CMS eases FDG-PET reimbursement requirements

The Centers for Medicare & Medicaid Services last week issued a proposed decision memo to reverse a requirement that FDG-PET scans of patients with solid tumors be reported to the National Oncologic PET Registry (NOPR). In theory, this should make it easier for PET providers to receive reimbursements, since CMS requires them to report such data in order under its coverage with evidence development (CED) requirement.

In addition, CMS proposed to cover one FDG-PET scan when it's used to guide physician management of a malignant tumor after completion of an initial anticancer strategy. CMS did make an exception in the case of prostate cancer.

Coverage of additional scans will be up to local Medicare Administrative Contractors.

According to CMS, in making its recommendation it examined evidence from the NOPR and other sources in order to determine whether FDG-PET will meaningfully improve health outcomes in beneficiaries who have completed an initial treatment regimen for malignant cancers or will guide physician management of subsequent anti-tumor treatment strategies.

According to the memo, CMS did not find evidence that FDG-PET improves health outcomes, but did determine that FDG-PET "changes physician management in this context. ... [T]he evidence shows that physicians are able to use the results of this diagnostic test in the treatment of patients with brain, pancreas, soft tissue sarcoma, small cell [of lung], thyroid, testis, or any other solid cancers."

An exception was made in the case of prostate cancer, according to CMS, because the available evidence did not support "the usefulness of FDG PET in beneficiaries who have completed initial treatment of prostate cancer."

"We believe that the body of evidence as a whole argues against the persuasiveness of the NOPR results on this issue," the memo said. "Consequently, CMS proposes that use of FDG PET/CT when used to guide subsequent anti-tumor treatment strategy for patients with cancer of the prostate is not reasonable and necessary."

According to a study published last week in the Journal of the National Cancer Institute, while Medicare spending for advanced cancer significantly varies across regions, there is no direct link between higher regional spending and improved patient survival. Researchers did find, however, that higher cancer care spending was strongly associated with more frequent and longer hospital stays

To learn more:
- read the proposed decision memo


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