Lawmakers blast ‘flawed’ CMS reimbursement policy for diagnostic imaging drugs

Two U.S. congressmen are blasting the Centers for Medicare & Medicaid Services’ “flawed” payment policy for diagnostic imaging drugs and requesting a meeting with the influential agency.

In a recent letter to the acting CMS administrator, Reps. Scott Peters, D-Calif., and Bobby Rush, D-Ill., expressed “concern” around Medicare reimbursement methodology for radiopharmaceuticals. They noted that some 20 million Americans benefit from nuclear medicine exams each year, yet barriers in the federal payment program are hindering coverage.

“The nuclear medicine industry is developing exciting new drugs to provide precision imaging for hard-to-diagnose diseases such as Alzheimer’s disease, Parkinson’s disease, cardiovascular disease, and prostate, breast, and neuroendocrine cancers,” the two representatives wrote April 5. “However, the flawed reimbursement policy utilized by the Centers for Medicare and Medicaid Services threatens patient access to these cutting-edge innovations by creating a disincentive for hospitals to use the most appropriate diagnostic drugs.”

Peters and Rush noted that since 2008, CMS has treated such diagnostic pharmaceuticals as “ancillary” to the imaging procedure in the hospital setting. This has resulted in drug costs being “policy packaged” into the procedure amount in payment classifications.

Doing so, however, “does not work,” as the cost of these radiopharmaceuticals often significantly exceeds the cost of the packaged procedure, they wrote.

“The net result is that beneficiaries do not always have access to innovative diagnostic radiopharmaceuticals at readily accessible healthcare locations,” the two wrote to Administrator Elizabeth Richter.

Industry advocates such as the Society of Nuclear Medicine & Molecular Imaging have been pushing this change for 12 years. And the arrival of newer precision diagnostic radiopharmaceuticals has only “exacerbated” this challenge. CMS has an opportunity to unpackage these drugs as part of its final payment rule issued in 2020 but opted to reject advice from its advisory committee and imaging stakeholders, the two wrote.

Peters and Rush are requesting a meeting and urging CMS to change this policy “in light of the adverse impact on beneficiary access and care.” SNMMI highlighted the lawmakers’ letter in a Monday update to its members.

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