CT Perfusion Policy Change: Palmetto GBA 

MSN noted a pattern of several Medicare Administrative Contractors (MACs) denying CT perfusion studies for patients experiencing stroke symptoms.  Near the end of 2022 and the MSN coding team began the challenging task of petitioning a change in medical policies.

Renee Engle, RCC, RCCIR, MSN-ARC, FRBMA explained, “Patients in the Palmetto GBA Medicare jurisdiction would present with stroke symptoms and physicians appropriately ordered a CT Cerebral Perfusion Analysis (0042T) to determine if the patient was experiencing a stroke. There is a narrow window of time for the effective treatment of stroke patients so prompt actions are critical.  The problem arose if the patient had a negative study even if stroke symptoms were evident.  This meant if the CT showed the patient didn’t have a stroke, the claim was denied as not medically necessary even if treatment decisions were made based on the results of the study, whether positive or negative.” 

She continued, “Each Medicare jurisdiction establishes policies through their Local Coverage Determinations (LCDs) and MSN began the slow process of influencing change by petitioning each Medicare MAC to allow the inclusion of stroke symptoms as an indication of medical necessity.  We had the support of key physicians among our client groups to provide the clinical argument and scientific evidence to argue for payment of CT Perfusion studies based on the analysis of stroke symptoms even when negative findings occurred.  It took research, ongoing communications and persistent follow-up but the Palmetto GBA modification was highly successful.”