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Recent HCFA Recommendations for Additional Uses of PET
In the last days of December 2000, the Health Care Financing
Administration recommended Medicare reimbursement of PET for diagnosis,
staging and restaging of several additional cancers: esophageal
and head and neck cancers. Lung and colorectal cancer were already
covered for reimbursement. The agency additionally recommended
Medicare reimbursement for assessing myocardial viability and
imaging the location of refractory seizures. Private insurers
generally follow Medicare guidelines for reimbursement.
The chart below shows the results of the
HCFA decision in December 2000 recommending new reimbursement
for diseases and conditions. This chart also shows which three
conditions are being referred for consideration by the Medicare
Coverage Advisory Committee (MCAC), that will internally generate
new requests for a national coverage decision.
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Clinical Condition
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Coverage Decision
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Lung Cancer (non-small
cell)
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Diagnosis, staging and
restaging
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Esophageal Cancer
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Diagnosis, staging and
restaging
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Colorectal Cancer
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Diagnosis, staging and
restaging
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Lymphoma
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Diagnosis, staging and
restaging
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Melanoma
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Diagnosis, staging and
restaging; non-covered for evaluating regional nodes
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Head and Neck Cancers
(excluding CNS and thyroid)
|
Diagnosis, staging and
restaging
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Breast Cancer
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Referred to MCAC Diagnostic
Imaging Panel
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Covered following inconclusive
SPECT; referred to MCAC Diagnostic Imaging Panel for review
of possible additional uses
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Covered for presurgical
evaluation
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Alzheimer's Disease/Dementia
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Referred to MCAC Diagnostic
Imaging Panel
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Myocardial Viability
Reimbursement for PET to assess myocardial viability
in cases in which SPECT imaging (Thallium or sestamibi) is inconclusive
has been recommended by Medicare. PET has been found to be particularly
helpful in patients with lower ejection fractions in whom revascularization
procedures carry increased risk.
Refractory Seizures
Reimbursement for PET to assess for areas of altered
glucose metabolism associated with refractory epileptogenic foci
has been recommended. Current coverage recommendations include
use in patients for presurgical evaluations.
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