CMS Proposal Regarding Reimbursement for New Oncology PET Tracers

December 17, 2012

Last week, the Centers for Medicare and Medicaid Services (CMS) proposed a new policy that could make it easier for new oncology PET tracers to win reimbursement.  However, this change will not apply to tracers used for neurology and cardiology applications.  CMS proposed that local Medicare administrative contractors determine coverage within their respective jurisdictions for oncologic PET imaging using radiopharmaceuticals for indications that are approved by the U.S. Food and Drug Administration (FDA).

This proposal would remove national noncoverage for any uses of the FDA-cleared PET radiopharmaceuticals that have not been determined nationally. The proposal would also cover hybrid modalities, such as PET/CT and PET/MRI.  Additionally, the change would not prevent CMS from determining national coverage for any radiopharmaceutical uses in the future.  If the agency did make such a determination, it would supersede local contractor decisions.

This proposal comes after a formal request regarding national noncoverage from the Medical Imaging and Technology Alliance , which had the support of the Society of Nuclear Medicine and Molecular Imaging as well as the American College of Radiology, the Council on Radionuclides and Radiopharmaceuticals, and the World Molecular Imaging Society.