Medicare rebate for PET CT scans

Hi Barry,

Thanks for your question.

Our understanding is if you have paid privately out of pocket for these previous scans the Medicare rebate should still be accessible. You would though need to satisfy the criteria for the item number which is below:

Item 61564 – Whole body PSMA PET study for the restaging of the patient

The requesting specialist or consultant physician is to record in the clinical notes and the imaging request that the patient has undergone prior locoregional therapy for prostatic adenocarcinoma and is considered potentially suitable for further locoregional therapy for recurrent disease.

• This item can be claimed by patients with:

a) a prostate specific antigen (PSA) increase of 2ng/ml above the nadir after radiation therapy; or

b) failure of PSA levels to fall to undetectable levels; or

c) rising serum PSA after a radical prostatectomy.

In general, there are few scenarios or indications in which Medicare Subsidises PSMA PET scans.

1. The first is for initial staging or intermediate or high risk prostate cancer (defined as Gleason 7 or Grade Group 2 or higher), for a previously untreated patient who is considered curative treatment
2. The second is for restaging of recurrent disease for a patient who was previously treated. In these cases a patient must either have: a PSA increase 2ng/ml above the lowest point after initial radiation therapy, or when a PSA fails to fall to an undetectable level or is rising after radical prostatectomy. In these cases a total maximum of 2 scans per lifetime are payable.
3. A newer indication is for people considering eligibility for Lutetium Therapy for cancer which is resistant to hormone therapy following hormone therapy, androgen receptor pathway inhibitors and one line of chemotherapy.

The Medicare Benefits Division are considering the need for additional scans. PCFA has advocated in support of this increase in the number of scans in a lifetime. We are eagerly awaiting a response on the this for yours and many other men’s benefit. As soon as we have a response we will provide a further update.

You can read more on eligibility and the exact conditions for PSMA PET scans here: https://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Factsheet-Diagnostic-imaging-1July22

and for PSMA scan for Lutetium Therapy: https://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Factsheet-Therapeutic+nuclear+medicine+therapy+for+metastatic+castrate+resistant+prostate+cancer or in the the attached factsheets.

If you need to clarify any details, please feel free to call our team on 1800 22 00 99.

Bernie

Team PCFA