Partial Victory as MAC Issues Local Coverage Determination Expanding Access to CT Perfusion Analysis

Palmetto GBA, one of the seven Medicare Administrative Contractors (MACs) assigned to process Medicare Part A and Part B medical claims for Medicare Fee-For-Service (FFS) beneficiaries released a final local coverage decision (LCD) and billing and coding article for Computed Tomography Cerebral Perfusion Analysis (CTP) 0042T effective June 2. This policy will only be effective within Palmetto GBA’s jurisdictions servicing Alabama, Georgia, North Carolina, Tennessee, South Carolina, Virginia, and West Virginia.

The American College of Radiology® (ACR®) encourages radiologists in Palmetto GBA’s jurisdictions to access the latest coverage documents now, as physicians will be reimbursed for the CT Perfusion studies that include signs and symptoms for stroke patients even without positive findings. MACs consistently denied coverage for CTP in cases where patients present with stroke-like symptoms but are later found to be negative for CT perfusion abnormalities consistent with a large vessel occlusion on imaging.

The ACR Contractor Advisory Committee (CAC) Network members and MSN Healthcare Solutions began tracking updates to this coverage policy in September 2022, and led efforts to expand access and availability of this test to Medicare beneficiaries. MSN Healthcare Solutions initiated a dialogue with each Medicare MAC, urging them to reconsider their stance and include stroke signs and symptoms as a valid indication for medical necessity.

MSN and ACR CAC Network local advocacy efforts and follow-up on an LCD reconsideration request to Palmetto GBA have led to the addition of 53 ICD -10 CM (International Classification of Diseases, Tenth Revision, Clinical Modification) diagnosis codes that support medical necessity to the existing billing and coding article. The new LCD considers many of the presenting signs and symptoms inherent in the clinical decision-making process for this study to be covered.

The College continues to review the CT Perfusion policies for the other MACs and work to expand these revisions from coast to coast. If you or your practice regularly perform this procedure and would like to advocate for similar policies to be adopted, contact Alicia Blakey, ACR Principal Economic Analyst.

If you have questions or would like more information about local coverage policies and activities, visit the ACR CAC website, or contact Alicia Blakey.