Expanded PET Coverage of Cervical, Brain, and Other Cancers
The American College of Radiology is pleased to announce that the Centers for Medicare and Medicaid Services (CMS) has proposed to expand national coverage on positron emission tomography (PET) for 1) the detection of pretreatment metastases in newly diagnosed cervical cancer subsequent to negative conventional imaging, and 2) brain, ovarian, pancreatic, and small cell lung cancers for those physicians participating in certain clinical trials and PET registries. CMS has decided that PET for staging or recurrent or residual disease in testicular cancer will not be covered. CMS is confident the proposed coverage will become official CMS policy and will make its final decision by March 2005.
New Concept for National Coverage
In an effort to overcome the challenge of obtaining evidence to determine if coverage of a service is appropriate, CMS developed a new concept for national coverage by allowing payment for these PET services (brain, ovarian, pancreatic, and small cell lung cancers) for those physicians who have their Medicare patients enrolled in 1 of 3 approved clinical trials/PET registries.
A longstanding challenge to gaining national coverage for new technologies is the availability of literature to show a service is medically needed and improves patient health outcomes. CMS recognizes that physicians will not have an incentive to participate in clinical trials in order to provide the data needed for national coverage decisions without also paying for the studies that are done.
The 3 types of approved clinical trials are those that meet the requirements of the 1) Food and Drug Administration, 2) national coverage analyses, and 3) PET registry designed to provide additional information on the accuracy and utility of PET procedures with an emphasis on appropriate credentialing by hospitals and providers. The PET registry also focuses on the qualifications and training of the personnel performing the service and the physicians interpreting the image.
The ACR recommended to CMS that it utilize ACR nuclear medicine PET accreditation in an effort to prevent the development of a different set of PET credentials and requirements that could ultimately do more harm than good.
The 2004 September/October issue of the ACR Radiology Coding Source™ contains more detailed information on the new 2005 PET and PET/CT codes and can be accessed online from the ACR Web site (www.acr.org), under the Coding and Reimbursement tab. The CMS PET coverage decision is also available on CMS' Web site at: http://www.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?id=92.
If you have any questions or would like additional information, please contact the Economics and Health Policy Department at (800) 227-5463, ext 4043, or e-mail economics@acr.org.