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Back To Vidyya Medicare Expands Coverage Of PET Scans

Coverage To Improve The Care Of Patients Who Have Or May Have One Of Six Types Of Cancer

The Health Care Financing Administration (HCFA) announced today it is expanding Medicare coverage of positron emission tomography (PET), an innovative imaging technology, to improve the care of patients who have or may have one of six types of cancer. Additional coverage is also provided for some patients with refractory epilepsy or who may be candidates for coronary revascularization.

"PET is a technology that has tremendous promise," said Jeffrey Kang, director of HCFA's Office of Clinical Standards and Quality. "Our expanded coverage of this diagnostic tool provides additional clinical information to physicians that may influence the management of care for many Medicare beneficiaries."

This science-based coverage decision provides important expanded coverage of dedicated full circular ring PET scanners and some partial ring systems for any clinically appropriate use for six types of cancer ? lung, colorectal, lymphoma, melanoma, esophageal, and head and neck (but not brain or thyroid) cancer ? and new coverage of the neurologic and cardiac applications. The effective date will be announced shortly.

The use of PET may allow some Medicare beneficiaries to avoid undergoing invasive procedures and may also give beneficiaries and their physicians information that will increase confidence in the management of their care.

Consideration of requests for coverage of three additional applications ? myocardial viability, dementia, and breast cancer ? will be referred to the Medicare Coverage Advisory Committee, a panel of top private sector experts created to advise HCFA on important coverage issues.

HCFA had received an external request for broad coverage of PET for a multitude of cancers, one cardiac application, and two neurological applications. The conditions not covered under this decision remain noncovered, and HCFA is inviting interested parties to submit new formal requests for coverage for individual cancers or for broad coverage.

"Our goal is to provide a national, science-based coverage decision that will promote beneficiary access to this promising technology, " said Kang, HCFA's chief clinical officer. "We expect to expand coverage for additional conditions when we accumulate sufficient scientific evidence."

PET is a specialized imaging technique that was developed in the 1970s. It involves the injection into a patient of a very small amount of a radioactively labeled natural compound such as sugar or water. The most commonly used radiopharmaceutical in PET is fluorodeoxyglucose (FDG), which is similar in structure to glucose or simple sugar. Once FDG is injected, a PET scanner is used to image a specific function or physiological process within the body by measuring the concentration and distribution of the radioactive FDG throughout the body.

Prior to today's coverage decision, only specific uses for PET, such as localization of recurrence for any given cancer, have been covered by Medicare. This new policy decision provides coverage for all clinically appropriate uses of PET for six cancer types. This means broader coverage for previously covered cancers as well as for two additional ones.

This change is a significant modification in HCFA's approach to PET scans and a major step toward broad coverage. HCFA will now cover diagnosis, staging and re-staging for any covered cancer for which there is empirical evidence for at least one clinically appropriate indication. For example, HCFA previously covered PET scans for colorectal cancer for one narrow indication ? in the case of recurrent colon cancer evidenced by a rising carcinoembryonic antigen level. Now, HCFA has expanded coverage of PET for colorectal cancer for all other diagnostic, staging and re-staging reasons.

For coverage of PET in primary cancer diagnosis, PET must be used to potentially avoid or direct an invasive diagnostic procedure. For use in staging or restaging of disease, PET is only covered if the stage of the cancer remains uncertain following a conventional imaging work-up and if the clinical management of the patient may differ according to the stage of the disease. Where the evidence demonstrates PET is not clinically useful, that use in a specific cancer type will be explicitly excluded from coverage.

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Editor: Susan K. Boyer, RN
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