CMS has denied the College’s most recent request to re-open consideration for national Medicare coverage for CT colonography (CTC) as a screening study for colorectal cancer (CRC). The response comes after several prior denials and despite endorsements from the U.S. Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS). ACR Colon Cancer Committee Chair Judy Yee, MD, FACR, who led the ACR’s request for approval, is understandably baffled. “CTC has been rigorously validated for many years,” says Yee. “It makes no sense that all other validated CRC screening tests are approved by CMS except CTC.”
Beginning in 2009, the ACR has repeatedly requested that the CMS Coverage and Analysis Group include CTC as a covered exam for colorectal cancer screening for Medicare beneficiaries. “At that time, CMS conducted a national policy analysis on CTC for screening and concluded that the evidence was insufficient to support coverage,” says Kathryn Keysor, ACR’s senior director of economic policy. “The group determined that the data were not generalizable to the Medicare population. In addition, there were concerns with radiation dose and extracolonic findings.” Since then, several studies have been published on CTC in the Medicare population, including an analysis of the ACR Imaging Network (ACRIN) trial data, as well as studies on radiation dose and extracolonic findings. And yet, CMS has rejected the College’s requests to re-review the non-coverage decision.
“Each time coverage is denied, CMS tells us that the evidence presented is insufficient to change the coverage decision,” says Yee. “Initially, they wanted more data on the implications of extracolonic findings, radiation dose, and the performance of CTC in senior cohorts. We feel we have addressed these issues with peer-reviewed publications; in fact, there is more evidence validating CTC compared to other CMS-reimbursed CRC tests.”
CMS often sets the standard for coverage; once procedures are approved, insurance companies frequently follow suit. Not so for CTC. “In this case, the largest private payers already reimburse for
screening CTC, which is unknown to a lot of people,” says Yee. “The fact that a federally funded organization like CMS does not support a valid, endorsed option from another federal body like
the USPSTF as well as the ACS is really damaging to people in this country.”
Each time coverage is denied, CMS tells us that the evidence presented is insufficient to chance the coverage decision.
Like colonoscopy, CTC can detect both the precursor polyp and the cancer itself in the whole colon. However, several studies show that CTC is more accepted by people of color, notes Yee.1 “CTC can be used in underserved populations to help improve healthcare disparities,” she says. Unfortunately, continued denials also mean delayed care for some patients due to backlogs in colonoscopy availability that existed before the COVID-19 pandemic and were subsequently worsened by the crisis. This delay in screening is associated with increased colorectal cancer rates and increased morbidity and mortality, Yee adds.
Yee and her colleagues on the ACR Colon Cancer Committee have published landmark papers on the topic and continue to provide data to justify coverage for screening CTC. “We have met with CMS and USPSTF several times,” says Yee. “We provided a Congressional briefing in 2018 to advocate for and educate members of Congress and staff about CTC. We develop all responses to these organizations addressing any questions and concerns regarding CTC. We also lead webinars to educate radiologists, referrers, and others.”
Fellow radiologists can share their support for CTC coverage by advocating at state and federal levels. All of the ACR’s colon cancer screening resources, including webinars and articles, are available here. “At the ACR meeting several years ago we had great participation during Hill Day,” Yee says. “Additionally, we strongly encourage all sites performing CTC to register their location on the ACR My CT Colonography locator website. Registration is simple, quick, and at no cost and will help patients and referrers to easily find your site.”
In addition to the Committee’s work, patient advocacy groups have backed the ACR’s request to CMS to review its decision. The Black Women’s Health Imperative, the Colorectal Cancer Alliance,
the Colon Cancer Coalition, the Prevent Cancer Foundation, and the Blue Hat Foundation all co-signed the ACR’s most recent request to CMS. “Patient advocacy groups are extremely important,” says Yee. “After all, their constituents are the patients we are advocating for, and they are the ones who have experienced firsthand the terrible consequences of having colorectal cancer.”