Medicare Reimbursement

Medicare Reimbursement Information

The following resources are compiled for sites' utilization while navigating Medicare reimbursement for standard procedures related to Alzheimer’s and dementia care. The resources are compiled to  provide accurate and authoritative information, and every reasonable effort has been made to ensure their accuracy. Nevertheless, the ultimate responsibility for correct coding and billing lies with the user. ALZ-NET makes no representation, warranty or guarantee that these resources are error-free or that the use of these resources will prevent differences of opinion or disputes with payers. ALZ-NET will bear no responsibility or liability for the results or consequences of the use of these resources. 

FDA Approved Therapies for AD

The Centers for Medicare and Medicaid Services (CMS) issued a National Coverage Determination (NCD) on April 7, 2022, which allows conditional coverage of monoclonal antibodies (mAB) directed at amyloid for the treatment of Alzheimer’s disease under Coverage with Evidence Development (CED). A full list of approved CED studies can be found here.

Effective January 29, 2024, enrollment into ALZ-NET permits coverage of traditionally approved mAB treatments directed at AD for Medicare beneficiaries. Number: NCT06170268

Therapies that are covered under this CED approval include:

  • LEQEMBI™ (Lecanemab)

Additional resources related to medical billing under Coverage with Evidence Development:

Amyloid PET for Dementia and Neurodegenerative Disease

On October 13, 2023, The Centers Medicare and Medicaid Services (CMS) issued a public announcement that retired the National Coverage Determination (NCD) on amyloid PET and ended Coverage with Evidence Development (CED) as a criterion for coverage of amyloid PET scans. Coverage determinations for amyloid PET are now at the discretion of the Medicare Administrative Contractors (MACs)

Current CMS Reimbursement Rates

Hospital-based PET Facilities:

The National 2024 OPPS payment for CPT code 78811 or 78814 (limited body PET or PET/CT, respectively) is $1,354.34 – $1,492.14, respectively (rates are adjusted by local wage indexes, so the exact payment will vary slightly based on region). Payment for the diagnostic radiopharmaceutical is packaged into the OPPS payment amount. For hospital-based PET facilities, there is a co-payment or co-insurance associated with the procedure.

Physician Offices and Independent Diagnostic Testing Facilities (IDTFs):

For physician offices and IDTFs, payment is determined by the Medicare Physician Fee Schedule (MPFS). The technical component payment for the procedure is carrier priced but is often capped at the OPPS technical component rate (For CPT 78811 at $1,354.34 and 78814 at $1,492.14). Payment for the diagnostic radiopharmaceutical is based on the invoice cost (approximately $3,000, depending on the product used).

In the MPFS setting, all rates are subject to co-payment, co-insurance and any deductibles that the patient’s Medicare plan requires. The co-payment policies for the diagnostic radiopharmaceutical differ in the MPFS setting versus the OPPS.

Professional Component Payment:

The national payment rates for the professional reading of amyloid PET imaging: 78811-26 ($68.44) and 78814-26 ($97.91).

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