CMS Weighs Expanding Coverage of PET Cancer Scans

In In The News by Barbara Jacoby

By: Kerry Young


In the latest round of battles over Medicare payments for positron-emission tomography, or PET, scans, federal officials are considering a request to greatly widen coverage for a form of the test to track whether cancers have spread to the bones.

Doctors who oversee a key research body for use of PET scans in cancer patients have asked for national Medicare coverage of a version of test that uses a form of sodium fluoride to check for unusual growths in bones. The Centers for Medicare and Medicaid Services now limits its payment for this product to people who participate in the National Oncologic PET Registry (NOPR), a requirement that is part of the agency’s “coverage with evidence development” approach to evaluating products.

In a letter last month to CMS, the leaders of the NOPR argued that finding from this research effort on the sodium fluoride scans support their request to end the data collection requirement, and allow national Medicare coverage with the product for cancer in general. Reports made by doctors to the NOPR indicate that the scan allowed them to avoid ordering additional noninvasive tests in 71 percent of cases and invasive procedures in 66 percent, according to the letter.

“The NOPR has been successful in meeting the goal for which it was established — providing clear, extensive data on the previously little-researched question of whether there is a clinical benefit” of using the scans to identify bone metastasis,  wrote Bruce E. Hillner, the chair of the NOPR and his cochairs, Barry A. Siegel and Anthony F. Shields, in a Feb. 15 letter to CMS.

CMS formally accepted their request for its national coverage analysis process on March 16, and will accept comments regarding it through April 15. A proposed decision is due Sept. 16, with a final one slated to be completed by Dec. 15.

PET scans seem to have attracted special scrutiny from CMS over the years, with the agency having used the national coverage analysis more than dozen times for different forms and uses of the test, such as checking for signs of Alzheimer’s disease. That makes PET scans one of the technologies most heavily studied by CMS through its NCA process.

In PET tests, a small amount of a radioactive material known as a tracer is injected into a patient. Doctors can then again information about what’s happening in the body through following the path of the materials, such as checking for the spread of cancer.

CMS created the NOPR in 2006 as part of its answer to a request that Medicare cover PET testing with another agent, F-fluorodeoxyglucose (FDG), for more cancers, Hillner, Siegel and Shields noted in their letter. By 2013. CMS approved a request from NOPR to end the data collection requirement and provide coverage for essentially all cancer uses.