CMS Expands PET Scan Coverage
A National Coverage Determination (NCD) issued April 3 by the Centers for Medicare & Medicaid Services (CMS) expands coverage of positron emission tomography (PET) scans for the diagnosis and treatment of most solid tumor cancers in Medicare patients and removes the clinical study requirement in some cases.
The NCD also establishes a new coverage framework. Rather than the standard four-part diagnosis, staging, restaging, and monitoring response to treatment categories, CMS will now use a two-part framework to differentiate initial and subsequent treatment strategies.
Consequently, PET imaging coverage depends on not only the type of tumor treated but also the treatment stage. For example, PET imaging used to determine the appropriate initial treatment strategy for a patient suspected of having a brain tumor is covered. Subsequent PET imaging, however, hinges on whether the physician fulfills the Coverage with Evidence Development (CED) requirement. Several other types of solid tumors have this same requirement for subsequent treatment strategies; whereas other types of solid tumors have the CED requirement at just the initial treatment stage.
Remember, however, CMS will pay for only one PET study for a beneficiary with a biopsy-proven or strongly suspected solid tumor based on other diagnostic testing and the treating physician orders the PET scan to determine the location and/or extent of the tumor.
Read the final decision on the CMS Web site for complete coverage changes on oncologic uses of PET imaging.