Is Insurers' Opposition to CAC Scans Softening? | MedPage Today about:reader?url=https%3A%2F%2Fwww.medpagetoday.com%2Fo...

medpagetoday.com

Is Insurers' Opposition to CAC Scans

Softening?
Anthony Pearson, MD

4-5 minutes

Opinion > Skeptical Cardiologist

— The Skeptical Cardiologist explains how one

patient got it covered

by January 10, 2020

Unless you live in Texas, you will have to pay out of pocket for a
coronary artery calcium (CAC) scanopens in a new tab or window.
Insurers and Medicare won't pay a dime for this simple test that
progressive preventive cardiologists and primary care docs rely on
to better determine who is at risk for heart attacks and sudden
death.

But, as we enter 2020, perhaps this failure to cover our best tool to
detect subclinical atherosclerosis can be reversed. To my surprise,
earlier this week, a patient of mine revealed to me that
UnitedHealthcare had reimbursed him for the CAC scan he had
done earlier in 2019.

It wasn't easy or straightforward, but his process may work for

others. I asked him to email me the letter he sent that resulted in

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coverage, which I have copied below:

As discussed in your office today, I was able to get my insurance

company (UnitedHealthcare) to reimburse me from the Cardiac
Calcium Scoring costs of $125 after filing an appeal through my
former employer. Below, as requested, is the simple write up I
provided to them.

I visited a cardiologist (Dr. Anthony Pearson) in May 2019

regarding heart palpitations I had with increasing frequency. He
performed a variety of diagnostic tests (blood work, Holter monitor,
echo stress test), which were all covered by UHC. Because these
tests did not show any issues, he suggested I have a Cardiac
Calcium Scoring Test, which I completed on May 24, 2019. The
test showed that I had serious coronary artery disease (score of
over 800), which caused the cardiologist to prescribe a daily baby
aspirin and a statin medicine (also covered by UHC). While I was
told that the Cardiac Calcium Scoring Test cost is not covered by
insurance, this is the one and only test that indicated I was at a
severe risk for a coronary artery event (significant or total
blockage) and, per the cardiologist, may have saved my life or
perhaps avoided an unexpected significant cost (e.g. bypass
surgery) by catching the issue early.

To recap, St. Luke's Hospital did not submit a claim for the $125
cost of the Cardiac Calcium Scoring Test because they said no
insurance company pays for this test. This test was ordered by my
cardiologist, Dr. Anthony Pearson, and was performed at St.
Luke's Hospital in St. Louis. I am requesting reimbursement for the
cost of this test for the reasons stated above.

The UnitedHealthcare explanation of benefits contained this claims

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summary:

It would appear the mighty wall that insurers and the Centers for
Medicare and Medicaid Services have put up against paying for
CAC scans is crumbling and can be breached.

I highly recommend all patients who have gotten an appropriately-

ordered CAC scan go through this process with their insurers to
attempt to obtain reimbursement.

Anthony Pearson, MDopens in a new tab or window, is a private

practice noninvasive cardiologist and medical director of
echocardiography at St. Luke's Hospital in St. Louis. He blogs on
nutrition, cardiac testing, quackery, and other things worthy of
skepticism at The Skeptical Cardiologistopens in a new tab or
window, where a version of this post first appeared.

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