Model LCD suggests terms for Medicare coverage

March 1, 2006

The American College of Radiology and the American College of Cardiology called a truce in their turf battle over cardiac CT to jointly write a document intended to help local Medicare insurers set the terms for the acceptance and coverage of cardiac CT procedures.

The American College of Radiology and the American College of Cardiology called a truce in their turf battle over cardiac CT to jointly write a document intended to help local Medicare insurers set the terms for the acceptance and coverage of cardiac CT procedures.

The resulting Model Local Coverage Determination, published in December, was developed over six months in 2005 by a working group that included representatives of the ACR, ACC, American Society of Nuclear Cardiology, North American Society of Cardiac Imaging, Society of Cardiac Angiography and Intervention, and Society of Cardiovascular CT.

The 15-page document covers the essential components of a local coverage determination, a report that Medicare's 14 regional contractors generate to independently decide if the federal health insurance program will reimburse providers in their regions for a new medical procedure. LCDs are often the first step toward general acceptance of a new technology.

The ACR and ACC set aside their political differences to help assemble the Model LCD, according to Dr. John Patti, chair of the ACR's economics committee.

"We had a lot of people from each organization working closely together, with numerous conference calls, e-mails, and a whole-hearted effort on the part of each organization and all of its representatives to do what's best for patients in the long run," Patti said.

The presence of a representative of the Blue Cross/Blue Shield Association raised hopes for quick acceptance of cardiac CT by private insurers, but Dr. Carole Redding Flamm, senior medical director of the BCBSA's office of clinical affairs, left the working group before the document was completed.

BCBSA policy is governed by a 2005 medical technology assessment that pointed to deficiencies in 16-slice CTA performance, suggesting that it was premature to recommend BCBS reimbursement for the procedures. An update is planned later this year. -JMB