Aetna Coverage Decisions
Aetna to Reimburse for Computer-Aided Detection for Mammography
Effective April 1, 2005, Aetna began reimbursing for computer-aided detection (CAD) for mammography, thanks in part to the ongoing efforts of the ACR Managed Care Committee. The ACR confirmed this policy change through a telephone conversation with Aetna's senior medical director for reimbursement policy.
Aetna's medical policy for CAD for mammography had previously classified the service as "a quality adjunct to mammography…an integral part of a radiology center's quality improvement program" that was not separately reimbursed. Many radiology practices have been diligent at the local level in pursuing reimbursement for CAD through negotiations with local payer contacts and by filing compliance dispute claims under the Aetna class action lawsuit. The ACR Managed Care Committee worked at the national and local levels to educate Aetna and other payers regarding the use of CAD.
Aetna to Reinstate Reimbursement for Continuing Medical Physics Service
In response to the extensive efforts of the ACR Managed Care Committee and the ACR Economics Committee on Medical Physics, effective April 1, 2005, Aetna reinstated reimbursement for the continuing medical physics consultation service, CPT® code 77336. The change will be effective for dates of service on or after April 1, 2005.
An Aetna medical policy bulletin released in January 2004 had announced Aetna's decision not to reimburse for this critical service, stating "Aetna considers the continuing medical physics consultation service to be a quality adjunct to a course of radiation therapy. When used during the normal course of radiation therapy, the medical physics consultation is considered as an integral part of quality management programs and is not separately reimbursed." In response to this announcement, the ACR Managed Care Committee, with help from the ACR Economics Committee on Medical Physics, participated in several conference calls with Aetna leadership and presented numerous letters to Aetna outlining the position of the ACR, ASTRO, and AAPM regarding reimbursement for this service. ASTRO and AAPM were also involved in separate discussions with Aetna and all 3 organizations worked on parallel tracks to achieve this victory.
If you have any questions concerning Aetna's policy changes, contact Angela Stanley in the ACR Economics and Health Policy Department at (800) 227-5463, ext 4560.