Understanding Restrictions on Access to Medicare-Funded Diagnostic Imaging

By ahhb
Friday, 19 June, 2015

For most Australians, healthcare is simply an occasional trip to the family doc and perhaps an X-Ray or two - fully funded by Medicare, of course. However, for those Australians who suffer from serious and ongoing conditions, such as cancer and Alzheimer’s disease, it is not nearly so simple.

Patients who require more intensive and complex medical services find themselves facing great uncertainty about the role of Medicare in the patient journey – this is particularly so with specialist services such as diagnostic imaging. Many patients are unaware of the limits and restrictions to Medicare services, which often leads to unexpected and significant out-of-pocket expenses when accessing diagnostic imaging services.
Focusing on two of diagnostic imaging’s most restricted and expensive modalities - Magnetic Resonance Imaging (MRI) and Positron Emission Tomography (PET) – we look at (i) the requirements patients must satisfy to be eligible for the Medicare rebate; and (ii) highlight some of the services that are not covered by Medicare.
General Restrictions

MRI is a popular modality due to its ability to create highly detailed images that aid in the diagnosis and treatment of a whole variety of conditions including cancer, multiple sclerosis and spinal injuries. Given its utility it is no surprise that surgeons will often refuse to operate without an MRI.
Funding for MRI under Medicare is very limited and the services that are funded involve a number of restrictions before patients are able to claim a Medicare rebate. There are four factors every patient should consider when they are referred by their doctor for an MRI:

  • Not all MRI units attract Medicare funding. In fact, there are only 349 MRI licences provided by the Australian Government that attract Medicare funding nationwide. These licences can be either full or partial, meaning that some Medicare services will not be available on MRI units with a partial licence. This means that patients must ensure that their imaging is being conducted on a Medicare funded MRI unit in order to be eligible for a Medicare rebate;

  • Medicare has a separate set of services for children under 16 years. This means that the eligibility of certain services will vary depending on whether a person is over or under 16 years of age;

  • Patients will often encounter restrictions on how often they can access Medicare-funded services. For most services patients are only eligible for Medicare funding for 1-3 presentations in a 12 month period. If a patient requires more than the maximum number of presentations they will not receive further Medicare funding for those services until the 12 month period has elapsed;

  • In order to be eligible for Medicare rebates for MRI, patients are generally required to have a referral from a specialist, not a general practitioner. If patients do not have the appropriate referral, Medicare will not subsidise or reimburse the cost of the examination, even if the service is provided by a Medicare-funded MRI unit.

What is not covered by Medicare?
Arthritis and Chronic Pain
MRI is valuable for early diagnosis and staging of Arthritis as it creates high resolution images showing cartilage integrity and degradation of bone in affected joints. It is also valuable in diagnosing the underlying causes of chronic pain, thereby preventing any further deterioration. While this modality is generally supported by Medicare, conditions such as tempero-mandibular disorder, which can be caused by Arthritis in the jaw joint, do not attract a Medicare rebate.
MRI plays a major role in the patient journey for those who suffer from a wide range of cancers. This is due to its sensitivity in the detection of cancer, both primary and metastatic, and in monitoring the progression of various cancers. Examinations for diagnosis and treatment are available for selected cancers under Medicare, however, there are a number that are either not fully funded or have high restrictions that compromise its utility. MRI examinations for prostate, ovarian and pancreatic cancers, for example, are not eligible for any Medicare funding. Similarly, Diffusion Weighted Imaging (DWIBS) for Leukaemia is also not eligible for Medicare funding.
While MRI scans for breast cancer are eligible for Medicare funding, the complex eligibility requirements severely limit accessibility to patients. The eligibility requirements are:

  • A dedicated breast coil must be used;

  • The request must identify that the person having the scan is asymptomatic and under 50 years of age; and

  • The request must identify either that (i) the patient is at high risk of developing breast cancer due to a specific number of relatives being diagnosed with breast cancer; or (ii) that genetic testing has identified the presence of a high risk breast cancer gene mutation.

