The Dilemma of a Disconnect Between Guidelines, AUC and Reimbursement

A commentary published July 31 in the Journal of the American College of Cardiology, discusses an discordance between appropriate use criteria (AUC) for implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT), the guidelines and the Medicare National Coverage Determination (NCD), which “places clinicians in the difficult dilemma of trying to do the ‘right thing’ for their patients, while recognizing the ‘right thing’ may not be covered by the payor or insurer.”

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The authors, past and current leaders of the ACC, the American Heart Association (AHA) and Heart Rhythm Society (HRS), explain that the current NCD for primary prevention ICD implantation “is based on seminal trials,” was last revised in 2005, and “does not address many of the scenarios for primary prevention ICD use that were considered appropriate by the AUC authors.”

To address the discordance, they urge the ACC, AHA and HRS to “advocate for legislation that protects physicians who follow the clinical guidelines or the AUC.” In the meantime, they suggest several short term options including appropriate candidates wearing an external defibrillator vest “until the requisite time period has passed;” the hospital contacting the Medicare fiscal intermediary “to prevent any allegation of fraudulent billing or deception;” or having the patient sign an Advanced Beneficiary Notice “to acknowledge that the ICD implant may not be covered and he or she may be responsible for the procedure and the device.”

They add that “physicians who believe that a device is indicated in a situation not covered by the NCD must document their thought process and rationale,” and encourage physicians to work with their coders to clearly state when events occur. They add that “reassessment of the NCD should be considered on a regular basis to keep up with the latest clinical evidence. In an ideal world, the NCD should be constructed in a flexible format enabling ease for adaptable coverage criteria to be congruent with the evidence based science and appropriate clinical use.”

Keywords: Deception, Insurance Carriers, Medicare, Defibrillators, Implantable, Primary Prevention, Cardiac Resynchronization Therapy

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