The Centers of Medicare & Medicaid Services (CMS) has decided that no national coverage determination is appropriate for cardiac CT angiography (CCTA) to diagnose coronary artery disease (CAD) at this time—and thus, Medicare reimbursement remains in tact.
In a Final Decision Memo, that was issued a day earlier than expected, CMS maintained the status quo that coverage should be determined by local contractors through the local coverage determination process or case-by-case adjudication.
The statement said that while “there are other uses of CTA, this decision focuses only on the use of CTA for the evaluation of the coronary arteries in patients with symptomatic coronary artery disease (e.g., chest pain). Imaging performed on patients without chest pain (asymptomatic patients) would be considered screening and is not an available benefit in the Medicare program.”
As stated, the decision does not extend coverage to include patients who are not suffering from angina.
When CMS first proposed the coverage decision in December 2007, the agency proposed a national coverage decision, which requires the initiation of a clinical trial to establish whether CCTA is useful for either of the following types of patients: symptomatic patients with chronic stable angina at intermediate risk of CAD, or symptomatic patients with unstable angina at a low risk of short-term death and intermediate risk of CAD.
Yesterday’s decision allows for all 50 states to continue to follow the local coverage determinations to pay for CCTA, as opposed to having a national mandate
CMS stressed that their decision not to change the policy is because the agency evaluated the clinical evidence. The agency determined “the critical appraisal of the evidence enables us to determine to what degree we are confident that: 1) the specific assessment questions can be answered conclusively; and 2) the intervention will improve health outcomes for patients. An improved health outcome is one of several considerations in determining whether an item or service is reasonable and necessary.”
Ultimately, CMS recognized that this type of diagnostic testing for patients with CAD will produce positive health outcomes, as supported by the clinical evidence in the investigatory process.
When CMS first proposed the coverage decision in December 2007, they requested public comment. In all, the agency received 670 comments, 10 of which agreed with the decision, while 649 were opposed, and the remaining provided no clear direction for coverage.