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The American College of Cardiology (ACC) has been meeting with health plans and advocating for more efficient and less burdensome alternatives to existing prior notification and approval programs for cardiac imaging. Just last month, the College sent a letter to Sen. Rockefeller (D-W.V.) supporting his investigation into inappropriate pre-authorization denials for cardiac stress testing by Blue Cross Blue Shield of Delaware and MedSolutions. In addition, the College is developing an alternative plan to radiology benefit managers (RBMs) based on use of appropriate use criteria. The alternative solution would transparently reduce inappropriate imaging, while limiting hassles for doctors and reducing costs to health plans. In the meantime, several large health plans are expanding their existing prior notification and approval programs to new cardiac diagnostic modalities beginning this summer and fall. The affected modalities include echocardiography, nuclear cardiology, diagnostic cardiac catheterization and electrophysiological device implantations (ICD and pacemakers). The requirements vary by insurer, member plan and service market and ACC members are strongly encouraged to familiarize themselves with the requirements in order to ensure proper payment. Programs that will be expanded include:
AETNA: As of May 15, all outpatient elective stress echocardiography and diagnostic cardiac catheterizations require prior authorization. Anthem BCBS (WellPoint): All outpatient elective echocardiography will require prior authorization. This will take effect Sept. 1 (Connecticut, Colorado, Nevada, Georgia, New Hampshire, Maine), Nov. 1 (Ohio, Indiana, Kentucky, Michigan, Wisconsin) or is not yet determined (California). Highmark BCBS (Pennsylvania): Starting Sept. 1, all outpatient, non-emergency imaging procedures (nuclear cardiology and stress echocardiography) will require prior authorization. UnitedHealthCare (UHC): UHC will expand its prior notification program to include all outpatient, inpatient and emergent diagnostic cardiac catheterization and electrophysiology implantation procedures beginning July 1 (Florida, Montana, North Carolina, Ohio, Wisconsin) or at a yet-to-be determined date. Please continue to use the ACC’s imaging hassle form located on the “Practice Management” section of Cardio-Source.org to report any issues with pre-authorization so that College leaders and staff can better advocate on members’ behalf. The ACC, American College of Radiology, American Society of Neuroradiology, North American Society for Cardiovascular Imaging, and the Society for Cardiovascular Magnetic Resonance have drafted comments that support the Centers for Medicare and Medicaid Services’ (CMS) Proposed Decision Memo for Magnetic Resonance Angiography (MRA). The Proposed Decision Memo examines the current evidence to determine whether certain indications for MRA that are not covered by Medicare should be covered. The memo discusses allowing local Medicare contractors to use their discretion to cover use of MRA for additional indications. The letter indicates the groups’ support of the CMS reconsideration. Their proposed approach allows physicians a “flexibility ... to utilize the appropriate MRI / MRA technique based upon a patient’s unique clinical situation.”