Medicare Expands Coverage of PET Scans for Cancer Diagnoses

on Wednesday, 15 April 2009. All News Items

In a National Coverage Determination update released April 6, 2009, CMS removed the clinical study requirements for PET scans used to support initial diagnosis, treatment or staging of most solid tumors.  Prior to this decision, providers were required to report data to the NOPR (National Oncologic PET Registry) about how the scans affected doctors’ treatment decisions.  Therefore, Medicare will cover one FDG PET scan for patients with most solid tumors to determine location and/or extent of the tumor for certain therapeutic purposes related to the initial treatment strategy.
The NCD update also expands the coverage of PET scans for subsequent follow up testing for cervical or ovarian cancers and myeloma to not require the NOPR data reporting.  Please note that use of PET scans to monitor progress of treatment or remission for some cancers still requires NOPR data reporting for coverage under the Coverage with Evidence Development (CED) program.
Please see Appendix A below from the Decision Memo that summarizes the changes by tumor type.  CED means that the NOPR data reporting is required for coverage.  The complete NCD decision memo can be viewed at PET Scan Decision Memo .

Appendix A: Effect of Coverage Changes on Oncologic Uses of FDG PET
See NCD Manual for specific coverage language.

Final Framework
Solid Tumor Type Initial Treatment Strategy* Subsequent Treatment Strategy**
Colorectal Cover Cover
Esophagus Cover Cover
Head & Neck (not thyroid or CNS) Cover Cover
Lymphoma Cover Cover
Non-small cell lung Cover Cover
Ovary Cover Cover
Brain Cover CED
Cervix (1) or CED Cover
Small cell lung Cover CED
Soft Tissue Sarcoma Cover CED
Pancreas Cover CED
Testes Cover CED
Breast (female and male) (2) Cover
Melanoma (3) Cover
Prostate N/C CED
Thyroid Cover (4) or CED
All other solid tumors Cover CED
Myeloma Cover Cover
All other cancers not listed herein CED CED

 * Formerly “diagnosis” and “staging”
** Formerly “restaging” and “monitoring response to treatment when a change in treatment is anticipated”
N/C = noncover

(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: Noncovered for diagnosis and/or initial staging of axillary lymph nodes. Covered for initial staging of metastatic disease.
(3) Melanoma: Noncovered 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.

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