I

104TH CONGRESS

1ST SESSION H. R. 2194

To provide for cost savings in the medicare program through cost-effective

coverage of positron emission tomography (PET).

IN THE HOUSE OF REPRESENTATIVES

AUGUST 4, 1995

Mr. DUNCAN introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Commerce,

for a period to be subsequently determined by the Speaker, in each case

for consideration of such provisions as fall within the jurisdiction of the

committee concerned

A BILL

To provide for cost savings in the medicare program through

cost-effective coverage of positron emission tomography

(PET).

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE.

4 This Act may be cited as the ‘‘Medicare PET

5 Coverage Act of 1995’’.
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1 SEC. 2. CLARIFICATION OF MEDICARE COVERAGE OF, AND

2 PAYMENT FOR, ITEMS AND SERVICES ASSOCI3 ATED WITH POSITRON EMISSION TOMOG4 RAPHY (PET).

5 (a) IN GENERAL.—Nothing in title XVIII of the So6 cial Security Act, or any other provision of law, regulation,

7 policy, or interpretative statement, shall be construed to

8 prohibit under parts A and B of such title coverage of,

9 and payment for, items and services associated with the

10 use of positron emission tomography (PET) for a covered

11 medical indication (as defined in subsection (b)(1)) where

12 the use meets the following conditions:

13 (1) The PET is used as a substitute for other

14 diagnostic procedures or to assist a physician in as15 sessing whether exploratory surgery, surgical treat16 ment, radiation, transplant, or any other diagnostic

17 or therapeutic procedure is medically necessary.

18 (2) The PET is performed at a facility that is

19 licensed under (or otherwise operating in compliance

20 with) State law.

21 (b) COVERED MEDICAL INDICATION DEFINED.—

22 (1) IN GENERAL.—For purposes of subsection

23 (a), the term ‘‘covered medical indication’’ means—

24 (A) any medical indication described in

25 paragraph (2), or
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1 (B) any other medical indication where the

2 carrier involved (or the Secretary of Health and

3 Human Services) estimates that it will be less

4 costly to the medicare program under such title

5 (on average) to use the protocol using PET for

6 the indication than to use any alternative proto7 col which has similar diagnostic accuracy and

8 therapeutic outcome for that indication.

9 (2) SPECIFIC MEDICAL INDICATIONS COV10 ERED.—The following are the medical indications

11 described in this paragraph:

12 (A) Localization of epileptogenic focus in

13 patients with complex partial seizure disorders.

14 (B) Differentiation of recurrent brain tu15 mors from radiation necrosis in patients who

16 have previously received radiation therapy treat17 ment.

18 (C) Detection and assessment of tumors

19 associated with breast cancer, lung cancer, or

20 colorectal cancer.

21 (D) Determination of cardiac perfusion

22 and viability in patients with left-ventricular

23 dysfunction or cardiomyopathy.

24 (c) DEFINITIONS.—In this section:
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1 (1) The terms ‘‘positron emission tomography’’

2 and ‘‘PET’’ mean a diagnostic imaging technology

3 used, in a manner generally accepted by the medical

4 community and recognized in the medical literature,

5 to measure biochemical and physiologic function in

6 the human body.

7 (2) The term ‘‘diagnostic and therapeutic proto8 col’’ means, with respect to a specific medical indica9 tion, all of the diagnostic procedures and resulting

10 therapeutic procedures used in diagnosing and treat11 ing the indication.

12 (d) EFFECTIVE DATE.—This section shall apply to

13 PET used on or after 30 days after the date of the enact14 ment of this Act, without regard to whether or not regula15 tions to carry out this section have been promulgated by

16 such date.

17 (e) REVISION OF NATIONAL COVERAGE DETERMINA18 TION.—The Secretary of Health and Human Services

19 shall revise the medicare national coverage decision relat20 ing to coverage of PET to be consistent with this section.

21 Nothing in this section shall be construed as preventing

22 the Secretary from expanding such coverage decision be23 yond the coverage required under this section.

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