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Friday, February 11, 2011

Coverage of PET for Suspected Alzheimer’s

CMS Proposes Expanded Coverage of PET for Suspected Alzheimer’s

On June 15, 2004, CMS proposed offering Medicare coverage of PET scans to aid in the diagnosis of elderly patients with mild cognitive impairment whose condition has remained undiagnosed despite a thorough clinical evaluation. According to a press release, CMS determined that PET scans for such patients may aid in providing a definitive diagnosis of Alzheimer’s Disease (AD). CMS had previously considered and rejected Medicare coverage of PET to help diagnose AD, but reconsidered its decision. We’ll summarize CMS’s decision. Plus, we’ll tell you when you can expect it to become effective.

Thorough Workup Required

According to the Draft Decision Memo issued on June 15, Medicare won’t cover PET scans to diagnose AD in every elderly patient. But Medicare may cover a PET scan if a patient has:

■ Received a recent diagnosis of dementia;
■ Experienced a documented decline in cognitive function for at least six months; and
■ Undergone other diagnostic tests that have failed to yield a definitive diagnosis.

To be eligible for coverage, the patient already must have undergone a thorough evaluation by a physician
experienced in diagnosing and assessing dementia, and that physician must have performed a specified battery of tests in an attempt to diagnose the patient’s dementia. Also, Medicare will cover the PET scan only if the treating physician has complied with significant documentation requirements.
Insider Says:You can get a copy of the CMS Draft

Decision Memo at www.cms.hhs.gov/coverage. Under “Medicare Coverage Database” click on “National Coverage Analyses” and then look in the box labeled “Pending.” You’ll find it under “Reconsiderations.”

PET Won’t Be Covered Until Instructions Issued

CMS accepted comments on its decision for 30 days, until July 15. CMS will consider these comments and will release instructions to carriers by Oct. 15 about how to handle claims for PET to diagnose AD, according to the June 15 press release. We’ll tell you about CMS’s final decision and the instructions in future issues of the Insider.

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