Imaging advocacy group slams ‘extremely restrictive’ Medicare coverage determination
An industry advocacy group is slamming one Medicare Administrative Contractor’s “extremely restrictive” payment policy related to PET imaging.
Earlier this year, the MAC in Tennessee issued a proposed local coverage determination, rejecting reimbursement for positron emission tomography for inflammation and infection. Nashville-based CGS Administrators contend that PET use in such cases is experimental or investigational, advocates reported Friday.
The Society of Nuclear Medicine and Molecular Imaging criticized the claim, and any notion that physicians are overusing PET for this indication, in a May 26 news update.
“The SNMMI is most concerned that your extremely restrictive proposed coverage criteria will limit the delivery of highly appropriate imaging care to your beneficiaries to the detriment of their care,” the society wrote in a March letter to the chief medical officer at CGS Administrators. “SNMMI strongly believes that PET scans will not be overused in cases of suspected infection/inflammation but rather will be applied as a problem-solving tool when other diagnostic methods have come up negative or equivocal, often in critically ill patients.”
CGS Administrators’ coverage determination “incorrectly rejects” PET coverage, SNMMI added, and “wrongly classifies” several uses of the technology as experimental or investigational. Those include fever of unknown origin in immunocompromised patients, native endocardial valve infections, total knee replacement, chronic swelling in the bone, diabetic foot, and infections in the vertebrae.
The society wants the local Medicare Administrative Contractor to withdraw its coverage determination. Or, at a minimum, MACs should cover all indications that have an appropriate-use criteria score of 7 or higher. It also wants coverage for imaging tied to fever of unknown origin “regardless of category.” SNMMI noted that the immunosuppressed patient population is especially susceptible to unusual infections, and “more rapid diagnosis is often needed.”
“SNMMI strongly recommends that substantial revisions be made to the proposed LCD to align it with the clinical evidence,” SNMMI President Munir Ghesani, MD, wrote in his March 19 letter. “SNMMI understands that for a number of inflammation/infection indications, use of PET and PET/CT may not be first-line diagnostic tools. In those cases, CGS should cover PET and PET/CT as second-line tools when the primary tools (e.g., echocardiography for suspected native cardiac valve infection) are inconclusive. As a general matter, that is a much better approach to coverage than not covering PET and PET/CT at all.”
CMS also previously discussed possible restrictions around covering PET for inflammation and infection in 2021.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.