Positron Emission Tomography (PET) Medicare Coverage Expansion Benefits Senior Americans

Washington, December 18,. 2000. The Health Care Financing Administration (HCFA) issued a National Coverage Decision broadly expanding Medicare reimbursement for positron emission tomography (PET) scans to allow older Americans greater access to this breakthrough diagnostic modality. This decision also represents a significant shift in the framework used by HCFA for evaluating diagnostic imaging modalities, according to the Academy of Molecular Imaging (AMI).

Friday's Medicare coverage decision provides for the broad use of PET in six cancers; lung, colorectal, lymphoma, melanoma, head and neck and esophageal. In each of these cancers, PET is covered broadly from diagnosis and staging to assessment of therapy and the recurrence of disease. This marks the first time that HCFA has set a national coverage policy that allows physicians to use their judgement of how best to use PET to improve the care of their patients. In addition, coverage is provided for determining which patients will benefit from revascularization in heart disease and for identifying epilepsy patients who will benefit from surgery.

The fundamental importance of PET is its capability to examine the biological origins of disease so that illness may be diagnosed and treated earlier and more effectively. Dr. Michael E. Phelps, Chairman of Department of Molecular and Medical pharmacology at UCLA and winner of the 1999 Enrico Fermi Award from President Clinton for his invention of the PET scanner stated that "Today marks a significant advancement in the recognition for PET as a technology originating from the revolutionary changes occurring in biology and biotechnology that are changing the world we live in. Sean Tunis, Jeff Kang and their colleagues at HCFA have created a new framework for evaluating molecular imaging technologies like PET. They still require evidence from clinical studies for determining the practical value in patient care, but have opened up the criteria to allow evidence from biology to provide a fundamental foundation for a new test. The importance of this is self-evident when you consider that disease is a biological process and it is these very processes that PET examines. With this, HCFA is also recognizing that the merging of biology and medicine is changing our understanding, diagnosis and treatment of disease."

According to Dr. Val Lowe, President of Academy of Molecular Imaging and a leading physician specializing in PET at the Mayo Clinic, HCFA's decision will have a positive impact on improving the care of American Seniors. Said Lowe "HCFA has taken an important step in broadly expanding coverage of PET scans. Giving seniors additional access to this important new diagnostic test for these cancer indications and cardiovascular disease will be the difference between life or death for some, and for others will have a direct impact on improving their treatment and their quality of life. Dr Edward Coleman, Vice Chairman of Radiology at Duke University, stated that: "The expanded PET coverage is also cost-effective for the health care system since it can reduce the number of tests needed to diagnose, stage and track a disease, and can prevent unnecessary and less effective procedures and treatment."

In clinical practice today, PET is being used to improve the diagnosis and treatment of patients with many different cancers, cardiac diseases, and neurological disorders. Dr. Phelps stated "PET is being used to improve the diagnosis and treatment of diseases not yet covered by HCFA. HCFA's new structure for making coverage decisions on PET based on the known biology of disease and proof that these principles apply to a particular disease by clinical evidence, will allow acceleration of the coverage decisions for PET, while retaining and in fact improving the accuracy of the coverage decision. This will be important for the next requests for diseases effecting women such as breast, ovarian, cervical, uterine and vaginal cancers, as well as for diseases like prostate cancer and Alzheimer's."

PET is a powerful proven imaging modality that displays the biological basis of how organ systems of the human body function normally and fail in disease that is not provided by imaging technologies that examine the structure of organs. PET can effectively pinpoint the source of cancers, heart and neurological diseases, eliminating the need for redundant diagnostic tests and surgical procedures when they won't be effective. PET provides physicians with images of the entire body so all organ systems can be examined for disease in a single procedure. In the diseases approved by HCFA, as well as others, biological examinations with PET has been shown to be more accurate than examinations that look for structural abnormalities of disease with CT and MRI, as well as to provide improvements in selecting the best treatment in a large fraction of patients.

The Academy of Molecular Imaging is a non-profit educational society founded in January of 1991. The mission of the AMI is to advance the science of PET and other molecular imaging techniques and to aid their entry into the health care system.