Nebraska Department of Insurance

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THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM

JUNE 2002 NICA NEWS

CHANGES

MEDICARE TO EXPAND COVERAGE OF POSITRON EMISSION TOMOGRAPHY FOR PATIENTS WITH BREAST CANCER

The Centers for Medicare &Medicaid Services (CMS) announced it intends to cover Positron Emission Tomography (PET), a high-tech diagnostic tool, in the management of care for patients with breast cancer.

When a woman has been diagnosed with breast cancer, PET can serve as a means of evaluating the extent of the disease and assist doctors in determining the response to treatment in women with severe disease.

"Through this new coverage, Medicare is offering an important additional weapon in the fight against breast cancer," said HHS Secretary Tommy G. Thompson. "PET technology can give physicians treating breast cancer patients potentially life-saving information not provided by traditional imaging."

Breast cancer is the most common non-skin cancer in United States women, accounting for nearly 30 percent of newly diagnosed cancers, with an incidence of 182,800 new cases and 53,000 deaths in the year 2000. Approximately 90,000 Medicare beneficiaries are diagnosed with breast cancer each year.

Under this new policy, Medicare will cover PET full-and-partial ring scanners as an adjunct to standard imaging modalities for:

* Staging patients with distant metastasis or restaging patients with locoregional recurrence or metastasis, and monitoring tumor response to treatment for women with locally advanced and metastic breast cancer.

PET is a non-invasive imaging procedure used for measuring the concentrations of positron-emitting radioisotopes within the tissue of living subjects.

Malignancies can cause abnormalities of blood flow or metabolism before anatomic changes are apparent. Thus, disease can be detected by PET when anatomic imaging studies are still normal. PET also may help treating physicians differentiate benign from malignant processes.

This is the latest CMS expansion of Medicare coverage of important new medical technology for its beneficiaries. In December 2000, CMS gave Medicare coverage for the use of PET for non-small cell lung cancer, esophageal cancer, colorectal cancer, lymphoma, melanoma, head and neck cancers (excluding thyroid), and limited coverage for myocardial viability.

CMS will publish a National Coverage Decision creating this new coverage. Actual implementation will come when CMS issues instructions for the private contractors that process and pay Medicare claims. More information can be found at: www.hcfa.gov/coverage

MEDICARE NOW COVERS GLAUCOMA DETECTION EYE EXAM
New Coverage to Benefit At-Risk Populations

Medicare now covers an annual dilated eye examination for all people at high risk for glaucoma. This important new preventive benefit will safeguard the vision of millions of Americans enrolled in the Medicare program.

This new coverage, effective January 1, 2002, is consistent with recommendations from the National Eye Institute, one of the Federal government's National Institutes of Health, as well as from eye care professional organizations and consumer groups.

Glaucoma, a leading cause of blindness, affects about three million Americans -- half of whom don't know they have this eye disease.

The new benefit defines high risk Medicare beneficiaries as those with diabetes; those with a family history of glaucoma; and African Americans aged 50 and older. Glaucoma is five times more likely to occur in African Americans than in whites and about four times more likely to cause blindness in African Americans than in whites.

The "air puff" test, which measures eye pressure, is one part of a glaucoma examination but this test by itself cannot detect glaucoma. Glaucoma is found most often during an eye examination through dilated pupils, which means drops are put into the eyes to enlarge the pupils. The eye care professional then can see more of the inside of the eye to check for signs of glaucoma.

For more information on glaucoma, write to: