Alzheimer’s patients rely on PET scans to know if new treatments might benefit them. But their ability to access the scans is now up in the air due to a policy change from the Centers for Medicare and Medicaid Services.
The End of the One-Scan Cap
CMS ended their National Coverage Determination for PET beta amyloid imaging, ending coverage with evidence development. The agency will also no longer limit patients to a single PET scan, which is used to diagnose Alzheimer’s and to determine whether patients are good candidates for certain treatments. Continued scans are often needed to assess whether the treatment is working.
Medicare and Medicaid Coverage for PET scans was capped until recently at one per patient per lifetime by a National Coverage Determination. The restriction significantly limited the potential benefits of monitoring disease progression. Amyloid PET imaging is the emerging standard for Alzheimer’s treatment, and the data generated by PET scans could contribute to future developments and, one day, a cure.
By removing the national coverage determination, however, the Centers for Medicare and Medicaid Services has effectively shifted responsibility for coverage decisions to a different entity – raising new questions for patients, their providers and their caregivers.
Providing Equitable Coverage for Alzheimer’s Treatment
Decisions about coverage for PET scans now fall to individual Medicare administrative contractors – private health insurers who process claims for Medicare beneficiaries.
The change raises concerns about patient access. Limited coverage for PET scans could limit patients’ ability to benefit from treatment.
Until the Centers for Medicare and Medicaid Services acts more definitively to establish PET scan coverage, Medicare administrative contractors should attempt to offer consistent, expansive coverage to ensure patients get the best possible treatment with the least confusion.
Consistency is especially important because barriers to diagnosis and treatment impact disadvantaged communities most. Underserved populations are more likely to develop Alzheimer’s disease and less likely to participate in clinical trials like those that produced antibody treatments.
By providing guidance for expanding coverage, equity and access, policymakers can help to ensure that cost and administrative hassles do not stand in patients’ way.
Alzheimer’s in America
Rates of Alzheimer’s diagnosis continue to rise in the United States, with an estimated 6 million Americans living with the condition.
Researchers are making great strides in improving the standard of care for Alzheimer’s and dementia patients. Monoclonal antibody treatments are now available to directly treat the amyloid plaque buildup that characterizes the disease.
Access to PET scans is a critical step for Alzheimer’s patients who stand to benefit from breakthrough treatments.