The paths to Medicare reimbursement for dedicated PET and coincidence cameras have diverged and there appears to be no hope of reuniting them.
As of July 1, Medicare will reimburse users of dedicated PET scanners for the diagnosis, staging, and restaging of six types of cancer: lung, colorectal, lymphoma, melanoma, esophageal, and head and neck (exclusive of cancers involving the brain or thyroid). The agency will not reimburse users of coincidence cameras for the same studies, pending the Health Care Financing Administration’s development of a performance standard for these cameras.
Because third-party payers, many of which are contractors to Medicare, usually mimic HCFA policy in making their own coverage decisions, this action affects a wide customer base and places the future of positron imaging at risk.
The outcome will have an impact on the appeal of coincidence cameras that are capable of positron imaging. It also raises the possibility that PET policy changes implemented by HCFA, which runs the Medicare program, could signal a change in how Medicare reimburses examinations that use other diagnostic imaging equipment.
In policy issued Dec. 15, HCFA grouped dedicated bismuth germanate (BGO) PET scanners together with coincidence cameras that have a 1-inch crystal. The policy called for reimbursement of both types of positron technologies. An April 10 memorandum to intermediaries and carriers, however, called into question the inclusion of these cameras for the extended coverage.
“For indications covered beginning July 1, 2001, scans performed with dedicated full-ring scanners will be covered,” HCFA stated. “However, coverage of PET using camera-based systems is now under further review as a separate national coverage determination.”
Following this memorandum, HCFA distributed a tracking sheet on April 13, explaining that the agency has issued an internal formal coverage request to examine the comparative performance of all system types approved for marketing by the FDA as PET scanners.