Radiology societies demand moratorium on enforcement of ‘concerning’ Medicare decision

Four radiology societies are pushing for a moratorium on enforcement of a coverage decision for a key interventional procedure. 

The American Society of Neuroradiology and others on Friday wrote to 3 of the 7 Medicare Administrative Contractors outlining their concerns. Their ire stems from the delivery of a minimally invasive procedure to relieve chronic lower back pain. 

MACs have issued coverage determinations claiming arthrodesis of the sacroiliac joint—which involves making a small incision to fuse two bones together—is not medically necessary. More specifically, the three MACs are refusing to cover these procedures when radiologists or other physicians do not use a screw or other implant to transfix the joint across the bone. Alternatively, some utilize grafts or other techniques to hold the bones together, but certain MACs have deemed this practice unreasonable or unnecessary.  

“We respectfully request a moratorium on the implementation of these [local coverage determinations] to facilitate this discussion while avoiding patient diversion to costly and less effective alternatives in the interim,” the neuroradiology society, American College of Radiology, Society of Interventional Radiology and the American Society of Spine Radiology wrote to the three MACs Feb. 21. “Namely, we wish to present further evidence with respect to the selection criteria for minimally invasive sacroiliac joint fusion without placement of a transfixation device.”

MACs making this unfavorable decision include the Celerian Group Company Administrators, Noridian Healthcare Solutions, and Palmetto GBA. In the coverage determinations, they noted that the field has developed new implant techniques designed to confer the benefits of permanent joint stabilization with a more “reasonable safety profile.” However, the radiology groups believe Medicare contractors are basing decisions around medical coding changes that have not yet been finalized and conversations that are still ongoing. Multiple specialty spine societies are seeking to alter related procedural billing codes, but these updates will not take effect until 2026. 

Further, radiologists believe modifications to medical terminology in the coverage documents are misguided. 

“We believe that this represents a misunderstanding by the MACs of the issues involved and provides additional justification for serious concern the MACs do not have a firm understanding of what they will and will not be covering,” the groups wrote. “We therefore recommend withdrawing this final [local coverage determination] prior to its effective date … to allow for further discussion with your experts, including the societies represented here and their [Current Procedural Terminology] advisors, who are integrally involved in the CPT code development process.”

They’re asking the three MACs to withdraw these determinations before April 17 when they’re slated to take effect. ASNR et al. are hoping to work with the three MACs to assess the evidence and update determinations to provide “safe, clinically effective, and cost-effective care to Medicare beneficiaries.” They also want a chance to address nuances around CPT codes 27278 and 27279 and related reporting requirements. 

“The ACR Contractor Advisory Committee Network representatives continue to monitor local coverage activities and address concerns that will adversely impact the interventional radiology community,” the college said in a news update published Friday.