Medicare Denies Coverage of Certain PET Scans

A recent change to Medicare reimbursement of PET scans shows why physicians need to stay abreast of this kind of information.

Before ordering positron emission tomography (PET) scans to identify cancer metastasis to the bone, patients should be educated about Medicare coverage.

It’s the holiday season and when I read the announcement that Medicare won’t cover the use of a NaF-18 PET, a scene from Christmas Vacation came to mind. Specifically, where Chevy Chase finally receives his Christmas bonus only to discover it’s the “Jelly of the Month Club.” After a series of antics by a cousin-in-law, the company owner finally decides to reinstate the bonus plus an additional percentage. For now, physicians and patients are stuck with the “Jelly of the Month Club.”

On Dec. 15th, CMS released a memo (CAG-00065R2) indicating that, “[t]he Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to determine that use of a NaF-18 positron emission tomography (PET) scan to identify bone metastasis of cancer is not reasonable and necessary to diagnose or treat an illness or injury or to improve the functioning of a malformed body member and, therefore, is not covered under § 1862(a)(1)(A) of the Social Security Act.” While there is a 24-month grace period, which expires on or about Dec. 15, 2017, further analysis will be done. During this period, CMS shall proceed with the requisite standard, “coverage with evidence development (CED) under §1862(a)(1)(E) of the Social Security Act for NaF-18 PET to identify bone metastasis of cancer contained in section 220.6.19B of the Medicare National Coverage Determinations Manual.” It is also helpful for both patients and providers alike to know that all of uses and clinical indications of the NaF-18 PET are not covered.

During the next two years, CMS will be addressing the following:

“Does the addition of NaF-18 PET imaging lead to:

-A change in patient management to more appropriate palliative care; or

-A change in patient management to more appropriate curative care; or

-Improved quality of life; or

-Improved survival?”

While it appears as though the rationale is rooted in the notion that other diagnostic tests exist to detect bone metastases, Regardless, this is one less option for patients and providers, who would utilize Medicare and Medicaid for payment. For a complete history, go here.

This is just one more reason to highlight that physicians need to stay abreast of the current reimbursement environment - both for patient care and fiscal planning.