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Medicare In Brief

This article was originally published in The Gray Sheet

Executive Summary

Comments on PET for solid tumors, myeloma: Physicians and specialty societies are urging CMS to reconsider Medicare policy that allows doctors to perform only one positron emission tomography scan when planning initial radiation treatment in patients with solid tumors or myeloma. "The current 'one scan' restriction precludes obtaining the specially aligned PET scan that is required for radiation treatment planning," says David Milstein, M.D., Albert Einstein College of Medicine. America's Health Insurance Plans, however, argues against additional PET scans without evidence that second tests are necessary to make treatment decisions and that those decisions improve health outcomes. The Academy of Molecular Imaging suggests "it is possible to extend coverage for certain limited radiation therapy purposes ... without allowing the exception to consume the rule." CMS opened its national coverage analysis in November and will issue a proposed decision by May 9, 2010 (1"The Gray Sheet" Nov. 16, 2009)

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CMS updates coverage policy on PET for cervical cancer: The Medicare agency finds there is now enough evidence to call positron emission tomography for cervical cancer "reasonable and necessary" for staging cervical cancer patients, and will no longer require data collection as a condition of coverage (1"The Gray Sheet" May 18, 2009). CMS will cover one PET scan for staging beneficiaries with biopsy-proven cervical cancer to help determine the location or extent of the tumor. Coverage is limited to the following therapeutic uses: to determine if the patient is a good candidate for an invasive diagnostic or therapeutic procedure; to determine the best anatomic location for an invasive procedure; or to determine the anatomic extent of a tumor when treatment depends on the extent of the tumor. The imaging test remains non-covered as a tool to diagnose cervical cancer. This recent decision does not restrict the use of PET scans already covered for detection of metastases during the pre-treatment management phase of patients with newly diagnosed and locally advanced cervical cancer who show no extra-pelvic metastasis on conventional imaging tests such as CT or MRI (2"The Gray Sheet" April 13, 2009)

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