Medicare Greatly Increases
Coverage for PET/CT in Oncology
The Centers for Medicare & Medicaid Services (CMS) announced a new coverage
policy for oncologic PET and PET/CT scans effective April 6, 2009. The new
coverage utilizes the PET/CT imaging information gleaned from the results of
2006-2009 National Oncological PET Registry (NOPR).
Under the new guidelines, PET/CT coverage is now classified as a diagnostic
tool for one of two strategies: Initial Treatment Strategy and Subsequent Treatment
Strategy. Both strategies provide greatly expanded PET/CT coverage (see
Indication Matrix below) over the previous 4-phase coverage that was limited
to diagnosis, staging, restaging and monitoring response to therapy.
Initial Treatment Strategy
PET/CT performed as part of an evaluation for determination of an initial treatment
strategy is now covered by CMS in the 13 major cancer types, including myeloma.
Additionally, all other types of solid tumors not included in the major 13
listed are now covered. The coverage includes PET/CT in clinical situations
when (1) the PET/CT results may assist in avoiding an invasive diagnostic
procedure, or when (2) the PET/CT results may assist in determining the optimal
anatomical location to perform an invasive diagnostic procedure. In general,
for most solid tumors, a tissue diagnosis is made prior to doing a PET/CT
scan and therefore the scan is performed for staging rather than diagnosis.
Subsequent Treatment Strategy
PET/CT is also a CMS-covered service when used in subsequent treatment strategy
evaluation (formerly restaging, detection of suspected recurrence, and treatment
monitoring) of patients with the following cancers: breast, cervix, colorectal,
esophageal, head and neck, lymphoma, melanoma, myeloma, non-small cell lung,
ovary, and thyroid. For all other cancers, PET/CT coverage for subsequent
treatment strategy evaluation requires participation in the new NOPR 2009
registry. (Washington Imaging Services is a participant in this cancer registry.)
PET/CT is covered for restaging and detection of suspected recurrences:
- after completion of treatment for the purpose of detecting residual disease;
or
- for detecting suspected recurrence or metastasis; or
- to determine the extent of a known recurrence─if it could potentially
replace one or more conventional imaging studies when it is expected that
conventional study information is insufficient for the clinical management
of the patient.
Restaging applies to testing after a course of treatment is completed, and
is covered subject to the conditions above.
Important Considerations
As noted above, PET/CT is not covered as a screening test (i.e., testing patients
without specific signs and symptoms of disease) and thus is not covered for
surveillance of patients treated for cancer in whom there is no clinical
reason to suspect recurrent disease.
Treatment monitoring refers to use of PET/CT to monitor tumor response to
treatment during the planned course of therapy (i.e., when a change in therapy
is anticipated).
As an example, PET/CT performed under NOPR 2009 may be covered for monitoring
after 2 or 3 of a planned 6 cycles of chemotherapy in a patient considered
not to be responding as expected.
What Does This Mean for Cancer Patients?
Routine coverage for initial treatment for lymphoma, melanoma, breast cancer,
colorectal cancer, esophageal cancer, head & neck cancer, and non-small
cell lung cancer has been expanded to include brain cancer, ovarian cancer,
pancreatic cancer, small cell lung cancer, soft tissue sarcoma, thyroid cancer,
testicular cancer, and all other solid cancerous tumors. Clinicians will
now have the assistance of PET/CT as a diagnostic tool for all of Medicare
patients with all solid tumors. This expanded coverage should trickle down
over the next few months to include private insurance companies as well.
Additionally, restaging and monitoring for response to therapy now routinely
covers the 7 most common types of cancer and NOPR 2009 covers the remainder.
Clinicians will be able to utilize the salient features of PET/CT to restage
patients and to monitor response to treatment regimens.
What Else Should I Know?
PET/CT is explicitly not covered by CMS for initial treatment strategy evaluation
for several specific cancer types/indications:
- diagnosis and auxiliary nodal staging of breast cancer.
- assessment of regional lymph nodes in melanoma─all other uses for
initial staging are covered.
- diagnosis of prostate cancer and initial staging of newly diagnosed prostate
cancer.
- thyroid cancer is covered for restaging of follicular cell types only.
- cervical cancer for initial treatment strategy evaluation is covered for
the detection of pre-treatment metastases (i.e., staging) in newly diagnosed
cervical cancer subsequent to conventional imaging that is negative for extra-pelvic
metastasis. All other uses are CED.
The day-to-day procedure for ordering a PET/CT has not changed. Minor changes
will appear on the Rx form to reflect the increased coverage. Please call Gary
Beneze at Washington Imaging Services (425-462-4742) if you have any questions..
CMS Coverage Indication Matrix
|
Final Framework |
Solid Tumor Type |
Initial Treatment Strategy* |
Subsequent Treatment Strategy** |
Colorectal |
Covered |
Covered |
Esophagus |
Covered |
Covered |
Head & Neck (not thyroid or CNS) |
Covered |
Covered |
Lymphoma |
Covered |
Covered |
Non-small cell lung |
Covered |
Covered |
Ovary |
Covered |
Covered |
Brain |
Covered |
NOPR 2009 |
Cervix |
1 or NOPR 2009 |
Covered |
Small cell lung |
Covered |
NOPR 2009 |
Soft Tissue Sarcoma |
Covered |
NOPR 2009 |
Pancreas |
Covered |
NOPR 2009 |
Testes |
Covered |
NOPR 2009 |
Breast (female and male) |
2 |
Covered |
Melanoma |
3 |
Covered |
Prostate |
N/C |
NOPR 2009 |
Thyroid |
Covered |
4 or NOPR 2009 |
All other solid tumors |
Covered |
NOPR 2009 |
Myeloma |
Covered |
Covered |
All other cancers not listed herein |
NOPR 2009 |
NOPR 2009 |
| * |
|
Formerly “diagnosis” and “staging” |
| ** |
|
Formerly “restaging” and “monitoring response to treatment
when a change in treatment is anticipated” |
| n/c |
|
Not covered |
| (1) |
|
Cervix: Covered for the detection of pre-treatment metastases (i.e.,
staging) in newly diagnosed cervical cancer subsequent to conventional
imaging that is negative for extra-pelvic metastasis. All other uses are
CED. |
| (2) |
|
Breast: Not covered for diagnosis and/or initial staging of auxiliary
lymph nodes. Covered for initial staging of metastatic disease. |
| (3) |
|
Melanoma: Not covered for initial staging of regional lymph nodes. All
other uses for initial staging are covered. |
| (4) |
|
Thyroid: Covered for subsequent treatment strategy of recurrent or residual
thyroid cancer of follicular cell origin previously treated by thyroidectomy
and radioiodine ablation and have a serum thyroglobulin >10ng/ml and
have a negative I-131 whole body scan. All other uses for subsequent treatment
strategy are CED (NOPR 2009—Coverage with Evidence Development). |
|