The small list of cardiac imaging AI solutions to earn Medicare reimbursements just got bigger, following CMS’ move to add an OPPS code for AI-based coronary plaque assessments. That represents a major milestone for Cleerly, who filed for this code and leads the plaque AI segment, and it marks another sign of progress for the business of imaging AI.
With CMS’ October 1st OPPS update, Cleerly and other approved plaque AI solutions now qualify for $900 to $1,000 reimbursements when used with Medicare patients scanned in hospital outpatient settings.
- That achievement sets the stage for plaque AI’s next major reimbursement hurdle: gaining coverage from local Medicare Administrative Contractors (MACs) and major commercial payers.
Cleerly and its qualifying plaque AI competitors join a slowly growing list of Medicare-reimbursed cardiac imaging AI solutions, headlined by HeartFlow’s FFRct ($930 – $950), which has now expanded across MAC regions and commercial payers.
- The last 1.5 years also brought a temporary NTAP reimbursement for Caption Health’s echo AI guidance solution ($1,868) and a CPT III code for performing automated coronary artery calcium score assessments using chest CTs that were performed for other (non-CAC) reasons.
The new reimbursement should also drive advancements within the CCTA plaque AI segment, giving providers more incentive to adopt this technology, and providing emerging plaque AI vendors (e.g. Elucid, Artrya) a clearer path towards commercialization and VC funding.
The Takeaway
CMS’ new plaque AI OPPS code marks a major milestone for Cleerly’s commercial and clinical expansion, and a solid step for the plaque AI segment.
The reimbursement also adds momentum for the overall imaging AI industry, which finally seems to be gaining support from CMS. That’s good news for AI vendors, since it’s pretty much proven that reimbursements drive AI adoption and are often necessary to show ROI.
