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Potential new opportunity for Medicare coverage of non-oncologic PET imaging studies

The Calendar Year 2022 Medicare Physician Fee Schedule (MPFS) proposed rule published by the Centers for Medicare and Medicaid Services (CMS) brought some potential good news about the prospects of greater Medicare coverage for additional positron emission tomography (PET) services. This news was celebrated by the Society of Nuclear Medicine & Molecular Imaging (SNMMI). 

PET is a noninvasive diagnostic imaging procedure that assesses the level of metabolic activity and perfusion in various organ systems of the human body. A positron camera is used to produce cross-sectional tomographic images, which are obtained from positron-emitting radioactive tracer pharmaceuticals that are administered intravenously to the patient.

Currently, Medicare coverage for PET services is basically limited to diagnostic testing for patients with enumerated cancer conditions as outlined in National Coverage Determination (NCD) for PET Scans (220.6), last updated in 2013.

In the 2022 MPFS proposed rule, CMS announced that it is proposing to remove "exclusionary language" from the NCD, leaving coverage decisions for non-oncologic PET indications largely to the discretion of local Medicare Administrative Contractors (MACs). Since the NCD was last updated in 2013, new non-oncologic PET agents have been approved by the FDA, and various national medical specialty societies have published guidelines relevant to the appropriate use of the new non-oncologic PET agents.

As SNMMI notes, CMS believes that extending local contractor discretion for non-oncologic indications of PET provides an immediate avenue to potential coverage in appropriate circumstances and provides a framework that better serves the needs of the Medicare program and its beneficiaries.

When this proposal is adopted as expected, new FDA-approved non-oncologic radiopharmaceuticals will be covered for non-oncologic cases determined at the discretion of the local MACs.

On July 13, 2021, CMS published its CY 2022 MPFS Proposed Rule—including a significant change for nuclear medicine.

Tags

health care & life sciences, medicare, nuclear medicine, pet

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