Medicare Proposes Expanding Coverage of PET Scans for Wider Benefits

Medicare is planning to expand its coverage of PET scans, a diagnostic tool used in the detection of Alzheimer’s disease. This policy change could enhance patients’ access to new treatments entering the US market.

The current Medicare policy only allows coverage for one PET scan per lifetime for patients participating in clinical trials, but the proposed plan would eliminate this restriction.

Under the Medicare proposal, regional organizations known as Medicare Administrative Contractors would have the authority to decide whether to cover PET scans as a diagnostic tool. These contractors base their coverage decisions on the “reasonableness and necessity” of the services in diagnosing illnesses.

Chiquita Brooks-LaSure, the head of the Centers for Medicare and Medicaid Services, stated that the proposed policy “fulfills CMS’ commitment to allow broader coverage of this diagnostic test.” A final decision on the matter is expected within 90 days, as per a CMS spokesperson.

PET scans are crucial in identifying the presence of amyloid protein in the brain, a marker for Alzheimer’s disease. These scans are the most common method for diagnosis.

Medicare beneficiaries typically cover 20% of the cost of a PET scan after meeting their deductible. Based on estimations from a May study published in the medical journal JAMA Internal Medicine, the cost per patient for a single scan amounts to approximately $313.

Dr. Sean Tunis, former chief medical officer at CMS, believes that regional contractors may have varying coverage decisions for PET scans. However, these organizations usually collaborate on major issues, so it is unlikely that their policies on PET scans will differ significantly across the US. Tunis, now a consultant at Rubix Health, emphasized this point.

Medicare’s coverage of PET scans will facilitate patient access to new treatments like Leqembi, which recently received approval from the Food and Drug Administration.

Although Medicare now covers Eisai and Biogen’s Alzheimer’s treatment Leqembi, patients must be diagnosed with mild cognitive impairment or mild Alzheimer’s disease and provide documented evidence of amyloid in the brain.

Most patients choose PET scans for confirming the presence of amyloid because they are less invasive than alternative diagnostic tools like spinal taps. Blood tests for Alzheimer’s are also in development, with some already in limited use, but they have not been widely adopted yet.

Medicare has expressed that it will cover other Alzheimer’s antibody treatments under the same conditions if they receive FDA approval. Eli Lilly expects the FDA to make a decision on its treatment, donanemab, by the end of this year.

The Alzheimer’s Association, an advocacy group for individuals affected by the disease, views Medicare’s proposed policy as a significant step forward that eliminates unnecessary barriers for patients. Maria Carrillo, the association’s chief scientific officer, applauds this decision.