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Heart Doctors Await Medicare's Decision on Reimbursement for Cardiac CT Scans

external sites:
Proposed Decision Memo for Computed Tomographic Angiography
-- CMS

Public Comments on Proposed Decision Memo
-- CMS

Joint Comments on the Proposed Decision Memo for Computed Tomographic Angiography
-- American College of Cardiology, American College of Radiology, American Society of Nuclear Cardiology, North American Society of Cardiovascular Imaging, Society for Cardiovascular Angiography and Interventions, and the Society of Cardiovascular Computed Tomography

March 5, 2008 -- Next week the Centers for Medicare and Medicaid Services (CMS) is scheduled to announce a decision on coverage for Computed Tomographic Angiography, commonly called Cardiac CT or CT Angiography (CTA). A December proposed decision memo called for significantly cutting back reimbursement for CTA, except in two indications:

  1. Symptomatic patients with chronic stable angina who are at "intermediate risk" of having coronary artery disease (CAD); or
  2. Symptomatic patients with unstable angina at a low risk of short-term death and intermediate risk of CAD.

In both cases, patients would need to be enrolled in an approved Clinical Trial. This memo, if enacted, would represent a wholesale cut back in the utilization of coronary CT nationwide -- including its use in emergency situations.

Like all CMS coverage change proposals, there was a 30-day comment period following. But since this proposal was released on December 13, 2007, the comment period spanned a two week holiday period in which many were on vacation. Nevertheless, CMS was swamped with over 500 comments from a wide range of radiologists, cardiologists and patients, calling for CMS to re-think this decision. Dr. Armin Zadeh of Johns Hopkins Medical Center even invited the CMS team to visit his lab to see a true state-of-the-art CT facility. A joint letter was submitted by most of the major medical societies concerned with heart disease and imaging. Angioplasty.Org also posted an open letter to CMS, pointing to the increased patient safety afforded by this non-invasive test for arterial blockage.

At the heart of most criticisms was the fact that CMS had been working with older data and had not looked at the most current results of important clinical trials, such as the CorE 64 and others -- trials which proved, among other things, the very high 99+% negative predictive value of 64-slice Cardiac CT. Multislice CT is a relatively new technology, one that is advancing every month. Earlier systems used 16-slice technology, but the current standard is 64-slice, and Toshiba recently unveiled their 320 slice CT, which would image the entire heart in one beat, reducing radiation exposure while increasing accuracy and speed. The other major CT manufacturers, Siemens, Philips and GE, also have new generation systems that can reduce radiation and increase accuracy.

The concern among imaging specialists is great. Daniel S. Berman, President-Elect of The Society of Cardiovascular Computed Tomography, commented to Angioplasty.Org:

Daniel S. Berman, MD
Daniel S. Berman, MD

"There is very strong evidence that the CT coronary angiogram is the most accurate non-invasive test for the detection of coronary artery disease. Period! Nothing comes close.

"Hopefully the comments to CMS will be reviewed and acted on appropriately, but I also think that it's not inappropriate for people to contact their Congressmen to let them know. Congress needs to be aware that this process is underway. I'm not trying to offend anybody at Medicare. I just want to make sure that it's something that's done in the light of day, with all of the appropriate evidence being considered before it becomes a fixed set of guidelines that will potentially set back one of the most important developments in cardiac imaging that I've seen in my lifetime. And I've had an entire career dedicated to this, for over 30 years, in cardiac imaging."

Dr. John McBarron Hodgson, past-president of the Society for Cardiovascular Angiography and Interventions, hopes that all these comments will be taken into consideration and he believes that the joint organizational letter and soon-to-be-published studies will allay Medicare's concerns. He recently told Angioplasty.Org:

"CMS is afraid that everybody's going to stack tests -- that you'd get a CT, then a nuclear stress test, then an invasive cath. So, in our most recent letter, we have this consortium of radiologists and interventional and nuclear cardiologists and general bodies, and everybody's in there together saying cardiac CT is good, don't mess with it! We're doing good here!

"And we now have papers that are going to be presented soon, and the data's really amazing. I mean, you can predict outcome, and we've gone on record now to say that if you have a normal cardiac CT, you do not need any other tests. So, that's the kind of stuff that CMS is really interested in, that we will come out and say “Hey, if you've got a negative CT, you don't need all these other tests”.

    John McBarron Hodgson, MD
John McBarron Hodgson, MD

Many cardiologists have commented to Angioplasty.Org that they believe Cardiac CT may ultimately replace much of the nuclear stress testing being done: a test that can be less accurate in diagnosing coronary disease, and one that also carries a significant radiation dose. Other ongoing studies have been giving high marks to Cardiac CT in the Emergency Department for being able to quickly and definitely diagnose coronary blockages and heart attacks in cases where the standard tests are inconclusive.

Meanwhile all eyes in the cardiac imaging world are trained on next week's decision by Medicare.

(Reported on March 5, 2008 by Burt Cohen, Angioplasty.Org)