Medicare Compliance & Reimbursement

Experts remain lukewarm on the new coverage.

After numerous requests to reconsider its previous non-coverage decision, the Centers for Medicare & Medicaid Services revisited the evidence -- and officially changed its tune about coverage of positron emission tomography for beneficiaries suspected to have Alzheimer's disease.

According to a CMS release, the June 15 draft decision comes after an "exhaustive review" of evidence tipped the scales in favor of coverage for PET scans used to diagnose AD in cases where diagnosis remains uncertain despite a thorough clinical evaluation.

CMS' chief medical officer Dr. Sean Tunis says CMS plans to allow coverage in additional community-based clinical studies as well. The trials will look at how effective PET scans are at diagnosing AD in a broader population of Medicare beneficiaries who develop symptoms of early dementia or unexpected memory loss.

Backing up the decision: expert input from the Agency for Healthcare Research and Quality, the National Institute on Aging and the Alzheimer's Association, as well as medical organizations.

Some experts remain cautious, however. Evidence of PET's diagnostic value remains limited, they say, and could lead to misdiagnosis and unnecessary medical costs.

CMS is seeking public input over the next 30 days, particularly on the clinical criteria used to identify eligible patients, and input on the design and implementation of the clinical trials. The final decision will be issued within 90 days.

To read the draft decision memo, go to: http://www.cms.hhs.gov/coverage.

Lesson Learned: Long-awaited coverage arrives for PET scans of patients with suspected Alzheimer's.