September 10, 2018
SNMMI and the American Society of Nuclear Cardiology have commended a proposed expansion of Medicare coverage for Cardiac PET. The proposal was made by BlueCross BlueShield of Tennessee. SNMMI and ASNC also recommended a number of other changes for BlueCross BlueShield to consider adding to its expanded coverage policy.
The letter is printed in full below:
Thank you for the opportunity to comment on the Draft Revised Policy on Positron Emission Tomography for Cardiac Applications (DMP0818-01) available at: https://www.bcbst.com/DraftMPs/PET_Cardiac_pol.pdf.
The Society of Nuclear Medicine and Molecular Imaging’s (SNMMI) more than 15,000 members set the standard for molecular imaging and nuclear medicine practice by creating guidelines, sharing information through journals and meetings, and leading advocacy on key issues that affect molecular imaging and therapy, research and practice.
ASNC is a 4,500-member professional medical society, which provides a variety of continuing medical education programs related to nuclear cardiology and cardiovascular computed tomography, develops standards and guidelines for training and practice, promotes accreditation and certification within the nuclear cardiology field, and advocates for furthering research and excellence in nuclear cardiology and cardiovascular computed tomography.
SNMMI and ASNC suggest that BCBS of Tennessee consider some additional sources of
information before finalizing this proposed policy:
1. American Society Of Nuclear Cardiology And Society Of Nuclear Medicine And Molecular Imaging Joint Position Statement On The Clinical Indications For Myocardial Perfusion Pet (see: http://snmmi.files.cmsplus.com/ASNC_SNMMI_Joint_Statment_on_the_Clinical_Indications_for_Myocardial_Perfusion_PET%20-%20FINAL.pdf)
2. Clinical Quantification of Myocardial Blood Flow Using PET: Joint Position Paper of
the SNMMI Cardiovascular Council and the ASNC (see: http://snmmi.files.cmsplus.com/docs/councils/CVC/J%20Nucl%20Med-2018-Murthy-273-93.pdf)
PET to determine absolute quantitation of myocardial blood flow
BCBS of Tennessee’s proposed policy labels this procedure as investigational and proposes to deny coverage for absolute quantification of myocardial blood flow. This non-coverage proposal is not supported by the conclusion of the Joint ASNC/SNMMI Position Statement which states:
“Blood flow quantification at rest and stress is used to measure myocardial flow reserve. It allows verification of adequate stress response, further improving interpretation confidence. Regional flow reserve shows the physiological significance of epicardial CAD, analogous to invasive fractional flow reserve (FFR). In the absence of epicardial CAD, flow reserve allows the assessment of microcirculatory function. The ability to routinely quantify myocardial blood flow in ml/min/gram is unique to PET, improves accuracy, risk stratification, and patient selection for interventions.”
Nor is the proposed non-coverage supported by key points in the conclusion of Joint Position Paper on Clinical Quantification of Myocardial Blood Flow Using PET which has the following key points:
• Accurate and reproducible quantification of MBF is possible with both 13N-ammonia and 82Rb (both of which are Food and Drug Administration–approved).
• Patients with preserved stress MBF and MFR are unlikely to have high-risk epicardial CAD.
• Severe reductions in global MFR (<1.5) are associated with a substantially increased risk of adverse outcomes and merit careful clinical consideration.
• A preserved global MFR of more than 2.0 has an excellent negative predictive value for high-risk CAD (i.e., left main and 3-vessel disease).
The ability to measure flow absolutely, rather than comparatively increases the likelihood of defining patients with severe CAD. Conventional MPI by SPECT and PET measure the relative perfusion, that is, the assessment of regional myocardial perfusion relative to the region with the highest perfusion tracer uptake. This means that a global reduction in myocardial perfusion (‘‘balanced’’ reduction of flow) may remain undetected and that, in general, the extent of coronary artery disease (CAD) is underestimated, as has been demonstrated with both 201 Tl and 99m Tc-labeled perfusion tracers.
Therefore, we recommend that BCBS of Tennessee cover PET for absolute quantitation of myocardial blood flow.
Other Proposed Changes in the Coverage Policy
SNMMI and ASNC support BCBS’s proposal to cover PET for patients with either “significant left ventricular dysfunction under consideration for revascularization: or “suspected cardiac sarcoid” and we presume that BCBS meant to indicate “cardiac involvement of sarcoidosis” instead of “sarcoid.”
SNMMI and ASNC also support BCBS’s proposal to lower the BMI figure for covered patients from 35% to 30%. The literature supports the high diagnostic accuracy and prognostic value in this patient group because they are prone to poor image quality with SPECT and stress echo.
We appreciate the opportunity to comment on the proposed coverage policy. As always, we are ready to discuss any of its comments or meet with BCBS of Tennessee on the above issues. In this regard, please contact Wayne Powell at firstname.lastname@example.org or Georgia Lawrence at email@example.com.
Satoshi Minoshima, MD, PhD
Society for Nuclear Medicine and Molecular Imaging
Prem Soman, MD, PhD
American Society for Nuclear Cardiology