When it comes to reimbursement, radiology is always looking for good news. Or even palatable news, in many cases, and that goes for the whole healthcare system. Nuclear medicine, and PET more specifically, has been contributing its share of good reimbursement news over the last several years. And as we focus this month’s issue on Nuclear Medicine, the good news continues as the Centers for Medicare and Medicaid (CMS) increase the number of medical indications for PET.

In the past year, PET advocates have convinced CMS to pay for tests that use PET to determine myocardial viability in patients who have ischemic heart disease and how well they may respond to revascularization. Coverage also continues for FDG PET when used as a follow-up to an inconclusive SPECT exam. This takes effect Oct. 1, 2002. In making its decision, CMS said that both SPECT and PET “are reasonable and necessary as a primary or initial diagnostic study for determining myocardial viability prior to revascularization” and that PET “continues to be reasonable and necessary following an inconclusive SPECT.”

CMS also extended its coverage to the use of PET for patients with breast cancer, effective Oct. 1, 2002. Medicare now will offer reimbursement coverage for FDG PET imaging via full- or partial-ring scanners as an adjunct to standard imaging modalities for staging patients with distant metastasis or restaging patients with locoregional recurrence or metastasis. This also covers the monitoring of tumor response to treatment for women with locally advanced and metastatic breast cancer when a change in therapy is contemplated. CMS has left open the possibility of examining further research into the use of PET for initial evaluation of dense breasts although the panel voted down the use of PET for initial diagnosis in breast cancer and initial staging of axillary lymph nodes. (Note: With the exception of mammography, statutory limitations preclude Medicare coverage for screening).

While those two wars were won, one battle still rages. Efforts to establish Medicare reimbursement for FDG PET for Alzheimer’s disease failed unanimously in January, with the agency ruling “PET has yet to demonstrate to the agency’s satisfaction that there are clinical benefits in evaluating possible Alzheimer’s patients with PET.” The passion lives on, and CMS has not seen the last of advocates on this issue.

Once thought to be an insane business proposition, new PET centers are beginning to thrive and multiply as are mobile PET providers. PET imaging revenues could increase to the range of $880 million by 2007, more than quadrupling revenue totals of recent years, according to market research firm Frost & Sullivan. In all, Society of Nuclear Medicine estimates more than 3,900 hospital-based departments annually perform 10 to 12 million nuclear medicine imaging (of which there are about 100 procedures) and therapeutic procedures. And why not, patients are “in the know” as well, and are demanding PET scans of their physicians, especially in localizing and staging cancer. A broader base of physicians are learning of PET and SPECT’s merits in many specialties, including neurology, oncology, orthopedics, renal care, cardiology, pulmonary care and many others such as urology and blood cell disorders. Let’s all hope the good news continues.

Mary C. Tierney, Editor
mtierney@mwc.com