XXXXXX XX , 2014

Name

Title

Company

Address

Address

Dear Dr. XXXX,

I am writing to express my profound concerns regarding your prior-authorization policy formyocardial perfusion imaging (MPI) studies developed by your contracted radiology benefits management (RBM) firm, [RBM name] , and implemented by[Health Plan Name]. Specifically, I am troubled that while these imaging guidelines purport to rely on theAppropriate Use Criteria developed by the ACC and ASNC, the [Health Plan Name]policy instead manipulates the Appropriate Use Criteria torecommend one non-invasive diagnostic imaging modality over another.

In particular, I am concerned that this policy suggests that stress echocardiography can or should be substituted for myocardial perfusion imaging in most clinical situations. This incorrectassumption by [RBM] and[Health Plan Name] represents an uninformed assessment of our Appropriate Use Criteria and confusesthe proper application of these two important advanced diagnostic imaging tools, both of which are separately and distinctly useful in the evaluation of patients with suspected or known coronary artery disease. The perception that MPI studies and stress echo studies are interchangeable is clearly misguided, as the decision regarding which test to utilize for a given patient takes into account many factors specific to that patient. For example, a physician would consider the patient’s physical characteristics and demographics, as well as clinical variables, provider experience and modalities available for their use when selecting the appropriate test.Thus, it is critical to ensuring quality care for patients that the physician is the one to consider and weigh these factors in deciding which treatment is most appropriate for the patient..

In addition, I am concerned that [RBM Name] may not be relying on the most up to date or relevantAppropriate Use Criteria in developing this policy. Our Societies strongly urge [RBM Name] to correct this documentation and to employ the most recent Appropriate Use Criteria developed by the Societies which was updated in 2009.[1]In addition, the ACC and American Heart Association Appropriate Use Criteria and Practice Guidelines, are not intended to recommend a “most appropriate” test. Rather, the guidelines discuss when a given modality is appropriate based on specific indications presented in the patient. Therefore, it is entirely inappropriate for payers or RBMs to utilize the guidelines as the basis for steering patient testing from one imaging modality to another under the guise of the implementation of ACC/ASNC Appropriate Use Criteria.

In addition, our Societies remain concerned with any use of prior notification/ authorization programs for diagnostic imaging tests. This concern stems from the large administrative burden they place on physician practices, particularly small practices, whichintrudes on the physician-patient relationship. Often, these onerous programs force offices to hire additional employees just to process requests for studies with insurers. These are costs that are simply not sustainable by many practices who are already struggling to cope with drastic reductions to reimbursement for MPI studies in 2010.

I would welcome the opportunity to discuss other potential solutions for addressing inappropriate imaging as well as ways to improve cardiovascular care through the appropriate use of nuclear cardiology studies. It would be our pleasure to meet with your organizations to discuss this policy in further detail at your earliest convenience. Should you have any questions or concerns regarding my comments, feel free to contactme at [PRACTICE OR HOSPITAL NAME AND CONTACT INFORMATION]. You may also contact the American Society of Nuclear Cardiology, Georgia Hearn, Senior Specialist, Regulatory Affairs at 301-215-7575 ext. 207.

Sincerely,

[1]ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM: 2009Appropriate Use Criteria for Cardiac Radionuclide Imaging, JACC, Volume 53, No. 23, 2009. USE CRITERIACardiacRadionuclideImaging2009.pdf