PET scans for Alzheimer's rejected for Medicare pay

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HIPAA policies, transitions to higher care levels can cause residents to feel stigmatized
HIPAA policies, transitions to higher care levels can cause residents to feel stigmatized

Earlier this year, the Department of Health and Human Services released an action plan for tackling Alzheimer's diagnostics, treatment and funding.

Now, an HHS agency has announced that Medicare will not pay for certain imaging scans used to help diagnose Alzheimer's. The apparent contradiction between strategy and execution has some provider groups upset.

The Centers for Medicare & Medicaid Services will not grant Medicare coverage for positron emission tomography scans. PET scans can detect beta-amyloid in the brain, which is a sign of Alzheimer's. 

A PET scan by itself cannot confirm a diagnosis of Alzheimer's but it can be part of a bigger battery of tests that doctors use in the diagnosis process.

CMS officials, however, declared in their Sept. 27 release that there is “insufficient evidence” that PET scans are “reasonable and necessary” for diagnosing and treating Alzheimer's.

Instead, Medicare funds may go toward Alzheimer's-related PET scans in the context of certain types of clinical trials, or when a scan can exclude Alzheimer's in narrowly defined and clinically difficult differential diagnoses, “such as AD versus frontotemporal dementia (FTD).”

Medicare will cover one PET scan per person in clinical studies that meet a long list of criteria set by federal regulators. 

Ultimately, a government panel of experts that reviewed study results and submitted comments called for more in-depth research since it could not “confidently conclude” that PET scans improve health outcomes in individuals who display signs or symptoms of Alzheimer's.

Pharmaceutical manufacturer Lilly USA LLC originally made the request for expanded Medicare coverage in July 2012. Lilly is the maker of the PET amyloid radiopharmaceutical florbetapir (Amyvid™). 


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