Medicare Will Continue To Provide Coverage For Heart Scan, CMS Says

Main Category: Medicare / Medicaid / SCHIP
Also Included In: Heart Disease;  Radiology / Nuclear Medicine
Article Date: 14 Mar 2008 - 11:00 PST

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CMS on Wednesday said Medicare will continue to pay for a form of CT scan that can detect heart disease, despite "uncertainty regarding any potential health benefits" from the procedure, the New York Times reports. According to the Times, there is "growing concern that the CT scans are being done increasingly on those who show no signs of heart disease, subjecting them needlessly to radiation risks." The scan is an alternative to angiography, in which a catheter is inserted into the blood vessels. Angiography is only performed on patients who have signs of heart disease.

Because of "misgivings over whether there was enough evidence to justify paying for the tests under Medicare," CMS in December 2007 said Medicare would not cover CT scans unless patients were enrolled in a study on the procedure's effectiveness. CMS' decision was "met with fierce resistance" from doctors and medical equipment makers, who said that the scans are "an important alternative to conventional angiography" and that patients who were unable to enroll in the studies would be "unfairly denied access to the technology."

Under CMS' latest decision, local insurance carriers that oversee medical claims will determine whether to cover the scans. Most of the carriers already cover the scans, which can cost $600 or more, according to the Times. In 2006, Medicare paid $40 million to $50 million for about 70,000 of the scans. According to the Times, CMS' decision "means their use is likely to continue to climb" because private insurers "often follow Medicare's lead" on what procedures they cover.

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CMS Chief Medical Officer Barry Straube said, "We found that the evidence is not black and white either way," adding that because of the criticism of the agency's preliminary decision, it did not have enough reason to override local insurers' decisions that the tests are medically necessary. He said, "Before we make a significant change in policy, we need more evidence" of the scans' medical necessity. Mark Grant, a senior scientist for the Blue Cross and Blue Shield Association, said, "Before it enters widespread use, it needs to be critically examined, and it has not been."

Daniel Berman, president-elect of the Society of Cardiovascular Computed Tomography, said, "Within one year, there will be 10 times as much evidence of the effectiveness" of the heart scans. However, according to Sean Tunis, a former Medicare official who is director of the not-for-profit Center for Medical Technology Policy, such studies would be difficult to organize without CMS' insistence (Abelson, New York Times, 3/13).

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