NEJM Editorial: Cardiac CTA evidence may not warrant reimbursement, yet

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CHICAGO—CT again is in the hot seat at the 94th annual meeting of the Radiological Society of North America (RSNA) due to a New England Journal of Medicine editorial that accompanies the CorE 64 study published November 27th that questions whether cardiac CT angiography yet has enough clinical evidence to support its CMS widespread reimbursement. In March, CMS chose to continue local coverage determination for CCTA.

Last year, a NEJM study that coincided with RSNA questioned the cancer risk associated with the radiation dose of CT scans.

In “Pay Now, Benefits May Follow — The Case of Cardiac Computed Tomographic Angiography,” authors Rita F. Redberg, MD, and Judith Walsh, MD, MPH suggest that CMS should have more carefully weighed clinical outcomes in making its coverage determination.    

“The use of cardiac imaging has been increasing by 26% per year, despite a lack of evidence of outcome benefit,” the authors wrote. “Without such evidence, a high-resolution cardiac CT angiographic image of the heart is just another pretty picture. In fact, there is some evidence that cardiac imaging leads to additional unnecessary procedures, such as additional diagnostic testing, revascularizations, or biopsies for "incidental findings." Worse, cardiac CT angiographic equipment bombards patients with radiation many orders of magnitude greater than that of traditional radiographs — posing a risk that has never been studied in depth.”

The authors continued, “Our fee-for-service system encourages the use of expensive but unproven medical devices by generously reimbursing for new procedures without regard to their benefit. Although randomized clinical trials are expensive and time-consuming, these costs must be weighed against those of procedures (and downstream tests) that may have little or no benefit or, worse, harmful consequences. The continued unrestrained use of new technology, in the absence of evidence-based criteria, portends a bleak future for Medicare and our health care system.”

Redberg, who reports receiving grant support from the Blue Shield of California Foundation, is a professor of medicine at the University of California, San Francisco (UCSF), School of Medicine and director of women's cardiovascular services at the UCSF Medical Center, both in San Francisco. Walsh is a professor of clinical medicine and epidemiology at the UCSF School of Medicine.

Health Imaging News will provide more details in tomorrow’s issue. To view the editorial, click here.