Sammy Chu, MD, FACR, Chair of the American College of Radiology® (ACR®) Contractor Advisory Committee (CAC) Network, and President of the Washington State Radiological Society contributed this post.

The Medicare Administrative Contractors, affectionately known as the MACs, are the medical insurance companies that actually process Medicare claims from physicians and hospitals. Medicare is such a large enterprise that the federal government contracts out these activities to the MACs, who can set coverage policies for their region called Local Coverage Determination policies, or LCDs. Back in 2019, there were changes to Medicare that provided a formal structure for the various MACs in the country to work together to develop these LCDs. The MACs have always had physician advisors— including radiologists — for their policies, meeting with each MAC in a state-level Contractor Advisory Committee, or CAC. How would these CACs function on a national level?

In the first “cross-country” CAC, the topic of vertebroplasty and kyphoplasty was discussed. These spinal procedures involve the injection of bone cement into fractured vertebrae. After the MACs and CAC members met in a large national meeting at the beginning of 2019, it took several months before the LCD policies were written up … and it was a disaster. Payment for subacute fractures, which have always been covered and which the medical literature strongly supports, was suddenly stopped. It took several more months and numerous phone calls before these were put back on the payment list.

When your ACR CAC members learned that facet joint injections were to be discussed, we all held our breath. How would things turn out this time? The MACs and CAC members met (virtually, of course) in May 2020, and the literature on the efficacy of these injections for chronic facet pain was discussed. After several hours of heated debate, radiology CAC members were unclear what the new policy would look like. We only found out a couple of weeks ago, and the result was significantly better than the initial vertebroplasty result. The facet joint LCD was what we expected. However, these meetings have revealed upcoming challenges with the new LCD policy development process. The input of radiology CAC members has become diluted with these large national meetings, and more recently, even been shut out completely. The topics of discussion have focused on spinal injections, which form a relatively small portion of most radiology practices. What happens if the MACs turn their attention to imaging protocols? Fortunately, CAC members are still able to voice our concerns with the medical directors of each MAC, and that is how we need to exert our influence. It has never been more important to “act locally,” and we need to recruit engaged radiology CAC members for each state. If you are interested in influencing payment policy, please reach out to Alicia Blakey,, or myself to get involved.

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