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

Abstract

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 costeffective 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-