A Call for CT Colonography Reimbursement

Computed tomography colonography (CTC) screening for colorectal cancer is less invasive, less costly, and has a better safety profile than optical colonoscopies (OCs), but is still not fully endorsed or reimbursed across the country. As a result, CTCs are not as widely used as they could be, according to Judy Yee, MD, who coauthored an article on the challenges of CT colonography reimbursement.

Diagnostic Imaging spoke with Yee, professor and vice chair in the Department of Radiology and Biomedical Imaging University of California, San Francisco and Chief of Radiology, SF VA Medical Center, about the long pursuit for CTC reimbursement.

What drives your interest behind supporting CT colonography and its reimbursement by insurance?

I am currently chair of the Colon Cancer Committee for the American College of Radiology. We’ve been working very hard over the past several years since Medicare decided not to support national reimbursement for screening CTC to obtain what is necessary for reimbursement. In the article we wrote, we summarize the newest evidence that has appeared in the literature and that addresses some of the concerns raised by the Centers for Medicare and Medicaid Services (CMS) and the U.S. Preventative Services Task Force (USPSTF).

Some physicians have expressed concern that CTCs can’t be as effective as OCs, particularly if something has been detected, such as a polyp, and physicians need to go in to remove it. Has this thinking changed?

I think there is evidence, and the ACR practice guidelines have always stressed this, that the incidence of malignancy in diminutive polyp, that is less than five millimeter, is extremely low and should not be a factor in considering reimbursement.

We do know that CTC is not as effectives as OC in detecting diminutive lesions, however that should not make a significant clinical difference. In fact, the goal should be to bring in more patients for screening because CTC has shown excellent sensitivity and specificity for clinically significant polyps. These would be more likely to be sent on to OC.

The cleansing protocol isn’t as rigorous for CTC, so if a patient needs to undergo one based on what is seen by CTC, can this less rigorous preparation be an issue?

Potentially, yes it could be. But the colon is clean enough that the gastroenterologist can use different maneuvers that would clear off the portion of the wall of the questionable area. It is still possible. The bowel cleansing is still rigorous enough for same day colonoscopy.

Do studies show that patients prefer CTCs over OTs?

[[{"type":"media","view_mode":"media_crop","fid":"21674","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_5672759256925","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1524","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; margin: 5px; border-width: 0px; border-style: solid;","title":"Judy Yee, MD","typeof":"foaf:Image"}}]]I think it depends on how the study is done and how the patients are asked the question. There are many studies that do show that CTC is preferred because it is less invasive and you don’t need sedation. You don’t need to take off a whole day of work. After a colonoscopy, you can’t drive yourself home because of the sedation, so someone else has to take the day to drive you home. You can return to your normal daily activities immediately after the CTC.

There is also the safety profile in terms of perforation. CT colonoscopy has a perforation rate that is 20 times less than optical colonoscopy.

Given all this information, why do you think there remains a reluctance to reimburse for CTC screening?

I think that back in 2008, CTC was caught in a perfect storm of the recession. And, I think this was also around the time that concerns were being raised about radiation doses in general - not specifically regarding CTC. I think we were entering a period where there was a sense that we needed more information before endorsing screening tests in general.

The reimbursement issue is being revisited now and this will continue through 2014. There are already many large private insurance companies that do reimburse for screening CTC. But, it’s not very obvious to all physicians. For example, they may not even know that CTC is already reimbursable by companies like United Health Care, Cigna, UniCare, and a lot of Blue Cross/Blue Shield coverages. That information needs to get out there by the payers.

What is the most important point you would like to get out regarding your article and the issue of reimbursement?

I think that CT colonography is not going away. It’s clearly a validated, useful test for both screening and for diagnosis of colorectal polyps and cancer, and that this is a complimentary tool that needs to be reimbursed to help save lives.

Colorectal cancer, unlike a lot of other malignancies that you screen for, is really to detect the precursor lesion so that you can prevent colorectal cancer from ever developing. Our goal is not so much to find the cancer, although we do find that as well, but it is to find that precursor polyp and to remove it. Then you can prevent the cancer from ever developing.

Unlike some other cancer screening tests, when you screen, you find the cancer. Here were can find the precursor. That’s a lot of health dollars that can be saved in terms of not only lives saved, but treatment cost in terms of expensive chemotherapy and surgery.

[[{"type":"media","view_mode":"media_crop","fid":"21675","attributes":{"alt":"","class":"media-image","id":"media_crop_8141099495867","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1525","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":" ","typeof":"foaf:Image"}}]]