Major Alabama payer opts to maintain reimbursement for cone beam CT scans

May 2019 – Vol. 38, No. 4

This major advocacy win is a tribute to the persistence and collaboration among all the affected stakeholders.

In December 2017, one of Alabama’s largest health insurance carriers announced a drastic reimbursement reduction for cone beam computed tomography (CT) scans, effective January 2018. Coordinated advocacy efforts occurring over the course of the next 18 months would eventually result in a significant win for practicing otolaryngology- head and neck surgeons in the state of Alabama. The resultant policy change highlights the importance of medical society collaboration, physician expert input and coordination, and an overall need for a multipronged approach in order to combat a detrimental coverage policy.

When the Alabama payer announced a planned payment reduction for cone beam CT (CBCT) of the paranasal sinus from $161 (Preferred Medical Doctor, PMD, Network) to $61.05, a 62% reduction, Scott Elledge, MD, was one of the first in the state to speak out against this flawed policy. Dr. Elledge began appealing this policy by working locally with other members of the Alabama Society of Otolaryngology, Head & Neck Surgery (ALASOHN). ALASOHN enlisted the services of a prominent Alabama attorney and joined forces with representatives from Xoran, a manufacturer of cone beam CT equipment. The parties were determined to pursue dispute resolution, arbitration, and even possibly litigation in order to overturn this coverage challenge. In continued pursuit of a remedy, Dr. Elledge then contacted the AAO-HNS to request the support of the Academy.

In May 2018, the AAO-HNS sent a comment letter to the Medical Director and Vice President of the Health Network Services, outlining the use of CPT 70485 (Computed tomography, maxillofacial area, without contrast material) as the appropriate code to describe CBCT scans (instead of CPT 75699 with modifier 52 as recommended by the payer). The Academy letter detailed CMS’ coverage criteria for CT scans. Further, the Academy refuted the Alabama payer’s claims that CBCT was of “lesser quality” compared to other imaging scans, addressed the accreditation requirements for CBCT scanners, and concluded that the CBCT scanner contributed to cost-savings for both the patient and the payer. Despite a comment letter provided by the national voice of otolaryngology, the payer refused to reconsider its policy without direct CMS guidelines on CBCTs.

Under the leadership of James C. Denneny III, MD, AAO-HNS CEO and Executive Vice President, Academy staff conducted a meeting in August 2018 with Kate Goodrich, MD, Chief Medical Officer at CMS, to discuss Medicare regulatory issues impacting the specialty. During this meeting, the AAO-HNS requested the necessary documentation to contest the Alabama payer’s misguided policy. Following the meeting, and after continued outreach to Dr. Goodrich and her staff, the Academy secured the necessary documentation, which eventually led to the Alabama payer to reverse their cone beam policy and maintain the appropriate $161 full payment for cone beam CT scans.

This major advocacy win is a tribute to the persistence and collaboration among all the affected stakeholders. The Academy relies on its membership to identify local and national coverage deficiencies and strives to combat coverage denials to allow members to provide the best care for their patients. In order to report a national coverage gap or local denial in your state, email healthpolicy@entnet.org.