Radiologists to Cigna: Revise hospital-based imaging policy to avoid harming pediatric patients

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A new Cigna policy that limits coverage for hospital-based MRI and CT scans could have a "profoundly negative" effect on children and adolescents who require advanced outpatient imaging, radiologist groups wrote in a Nov. 24 letter to Cigna leaders.

Effective Aug. 1, Cigna stopped covering MRIs and CT scans performed in a hospital setting that don't meet new medical necessity requirements. Cigna told Becker's that the policy helps direct members "to a freestanding radiology center or other office-based setting when there is not a clinical reason for services to be performed at a more costly hospital setting while continuing to allow coverage for services to be performed at a hospital location when the customer's condition truly warrants that level of care."

One of the stipulations of the policy is that an imaging service in a hospital outpatient department may be considered medically unnecessary for patients who are 10 or older. In their letter to Cigna leaders, the American College of Radiology and the Society for Pediatric Radiology urged the insurer to revise this age to 19. UnitedHealthcare, which has its own hospital-based imaging policy, uses 19 as its age restriction, but another national insurer, Anthem, uses 10.

The radiologist groups said providers who aren't "as familiar with pediatric imaging findings may recommend more, potentially unnecessary/inappropriate follow-up imaging examinations. Additional imaging will not only increase healthcare cost but also will expose the pediatric patients to unnecessary studies and, in the case of CT scans, increased exposure to radiation." 

Becker's reached out to Cigna for comment on the recommendation. The insurer said it is "reviewing the matter and are actively engaged in conversations with ACR in consideration of their concerns. Any provider with a clinical concern about site of care can always request an exception to the policy, and the clinical appropriateness of the request will be reviewed."

 

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