CMS Declines to Expand Medicare Coverage for CT Colonography
The Centers for Medicare & Medicaid Services has again declined to expand national coverage for computed tomography colonography (CTC) for colorectal cancer screening. Citing insufficient evidence, the decision maintains the current reimbursement status for the procedure. This move signals continued high scrutiny from CMS regarding coverage expansion for advanced imaging modalities.
- The American College of Radiology (ACR) has advocated for Medicare coverage of CT colonography for over 15 years, highlighting it as a less invasive screening option that doesn't require anesthesia. - In a significant policy shift, CMS finalized its proposal to cover screening CT colonography, effective January 1, 2025, under the Hospital Outpatient Prospective Payment System (OPPS) and Medicare Physician Fee Schedule (PFS). - The 2025 reimbursement rate for the technical component of the procedure will be $241.72, while the professional component is set at a rate of $108.68. - As part of this policy update, Medicare removed coverage for barium enema as a colorectal cancer screening method, citing it is no longer a recommended evidence-based procedure. - Proponents argue the availability of CTC may increase screening rates, as it is a safer procedure with a perforation risk 10 to 20 times lower than conventional colonoscopy. - Studies have shown that CTC is more effective and cost-efficient than stool-based DNA testing, with one analysis showing a 70-75% reduction in cancer incidence with CTC versus 59% for stool DNA tests. - Despite the coverage approval, the ACR has expressed concern that the reimbursement is subject to the Deficit Reduction Act of 2005 (DRA) payment cap, which they argue is inadequate and could limit patient access. - Many major private insurers, including UnitedHealthcare, Cigna, Aetna, and Anthem Blue Cross and Blue Shield, already provide coverage for screening CTC.
