Despite Medicare’s divisive denial of coverage for any CT colonography (CTC) cancer screening in 2009, Medicare claims show a spike in the procedure’s wider use and a dramatic increase in reimbursement rates for diagnostic CTC, according to a study published April 4 in the Journal of the American College of Radiology.
“Several well-designed multicenter trials now corroborate the results of an earlier landmark trial demonstrating equivalent performance of OC [optical colonoscopy] and CTC,” argued Richard Duszak Jr., MD, of Mid-South Imaging and Therapeutics in Memphis, Tenn., and co-authors. Despite these findings, in 2009 the Centers for Medicare & Medicaid Services (CMS) reaffirmed its denial of CTC for colorectal cancer screening, a decision that drew scorn and praise among practitioners and policymakers.
Four years of Medicare claims are available for the procedure, from 2005 through 2008, which receives varying reimbursements and denials from CMS depending on indication. The authors performed what they believed was the first formal analysis of CTC’s growth and coverage, aggregating Annual Medicare Physician Supplier Procedure Summary (PSPS) master files for all Medicare fee-for-service beneficiaries.
The data showed an increase in CTC procedures from 3,660 in 2005 to 10,802 in 2008. While the absolute number of denials increased, when paired with the dramatic growth in the overall number of procedures, denial of CTC fell from 70 percent of cases to 43 percent.
Wide variations were observed for CTC coverage according to region. Medicare beneficiaries in Boston and travelling workers (the ‘travelers railroad’) received the fewest denials per request at 35 percent and 28 percent, respectively. Meanwhile, Dallas, Seattle and Atlanta faced denial rates nearly twice as high, between 62 and 69 percent.
Many regions saw large decreases in denial rates, including Chicago (from 90 percent in 2005 to 34 percent in 2008), Philadelphia (85 to 29 percent) and Seattle (97 to 44 percent). San Francisco, New York and Boston saw single-digit percentage increases in denials over the period.
Duszak and colleagues attributed the geographic disparities to regional coverage policies and to advocacy and education campaigns by organizations like the American College of Radiology (ACR). “We believe that such organized advocacy activities and their resulting expansion of coverage largely explain the overall decreased denial rates for CTC we have reported.”
Radiologists were by far the dominant provider of diagnostic CTC, performing nearly 26,000 of the total 28,000 procedures in 2008, the authors found. Gastroenterologists performed just 1 percent of CTC exams among the Medicare population.
Duszak and colleagues said that diagnostic CTC “has established itself in practice as essentially an outpatient procedure,” with 92 percent of services performed in private practices and outpatient settings, “paving the way for ongoing convenient (and therefore potentially expanded) patient access.”
“Although a reduction in national denial rates from 70 percent to 43 percent reflects considerable early progress, when contrasted with denial rates of just 4 percent for established technologies such as abdominal CT, opportunities clearly exist for further improvements in patient access through ongoing expansion of coverage.” Duszak and colleagues indicated that with only 50 percent of eligible individuals undergoing colorectal cancer screening, and with the available capacity for increased CTC exams, the procedure could play a crucial role in increasing compliance, particularly among poor and rural populations.
The authors did not analyze private payor coverage, which could affect the nation’s overall rates, particularly because private payors are the insurer of choice for most Americans.
With diagnostic CTC claims tripling in the first four years for which Medicare claims for the procedure were available, the authors estimated that “[p]hysician awareness of their own regional coverage policies should facilitate that expansion.”