CMS declines to revisit CT colonography coverage
By Eric Barnes, www.AuntMinnie.com staff writer
December 15, 2016 — In a stunning year-end setback for screening CT colonography, the U.S. Centers for Medicare and Medicaid Services (CMS) has turned down a request by advocates for CT colonography to reconsider its 2009 decision not to pay for the imaging-based colon cancer screening exam.
The American College of Radiology (ACR) said it has been informed by CMS that the agency would not be reopening the coverage review. A CMS spokesperson confirmed the decision with AuntMinnie.com but added that the agency can decide to initiate the reconsideration process at any time.
The decision is a serious blow to the CT Colonography Coalition, a group that includes the ACR and several major colorectal cancer screening advocacy groups. The coalition had submitted a formal request to CMS for review in August, after the U.S. Preventive Services Task Force (USPSTF) included CT colonography (CTC) among the colon cancer screening tests that it recommended, giving the exam a “B” rating earlier this year.
“The Centers for Medicare and Medicaid Services’ decision not to re-examine Medicare coverage for CT colonography is out of step with modern medicine and the needs of America’s seniors,” said Dr. Judy Yee in a statement released today by the ACR. Yee heads the ACR’s colorectal cancer working group and serves as chief of radiology at the San Francisco Veterans Affairs Medical Center. “Abundant efficacy and cost-effectiveness evidence demonstrates that CTC (also known as virtual colonoscopy) is a front-line colorectal cancer screening tool.”
With its June 2016 approval of CTC for screening, the USPSTF joined a broad range of healthcare and colorectal cancer care advocacy groups supporting the exam, including the ACR, American Cancer Society, U.S. Food and Drug Administration, and U.S. Multi-Society Task Force, as well as several commercial payors such as UnitedHealthcare, Cigna, Blue Cross/Blue Shield insurers, and Kaiser Permanente. Laws in 33 states and the District of Columbia mandate that insurers cover CTC. The Agency for Healthcare Research and Quality (AHRQ) and the National Committee for Quality Assurance (NCQA) have recognized CTC as a metric (known as the HEDIS measure) for colorectal cancer screening.
“Yet Medicare patients who need this lifesaving screening the most are denied coverage,” Yee said in the ACR statement. “This must change if we are to attract the up to 40% of Americans who should be screened for [colorectal cancer], but choose not to, to get tested. Lives are being lost every day that Medicare coverage is denied.”
Representatives of the coalition and the ACR met with CMS on December 13 to discuss its reasoning for the decision, and today they vowed to keep working for approval.
“The ACR will work closely with CMS to resolve any issues that they may still have about CTC,” the ACR said. “The college will also continue to work with the colorectal cancer care advocacy groups, patients, lawmakers, and other decision-makers to secure Medicare coverage for CT colonography.”
Breast tomosynthesis screening, 3-D mammography, will be covered by fully-insured commercial plans starting Jan. 1
ConnectiCare will cover breast tomosynthesis screening, a three-dimensional mammogram, for all our fully-insured commercial members in 2017. The member’s cost-share will depend on his or her benefits plan.
Preauthorization will not be required for this service, which the state of Connecticut mandates be included in all fully-insured individual and employer-sponsored plans that are new and renewing after Jan. 1, 2017.
ConnectiCare’s coverage of this service, identified with a procedure code of 77063, will be as follows:
- For employer-sponsored large group plans, we will cover the service as preventive as long as it is coded and meets the same age and frequency requirements as a routine, preventive annual mammogram:
Procedure code: 77063
Frequency: Once a year*
Other requirements: women age 40 and older
Harvard Pilgrim has updated the CT screening for Lung Cancer Medical Policy
Harvard Pilgrim has updated the CT screening for Lung Cancer Medical Policy to include new coding requirements. For dates of service beginning January 1, 2017, please submit your request for prior authorization and reimbursement for lung cancer CT screening using HCPCS code G0297, rather than CPT code 71250. Prior authorization for outpatient diagnostic imaging will continue to be performed through NIA Magellan; providers may submit their request through NIA Magellan’s website at www.radmd.com or by calling NIA Magellan at 800-642-7543.
