PET: The Governmental Reimbursement Perspective

Abstract

The clinical applications of PET have been determined only recently. Reimbursement for clinical PET studies has a major effect on the utilization of PET. The research applications of PET are well documented, but the clinical applications of PET are not as well accepted. Reimbursement for clinical studies is limited to a few specific indications by a small number of private insurance companies at this time. The Health Care Financing Administration (HCFA) has referred the review of PET to the Office of Health Technology Assessment (OHTA). HCFA administers Medicare, and thus reimbursement from the Federal Government will be determined by HCFA. HCFA and OHTA have determined that they will not complete their review until the radiopharmaceuticals are approved by the Food and Drug Administration (FDA). Rubidium-82 is an FDA-approved radiopharmaceutical, but F-18-fluorodeoxyglucose (FDG) has not been approved by the FDA as yet. Thus, significant uncertainty still is present in the status of reimbursement by the Federal Government.