Medicare Coverage of Screening CT Colonography

The ACR and its partners have submitted solid recommendations. Now we wait for the results.blueribbon

March 2015

March is Colon Cancer Awareness Month, and I cannot think of a better time to reengage policy-makers about the value of CT colonography

(CTC) for colon cancer screening. As many of you may recall, the battle to convince CMS that screening CTC should be a covered benefit for Medicare beneficiaries has been difficult. In 2008, a multi-society task force including the American Cancer Society concluded that screening for colon polyps using CTC was an acceptable means of early colon cancer detection.¹ And while some private payers cover CTC for colon cancer screening, CMS still does not provide Medicare coverage. Considering the peak incidence for colon cancer is between 60 and 79 years old, Medicare remains the most important payer to provide this benefit.
Colon cancer is our nation's third leading cause of death, with more than 140,000 new cases reported each year. The Centers for Disease Control and Prevention estimates that up to 30,000 colorectal cancer deaths each year could be prevented if all those age 50 and older were screened regularly. And while optical colonoscopy (OC) is a covered benefit, it is estimated that up to half of those who should be screened for colorectal cancer are not. Although there are many barriers to screening for colorectal cancer, the requirement for conscious sedation and the small risk of perforation and other complications may discourage many people from undergoing colonoscopy.
In 2008, researchers reported the results of ACRIN®'s National CT Colonography Trial, which found equal rates of detection for CTC and OC for colorectal adenomas and cancers greater than 10 mm in diameter. These data, along with work from the Department of Defense, were used to engage CMS in a national coverage determination for CTC. Unfortunately, in 2009, CMS somehow concluded that the evidence did not support using CTC as an alternate for OC in screening for colorectal carcinoma. One of the erroneous conclusions of the coverage determination group at CMS was that the data from the trials were not "generalizable to the Medicare population."² And, despite their apparent but unstated concern about the cost of a new screening modality, physicians affiliated with CMS wrote an editorial in the New England Journal of Medicine proclaiming the "landmark decision" an "unprecedented endorsement of evidence-based medicine."³ I wonder how many lives might have been saved if coverage for screening CTC had been approved five years ago.
Since that time, the ACRIN researchers have shown that when the colonography data were reanalyzed for the Medicare group alone, the same results were achieved.4 Additionally, studies found that CTC using low-dose CT protocols is unlikely to increase cancer risk and that CTC is much less likely to be associated with significant complications than OC. CTC has also been shown to be more cost-effective than OC, and, in general, only 8 to 12 percent of patients undergoing CTC will require follow-up OC and biopsy. While detection of extracolonic findings continues to be debated, in truth, the vast majority of these findings will not need further workup. Some view the workup of incidental findings as an added cost, but for others the ability to detect unsuspected life-threatening conditions is a benefit.
As more evidence has become available about the value of CTC in all segments of the population at risk for colon cancer, the U.S. Preventive Services Task Force (USPSTF) announced in January 2014 that it would reevaluate colon cancer screening tests, including CTC. Based on the Affordable Care Act, in order for CMS to cover a screening test, the examination must have a favorable rating from the USPSTF. We submitted comments to the USPSTF more than a year ago, but we have not seen a work plan for CTC.
In the meantime, in August 2014, CMS approved coverage of the Cologuard stool DNA test for detection of colon cancer. We hope this may signal the expansion of screening options for detection of colon cancer. To hasten the process, we will use our contacts in the legislature to push the USPSTF and CMS to make expeditious decisions in support of our patients' health. Medicare got it right for lung cancer screening. Let's hope it will do the same for CT colonography — and soon.

By Bibb Allen Jr., MD, FACR, Chair

1. Levin B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin 2008;58:130–160.
2. Centers for Medicare and Medicaid Services. National coverage determination for colorectal cancer screening tests. Available at Accessed Jan. 12, 2015.
3. Dhruva SS, Phurrough SE, Salive ME, Redberg RF. CMS's landmark decision on CT colonography—examining the relevant data. N Engl J Med 2009;360:2699–2701.
4. Johnson CD, et al. The National CT Colonography Trial: assessment of accuracy in participants 65 years of age and older. Radiology 2012;263(2):401–408.

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