Jay Reinstein, who suffers from Alzheimer’s, sits on a mattress after receiving a PET scan at MedStar Georgetown University Hospital in Washington, DC on June 20, 2023.
Michael Robinson Chávez | The Washington Post | Getty Images
Medicare plans to increase its protection of PET scans which might be used to help diagnose Alzheimer’s disease, a serious shift in coverage that would make it simpler for sufferers to entry new treatments which might be coming into the U.S. market.
The proposal would abolish Medicare’s present nationwide coverage. Right now, this system for seniors will solely cowl one PET scan per lifetime for sufferers collaborating in scientific trials.
The Medicare proposal would enable regional organizations, known as Medicare Administrative Contractors, to determine whether or not to cowl the diagnostic device. These regional contractors make protection choices primarily based on whether or not a providers is “affordable and mandatory” for the prognosis of an sickness.
Chiquita Brooks-LaSure, head of the Centers for Medicare and Medicaid Services, mentioned in a press release Monday that the proposed policy “fulfils CMS’ dedication to enable broader protection of this diagnostic take a look at.” A remaining resolution might are available in 90 days, a CMS spokesperson mentioned.
PET scans are an important diagnostic device that detect an amyloid protein on the mind that’s related to Alzheimer’s disease. The scans are the most typical methodology to help diagnose sufferers.
People on Medicare usually pay 20% of the price of a PET scan after assembly their deductible. The value of a single scan would come to about $313 per affected person, in accordance to one estimate in a May examine printed within the medical journal JAMA Internal Medicine.
Dr. Sean Tunis, former chief medical officer at CMS, mentioned it’s doable that the regional contractors might provide you with completely different protection choices for PET scans. But these organizations usually work collectively on main points and there is not cause to assume their insurance policies on PET scans would differ extensively throughout the U.S., mentioned Tunis, who’s now a advisor at Rubix Health.
Medicare protection of PET scans ought to make it simpler for sufferers to entry new remedies resembling Leqembi, which was accredited by the Food and Drug Administration earlier this month.
Medicare has agreed to cowl Eisai and Biogen’s Alzheimer’s remedy Leqembi, however it requires sufferers to be recognized with gentle cognitive impairment or gentle Alzheimer’s disease with documented proof of amyloid on the mind.
Most sufferers go for PET scans to verify amyloid presence as a result of the imaging is much less invasive than different diagnostic instruments resembling spinal faucets. Blood exams are additionally in improvement, with some already in restricted use, however they haven’t been broadly rolled out but.
Medicare has mentioned it can additionally cowl different Alzheimer’s antibody remedies with the identical circumstances in the event that they obtain approval from the FDA. Eli Lilly expects the FDA to decide on its remedy, donanemab, by the top of the 12 months.
The Alzheimer’s Association, the lobbying group that advocates for folks residing with the disease, mentioned the brand new coverage proposed by Medicare would take away pointless limitations for sufferers. Maria Carrillo, the affiliation’s chief scientific officer, known as the choice a “main step ahead.”
