Medicare approves coverage of FDG-PET for 11 cancers

April 6, 2009

The Centers for Medicare and Medicaid Services has opened a new chapter in the practice of positron emission tomography with the announcement for a national Medicare payment policy that expands coverage of PET scans in the initial treatment strategy of most solid cancers and for myeloma.

The Centers for Medicare and Medicaid Services has opened a new chapter in the practice of positron emission tomography with the announcement for a national Medicare payment policy that expands coverage of PET scans in the initial treatment strategy of most solid cancers and for myeloma. Nuclear physicians immediately praised the long awaited decision.

According to the decision memo published April 3, CMS will replace the previous four coverage categories, including diagnosis, staging, restaging, and monitoring response to treatment, with a two-part system. The new national coverage determination (NCD) will be used to differentiate FDG-PET scans done to plan initial tumor treatment strategy from further imaging needed to guide patient management after the completion of initial treatment.

In the past, PET scans were reimbursed only if the data were submitted to the National Oncologic PET Registry. With the new decision, PET facilities no longer need to fulfill the NOPR requirement.

CMS determined that available scientific evidence was strong enough to show that FDG-PET could guide the appropriate initial treatment strategy for patients with suspected solid tumors and myeloma and lead to improved health outcomes. The new NCD will cover one PET scan for patients with solid tumors that are biopsy proven or strongly suspected based on other diagnostic exams. CMS will reimburse PET imaging done for the initial diagnosis and management of breast, cervix, colorectal, esophageal, head and neck, lymphoma, melanoma, non-small cell lung and thyroid cancers.

CMS has added to the coverage list ovarian cancer and myeloma. In total, the new coverage policy for the initial diagnosis and subsequent treatment strategy includes 11 indications. PET coverage for all other cancers will still require participation in an approved coverage with evidence development program.

SNM applauded CMS decision and said it was based to a significant degree on compelling clinical evidence of the effectiveness of PET for cancer management and treatment provided by the NOPR. According to SNM, the new CMS decision will save patients thousands of dollars that would otherwise have to come out of their own pockets. The decision also increases the likelihood that private insurers will eventually follow CMS’ lead.

“This is a major victory for patients,” said SNM president Robert W. Atcher, Ph.D. “CMS’ decision to cover PET scans for cancer demonstrates the intrinsic medical value of PET and important role of these scans in diagnosing, staging, restaging and monitoring treatment for many cancers.”

For more information from the Diagnostic Imaging and SearchMedica archives:

Proponents call proposed PET coverage ‘bittersweet' Medicare proposes expanded coverage for cancer-related FDG-PET Panel pans clinical trials justifying PET coverageImaging research efforts place focus on clinical effectiveness