VA scales back proposal on nurses reading imaging exams
By Brian Casey, www.AuntMinnie.com staff writer
December 13, 2016 — In a victory for radiologists, the U.S. Department of Veterans Affairs (VA) has scaled back a proposal that grants expanded duties to advanced-level nurses within the VA system, by removing language that some observers believed could have allowed nurses to perform and interpret medical imaging studies.
In a final rule being published December 14 in the Federal Register, the VA issued a final decision on a proposal to grant what’s called “full practice authority” to nurses who have advanced training. Designed to address an ongoing personnel shortage at the VA, the proposal gives some nurses expanded responsibilities in areas such as radiology, anesthesiology, and pathology.
The final rule clarifies some language in the original proposal that had vexed the radiology community by implying that nurses would be able to interpret medical images — a task that requires radiologists to go through 10 years of formal medical training. Instead, the VA amended the language by allowing advanced-level nurses to order studies but not perform or interpret them — a change that won the approval of the American College of Radiology (ACR).
The VA has been scrambling to cope with a shortage of qualified healthcare personnel that has resulted in delays in medical care for veterans — with some patients on waiting lists dying before they could receive care.
At the same time, nursing groups have been pushing the idea of full practice authority, which they interpret as allowing nurses with advanced training to take on duties once reserved exclusively for physicians. Nursing advocates had noted that some advanced-level nurses working in the VA system were unable to perform duties they had been granted the authority to perform at the state level, leading to confusion and varying standards of care.
These two trends coalesced in a May 25 proposed rule issued by the VA that would give nurses more authority to direct and practice medical care. The proposal divided advanced-level nurses into four categories, each of which could perform some procedures currently performed only by doctors.
With respect to medical imaging, the proposed rule would give certified nurse practitioners (CNPs) the ability to “Order, perform, supervise, and interpret laboratory and imaging studies.”
That language set off alarm bells in the imaging community, which characterized the proposal as “crossing a Maginot Line” by letting imaging studies be interpreted by nonphysicians. Imaging groups led by the ACR organized opposition to the proposal, citing both its intrusion on physician scope of practice as well as its implications for the quality of care for veterans.
The VA acknowledged these concerns in the December 14 final rule, in which the agency cited a number of comments it received in opposition to the rule and its implications for medical imaging. Commenters raised the issue of the extensive training that radiologists receive, while others proposed that only radiologic technologists should be able to perform imaging studies. This led the VA to clarify what it was trying to accomplish with the proposal.
“It is not VA’s intent to replace our highly qualified radiologists or radiological technologists,” the final rule states. “VA is committed to providing high-quality healthcare for our nation’s veterans and is proud of the outstanding work performed by radiologists in our system.”
The VA noted in the final rule that during the course of care within the VA system, other healthcare providers outside radiology such as those in emergency departments and primary care and specialty clinics already review radiology exams and make evaluations based on the findings of radiologists. The goal of the proposal was not to change the way imaging studies are performed and read.
“All radiology studies are formally performed and read by individuals who are credentialed in radiology,” the final rule states. “This rule-making will not change this practice.”
To clarify the issue, the VA removed the language on “performing, supervising, and interpreting imaging studies,” and replaced it with a statement that certified nurse practitioners could “order laboratory and imaging studies and integrate the results into clinical decision-making.”
What if certified nurse practitioners ordered more imaging exams than physicians, resulting in additional costs and added radiation exposure to patients? The VA noted that it had received comments to this effect, but it had found no evidence to back the claim that CNPs ordered more imaging studies. Therefore, it would let stand the provision allowing CNPs to order imaging exams.
The final rule also left in place full practice authority for nurses with the clinical nurse specialist (CNS) or certified nurse-midwife (CNM) titles. But in a blow to nursing groups, a proposal that would have given full practice authority to certified registered nurse anesthetists (CRNAs) was removed from the final rule.
After leading the opposition to the proposed rule, the ACR issued a statement noting that it was satisfied with the VA’s revisions to the initial proposal in the final rule.
“The ACR commends the VA for maintaining a collaborative, integrated, physician-supervised approach to imaging care,” the group said in the statement.