Medicare decides not to pay for virtual colonoscopies

The Colon Cancer Alliance is extremely disappointed that the Center for Medicaid Services (CMS) opted to deny coverage for CT Colonography (CTC), commonly known as virtual colonoscopy. CTC has proven to be a very effective method of early detection and prevention of colon cancer. This decision now leaves millions of older Americans exposed to a higher risk of colon cancer. It also exacerbates an unequal standard of care between Medicare beneficiaries, who do not have the choice to undergo a virtual colonoscopy, and those with private insurance who do. America’s seniors deserve better. They deserve the same access to colorectal screening tools as Americans fortunate enough to have private health insurance.

“About 150,000 Americans are diagnosed with colorectal cancer every year, the majority of them Medicare aged. It’s the third highest cause of cancer in the country and the second leading cause of cancer deaths. Caught early, it has cure rates of more than 90 percent and through proper screening can be avoided entirely.

Making virtual colonoscopy more easily available as an alternative to standard colonoscopy would be an important tool that ultimately motivates more Americans 50-plus (45 in certain minorities) to undergo a screening they might otherwise skip. Improved access to virtual colonoscopy has the potential to increase screening rates enough to save both lives and money.

It’s the right of an American senior to screen for colon cancer using any form of medically accepted, effective procedure they and their doctor choose. This is especially true in the case of virtual colonoscopy, where it’s cheaper, less invasive and equally medically effective as standard colonoscopy. By denying coverage for virtual colonoscopy, CMS is sending the signal that increased screening amongst the Medicare beneficiary population is unimportant. The Colon Cancer Alliance and its members strongly disagree with this sentiment. Medicare beneficiaries deserve access to virtual colonoscopies. We urge CMS to immediately re-open a coverage decision so it can consider additional data pertaining to the age 65 and above population.

Andrew Spiegel
Chief Executive Officer
Colon Cancer Alliance
(202) 434-8996 office
aspiegel@ccalliance.org
www.ccalliance.org

It seems the recent decision by CMS to deny reimbursement of CT Colonoscopy for lack of evidence did not look at “ALL” of the facts, evidence, and costs related to colon cancer. It is easy to over look some of the data out there and then claim lack of evidence.

Below are some pertinent facts relating to colon cancer that somehow did not appear in the 30 page decision by CMS to deny coverage:

Fact: 50,000 people are dying from colon cancer each year in the US.
Fact: Another 150,000 new cases are being reported each year.
Fact: Sadly, all of this is from a cancer that is more than 90% preventable by early screening.
Fact: CMS and other healthcare providers are paying billions of dollars for the treatment of colon cancer each year
Fact: Optical colonoscopy is the only procedure where polyps (that can become a cancer) can be removed.
Fact: Any screening method is only effective when it is used.
Fact: More than 50% of the screening age population is simply not getting screened using the “optical colonoscopy”.
Fact: There is evidence that optical colonoscopy for screening is underutilized by CMS recipients – published papers
Fact: The GI community currently does not have the capacity to meet the needs of the screening population (generally those over the age of 50).
Fact: CMS pays for screening tests with lower sensitivity, such as the barium enema or flexible sigmoidoscopy. The flexible sigmoidoscopy is equated to having a mammography test of one breast.
Fact: There is evidence that CTC is cost-effective for screening
Fact: CTC screening programs over the past 5 years have shown as much as 70% increase in colon cancer screening compliance

For those who use the argument that if you have a polyp you need to go for an optical colonoscopy to get it removed anyway: Yes, that is true for medically significant polyps. However, the fact remains that if people are not getting screened (by any method) then no one will find and remove the polyps that could prevent colon cancer to begin with.

On the topic of polyp removal, only 10%-20% of the general screening age population need polyps removed. However, without effective screening no one will know who falls into that 10%- 20% group.

CT Colonoscopy offers a proven, economical, and viable option for colon cancer screening. There is plenty of evidence in published clinical trials over the past 10 years to show that CTC is as good as OC for detecting clinically significant polyps. The commercial health insurance carriers see the light and are beginning to reimburse for CTC screening.

The problem is that CMS cites that all this supporting data is on patients with an average age of 58, not 65 (Medicare age). If 10-20% of those being screened (at 58) have polyps that can turn into cancer, imagine how many 65 and over will have polyps that turn into cancer because they are NOT screened! Did CMS make a truly medical decision or a financial one by taking the easy way? Reimbursement for CT Colonoscopy now may increase some Medicare costs in the short-term, but would save enormous amounts later by significantly reducing the cost of treating colon cancer. Is CMS “passing the buck” to control their spending now vs. investing in the future?

On one hand, our government talks about preventative health care, on the other, we are paying billions of dollars for treating colon cancer now but do nothing to improve prevention of the disease even when it is available. The reality is that optical colonoscopy is not working as it should for colon cancer prevention. Should we ignore this problem by choosing to accept it, or do something about it in a proactive manner? Maintaining status quo, as CMS has done, is really not the option to choose.