of urgency to stroke patients’ conditions could yield $1-2 billion in annual nationwide 

 by preventing consequent hospital stays.


More than 5 million Americans have been diagnosed with Alzheimer's disease today, and by 2050, that number could nearly triple. On this trajectory, the direct 

 in adults over 65 could balloon to $1 trillion per year by 2050 (in today’s dollars) with a total of $20 trillion in medical costs over the next 40 years, according to the Alzheimer’s Association.

For many years, Alzheimer’s has been difficult to distinguish from other common conditions associated with aging. Now, PET imaging can detect the presence of beta amyloid plaque in the brain - a common indication of Alzheimer’s - and help physicians diagnose patients when there is more time for them and their family and caregivers to plan accordingly. The ability to rule out Alzheimer’s through beta amyloid PET imaging could also help physicians avoid prescribing inappropriate or unnecessary treatments.

Alleviating the personal, societal and economic burden of Alzheimer’s is also a priority of the Obama Administration. In his fiscal year 2014 budget, President Obama included a $122 million increase for 

, education, outreach and caregiver support to bolster the implementation of the 

National Plan to Address Alzheimer's Disease

. In spite of these efforts, lagging policy prevents patients from benefiting from the latest innovations in brain imaging. For example, the Centers for Medicare & Medicaid Services (CMS) recently concluded that the evidence for beta amyloid imaging is not sufficient to cover the technology outright. Instead, CMS makes beta amyloid PET imaging available to Medicare beneficiaries only through the Coverage with Evidence Development (CED) process. This will limit coverage to approved imaging providers who participate in the CED process.


Parkinson’s disease, the second most common neurological condition after Alzheimer's, currently affects approximately 1 million people in the United States and 

 of Parkinson’s in the United States is estimated at $10.8 billion, 58 percent of which is due to direct medical costs. If these costs continue to increase steadily, they will eventually double in 2040. Moreover, clinical exams alone, especially early in the disease, are often inconclusive and can result in misdiagnosis. A considerable share of Medicare beneficiaries with 

 disease and vascular dementia are misdiagnosed with Alzheimer’s; these patients incur higher medical costs as a result.

Fortunately, promising advances in molecular imaging will give physicians the capability to correctly diagnose Parkinson’s. For example, a nuclear medicine scan can now help differentiate essential tremor from Parkinson’s and other neurological conditions, a step in the right direction towards alleviating the emotional and economic burden of Parkinson’s on individuals and families affected by this disease.


So, what’s next in brain exploration?  For many years, traditional medical imaging modalities were used either to detect anatomic abnormalities or to evaluate an organ’s function in order to diagnose disease. Now, hybrid modalities are combining the power of two imaging technologies into one, providing an even more comprehensive and highly detailed view inside the body. For example, the 

 of MR imaging and PET is increasingly being used to assess brain cancer, neurodegenerative diseases, and acute and chronic stroke, as well as in research to evaluate disorders associated with changes in mental status, including depression, dementia, schizophrenia and obsessive-compulsive disorders. PET contributes functional and physiological information about a disease, while MR adds anatomic detail with high spatial resolution and soft-tissue contrast, making the hybrid a powerful combination.

These are just a few examples of how advanced medical imaging, including CT, PET, PET/MR and molecular imaging, can lead to appropriate treatments for devastating conditions such as Alzheimer’s, Parkinson’s and stroke. Increasing patients’ access to these scans will improve health outcomes. More dramatically, it will help us see inside the brain and solve mysteries that have proven intractable until now.

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Should Medicare beneficiaries have access to the same testing benefits as individuals with private health insurance? That question is at the crux of Medicare’s deliberation of a coverage decision for imaging high risk beneficiaries for lung cancer. Unfortunately, a Medicare advisory panel recently concluded that while low-dose CT (LDCT) could save thousands of lives, the benefits are insufficient to recommend coverage. This conclusion is surprising and disappointing, particularly given the evidence that indicates exactly the opposite.

LDCT is an advanced imaging technology that can detect tumors as small as a grain of rice. Compared to a standard chest X-ray, LDCT can 

 (NLST) also determined that 12,000 deaths could be avoided every year if high-risk patients underwent a LDCT scan.

In addition, data show that LDCT for patients at high risk of lung cancer is cost effective. An 

 found that coverage of LDCT for lung would cost about $1 per insured member per month in 2012 dollars. The cost per life-year saved would be less than $19,000, an amount that is at least 

 as other essential screening tests including breast, cervical and colorectal cancer screenings. Furthermore, 

 of NLST data presented at a Joint Meeting of the National Institutes of Health Board of Scientific Advisors and National Cancer Advisory Board in June 2013 also concluded that LDCT for patients at high risk for lung cancer is a cost effective diagnostic tool.

These data are even more dramatic considering that 

 are living with lung cancer. This year alone, an estimated 

 are expected to die from lung cancer, accounting for approximately 27 percent of all cancer deaths. Nearly two decades ago, lung cancer surpassed breast cancer as the leading cause of cancer-related deaths among women and now, the disease is the leading cancer killer in both men and women in the United States.

One reason lung cancer is so deadly is that symptoms of the disease do not typically manifest until it has reached advanced stages. In approximately 

 of people diagnosed with lung cancer, the diagnosis is made after the disease has advanced. In 

 of those diagnosed, the cancer has reached stage three. 

Given the prevalence of lung cancer and the proven effectiveness of LDCT, it’s not surprising that military hospitals began phased implementation of these scans to detect lung cancer in its earliest, most treatable stages. In November of 2013, the Naval Medical Center San Diego joined Walter Reed National Military Medical Center in Bethesda, Md., and Naval Medical Center, Portsmouth, Va., using NLST criteria. The Department of Veterans Affairs (VA), the Department of Energy (DoE) and a number of private insurers, such as WellPoint, Blue Cross Blue Shield affiliates and Anthem affiliates, have also followed.

Several cancer organizations that represent diverse groups of patient advocates across the country have also voiced strong support for coverage, including the American Association for Thoracic Surgery (AATS), the American Society of Clinical Oncology (ASCO), the American Cancer Society (ACS), the American College of Clinical Pharmacy (ACCP) and the Lung Cancer Alliance (LCA).

Perhaps the voice that rings loudest in support of LDCT coverage is that of the U.S. Preventive Services Task Force (USPSTF).  In January of this year, USPSTF finalized its 

 for the use of annual LDCT scans for individuals ages 55 to 80 who are at high risk for lung cancer. Because the final USPSTF statement was put into place before 2014, all private insurance payers will be required to cover the screening by January 2015.

The medical imaging community stands ready to implement life-saving LDCT so that Medicare beneficiaries can access the benefits already enjoyed by those with private insurance. This includes resources – such as the American College of Radiology (ACR) 

 (Lung-RADS) quality assurance tool – to ensure physicians have the support they need to provide this service. The tool is designed to standardize LDCT reporting and management recommendations, reduce confusion in LDCT interpretations and facilitate outcome monitoring.  

From a technology perspective, medical imaging manufacturers have developed equipment that is able to perform LDCT scans at an even lower dose than the rates from the NLST trial. The availability of these technologies is already widespread: CT equipment able to perform low-dose scans is available in community settings throughout the country.

The Centers for Medicare & Medicaid Services (CMS) is set to issue its proposed Medicare reimbursement determination in mid-November, with a final determination in February 2015. This decision has the potential to save tens of thousands of lives right now. Time is of the essence.

The evidence exists that low-dose CT can save the lives of patients at high risk for lung cancer, according to MITA.

Gail Rodriguez, Executive Director, MITA

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