In response to significant public opposition, Anthem recently updated its controversial site-of-service imaging steerage policy to expand the list of situations when advanced radiologic imaging is considered “medically necessary” in a hospital outpatient department setting.
The revision, effective Nov. 9, adds the following circumstances to the previous exceptions to Anthem’s policy that otherwise denies coverage for CT and MR services performed in hospital outpatient departments:
- The individual is less than 10 years old; or
- The individual has a known chronic disease that is expected to require imaging at multiple time points and the individual has had prior radiology imaging procedures for the diagnosis, management or surveillance of the disease at the hospital outpatient department or clinic (for example, follow-up of lung nodules, individuals with multiple sclerosis, aortic aneurysms, or inflammatory bowel disease, or individuals with cancer); or
- The individual has a known contrast allergy; or
- The imaging is pre-operative or pre-procedure where the surgery or procedure is being performed at the hospital or affiliated site; or
- Performance or imaging outside the hospital outpatient department or clinic would reasonably be expected to adversely impact or delay care
Though these new exceptions reduce the policy’s impact, the American College of Radiology remains strongly opposed to any payer policy that unilaterally eliminates a patient’s choice of service site under most circumstances. The decision on where services are performed should lie with the patient in consultation with her or his physicians and with out-of-pocket financial obligations part of the decision making.