Broader coverage for PET could simplify cancer care

With obstacles to routine Medicare reimbursement of FDG-PET for most cancer cases cleared away, the imaging community is now focusing attention on private insurers and coverage policies that restrict access to the imaging technology.

The Centers for Medicare and Medicaid Services issued a new national coverage determination April 3 stating that it agreed to pay for one FDG-PET scan for patients with solid tumors that are biopsy-proven or strongly suspected based on other diagnostic exams. Indications include breast, cervical, colorectal, esophageal, head and neck, non-small cell lung, thyroid, and ovarian cancers and lymphoma, melanoma, and myeloma.

PET imagers in academia and clinical practice praised the decision as a boon for Medicare patients, but the effect on private sector healthcare coverage is still unclear. Although patients with more generous plans may sit tight, those with insufficient coverage could start taking matters into their own hands. Patients have already filed class action lawsuits against Aetna and Blue Cross Blue Shield of Florida alleging that the insurers denied them life-saving diagnostic imaging services by refusing to pay for PET/CT scans.

For their part, PET proponents worry that the CMS decision could be used to justify new reimbursement cuts, said Fred Stuvek Jr., president and CEO of Trident Medical Imaging, a multimodality imaging center with six locations across Georgia. During an interview with Diagnostic Imaging, he recalled when the Deficit Reduction Act of 2005 forced the PET industry to absorb a 50% payment cut. Some PET centers were driven out of business.

Market research firm IMV's Medical Information Division reports that PET and PET/CT studies in the U.S. rose 4% in 2008 to about 1.5 million procedures. Though utilization continues to rise, last year's growth fell far short of the average 10.4% annual increases from 2005 to 2008, according to the company.

“Further cuts in reimbursement will be a crippling blow to the industry and result in restricted access to PET for the cancer patients that [the modality] will benefit the most, particularly in rural areas,” Stuvek told Diagnostic Imaging.

Until now, PET facilities performing staging, restaging, and therapeutic response exams for several cancers were required to participate in the National Oncologic PET Registry to qualify for Medicare reimbursement. The new national coverage determination eliminates the NOPR requirement for scans done to plan initial tumor treatment strategy. About 40% of the Medicare patients who underwent PET scans under the initial NOPR will now be able to receive them without going through the registry, said NOPR cochair Dr. R. Edward Coleman.

FDG-PET procedures designed to monitor the response to cancer therapy are still subject to the NOPR physician survey process. Those data will be analyzed to provide additional evidence on treatment outcomes that could eventually result in across-the-board coverage, he said.

SNM president Robert W. Atcher said that the CMS reimbursement decision will save patients thousands of dollars as well as increase the likelihood that private insurers will eventually follow Medicare's lead.

“That will save our referring physicians some time and hassle, and that's always beneficial,” said Ruth Tesar, CEO of Northern California PET Imaging Center in Sacramento.

The process should become streamlined once referring physicians appreciate the value of the new indications and learn they no longer have to go through the NOPR paperwork for an initial PET scan, Tesar said.

“I hope this will facilitate the acceptance by insurers to approve PET scans for cancer patients in a timelier manner,” Stuvek said. “Delays of weeks, or in some cases, ultimate nonapprovals, are unacceptable when time is of the essence and has life-threatening consequences.”