title: The disconnect between the guidelines, the appropriate use criteria, and reimbursement coverage decisions: the ultimate dilemma.
abstract: Recently, the American College of Cardiology Foundation in collaboration with the Heart Rhythm Society published appropriate use criteria (AUC) for implantable cardioverter-defibrillators and cardiac resynchronization therapy. These criteria were developed to critically review clinical situations that may warrant implantation of an implantable cardioverter-defibrillator or cardiac resynchronization therapy device, and were based on a synthesis of practice guidelines and practical experience from a diverse group of clinicians. When the AUC was drafted, the writing committee recognized that some of the scenarios that were deemed "appropriate" or "may be appropriate" were discordant with the clinical requirements of many payers, including the Medicare National Coverage Determination (NCD). To charge Medicare for a procedure that is not covered by the NCD may be construed as fraud. Discordance between the guidelines, the AUC, and the NCD places clinicians in the difficult dilemma of trying to do the "right thing" for their patients, while recognizing that the "right thing" may not be covered by the payer or insurer. This commentary addresses these issues. Options for reconciling this disconnect are discussed, and recommendations to help clinicians provide the best care for their patients are offered.
authors.affiliation: St. Vincent Medical Group, Indianapolis, Indiana. Electronic address: rifogel@aol.com.
authors.forename: Richard I
authors.initials: RI
authors.lastname: Fogel
authors.affiliation: Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Andrew E
authors.initials: AE
authors.lastname: Epstein
authors.affiliation: Tufts Medical Center, Boston, Massachusetts.
authors.forename: N A
authors.initials: NA
authors.lastname: Mark Estes
authors.affiliation: Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio.
authors.forename: Bruce D
authors.initials: BD
authors.lastname: Lindsay
authors.affiliation: Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia.
authors.forename: John P
authors.initials: JP
authors.lastname: DiMarco
authors.affiliation: Novant Heart and Vascular Institute, Charlotte, North Carolina.
authors.forename: Mark S
authors.initials: MS
authors.lastname: Kremers
authors.affiliation: Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Suraj
authors.initials: S
authors.lastname: Kapa
authors.affiliation: Department of Medicine & the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California.
authors.forename: Ralph G
authors.initials: RG
authors.lastname: Brindis
authors.affiliation: Cooper University Hospital, Camden, New Jersey.
authors.forename: Andrea M
authors.initials: AM
authors.lastname: Russo
mesh_terms: D000572:American Heart Association; D058406:Cardiac Resynchronization Therapy / Q000191:economics* / Q000592:standards*; D002309:Cardiology / Q000191:economics*; D002318:Cardiovascular Diseases / Q000191:economics / Q000628:therapy*; D019983:Guideline Adherence; D006801:Humans; D012051:Reimbursement Mechanisms / Q000592:standards*; D014481:United States
keywords: ACC; AHA; AUC; American College of Cardiology; American Heart Association; Appropriate Use Criteria; CRT; DOJ; Department of Justice; HRS; Heart Rhythm Society; ICD; NCD; National Coverage Determination; appropriate use criteria; cardiac resynchronization therapy; guidelines; implantable cardioverter-defibrillator