OHIP Coverage for Positron Emission Tomography (PET) Scanning
Effective October 1, 2009
Positron Emission Tomography (PET) scanning is now a publicly insured health service available to cancer and cardiac patients who have one of the eight clinical indications listed below:
- Solitary Pulmonary Nodule (SPN): for which a diagnosis could not be established by a needle biopsy due to unsuccessful attempted needle biopsy; the SPN is inaccessible to needle biopsy; or the existence of a contra-indication to the use of needle biopsy.
- Thyroid cancer: where recurrent or persistent disease is suspected on the basis of an elevated and/or rising thyroglobulin but standard imaging studies are negative or equivocal.
- Germ cell tumours: where recurrent disease is suspected on the basis of elevated tumour marker(s) - (beta human chorionic gonadotrophin (HCG) and/or alpha fetoprotein) and standard imaging tests are negative, or a mass persists after primary treatment for seminoma when curative surgical resection is being considered.
- Colorectal cancer: where recurrent disease is suspected on the basis of an elevated and/or rising carcinoembryronic antigen (CEA) level(s) during follow-up after surgical resection but standard imaging tests are negative or equivocal.
- Lymphoma: for the evaluation of residual mass(es) following chemotherapy in a patient with Hodgkin's or non-Hodgkin's lymphoma when further potentially curative therapy (such as radiation or stem cell transplantation) is being considered; or for the assessment of response in early stage Hodgkin's lymphoma following two (2) or three (3) cycles of chemotherapy when the chemotherapy is being considered as the definitive single modality therapy.
- Non-small cell lung cancer (NSCLC)
- For which curative surgical resection is being considered based on negative standard imaging tests; or;
- For clinical stage III NSCLC which is being considered for potentially curative combined modality therapy with radical radiotherapy and chemotherapy
- Limited disease small cell lung cancer: for evaluation and staging where combined modality therapy with chemotherapy and radiotherapy is being considered.
- Myocardial viability assessment in a patient suitable for a cardiac revascularization procedure or cardiac transplantation with ischemic left ventricular dysfunction (left ventricular ejection fraction of 40% or less); and prior myocardial viability or stress imaging assessment with another modality (i.e. SPECT using thallium, MIBI or dobutamine stress echocardiography) has been equivocal for viability or demonstrated insufficient viable myocardium or a patient with severe ischemic left ventricular dysfunction and known multi-vessel coronary disease (determined by coronary angiography) urgently requires an assessment of myocardial viability.
Frequently Asked Questions
Q1. What does this mean to patients and physicians?
Prior to October 1, 2009 your oncologist or cardiologist would have applied for you to obtain a PET scan through participation in a clinical trial or registry study (also known as “evaluation studies”), or by applying to the PET Access Program.
As of October 1, 2009, if you have one of the eight clinical indications now covered by OHIP (see top of page) , and your oncologist or cardiologist has determined that information provided by the interpretation of a PET scan would assist in directing appropriate treatment options, he/she will be able to request a PET scan in a way similar to that of any nuclear imaging procedure, such as a CT scan or MRI. There are no wait times for PET scans as currently provided and funded.
For referring physicians :
For the eight clinical indications now covered under OHIP (see top of page), rather than arranging for your patient to participate in an evaluation study, or applying to the PET Access Program, you may request a PET scan similar to the way you would request any nuclear imaging procedure. There are no wait times for PET scans as currently provided and funded.
For more information on how to access a PET scan under insured services (OHIP) visit www.petscansontario.ca
For Nuclear Physicians :
Prior to October 1, 2009, you were paid via the evaluation studies for providing and interpreting PET scans. Now you will be paid directly by OHIP. Please refer to OHIP Bulletin #4498 for payment schedules.
Q2. What if my oncologist or cardiologist thinks I should have a PET scan and my cancer or cardiac indication is not covered under OHIP?
The ministry will continue to fund evaluation studies and the PET Access Program at no cost to the patient.
Therefore, your physician may request that you obtain a PET scan by participating in one of the studies. If your particular situation does not qualify for participation in an evaluation study, your physician will continue to be able to make a request through the PET Access Program, where each application for funding is considered on a case-by-case basis.
Effective May 17, 2010, Physicians can visit www.petscansontario.ca for information on PET evaluative studies or the Ontario PET Access program. Alternatively, physicians can call the Toll Free Ontario PET Information Line with any questions relating to the referral of patients to any of the PET evaluation studies or the Ontario PET Access program 1-877-4PET-411.
General statement: Effective May 17, 2010 For information on PET scans in Ontario including insured PET services, PET evaluative studies or the Ontario PET Access program visit www.petscansontario.ca
Q3. What is Positron Emission Tomography (PET)?
