CMS denies coverage for NaF PET exams leaving experts, imaging groups confused

In a blow to Medicare patients with metastatic cancers, CMS announced Friday, June 8, it has rejected reimbursement coverage for 18F-sodium fluoride positron emission tomography (NaF PET) imaging.

 

The National Oncologic PET Registry (NOPR) Working Group believed they had gathered the necessary data and evidence to convince CMS that NaF-PET improved aspects of patient care, according to a statement. Analyses published in the Journal of Nuclear Medicine further demonstrated the radiotracer could lead to changes in patient management and more appropriate curative or palliative care for cancer patients.

 

“Those of us who have been working on this for the last seven years are pretty disappointed with the CMS decision,” NOPR co-chair, Barry Siegel, MD, said to Health Imaging. “We thought, based on our interactions with CMS…that we were on the right track. CMS was aware of what we were doing, understood what kind of data we were able to produce, and we produced what we said we were going to.”

 

CMS sent a May 9 letter, which was recently released, explaining their decision to three former NOPR co-chairs: Siegel, Bruce Hiller, MD, from the department of internal medicine at Virginia Commonwealth University, and Anthony Shields, MD, PhD and professor of medicine and oncology at Wayne State University.

"After a careful assessment of your request and supporting documentation, we have determined that the additional evidence submitted is insufficient to support a reconsideration as it would not change our existing national coverage determination (NCD)," wrote Tamara Syrek Jensen, director of CMS's coverage and analysis group. "Therefore, we are not accepting your request for an NCD reconsideration at this time."

 

In response to the CMS note, the World Molecular Imaging Society, American College of Radiology, Society of Nuclear Medicine and Molecular Imaging and members of the NOPR Working Group issued a statement June 8, urging CMS to reconsider its decision to decline coverage.

 

Siegel does not believe another reconsideration from CMS is likely, but suggested the best course of action going forward for the industry as a whole is to get the underlying NCD changed for PET.

 

“It’s kind of anomalous to say that we [CMS] cover a bone scan that’s not quite as good, but we won’t cover the one that’s considered the best possible bone scan,” he said.