PET Reimbursement Issues

FDA and Medicare approval of the radiopharmaceuticals used in PET has always been a prerequisite for public-sector reimbursement.

● Medicare will pay for PET if:

• The patient is enrolled in a study of PET efficacy
• If institutions are part of a "PET Registry"
  

● Insurance Coverage

• Most major insurers cover PET
• Coverage varies by carrier
• Pre-certification usually required
• Carriers may limit facilities at which PET is covered.
  

PET Pharmaceuticals:Clinical Utility

● Patient Management Outcomes showed that:

PET can change staging of CA in 43% of cases*
PET leads to major changes in management decisions in 39%*
PET increases diagnostic understanding in 59%**
PET influenced therapy choice in 36%**

General Tumor Imaging with FDG

● Most commonly used in oncology to detect and evaluate tumors:
FDG-PET is effective in the diagnosis and staging of the following cancers:
brain tumor, breast cancer, colorectal cancer, head and neck cancer, lung cancer, lymphoma, melanoma, musculoskeletal tumors, ovarian cancer, pancreatic cancer, and thyroid cancer.

Approved indications for whole-body ¹⁸F-FDG PET scans

■ solitary pulmonary nodule
■ completion staging and restaging NSCLC (non-small cell lung cancer)
■ staging and restaging-
■ esophageal ca
■ colon cancer
■ melanoma
■ lymphoma
■ head and neck ca
■ restaging and monitoring advanced breast ca
■ follicular thyroid ca post Rx
■ initial staging cervical ca

Awaiting Medicare Approval for whole-body ¹⁸F-FDG PET scans:

■ pancreatic ca
■ hepatoma
■ ovarian ca
■ testicular ca
■ thyroid ca
■ brain tumor
■ bladder ca
■ sarcoma

PET in Cardiology: Useful in cardiology to assess myocardial viability
Approved indications for cardiac ¹⁸F-FDG PET scans:
Cardiology enables physicians to:

■ screen for coronary artery disease
■ assess flow rates and flow reserve
■ distinguish viable from nonviable myocardium for bypass and transplant candidates.

CPT CODE Indication

78459 Cardiac metabolism
78499 Cardiac perfusion
78990 Radiopharmaceutical

PET in Neurology: Also useful in the brain for diagnosis of a variety of neurological conditions
Approved indications for cerebral ¹⁸F-FDG PET scans:

PET enables assessment of Alzheimer’s and other dementias, Parkinson’s, and Huntington’s
Localizes epileptic foci for qualifying and identifying the site for surgical intervention
Permits characterization, grading, and assessment of possible brain tumor recurrence

CPT CODE Indication
78608 Brain metabolism
78609 Brain perfusion
78990 Radiopharmaceutical

*(seltzer et al: abstract #408 snm 6/99- questionaire sent to 99 referring physicians)
**(comens et al: abstract #427 snm 6/99-questionaire before & after 153 PET scans)