Medicare Rebates for Breast Cancer Regarding PET Scans and MRI

In many cases specific to Medicare rebates, medical R&D and medical insurance companies are not always on the same page. But in light of the increasing cases of breast cancer in Australia and the need for a more accurate cancer diagnosis, the industry has come to a consensus — MRI and PET scans for breast cancer warrant a Medicare rebate. Referrals for these new Medicare items must be from a specialist.

Let’s take a look at what this announcement means for the women (and men) who may be suffering from or at a high risk for breast cancer.

New Services for MRI for Breast Cancer 

Starting November 1, 2019, two new services for breast cancer MRIs will qualify for Medicare rebates. These services include:

  • If a patient has a breast lesion, items 63531 (K) and 63532 (NK) cover an MRI for both breasts. The new service was considered important because of the inconclusive diagnostic nature of conventional imaging exams in this situation.
  • If a patient has already been diagnosed with breast cancer and there is a difference between the assessments made through conventional imaging and medical clinicians, new items 63533 (K) and 63534 (NK) have been created to account for the instances where MRI results may alter a patient’s treatment.

The measures above are both four-year interim procedures that are being used to allow the Medical Research Future Fund (MRFF) to conduct research on the effectiveness of those services. The Medical Services Advisory Committee (MSAC) is in charge of how these measures will be considered.

MRI Breast Scans (Image Source: Macquarie Medical Imaging)

New Services for Breast Cancer PET Scans

Also beginning November 1, 2019, the government will implement a new Medicare rebate schedule for two new PET items that will be used to evaluate breast cancer cases, as follows —

  • If a patient is considered suitable for active therapy and referred by a consultant or specialist, the new item 61524 has been created for whole body 18F-FDG PET study and performed for Stage III breast cancer.
  • Patients who are considered good candidates for active therapy may also fall under the new item 61525 if investigations must be performed to evaluate that there is a locally or regionally recurrent breast carcinoma or a possible metastatic disease. 

These changes were made under the recommendation of the MSAC in November 2018 and are supported by the institution as cost-effective, safe to patients, and clinically viable.

What These Changes Mean to Patients

The changes mentioned above will give suspected breast cancer patients a better chance for a more accurate diagnosis as well as more precise planning for surgery and treatment assistance for patients with invasive breast cancer. The medical community agrees that these changes should lead to improved outcomes all around with a system that is more efficient.

The number of patients that could be positively affected in Australia is quite significant. In 2019 alone, there were 19,535 new cases of breast cancer diagnosed, which represents 14% of all cancer cases in the country. There were 3,090 total deaths in Australia from breast cancer in 2019 as well.

The medical practitioners mentioned here have the ability to set their own service fees. Neither the government Medicare rebate nor the Medicare Schedule Fee fully reflects the total value of a service provider’s services or what that practitioner is allowed to charge for the service. It may include personal income as well as costs for the practice — all of which must be considered by the patient as well.

MRI and PET Scans in Breast Cancer Management

The importance of MRI and PET scans in breast cancer management cannot be overestimated. PET scans especially have the ability to help doctors more accurately detect where cancer cells are in the body. PET scans outpace CT scans in that they can spot live cancer tissue as well.

PET scans also measure vital signs of the body that can be used to initiate more effective treatment — data such as sugar and oxygen use by the body, blood flow, and many other important metrics.

If you want to learn more about MRI scans and how they help detect and treat breast cancer, you can follow this link for more information. You may also follow this link to learn more about PET scans

Make sure that you always consult with a trusted and fully licensed physician before taking any medical advice about cancer treatments.

If you need to get an MRI or PET scan done, get in touch and make an appointment with us today.

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