National coverage policy could restrict Medicare payments for coronary CTA

Medicare has proposed a national coverage policy for cardiac CT that would slam the door on outpatient payment for the most popular applications of cardiac CT.

The national coverage determination (NCD), announced Dec. 13, 2007, proposes to eliminate Medicare payment for coronary CTA unless it is performed as part of a clinical trial approved by the Centers for Medicare and Medicaid Services and is performed on symptomatic patients with either chronic stable angina at intermediate risk for coronary artery disease or unstable angina at low to intermediate risk of CAD.

The public comment period for the new rule ends Jan. 12, and it could be enacted as early as March 13.

If adopted, the national payment standard would supersede local coverage determinations that cleared the way for Medicare coverage of coronary artery CTA in all 50 states as of January 2007.

The CMS proposal outraged cardiac CT providers. In a written statement distributed over the Internet, Dr. Uma S. Valeti of the St. Paul Heart Clinic in St. Paul, MN, called the plan unprecedented.

"No widely used imaging modality in the last five decades had to deal with an NCD that was so premature or so restrictive as to severely deny access to technology for Medicare beneficiaries," he wrote.

The link between Medicare coverage for coronary CTA and clinical trials examining its impact on patient outcomes is called coverage with evidence development, according to Valeti.

"The yoke of continuous evidence development is going to kill it for all but the academic institutions and rare private practices like my own," said Dr. David Dowe, a cardiac CT specialist with Atlantic Medical Imaging. "The ACR tells me CMS was impossible to deal with on this topic and reacted only to the potential dollar outlays from cardiac CTA, ignoring the savings from decreased caths and stress tests."

CMS officials were not immediately available for comment about the proposed policy.

In a decision summary covering its rationale for the new payment policy, CMS found that published clinical trials are inadequate to conclude that cardiac CTA is reasonable and necessary for diagnosing coronary artery disease.

Two indications were deemed promising, however. They are symptomatic patients with chronic stable angina at intermediate risk of CAD and symptomatic patients with unstable angina at low risk of short-term death and intermediate risk of CAD. If adopted, the CMS payment policy would grant reimbursement to patients who are enrolled in clinical trials that examine the efficacy of those indications. The CMS report described 13 standards that must be met to gain its approval to operate such trials.

The national policy applies only to coronary artery CTA. The decision summary notes that CMS will defer to its regional carriers for coverage decisions concerning other cardiac CTA applications. The proposed NCD is described at this CMS site.

Valeti urged colleagues to express their views and comment.

For more information from the Diagnostic Imaging archives:

Study builds argument for CCT triple rule-out to screen chest pain patients in ER

Report from RSNA: 64-slice CTA bests SPECT in patients with coronary disease