Medicare and NOPR

Registry Covered Indications

CMS expanded coverage for FDG-PET to include all cancers and indications not presently eligible for Medicare reimbursement, but does not include PET performed as part of a clinical trial nor indications that are currently labeled as "non-covered".

Top Ten NOPR Cancer Sites

• Prostate
• Ovary and uterine adenexa
• Pancreas
• Bladder
• Kidney and other urinary tract
• Small-cell lung
• Stomach
• Non-small cell lung
• Uterus, body
• Liver and intrahepatic bile ducts

Top Ten NOPR Cancer Sites/Indications

• Ovary and uterine adenexa - Recurrence
• Prostate - Initial staging
• Prostate - Restaging
• Prostate - Recurrence
• Ovary and uterine adenexa - Restaging
• Ovary and uterine adenexa - Treatment monitoring
• Stomach - Initial staging
• Pancreas - Initial staging
• Bladder - Initial staging
• Pancreas - Suspected primary

Non-Covered Indications

• Breast cancer – diagnosis
• Breast cancer – initial staging axillary lymph nodes
• Melanoma – initial staging regional lymph nodes

Additional Indications Covered Through the Registry

The NOPR will significantly expand coverage while conducting a study on PET's effectiveness for currently non-covered cancers. This offers tremendous opportunity for demonstrating effective management of cancer patients and for the expansion of PET covered indications. Listed below are many potentially useful applications of PET imaging by indication. You should consult with the PET center physicians to discuss appropriate use of PET in specific patients.

Bladder Cancer

• Primary nodal staging
• Systemic metastases staging
• Evaluate local extent of disease and exclude lymph node involvement or distant metastases

Brain Tumor

• Diagnosing and grading the malignancy
• Determining the extent for treatment planning
• Directing biopsy (This helps to determine where in the brain to sample the tissue, by differentiating tumor from necrosis and edema.)
• Determining prognosis
• Determining the extent of tumor in treatment planning
• Monitoring response to treatment (surgery/radiotherapy/chemotherapy)
• Differentiate tumor from radiation necrosis and edema
• Determine how well the treatment affected the tumor
• Differentiate primary CNS lymphoma from toxoplasmosis
• Exclude metastatic disease of the brain
• Evaluating efficacy of surgery and radiation treatment

Hepatocellular Cancer

• Distinguishing between cirrhosis and hepatoma
• Evaluate local extent of disease and exclude lymph node involvement or distant metastases
• Identifying multifocal lesions
• Assessing response to treatment and differentiating tumor from necrosis, edema, and scarring

Musculoskeletal Tumors

• Evaluate local extent of disease and exclude distant metastases
• Measure treatment response and exclude recurrent/residual tumor following definitive therapy

Ovarian Cancer

• Staging lymph nodes
• Assessing response to treatment
• Evaluate suspected recurrence
• Identifying recurrent disease after surgery and radiation
• Detect recurrent/residual tumor prior to surgical exploration or additional chemotherapy

Pancreatic Cancer

• Characterization of a radiographically occult lesion
• Differentiation of chronic pancreatic masses from cancer
• Differentiation of benign processes such as pancreatitis, mucinous cyst adenoma and pseudocyst from malignant disease
• Rule out distant metastases for preoperative evaluation
• Staging nodal and liver metastases
• Assessing response to chemotherapy

Prostate Cancer

• Characterization of a radiographically occult lesion
• Evaluate local extent of disease and exclude distant metastases

Renal Cell Cancer

• Determining nature of renal masses
• Detecting and evaluating local disease spread and metastatic disease
• Assessing response of metastases to chemotherapy
• Detect recurrent/residual tumor prior to surgical exploration or additional chemotherapy

Small Cell Lung Cancer

• Staging lymph nodes
• Assessing response to treatment
• Evaluate suspected recurrence
• Identifying recurrent disease after surgery and radiation

Soft Tissue Sarcoma (this is a reversal from non-coverage)

• Visualization of soft tissue sarcoma
• Determine tumor malignancy grade before treatment
• Identify nodal involvement and local metastases
• Tailor treatment protocol based on tumor grade
• Assess response to presurgical treatment
• Assessment of bony healing in those patients who have received allograft transplants
• Assessment of high-risk pediatric patients being treated for Ewing’s sarcoma and osteosarcoma.
• Identify tumor recurrence

Stomach Cancer

• Characterization of a radiographically occult lesion
• Evaluating efficacy of surgery and radiation treatment

Testicular Cancer (this is a reversal from non-coverage)

• Staging of primary disease
• Assessing residual mass
• Further evaluating raised markers
• Characterization of a radiographically occult lesion
• Guide biopsy or surgical procedure
• Monitoring response to treatment

Unknown Primary

• Identifying primary site to determine treatment and evaluate for possible resection

Uterine Cancer

• Staging lymph nodes
• Assessing response to treatment
• Evaluate suspected recurrence
• Identifying recurrent disease after surgery and radiation

All other cancers not listed

• Staging lymph nodes
• Assessing response to treatment
• Evaluate suspected recurrence
• Identifying recurrent disease after surgery and radiation

Expanded Coverage for Thyroid Cancer and Cervical Cancer

Thyroid Cancer

• Diagnosis
• Staging
• Monitoring response to therapy
• Other restaging
• Other cancer types (medullary, anaplastic)
• Further evaluation for medullary thyroid cancer when rising calcitonin level and initial imaging with dimercaptosuccinic acid V, octreoscan, or metaiodobenzylguanidine is negative

Cervical Cancer

• Diagnosis
• Other staging
• Monitoring response to therapy
• Restaging
• Staging lymph nodes
• Identifying recurrent disease after surgery and radiation

Expanded Coverage includes Evaluation of Treatment Response

• Non small cell lung cancer
• Esophageal Cancer
• Head & Neck Cancer
• Colorectal Cancer
• Lymphoma
• Melanoma