If a person does meet all of the relevant eligibility criteria they are entitled to a single Medicare funded service in a 12 month period.
PET is a highly valued test that detects cancer before it can be found with other medical imaging techniques.
General Restrictions
Access to Medicare funded PET examinations is far more limited than MRI, with only 20 item numbers devoted to this particular modality. While it is often considered an expensive imaging modality, it is a highly valued test that can detect cancers before they can be identified with other modalities. It also allows doctors to provide patients with cost-effective treatment options and uniquely accurate updates on the progress of treatment. When patients are referred for a PET scan there are a number of factors that should be considered:

  • PET units are only eligible for Medicare funding if they are provided by a comprehensive practice that provides a full range of diagnostic imaging and cancer treatment services at the one site;

  • Only PET scans that use the ‘standard FDG tracers’ are eligible under Medicare. This means that many unique tracers that have been developed to diagnose specific conditions (such as the PSMA for prostate cancer) are not eligible for Medicare funding;

  • As with MRI services, patients are required to have a referral from a specialist in order to be eligible for a Medicare-funded service. Referrals from a General Practitioner will not be sufficient to attract Medicare funding.

What is not covered by Medicare?
Arthritis and Chronic Pain
PET scans are valuable in the assessment of the systematic involvement of arthritis, the evaluation of the active areas of the disease and diagnosing the underlying causes for chronic pain. While PET scans do provide many benefits, there is no Medicare funding available for musculoskeletal scans for the assessment of inflammation associated with arthritis (rheumatoid arthritis). Given the lack of access to this modality, many patients are forced to rely on other diagnostic imaging modalities for diagnosis and treatment.
Alzheimer’s Disease
PET scans are invaluable in the differentiation between frontotemporal dementia (FTD) and Alzheimer’s disease based on physiological activity. Unfortunately, Medicare funding is not available for PET scans for all forms of dementia including Alzheimer’s disease.
Heart Disease
There are a number of benefits stemming from PET for patients with heart disease. It is most valuable as a tool in cardiac disease assessment, however PET scans for cardiac assessment are not covered under Medicare, leaving many patients reliant on other modalities.
While the condition itself does not require diagnostic imaging services, conditions that stem from diabetes, such as osteomyelitis (the infection of the feet and long bones), will not attract a Medicare rebate if patients have access to more conventional Nuclear Medicine techniques such as ex-vivo WBC scanning.
PET scans have a unique ability to show the brain’s use of oxygen or sugar, providing valuable information that can be used to determine the origin of seizure activity. Funding for epilepsy examinations is limited to patients that are suspected of having refractory epilepsy or recurrent disease. Additionally, a patient’s condition must be confirmed in order to be eligible to access Medicare funding.
As with MRI services, PET scans are also quite limited for the diagnosis and monitoring of various cancers, only attracting funding for patients with residual, metastatic and recurrent disease. Cancers of the breast, bowel and ovaries attract this limited funding. Similarly, PET scans for Hodgkin’s and Non- Hodgkin’s Lymphoma patients are limited to patients with confirmed disease who are suspected of having a recurrent disease. Some cancers, such as breast and prostate cancer, do not attract any Medicare funding.
Tips for Patients
The Medicare system is complex and often leaves patients confused about which examinations and treatments attract Medicare funding, particularly when accessing diagnostic imaging services such as MRI and PET. However, it is important that patients know what questions to ask in order to ensure that they are fully prepared for the costs they may incur before undergoing the service. For patients who may require diagnostic imaging, MRI and PET in particular, it is important to ask the following questions:

  • Is the service eligible for Medicare funding?

  • Do I have the appropriate referral?

  • Does the service attract an out-of-pocket cost?

  • What payment options are available?

Given the importance of diagnostic imaging in the diagnosis and treatment of a wide range of conditions - and the potential outof- pocket costs patients can incur when accessing these services - it is important that patients are able to make informed choices about their healthcare without encountering unexpected costs. Healthcare professionals can also play a pivotal role in educating patients about the role Medicare has to play in the diagnosis and treatment of their illness.
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