Part B Insider (Multispecialty) Coding Alert

Published on Fri May 23, 2003 PDF

If your clinic performs positron emission tomography scans, you could be in for a big boost in business soon.

The Centers for Medicare & Medicaid Services announced that it was expanding coverage of PET scans to include Medicare beneficiaries with thyroid cancer and potential cardiac diseases. And CMS plans a demonstration project to decide whether PET scans can help patients who doctors suspect have dementia.

CMS said the new cardiovascular disease coverage includes conditions such as hypertension, coronary artery disease, congestive heart failure and stroke. After reviewing the scientific evidence for PET scans using radiopharmacological ammonia N-13, CMS decided that such scans would be useful for cardiac evaluations. So Medicare will cover ammonia N-13 PET scans for cardiac exams.

For a handful of patients with thyroid cancer, iodine-131 whole-body scans aren't useful in determining where the disease is located. For these patients, CMS now maintains that a PET scan may be useful, after a literature review and technology assessment, plus recommendations from the CMS Medicare Coverage Advisory Committee.

But CMS decided not to extend PET coverage to include soft-tissue sarcoma, a rare cancer that current diagnostic imaging techniques are capable of diagnosing. CMS found the evidence didn't show that PET improved outcomes in this population.

As for patients with Alzheimer's disease and other dementias, CMS says the jury is still out on the clinical benefits of PET scans. Medicare already covers clinical evaluations of cognitive impairment, as the American Academy of Neurology recommends. And CMS argues that the current evidence shows such workups remain the best way to diagnose and treat dementia.

But CMS will design a demonstration to examine whether PET can have a role in helping patients with suspected dementia. And the agency plans to work with the National Institutes of Health and pull together geriatricians, neurologists, radiologists, PET experts, and patient advocates to gather and explore the value of PET for Alzheimer's.

CMS notes that Alzheimer's is irreversible, as well as the commonest cause of dementia in the United States. Some experts have proposed using PET scans as a tool to diagnose and manage patients with the disease.

"We are pleased at the continued progress in gaining broader Medicare coverage for PET," said Terry Douglass, chairman and CEO of Knoxville-based CTI Molecular Imaging Inc., a leading supplier of PET equipment. Douglass said the decision on thyroid cancer came faster than expected, and the Alzheimer's study shows "continued progress to gain Medicare approval for Alzheimer's."

CTI doesn't expect Medicare to cover PET for Alzheimer's within the next two years. But the company is confident Medicare will extend the tests to dementia patients eventually because published clinical studies show a 93 percent accuracy when using PET to diagnose patients with Alzheimer's.

Medicare started covering PET scans in December 2000 and now covers PET scans for diagnosis, staging and restaging of a number of cancers, including lung, esophageal, colorectal, lymphoma, head and neck, and breast. Medicare also covers PET scans for myocardial viability and evaluation of refractory seizures before surgery.