I'm getting a PSMA PET scan at UCLA next week, so I can see if Lu PSMA therapy will be effective. My understanding is that this is a theranostic treatment, the scan confirms PSMA expression, which confirms that the Lu PSMA will have a site to bind to. I thought that the PSMA PET scan was a required step prior to treatment. Posts on the site talk about local doctors, and other countries administering Lu PSMA treatment, seemingly without scans.
There are two tracer drugs available for the PSMA PET scan, Ga 68 PSMA-11 and Pylarify (piflufolastat F 18). Ga 68 PSMA-11 was approved last December only for use at UCLA and UCSF. Pylarify was approved in May for other sites, and should be more widely distributed due to the longer half life of F 18.
Are those of you that are getting Lu PSMA therapy at other locations required to get PSMA PET scans? What I read of the treatments in Germany, they used scintography to measure the update of LU PSMA, not PET SCANS with a radioactive tracer prior to treatment.
Medicare did not pay for the Pylarify used in PSMA PET/CT Scan
First PSMA PET Scan at Mayo Jax
A PSMA PET/CT study is the first step to get therapy with Lu 177 PSMA. They do not treat if there are not visible mets (larger than 4 mm) which express PSMA. Ga 68 PSMA or 18 F Pylarify PET/CTs are acceptable tests for evaluating if Lu 177 PSMA therapy can be done.
The good news is that both PET/CTs are covered by Medicare now. This is a recent event. If one has had one or more of the following procedures :prostatectomy, radiation or chemo and PSA is progressing, the test will be covered by Medicare.
I thought PSMA scans were approved by FDA at the two California institutions, and we were all awaiting Medicare approval of them for certain indications.
( and we are awaiting FDA approval of the other type of PSMA scan, which then will be considered by Medicare for coverage in many other locations
If There is more recent info, can you share a link, please?
Ga 68 PSMA and 18 F DCFPyl (PYLARIFY) PET/CTs are covered by Medicare, if the patient has PC, and has an increase in tbe PSA after prostatectomy, radiotherapy or chemotherapy. I talked directly with UCLA and with the company making the Pylarify. Just call UCLA 310-794-1005.
Here is a link to the FDA announcement of the approval of 18 F DCFPyl (PYLARIFY) , fda.gov/drugs/news-events-h....
Page 8 of this document shows the update in medicare billing code for Ga 68 PSMA, cms.gov/files/document/mm12... . I don't understand medicare billing speak, but my understanding of the billing code change is that it makes it now billable.
Thanks for links. Billable vs definitely payable. They will establish coverage guidelines.
“listing of the radiopharmaceutical agent and procedure code do not imply coverage. All of the procedure codes are subject to Medicare rules and regulations, applicable Local Coverage Determinations (LCDs), and medical necessity. The radiopharmaceutical agents may be subject to CCI (Corrective Coding Initiative) editing and hospital outpatient prospective payment system rules. ”
I recently had an Axumin scan, which was equivocal after a continued rise in PSA to 0.72. My MO stated that they (Dana Farber Cancer Institute in Boston) now have /offer a PSMA test. I don’t know which contrast agent they use.
He said he wanted another PSA test in three months before pulling the trigger on a PSMA test, as insurance - according to him - will only cover the cost once, and he wanted it to be used with a better chance of success in locating where the PSA is coming from.
Good luck to us all!
This is the link to the document from Medicare. Search for Ga 68 PSMA PET CT and Pylarify I believe in pages 53 , 57 and 62 of the pdf format of the document (group 10 and Group 16).
cms.gov/medicare-coverage-d...
Most helpful. Right now I am just finding these are now covered by Medicare instead of a bone scan or after an inconclusive bone scan for initial diagnosis. I Will read more. Thank you so much. I assumed we’d see it in the press first.
It took me several days to find this information. The local cancer center started doing the Pylarify PET/CT, mi doctor order one and I called them to make the appointment and inquire about the coverage.
they were not sure if Medicare will cover it since I was going to be patient 1 for this test for them. I asked how much will be if Medicare does not covered it?. They said $ 21,700.00.
I did not want to risk it and I made an appointment with UCLA. UCLA told me that it will be covered by Medicare and I did not have to pay the $ 3,300.00 like in previous occasions. They did not know anything about Pylarify coverage.
Eventually getting in touch with Lantheus the company making Pylarify and using some of the codes for billing they sent me I could find the document from Medicare which is very recently, I believe from this week.,
The good news is that people with Medicare part B will have to pay around $ 1,000 (20% of the $ 5,000 to 6,000) that Medicare will pay for these PSMA tests. People with Medicare Advantage or supplementary insurances for part B, will have to pay nothing, or $ 200 to $300 . Big difference.
Yes, one place that my husband goes for specialty care said it might be $17,000…they were just pricing it.
If Medicare doesn’t cover it for a man’s specific situation, I believe he will be liable for the entire amount. “Any use and all uses of PET scans that are not specifically listed in the NCD are non-covered. Providers are encouraged to review the entire CMS NCD for PET Scans at: Medicare National Coverage Determination Manual, Chapter 1, Part 4 on the CMS Web site for further details and clarification of coverage. Providers are to bill G0235 for non-covered indications. ”
That document you so kindly shared was not a National one but one developed by one of the Medicare contractors for a specific geographic area including California.
Men need to be financially careful right now…like you were…they don’t need financial bad news on top of their cancer.
That is good news about UCLA!
Again, Thanks so much for sharing.