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Medical Coding News Archives

Coverage Changes for Oncologic Use of FDG-PET

 
May 26, 2009:

The Centers for Medicare & Medicaid Services (CMS) is changing all national coverage determinations (NCDs) that address coverage of FDG (fluoro-2-deoxy-D-glucose) positron emission tomography, or PET scan, for specific oncology conditions, while maintaining current coverage.

CMS released a decision memorandum for positron emission tomography (FDG) for solid tumors and myeloma on April 3, 2009. It outlines a coverage framework that replaces the four-part treatment categories of diagnosis, staging, restaging, and monitoring response to treatment, with a two-part framework: initial treatment strategy and subsequent treatment strategy. This change differentiates the FDG-PET imaging used to guide the initial treatment strategy from imaging used to guide subsequent treatment strategies after the completion of initial treatment.

This coverage reconsideration is based on new evidence developed under the Coverage with Evidence Development (CED) program. CMS collects data under the CED program on how certain medical technologies are used in clinical practice. CMS changed the section of the NCD manual that required prospective data collection for FDG-PET used in diagnosing, staging, restaging, and monitoring response to treatment for brain, cervical, ovarian, pancreatic, small cell lung, and testicular cancers. Coverage of FDG-PET imaging for diagnosing cancer and guiding treatment was linked to this data collection requirement. The data requirements were removed for all oncology indications for FDG-PET except for monitoring response to treatment.

The following table summarizes the changes:

Coverage Changes on Oncologic Uses of FDG PET

Solid Tumor Type

Initial Treatment Strategy
Formerly “diagnosis” and “staging”

Subsequent Treatment Strategy
Formerly “restaging” and “monitoring response to treatment when a change in treatment is anticipated”

Colorectal

Covered

Covered

Esophagus

Covered

Covered

Head & neck (not thyroid or CNS)

Covered

Covered

Lymphoma

Covered

Covered

Non-small cell lung

Covered

Covered

Ovary

Covered

Covered

Brain

Covered

Coverage with Evidence Development

Cervix

Covered for the detection of pretreatment metastases (i.e., staging) in newly diagnosed cervical cancer subsequent to conventional imaging that is negative for extra-pelvic metastasis. All other uses are Coverage with Evidence Development.

Covered

Small cell lung

Covered

Coverage with Evidence Development

Soft tissue sarcoma

Covered

Coverage with Evidence Development

Pancreas

Covered

Coverage with Evidence Development

Testes

Covered

Coverage with Evidence Development

Breast (female and male)

Noncovered for diagnosis and/or initial staging of axillary lymph nodes.
Covered for initial staging of metastatic disease.

Covered

Melanoma

Noncovered for initial staging of regional lymph nodes. All other uses for initial staging are covered.

Covered

Prostate

Noncovered

Coverage with Evidence Development

Thyroid

Covered

Covered for recurrent or residual thyroid cancer of follicular cell origin previously treated by thyroidectomy and radioiodine ablation with a serum thyroglobulin >10ng/ml and a negative whole body scan. All other uses for subsequent treatment strategy are Coverage with Evidence Development

All other solid tumors

Covered

Coverage with Evidence Development

Myeloma

Covered

Covered

All other cancers

Coverage with Evidence Development

 

Source: Appendix A of the Decision Memorandum

Sarah A. Serling, CPC, CPC-H, CPC-I, CCS-P, CCS
Clinical/Technical Editor

 

 
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