Efforts from a workgroup created by the Commission on Economics Chair Ezequiel Silva III, MD, FACR, have led the American College of Radiology (ACR®) to develop a model policy for prostate MRI to guide local and national coverage determination.
The effort comes in response to a 2019 Journal of the American College of Radiology (JACR®) article entitled National Private Payer Coverage of Prostate MRI. It investigated the national coverage landscape for prostate MRI services and assessed the presence of updated and accurate coverage requirements by private payers.
The article concluded that prostate MRI coverage varies widely among private payers, fails to recognize major clinical scenarios, is overly restrictive and is often not reflective of current clinical practice. These shortcomings have combined to create challenges for patients and referring physicians seeking to obtain ready access to prostate MRI services.
The College encourages the radiology community to use the workgroup’s new Prostate MRI Policy in discussions with private payers to gain coverage where it has been previously denied. As there are currently no national or local policies for prostate MRI, the policy can also be used to discuss authorizing possible coverage with local Medicare Administrative Contractors (MACs).
Prostate MRI, also referred to as multi-parametric or bi-parametric MRI depending on the examination protocol, is a diagnostic test intended to detect, localize and characterize primary cancer within the prostate. It entails obtaining high-resolution MR images of the prostate using multiple tissue contrast mechanisms and in multiple planes. Abnormalities in the prostate detected on the MRI may, in turn, serve as targets for a subsequent MRI-targeted prostate biopsy, often using advanced technologies to direct the biopsy to the area of the abnormality on the MRI.
The model coverage policy addresses prostate MRI in a range of pre-treatment settings, including biopsy-naïve patients, patients with a prior negative prostate biopsy, and patients with a prior prostate biopsy who are undergoing active surveillance or pre-operative staging. It was written to address the use of prostate MRI in the workup of suspected or known malignancies of the prostate.
Prostate MRI is not currently indicated in men with no risk factors, such as an abnormal prostate-specific antigen (PSA), abnormal serum or urinary biomarker, family history or abnormal digital rectal exam. Potential uses of prostate MRI in the workup of advanced (metastatic) and other prostate disorders were not addressed in the model policy.
The College thanks the following contributors of the model policy, including experts in prostate imaging and coverage: Andrew B. Rosenkrantz, MD (Co-Chair), Sammy Chu, MD, FACR (Co-Chair), Peter L. Choyke, MD, FACR, Katarzyna J. Macura, MD, PhD, FACR, Daniel Margolis, MD, Aytekin Oto, MD, Clare M. Tempany, MD, FACR, Jeffrey C. Weinreb, MD, FACR and Robert K. Zeman, MD, FACR.
We hope the dialogue will continue as the ACR Quality and Safety team is hosting a Prostate MRI Summit Friday, September 6 in Reston, VA. Topics will span both quality and economics.
Questions and comments may be directed to Alicia Blakey, ACR economics and health policy analyst.