More Unacceptable Denials: Now It’s PSMA-Targeted PET/CT Imaging

Application of next-generation imaging in biochemically recurrent prostate cancer

“…Advanced imaging modalities could contribute to guiding subsequent treatment decision-making in patients with BCR. However, several obstacles could prevent the routine adoption of NGI in the US clinical practice, including racial, geographical, and insurance coverage disparities in access [ 77 , 78 ]. In contrast, due to the actions taken by regulatory authorities in other countries such as Australia, accessible and insurance-covered PSMA PET/CT is replacing conventional imaging as the preferred imaging modality for patients with BCR, with potentially beneficial impact on patient care optimization [ 79 ].…”

“…However, limitations remain associated with image resolution and their routine adoption in clinical practice [ 83 ]. Despite the evidence of cost-effectiveness in the BCR setting [ 92 ], the wider use of NGI in the US practice is further impeded by inconsistent access and insurance coverage issues [ 78 ]. Clearly, there is a need for more evidence-based prospective clinical trials [ 35 , 70 ] and correlative guidelines to support the routine application of NGI in patients with BCR.…”

Assessment of real-world application of advanced prostate cancer management in Japan

“…While PSMA-PET scan has become widely available and a mainstay of diagnostic testing in certain parts of the world like Australia or Germany, there are countries lacking access or third-party payers/insurers have not been routinely recognizing these imaging modalities as standard-of-care practice. For instance in the United States (US), despite the US Food and Drug Administration (FDA) approval of certain PSMA tracers like 68Gallium Ga-PSMA-11 from the University of California San Francisco (UCSF) and University of California at Los Angeles (UCLA) on December 2020, 18F-DCFPyL Pylarify approval on May 27, 2021, there are still a swarm of denials by different insurers ( 7 ), which makes routine utilization of PSMA-PET scan challenging across different indications. This is despite the National Comprehensive Cancer Network (NCCN) updates on guidelines for prostate cancer imaging, where they suggested foregoing conventional imaging stating it is not a prerequisite prior to obtaining a PSMA-PET which can be an equally effective frontline imaging ( 8 ).…”