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54 Multislice CT in Coronary Heart Disease KCE Reports 82
6.3.2 Canada
6.3.3 Australia
a particular research setting with prospective data collection and analysis plan. In this
case, a clinical study would be required following specified conditions. MSCT
angiography would have to be performed with 32- or more slices CT machines. Finally,
the coronary disease screening as well as other uses of cardiac MSCT would stay
explicitly outside Medicare scope.
After the 30-day public comment period, Medicare did not introduce this proposed
coverage determination deciding that “no national coverage determination on the use of
cardiac computed tomography angiography for coronary artery disease is appropriate at this
time and that coverage should be determined by local contractors through the local coverage
determination process or case-by-case adjudication”. 144 If the proposed Memo had become
definitive, this would have replaced the current local policies by a much more restrictive
national one. The requirements in terms of evidence development, the list of indications
excluded from the proposed coverage and the definition of population eligible for
coverage would have limited the access to MSCT coronary angiography and meant an
end of the coverage for a majority of Medicare Beneficiaries.
Canada has a national health program composed of 13 interlocking provincial and
territorial health insurance plans, all of which share certain common features and basic
standards of coverage.
In Ontario for example, CT for coronary vessels scanning is not covered by the Ontario
Health Insurance Program unlike (multi-slice) CT for thorax and for other anatomic
sites. 41
In Québec private hospitals, the patient is charged the MSCT coronary angiography
while in public hospitals, the examination is covered under the thorax CT fee-forservice
with no extra out-of-pocket payment. The thorax CT medical fee-for-service,
independently from the technology involved, amounts to CAD 55.10 (€34) without
contrast product injection or CAD 63.60 (€40) with contrast product injection (tariffs
at March 1, 2008) . 145
A specific code for cardiac CT is currently under examination (personal communication
from Dr. Noël Bernard, Hôpital Laval, Institut de cardiologie de Québec).
Until now (May 2008), non-coronary CT angiography was covered by the Australian
national Medicare Benefit Schedule but coronary angiography was not covered. The
computed tomography coronary angiography not yet being assessed by the Medical
Services Advisory Committee, nor the CT angiography items neither the chest CT
items could be used for a MSCT coronary angiography. Details on non-coronary CT
angiography items are presented in appendix (Table 27).
In 2006, MSCT coronary angiography was submitted to be assessed by the Medical
Services Advisory Committee (MSAC) of Australia. The report has just been finalized by
the Adelaide Health Technology Assessment Agency (AHTA) and should be published
on the MSAC website around June, 2008. 146
Based on this report, the MSAC considered MSCT coronary angiography safer than
CCA and as effective as CCA in ruling out significant CAD in patients with symptoms
consistent with coronary ischemia, with a high negative predictive value allowing CCA
to be avoided if MSCT reveals no significant disease. The AHTA report included a
decision analytic model in order to determinate the post-test probability of CAD based
on the results of their own meta-analysis on the diagnostic accuracy of 64-SCT
coronary angiography on a per-patient basis. (Personal communication from Tracy
Merlin, Manager AHTA, University of Adelaide, May 2008) MSCT coronary angiography
was considered to be cost-effective only in patients presenting a low to intermediate
pre-test likelihood of CAD.
Therefore, MSAC recommended a public funding for MSCT coronary angiography on
specialist referral of patients with stable symptoms consistent with coronary ischaemia,