Blue Cross/Blue Shield opts to reimburse for PET scans in brain tumors and epilepsy

The nation's largest private insurer has endorsed reimbursementof positron emission tomography (PET) scans in brain tumors andepilepsy, and PET proponents believe federal payments are notfar behind.

The recommendation to pay for PET comes from the Blue Cross/BlueShield (BC/BS) Association's medical advisory panel. BC/BS coveragepolicies often set national standards. The PET endorsement maynudge the Health Care Financing Administration to adopt a similarpolicy, according to Michael McGehee, president of the Institutefor Clinical PET in Washington, DC.

"We are extremely pleased that the national BC/BS officehas recommended coverage of PET to its affiliates," he said."This is a major step forward."

BC/BS has recommended affiliates cover PET when used:

• to differentiate recurrent brain tumors from treatment-relatedtissue necrosis; and

• for localization of epileptogenic focus in patientswith complex or partial seizures who have failed to respond tomedical therapy and are being considered for surgical resection.

The recommendation follows a stringent review of PET basedon five assessment criteria developed by the insurer, said Dr.Andy Kelahan, assistant director of the technology managementdivision for the association.

Individual BC/BS offices are not bound by the national association'srecommendation, and are free to accept, modify or reject it, Kelahansaid. Based on an ICP database, BC/BS offices in 16 states nowpay for PET scans.

One of the largest of these, Blue Shield of California, adoptedthe policy in July. The plan covers 3.5 million people annually.McGehee predicts most BC/BS affiliates will also extend coverageto include PET.

"We know for a fact that individual offices are beginningto implement and accept this recommendation," he said. "Andthat's typical. It is rare for any one Blue not to abide by therecommendation of the national association."

Some Blues plans also pay for PET in the heart, although theposition of the national association is that cardiac PET applicationsare investigational, Kelahan said. That may soon change, however.

PET is considered a potentially powerful tool to differentiatepatients who will benefit from coronary bypass surgery, basedon demonstrations of residual myocardial function in the perfusedarea of a blocked artery. But until recently, data available forreview on this point have been limited. Studies using Food andDrug Administration-approved rubidium-82 have provided only anindirect view of myocardial function, he said.

With the FDA's favorable review of 18-fluorodeoxyglucose (FDG-18),that data may be worth reviewing. FDG, another PET radiopharmaceutical,permits direct demonstration of myocardial function and opensthe door to new data documenting PET's benefits in this area,Kelahan said.

"We will certainly want to go back and look at the literaturenow that the FDA has accepted FDG-18," he said. "Itmay be there is new information on FDG and cardiac applications."

The ICP has long lobbied HCFA to cover PET for four specificindications, including the two applications recommended by BC/BS.The other two concern myocardial viability and detection of coronaryartery disease, McGehee said.

The Medicare agency has been passing the buck on PET coveragesince 1989, when it asked the Office of Health Technology Assessmentto conduct a review. When that investigation was completed, HCFArequested the FDA to evaluate PET radiopharmaceuticals, even thoughthese agents are already regulated by state laws of pharmacy.

But between the FDA's nod to FDG-18 in May, and the BC/BS recommendationfor coverage, McGehee believes an announcement from HCFA is imminent.

"From our standpoint, the BC/BS recommendation ensuresHCFA will cover PET, at least for these two indications,"he said. "It is inconceivable HCFA would not cover this whenthe national Blues are."

BRIEFLY NOTED:

• University of California at Los Angeles researchers arepredicting PET may also prove a worthy adjunct to mammography.Because the technology detects tumors by metabolic activity andnot by size, PET may be most useful in determining effective treatment.

The UCLA study involved only 14 women and thus is not statisticallysignificant. But PET did correctly determine tumor status in 11of the 14, a finding that has interested the National Cancer Institutein pursuing further study.