SCAI position statement concerning coverage policies for percutaneous coronary interventions based on the appropriate use criteria Article Swipe

The Appropriate Use Criteria for Coronary Revascularization (AUC) were created in 2009 1, 2 and updated in 2012 3 through a rigorous process and then endorsed by major cardiovascular societies. The AUC were developed from a limited set of carefully defined clinical scenarios; they were not envisioned as covering every clinical situation, but rather, descriptive of common ones. The AUC have become widely accepted as one component of decision making, along with published clinical guidelines, physician experience, and patient preference. Regrettably, they have also come to be seen as an instrument for directing insurance coverage policy. While the original AUC document 1, 2 noted “it is hoped that payors would use these criteria as the basis for the development of rational payment management strategies to ensure that their members receive necessary, beneficial, and cost-effective cardiovascular care,” denial of coverage in individual cases based on the AUC category was not an intended purpose. In addition, the 2012 update 3 explicitly states that some inappropriate indications should be reimbursed and that the uncertain rating does not justify denial of payment. Policymakers and payors must be good stewards of the insurance system, and are increasingly challenged to find innovative ways to curb expenditures. Thus, it is tempting for them to view the AUC as a professionally mandated tool for “cost-cutting” 4. SCAI and its members recognize the essential need for prudent cost management but are very concerned with this unanticipated and detrimental approach to coverage determinations. This SCAI position statement addresses our members' apprehension that the application of AUC by many payors without consideration of other features of the patient's medical condition is far beyond the intent of the AUC, and has the potential for significant unintended consequences for patients and hospitals. Accordingly, this position statement outlines SCAI's recommendations regarding the use of AUC in making coverage determinations for percutaneous coronary intervention (PCI) procedures. SCAI and its members have several concerns. First, although the AUC may be useful in helping to guide insurance coverage, the AUC classification should not be the solitary reason used to deny coverage. Such unjustifiable application of AUC might be harmful to patients, and could be contrary to shared decision-making. For example, it is conceivable that a payor may decide that only those procedures classified by AUC criteria as “appropriate” will be covered; yet unquestionably, that is not the intent of the AUC. Second, individual third party payors should not develop their own “appropriateness criteria” for insurance coverage that are not based on guidelines and that are not subject to peer review. Finally, coverage determinations should take into account reasonable decisions by health care providers who are following accepted clinical guidelines. Outside expert review should be available prior to any determination of denial of coverage. These concerns are not unique to interventional cardiology 5. When decisions for coverage of medical care are based strictly on categories or algorithms, opportunities for physician–patient interaction that lead to shared decision-making and patient-centered care are limited. In particular, the weight of patient preference would be at the discretion of payors. Exclusions based on inflexible adherence to AUC that were never intended to be rigid categorizations may harm patients. We are concerned that lower income and less well-insured patients may ultimately receive disproportionately reduced access to necessary cardiovascular care, because they are less likely to have advocates willing to appeal coverage determinations. It is sensible for payors to consider AUC as one of several elements in pre-authorization of treatment options, and to encourage the use of AUC at the point of care 6. For stable patients for whom a procedure is rated as “rarely appropriate”, it is reasonable to expect physicians to document the medical justification for that patient and their particular situation. It is rational to require physicians to document the process of shared decision-making and patient preference for situations where PCI “may be appropriate”. However, denial of coverage based solely on a categorization of “rarely appropriate” or “may be appropriate” without a process that involves review by experts and consideration of patient preference and detailed condition may not be in the patients' best interest and therefore is not acceptable. Physicians must be able to use their experience and best judgment to interpret clinical guidelines and to apply them to individual patients, particularly when there is no definite right or wrong. In summary, SCAI is concerned that implementation of policies of coverage for PCI based solely on AUC nomenclature, or a non-peer reviewed set of arbitrary criteria, either prospectively or retrospectively, could compromise care of patients. SCAI is driven by our vision and mission to transform the treatment of expensive cardiovascular diseases by providing innovative solutions that improve care and reduce the economic burden of costly diseases on the healthcare system overall. SCAI is committed to seeking effective strategies to promote proper utilization of effective procedures while minimizing both overuse and underuse of PCI, and to assure patient access to optimal quality cardiovascular care.