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CMS decides not to mandate national coverage for imaging tests
Further analysis and data collection will determine if the decision will be revisited in the future.
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The Centers for Medicare and Medicaid Services will leave coverage decisions for computed tomographic angiography to local contractors instead of recommending national coverage.
The CMS had been proposing a change in coverage to the CT section of their National Coverage Determination Manual beginning in June 2008. Representatives from CMS would not comment on the decision, but an official statement was released once the decision had been reached.
According to the statement, the decision was “based on additional evidence and information provided to CMS during the comment period on the proposed National Coverage Determination,” which resulted in the decision to “continue the current coverage by the Medicare contractors through local coverage determinations.” In addition to allowing local contractors to make coverage determinations, the decision also allows case-by-case adjudication in all 50 states.
Support for local coverage
The decision was supported by other technology alliances and medical organizations that indicated that the proposed national coverage decision would hamper access to cardiac CTA. The Medical Imaging and Technology Alliance praised the decision, asserting in a press release that the proposed change “would have drastically limited patient access to CTA” and that it would potentially “eliminate the need for surgery or catheterization.” The American College of Cardiology also supported the decision.
“The decision was largely based on the fact that when CMS was confronted with a larger body of research indicating value for the procedure, they decided to hold off on a national coverage decision,” Jack Lewin, MD, chief executive officer of the ACC, told Cardiology Today. “The CMS decision was the right decision and the responsible decision for patients, but the profession also has a responsibility to tighten up the use of imaging tests, and we would ultimately like to do this in a partnership with radiology.”
Researchers from CMS examined technology assessments, reviews, clinical studies and meta-analyses prior to making the decision. Evidence that the diagnostic test had tangible benefits on health outcomes was a principal concern. According to a CMS memo, evidence supporting the Centers’ decision was considered sufficient if it could demonstrate that “cardiac CTA had the ability to diagnose or exclude CAD as well as invasive coronary angiography,” that it “reduced the need for invasive coronary angiography,” and if it demonstrated “improvement in health outcomes for patients with acute chest pain who present in the emergency room or other settings.”
The decision to keep coverage local, according to Lewin, did not necessarily signal the end to examination or consideration of national coverage. Ongoing analyses will be conducted to determine if the decision could be more appropriate in the future.
“We need more research at the forefront of imaging modalities to understand better where these tests are most effective and under what circumstances,” Lewin said. “The decision gives us some time to work on both appropriateness criteria and registry-based application of those criteria to reduce unnecessary use and promote the right test for the right patient the first time.” – by Eric Raible
For more information:
- To read more about the CMS decision, visit www.cms.hhs.gov.