Heart Doctors Await Medicare's Decision on Reimbursement for Cardiac CT Scans
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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:
- Symptomatic patients with chronic stable
angina
who are at "intermediate risk" of having coronary artery
disease (CAD); or
- 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 |
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"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. |
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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)
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