New Positive Results: Humana, Aetna, and Blue Cross/Blue Shield
By Matthew Budoff, MD, FSCCT
There have been dramatic improvements in coverage with cardiac CT across the country. These policies are the direct result of the robust and increasing evidence base to support the clinical utility and appropriate use of Coronary CTA. Further, it is the result of continued dialogue between SCCT members and payer representatives. The Advocacy committee of the Society has worked diligently with partners in industry and insurance to improve coverage based on evidence.
One local success story of SCCT working with local payors is Blue Shield of California’s recently revised coverage policy for Coronary CTA. This policy, updated in February 2017, now indicates that Coronary CTA may be considered medically necessary for the evaluation of patients with chest pain (without known coronary artery disease) in the acute (emergency department) setting, and for stable chest pain patients in the outpatient setting. The policy also maintains coverage for the evaluation of anomalous (native) coronary arteries.
It is critical for SCCT members to contact their local insurance plans to advocate for expansions in Coronary CTA coverage, using the recent example of Blue Shield of California. The Society advocacy committee can provide assistance to move this forward locally.
Aetna National also expanded coverage of CCT in 2017. The coverage not only covers those who are at low-intermediate risk (acute or stable chest pain), but include broad indications such as “Evaluation of asymptomatic persons at an intermediate pre-test probability of coronary heart disease or atherosclerotic cardiovascular disease who have an equivocal or uninterpretable exercise or pharmacologic stress test” and pre-operative assessment of high risk non-cardiac surgery and non-coronary (ie valve) surgery. The policy also covers calculation of FFRct (Heartflow) as well. Vein mapping, TAVR, and calcium scoring. Aetna is the first large payor beyond Medicare in several states to cover calcium scanning. Covered patients include: asymptomatic diabetics over 40 years old, 10-20% 10-year risk, and for pre-CTA assessment to evaluate if coronaries will be adequately seen.
The national Blue Cross/Blue Shield policy for CCT also changed in October 2016, which now considers Coronary CTA medically necessary for the evaluation of patients with chest pain (without known coronary artery disease) in the acute (emergency department) setting, and for stable chest pain patients in the outpatient setting and anomalous coronary artery assessment. While work still needs to be done (ie – individual Blue Cross or Blue Shield Carriers may not automatically update coverage to model after national plan decisions), we have an incredible opportunity to level the playing field with functional testing after all these years and all the studies.
International coverage is also improving, led by the NICE Guidelines from the UK, which made CT angiography first line therapy for assessment of chest pain across the country. While other nations are still well behind that curve, it will provide very strong evidence to payors around the country and the world. US Payors do look at international guidelines, so these 2016 guidelines can be used in our discussions with payors locally and nationally.