MITA “Disappointed and Surprised” by CMS PET Decision Memo

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CMS’ Proposed Decision Memo for Positron Emission Tomography (FDG) for Solid Tumors crept under the radar last month, but strong reactions from industry associations are finally surfacing. CMS proposed that “FDG PET for subsequent anti-tumor treatment strategy for beneficiaries with cancers of the prostate is not reasonable and necessary under § 1862(a)(1)(A), and therefore is nationally non-covered by Medicare.”

“Adding on the limitation for just one scan in subsequent treatment planning is certainly not something that either NOPER [National Oncologic PET Registry] or we think is going to be helpful for patients,” says Brian Abraham, senior policy director, Medical Imaging and Technology Alliance (MITA).

An article in Modern Healthcare also revealed that the decision memo sparked concern from PET manufacturers and officials at the American College of Radiology (ACR). “Lumping it together (and) saying it [PET] is not useful is not a good approach,” said Rathan Subramaniam, MD, PhD, MPH, in the article by Jaimy Lee. “It’s a valuable test in patients with aggressive prostate cancer. It should be funded.”

Gail Rodriguez, executive director of MITA, admits she was “disappointed and surprised” by the decision, but she adds that the “important thing is that we continue to work with CMS on how to get the right decisions made. We are going to do our darnedest.”

According to Abraham, CMS wrote the decision memo in response to a NOPER inquiry. However, the response apparently went beyond the scope of NOPER’s original question, which dealt with the coverage with evidence development (CED) requirement. “Being limited to only one PET scan after treatment is probably not the way to go,” reiterates Abraham. “I think you would find the co-chairs of the NOPER registry saying the same thing, as well as other professional societies.”

“This is about patients having access,” adds Rodriguez. “An arbitrary limiting of scans is probably not the right approach for clinicians or patients. Clinicians need information, and that is what these scans deliver.”