Medicare Reimbursement

Medicare Reimbursement Information

The following resources are compiled for site’s knowledge in navigating Medicare reimbursement for standard procedures related to Alzheimer’s and Dementia care. The below information is not specific to ALZ-NET, but applicable to the standard care that ALZ-NET participants will receive.

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 directed at amyloid for the treatment of Alzheimer’s disease under Coverage with Evidence Development (CED).

AD Related Imaging

The Centers Medicare and Medicaid Services (CMS) issued a National Coverage Determination (NCD) on September 27, 2013, which allows conditional coverage of amyloid PET under Coverage with Evidence Development (CED).

• Transmittal R1753OTN and MM9751 (Released November 17, 2016) - Coding Revisions to National Coverage Determination (NCDs)
• Transmittal R2955CP and MM8401 (Released May 14, 2014) - Mandatory Reporting of an 8-Digit Clinical Trial Number on Claims
• Transmittal 2915CP, Transmittal 164NCD, and MM8526 (Released March 27, 2014) - Medicare National Coverage Determination (NCD) for Beta Amyloid Positron Emission Tomography (PET) in Dementia and Neurodegenerative Disease

Current CMS Reimbursement Rates

Hospital-based PET Facilities:

The National 2021 OPPS payment for CPT code 78811 or 78814 (limited body PET or PET/CT, respectively) is $1,305.94 - $1,480.34, 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 $1,305.94 and 78814 at $1,480.34). 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 ($72.58) and 78814-26 ($104.33).