The Medicare Appropriate Use Criteria Program: A Review of Recommendations for Testing in Coronary Artery Disease

Abstract

Background: Congress established the Appropriate Use Criteria (AUC) Program to reduce unnecessary advanced imaging studies. Organizations that wish to develop AUC can apply to the Centers for Medicare & Medicaid Services (CMS) to qualify as provider-led entities (PLEs) under this program. Variable methods, content, and formatting of PLE-generated AUC could lead to clinician uncertainty about whether an advanced imaging test is appropriate or not.

Purpose: To review AUC published by CMS-qualified PLEs focused on advanced imaging tests for coronary artery disease (CAD), a "priority clinical area" identified by CMS.

Data sources: Publicly available data from the worldwide web searched on 29 August 2022.

Study selection: Approved AUC with recommendations related to testing for CAD.

Data extraction: Manual review of published AUC by all authors.

Data synthesis: Among the 17 CMS-qualified PLEs, only 7 had published AUC related to CAD. Substantial variation in the methods and formatting of these AUCs was observed. The number of clinical scenarios covered ranged from 6 to 210, and the number of advanced imaging methods covered ranged from 1 to 25. When specifically applied to clinical scenarios, many AUC offered no guidance on appropriateness; those that did conflicted with respect to appropriateness.

Limitation: Other CMS-identified priority clinical areas were not evaluated.

Conclusion: CMS-qualified AUC for imaging of CAD are heterogeneous and sometimes discrepant, creating substantial potential for uncertainty among clinicians seeking to provide their patients with appropriate imaging tests.

Primary funding source: No funding was received for this study.