PET cov­er­age ex­tended

Medi­care won’t stop cov­er­ing post-treat­ment scans

Modern Healthcare - - THE WEEK IN HEALTHCARE - Jessica Zig­mond

Medi­care pa­tients who have been treated for prostate can­cer and other solid tu­mors will con­tinue to have ac­cess to PET scans to guide sub­se­quent ther­apy. Physi­cians, pa­tients and med­i­cal imag­ing com­pa­nies talked the CMS out of vir­tu­ally end­ing pay­ment for post-treat­ment PET scans.

In March, the agency pro­posed stop­ping cov­er­age for post-treat­ment scans for prostate can­cer and a limit of one scan for other can­cers, look­ing to rein in imag­ing with ques­tion­able value. In­stead, Medi­care will cover three scans or­dered to help guide sub­se­quent anti-tu­mor treat­ment. The CMS will al­low lo­cal Medi­care ad­min­is­tra­tive con­trac­tors to de­ter­mine cov­er­age for ad­di­tional scans.

Gail Ro­driguez, ex­ec­u­tive di­rec­tor of the Med­i­cal Imag­ing & Tech­nol­ogy Al­liance, is­sued a state­ment call­ing the de­ci­sion “a step in the right di­rec­tion in en­sur­ing ac­cess to crit­i­cal imag­ing pro­ce­dures for pa­tients with can­cer.”

The tech­nol­ogy in­volves in­ject­ing F-18 flu-orodeoxyglu­cose (FDG) into the blood so the scan can iden­tify signs of can­cer metas­ta­sis. Dr. Robert Barr, chair­man of the Amer­i­can So­ci­ety of Neu­ro­ra­di­ol­ogy’s Health Pol­icy Com­mit­tee, said in an e-mail that the CMS’ change of course “rep­re­sents progress; FDG PET is a nec­es­sary tool for physi­cian de­ci­sion­mak­ing.”

The CMS also lifted the “cov­er­age with ev­i­dence de­vel­op­ment,” or CED, re­quire­ment in ef­fect since Medi­care started pay­ing for the tests in 2005. The rule meant Medi­care would cover FDG PET scans post-treat­ment only if providers sup­plied data and tracked out­comes in the National On­co­logic PET Reg­istry.

An anal­y­sis from con­sult­ing firm Avalere Health showed that 97% of pub­lic com­ments—or 195 out of 201 filed—ex­plic­itly op­posed the CMS’ pro­posal to limit scans. Of those com­menters, 170 were from in­di­vid­ual providers. Amer­ica’s Health In­sur­ance Plans en­dorsed the cov­er­age re­stric­tions.

“This is a win for a lot of the com­menters be­cause it’s bet­ter to have the as­sur­ance at the national level that more than one is cov­ered rather than leave it at the hands of lo­cal con­trac­tors,” Jenny Gaffney, a se­nior man­ager at Avalere, told Mod­ern Health­care. “This pro­vides as­sur­ance that if a pa­tient needs a sec­ond or third scan, then they will” be cov­ered, she con­tin­ued. Gaffney added that the de­ci­sion to lift the CED re­quire­ment is a big win, too, be­cause the CMS ac­knowl­edged that af­ter eight years, enough data had been col­lected to show that th­ese scans were nec­es­sary.

“There is hope for other tech­nolo­gies that find them­selves in sim­i­lar sit­u­a­tions where their cov­er­age has been con­fined to CED,” Gaffney said, adding that if ev­i­dence col­lected is ro­bust, then the CMS might re­con­sider their CED re­quire­ments.

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