For reimbursement services support, email us at info@girsinc.com or call us at 901-834-9119.
Over 5 million individuals in the United States and millions more globally have Alzheimer’s Disease (AD). The volume of AD patients is projected to triple to 16 million by 2050. In the past, postmortem brain studies were the only way to diagnose with certainty that a person had AD. The more recent imaging modalities including PET scans detect AD in patients when the patient is alive, but they are costly and not covered by most insurers in the U.S.
Four years ago, the initial results of a study consisting of 4000 participants showed that brain scans produced more accurate diagnosis of AD, and thereby altered treatment protocols and other living conditions decisions. However, these results were not enough for payer coverage.
A second study costing $100 million to study cost savings to the Medicare program was done that enrolled more than 25,000 Medicare beneficiaries. The study observed whether the scans saved money by decreasing hospitalizations and emergency room visits.
Stakeholders including the Alzheimer’s Association, the American College of Radiology, and several diagnostic companies sponsored the study. Medicare staff assisted with study design and reimbursed the scans. The study included 12,684 people. This Medicare patient population had either dementia or mild cognitive impairment (MCI) and received scans, compared to other Medicare recipients who did not get scans.
The study results were tracked closely by commercial payers too. The study did not meet the goal of reducing hospitalizations by 10% in the year following the scan: there was only a 1% difference in reduction of hospitalizations between those who were scanned and those who were not (24% for the patients who were scanned versus 25% of the others).
Given limited treatment options, there are questions regarding the value of testing. Although money isn’t saved from the scans, sponsors for treatments are trying to convince Medicare that they still serve a purpose and aid families that obtain positive diagnosis.
A spokesman for the Centers for Medicare and Medicaid Services (CMS) said that they consider all new information on risks and benefits. A formal reconsideration could be filed to review its 2013 decision to not cover the scans except in research and special circumstances.
Why Partner with GIRS?
We have extensive experience in the United States and globally for diagnostic reimbursement work. GIRS has done the maximum number of point-of-care diagnostics reimbursement work. We have assisted in reviewing NCDs, commenting, and developing strategies to reverse national non coverage for a range of technologies. Our work has enabled our clients and their accounts to:
- analyze the impact of payer policy changes for our clients’ Products;
- submit and follow up on redeterminations;
- submit evidence of the medical necessity by communicating payer needs with the providers;
- comment on policy changes on time;
- correct mistakes in payer policies;
- clarify policy language for accounts;
- educate the sales force and accounts in new payer policy language;
- overturn negative coverage decisions;
- lay the foundation of customized payer advocacy strategies based on policy changes.
For more information, email us at info@girsinc.com or call us at 901-834-9119.
Disclaimer: The information in this blog is based on payer information which is dynamic. It is accurate at the time of posting but should not be construed to be reimbursement or legal advice. CPT® is the trademark of the American Medical Association (AMA).
Sources:
https://www.paypal.com/invoice/p/#LYX5HJ49XFHW8LKQ
https://abcnews.go.com/US/wireStory/medicare-coverage-alzheimer-brain-scans-question-72075057
About GIRS For more than 17 years, GIRS has been assisting medical technology manufacturers with their market uptake and reimbursement strategies so that patients can have access to the care that they need. To implement successful market access strategies, the GIRS Value Discovery Landscape Assessments® team and the Payer Advocacy Compass® team work together to develop and implement foundation reimbursement landscape and payer advocacy strategies to obtain positive coverage, appropriate payment, and innovative payer contracting arrangements to improve market uptake. For more information, email us at info@girsinc.com or call us at 901-834-9119.