CMS-10583 IDEAS Eligibility Form

Imaging Dementia-Evidence for Amyloid Scanning Study Forms (IDEAS)
(version March 31, 2015)
ELIGIBILITY CONFIRMATION FORM
(to be completed with each new referral)
I certify that all of the following are correct:
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The patient is a Medicare or Medicare Advantage beneficiary.
The patient has had a verified diagnosis of MCI or dementia for longer than 24 months.
The patient meets AUC for amyloid PET (all must be checked):
 Cognitive complaint verified by objectively confirmed cognitive impairment
 The etiologic cause of cognitive impairment is uncertain after a comprehensive
evaluation by a dementia expert.
 Alzheimer’s disease is a diagnostic consideration.
 Knowledge of amyloid PET status is expected to alter diagnosis and management.

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The patient does not meet any of the exclusion criteria:
 Normal cognition or subjective complaints that are not verified by cognitive
testing.
 Knowledge of amyloid status, in the opinion of the referring dementia expert, may
cause significant psychological harm or otherwise negatively impact the patient or
family.
 Scan is being ordered solely based on a family history of dementia, presence of
apolipoprotein E (APOE)ε4, or in lieu of genotyping for suspected autosomal
mutation carriers.
 Scan being ordered for nonmedical purposes (e.g., legal, insurance coverage or
employment screening).
 Cancer requiring active therapy (excluding non-melanoma skin cancer);
 Hip/pelvic fracture within the 12 months prior to enrollment;
 Weight greater than that allowable by the PET table;
 Life expectancy less than 24 months based on medical co-morbidities.

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The patient has had a head MRI and/or CT within 24 months.

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The patient has had an appropriate clinical laboratory assessment (minimum: CBC,
standard blood chemistry profile, TSH, vitamin B12) within 12 months.

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The patient is expected to be able to tolerate amyloid PET imaging.

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Informed consent has been obtained from the patient or designated
surrogate/proxy.