@article{c5d6ed2d294c4f86bc6f87406d4e22a3,
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.",
keywords = "Appropriate Use Criteria, National Coverage Determination, guidelines, implantable cardioverter-defibrillator",
author = "Fogel, {Richard I.} and Epstein, {Andrew E.} and {Mark Estes}, {N. A.} and Lindsay, {Bruce D.} and Dimarco, {John P.} and Kremers, {Mark S.} and Suraj Kapa and Brindis, {Ralph G.} and Russo, {Andrea M.}",
note = "Funding Information: Dr. Epstein has received honoraria from Biotronik, Boston Scientific, Medtronic, St. Jude Medical, and ZOLL; research grants from Biotronik , Boston Scientific , Medtronic , and St. Jude Medical ; and fellowship support from Boston Scientific , Medtronic , and St. Jude Medical . Dr. Estes has been a consultant for Boston Scientific and Medtronic; received research support from Boston Scientific ; and received institutional fellowship grants from Boston Scientific , Medtronic , and St. Jude Medical . Dr. Lindsay has been a consultant for Biosense Webster and Jansen Pharmaceutical; and received speaking honoraria from Medtronic and Boston Scientific. Dr. DiMarco has been a consultant for Medtronic, St. Jude Medical, and Novartis; received speaking honoraria from Boston Scientific; and received research support from St. Jude Medical . Dr. Kremers has been a consultant for Medtronic and Cameron Health; received speaking honoraria from Boston Scientific; received research support from Medtronic , Boston Scientific , and St. Jude Medical ; and has equity in Boston Scientific. Dr. Kapa has been a consultant for St. Jude Medical. Dr. Russo has received honoraria from and been a consultant for Medtronic, Boston Scientific, Cameron Health, St. Jude Medical, Biotronik, and Biosense Webster; and received research support from Medtronic , Boston Scientific , and Cameron Health . All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. ",
year = "2014",
doi = "10.1016/j.jacc.2013.07.016",
language = "English (US)",
volume = "63",
pages = "12--14",
journal = "Journal of the American College of Cardiology",
issn = "0735-1097",
publisher = "Elsevier USA",
number = "1",
}