PET is a nuclear medicine imaging diagnostic tool. It was developed in the 1970s and was a research technology that was adopted by some countries without clarity about its effects on patient outcomes.
In Ontario, the funding of PET scans for the nine clinical indications as insured OHIP services has been based on evidence that its use optimizes patient outcomes. There are now eight cancers and one cardiac indication where PET scanning has been shown to be clinically effective, and the government is now insuring PET scans for these indications under OHIP.
For the circumstances in which PET scans will be insured under OHIP, PET scans are useful in determining the stage or extent of some cancers to aid in treatment decisions. PET scans have also been determined to be useful in making treatment decisions in certain advanced heart conditions.
Q4. Where can I go to obtain additional information on Positron Emission Tomography (PET) and Ontario's approach to implementation?
Additional information may be obtained from the PET Primer on the ministry's website.
Q5. What is the ministry rationale for insuring PET scanning now?
The ministry's position regarding PET scanning has always been that should evidence of clinical effectiveness be proven in particular circumstances, it will be funded as an insured OHIP service in those circumstances.
The ministry has been evaluating how to best use PET to improve decision making for cancer and cardiac treatment.It has funded clinical trials.Ontario's trials are leading to greater understanding of how PET can benefit patients. Ontario's clinical trials are resulting in high quality and internationally recognized evidence for the appropriate use of PET in diagnosis and treatment.
Based on the outcomes of these clinical trials and on the advice from the Provincial PET Steering Committee, Ontario has decided to fund seven cancer indications and one cardiac indication. International study results of clinical effectiveness and other considerations also played a role in this decision.
Q6. Where will PET scanning take place? Will these be different locations than those where the PET evaluation studies take place?
PET scans are available and the PET evaluation studies are carried out at five geographic sites :
- University Health Network (Princess Margaret Hospital)
- Sunnybrook Health Sciences Centre's Odette Cancer Centre
- Hospital for Sick Children
- Hamilton Health Sciences Centre
- St. Joseph's Healthcare
- London Health Sciences Centre
- St. Joseph's Healthcare London
- The Ottawa Hospital with cooperation of the University of Ottawa Heart Institute as required
- The University of Ottawa Heart Institute
- Thunder Bay:
- Thunder Bay Regional Health Sciences Centre
Q7. Is there enough capacity in the system to provide PET scans in a timely manner? Why doesn't every hospital have a PET scanner? Should every hospital have one?
There is currently adequate capacity to accommodate Ontarians PET scanning needs. This is based on projections as to the number of cancer and cardiac patients in Ontario who can be expected to have the indications for which PET scans would be a beneficial diagnostic tool.
Ontario has established one of the largest PET infrastructures in Canada, including 10 PET scanners at 9 centres.
At this time, there is no ministry consideration for increasing the number of PET scanners across the province.
Q8. If my local hospital wanted to obtain a PET scanning machine and be provided with funding to cover the operating costs, what is the process for doing so?
Public hospitals are publicly funded, corporations run by independent boards of directors. This is set out under the provisions of the Public Hospitals Act and other legislation. The boards are directly responsible for the day-to-day management of its hospitals, including the provision of patient programs and services.
If additional sites are required in future, and a hospital wishes to provide insured PET services to insured cancer and cardiac patients, it must have a PET/CT scanner and the services of qualified nuclear medicine personnel to provide oversight of insured PET services.
Hospitals are responsible for purchasing PET/CT scanning machines and do so through varying funding sources, such as equipment budgets, hospital foundation fund-raising, etc. The province does not provide funding for this.
Q9. Northern Health Travel Grant (NHTG) - Will the new OHIP coverage in any way effect patients who now qualify for the NHTG (when going for a PET scan as part of an evaluation study or special access program)?
The ministry will continue making the NHTG available to patients who qualify for a PET scan under ongoing evaluation studies and through the PET Access Program, should they meet all other NHTG Program eligibility requirements.
As of October 1, 2009, the NHTG funding will also be available to patients traveling to receive PET scans insured under OHIP, should they meet all other NHTG Program eligibility requirements.
To obtain additional details on the Northern Health Travel Grant program for PET scans and access a copy of the application form, please visit : http://www.health.gov.on.ca/en/public/publications/ohip/northern.aspx
Q10. Does the government anticipate an increase in the number of PET scans and wait times now that PET scans for certain health indications are covered under OHIP?
There is currently capacity in the system to provide PET scans for the eight clinical indications (see top of page); no waiting list is anticipated.
Q11. Which OHIP specialty would receive compensation from OHIP as a result of this change?
Physicians with specialty training in nuclear medicine will be compensated for providing and interpreting the scans.