The Centers for Medicare & Medicaid Services (CMS) announced on July 3, 2013 that Medicare will not support full coverage of advanced imaging tests and PET scans intended to diagnose dementia or neurodegenerative disease.
The Medicare Evidence Development & Coverage Advisory Committee determined that there is a lack of evidence as to whether PET screenings improve patient outcomes, and therefore advanced imaging tests will not be entirely covered by Medicare. However, CMS will cover the scans for certain patients participating in clinical studies, so long as the scans used in these studies are intended to find better strategies for identifying Alzheimer’s disease/are used to differentiate between two similar diagnoses such as frontotemporal dementia and Alzheimer’s disease.
Despite the recent Medicare decision, the Amyloid Imaging Task Force, created by the Alzheimer’s Association, maintains that there are real benefits to amyloid PET imaging. Though Medicare will not cover the procedures, the AIT has published the following list of recommendations on appropriate and inappropriate candidates for imaging (taken from the AIT website):
According to the AIT, appropriate candidates for amyloid PET imaging include:
- Those who complain of persistent or progressive unexplained memory problems or confusion and who demonstrate impairments using standard tests of cognition and memory.
- Individuals meeting tests for possible Alzheimer’s, but who are unusual in their clinical presentation.
- Individuals with progressive dementia and atypically early age of onset (before age 65).
According to the AIT, Inappropriate candidates for amyloid PET imaging include:
- Those who are age 65 or older and meet standard definitions and tests for Alzheimer’s, since a positive PET scan would provide little added value.
- Asymptomatic people or those with a cognitive complaint but no clinical confirmation of impairment.
According to the AIT, Amyloid PET imaging is also inappropriate:
- As a means of determining the severity of dementia.
- When requested solely based on a family history of dementia or presence of other risk factors for Alzheimer’s, such as the ApoE-e4 gene.
- As a substitute for genetic testing for mutations that cause Alzheimer’s.
- For non-medical reasons, such as insurance, legal or employment decisions.
Remember – though Medicare will not cover PET scans for the sole purpose of dementia screenings, Medicare does recognize other conditions that for which PET scans will be covered. For reference, please see below for the 2013 CPT codes related to PET imaging:
CPTs for Billing PET Scans
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| 78459 | MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) METABOLIC EVAL. |
| 78491 | MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; SINGLE STUDY AT REST OR STRESS |
| 78492 | MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; MULTIPLE STUDIES AT REST OR STRESS |
| 78608 | BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) METABOLIC EVALUATION |
| 78609 | BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) , PERFUSION EVALUATION |
| 78811 | TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); LIMITED AREA (EG, CHEST, HEAD/NECK) |
| 78812 | TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); SKULL BASE TO MID-THIGH |
| 78813 | TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); WHOLE BODY |
| 78814 | TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; LIMITED AREA (EG CHEST, HEAD/NECK) |
| 78815 | TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; SKULL BASE TO MID-THIGH |
| 78816 | TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; WHOLE BODY |
| G0219 | PET IMAGING WHOLE BONE; MELANOMA FOR NON COVERED INDICATIONS |
| G0235 | PET IMAGING, ANY SITE NOT OTHERWISE SPECIFIED |
| G0252 | PET IMAGING, FULL AND PARTIAL-RING PET SCANNERS ONLY, FOR INITIAL DIAGNOSIS OF BREAST CANCER AND/OR SURGICAL PLANNING FOR BREAST CANCER (E.G. INITIAL STAGING OF AXILLARY LYMPH NODES) |
| S8085 | FLUORINE-18 FLUORODEOXYGLUCOSE (F-18 FDG) IMAGING USING DUAL-HEAD COINCIDENCE DETECTION SYSTEM (NON-DEDICATED PET SCAN) |
This entry informed by:
“Medicare Won’t Cover PET Scans for Dementia Screenings.” – Amednews.com. American Medical Association, 15 July 2013. Web. 23 July 2013.
The Alzheimer’s Association: https://www.alz.org/research/funding/amyloid_imaging_task_force.asp
