5 of 7 Medicare Administrative Contractors approve payment for imaging AI software
Five of seven Medicare Administrative Contractors have now approved payment for a CT imaging artificial intelligence software.
The coverage determination pertains to AI-enabled, CT-based heart disease assessment. Providers have the potential to earn Medicare payment if the software is deployed in medically appropriate scenarios. These include when an individual is eligible for coronary CT angiography, presents with acute chest pain, and has no known heart disease.
Vendors offering the AI software include Cleerly, HeartFlow and Elucid.
“Coronary artery disease is the underlying cause of about 50% of deaths,” Ron Blankstein, MD, director of cardiac CT at Brigham and Women’s Hospital in Boston, said in an Oct. 24 announcement from HeartFlow. “The earlier we can diagnose and use tools to provide accurate plaque quantification, the earlier we can provide tailored treatments, potentially improving outcomes for patients,” he added later.
Coverage of the AI software will begin Nov. 24 for Medicare Administrative Contractors including WPS, CGS, Palmetto and NGS. The fifth MAC, Noridian, will start Dec. 8.
Reimbursement extends to Medicare beneficiaries with acute or stable chest pain and less than 70% stenosis found on coronary CT angiography (CCTA). The Centers for Medicare and Medicaid Services previously established a national payment amount of $950 when using this AI software in hospitals. The two MACs still refusing to reimburse for coronary CT AI will review payment requests on a case-by-case basis, California-based HeartFlow noted.
Cleerly also praised the CMS payment approval in a statement shared with Radiology Business sister site Cardiovascular Business.
“This decision means that 60.6 million Medicare beneficiaries and 33 million Medicare Advantage beneficiaries—an incredible 93.6 million total individuals—will now have access to noninvasive CT imaging,” James K. Min, MD, founder and CEO of Denver-based Cleerly, said in a statement. “This advancement is a monumental step forward in our mission to eliminate heart attacks and establish a new standard of care for heart disease.”
The American College of Radiology gave further details about the AI software when advocating for its coverage in June. Supervision, interpretation and reporting must be performed by a physician with advanced training in CCTA and related radiological exams. The AI tool does not replace the assessment of a qualified provider, ACR emphasized.
In a separate announcement, Boston-based Elucid noted that 70% of Medicare beneficiaries now have access to CCTA AI analysis after MAC Noridian’s decision. Cardiovascular disease is the most common cause of death and disability globally, driven by heart attack and stroke caused by plaque buildup and rupturing in the arteries. The cost of CVD in the U.S. is $219 billion per year, Elucid said Friday.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.