The Centers for Medicare and Medicaid Services (CMS) has paused the Appropriate Use Criteria (AUC) program for advanced diagnostic imaging and rescinded any current regulations, according to the 2024 Medicare Physician Fee Schedule (PFS) final rule.

Originally created by the Protecting Access to Medicare Act of 2014, the program intended for clinicians to first consult AUC before ordering advanced diagnostic imaging including computed tomography (CT), PET, nuclear medicine and MRI. AUC were defined by the program as evidence-based guidelines that assist clinicians in selecting imaging studies most likely to improve health outcomes for patients based on their individual clinical presentation. Clinicians would use clinical decision support mechanisms (CDSMs) to access the AUC.

The program had four major components with implementation deadlines:

1. Establishment of AUC by Nov. 15, 2025
2. Identification of mechanisms for consultation with AUC by April, 1, 2016
3. AUC consultation by ordering professionals and reporting on AUC consultation by Jan. 1, 2017
4. Annual identification of outlier ordering professionals based on low adherence to AUC for services furnished after Jan. 1, 2017

Several deadlines for the AUC program were not met; however, the program did begin an educational and operations testing phase on Jan. 1, 2020. Following this phase, CMS planned to establish mandatory prior authorization requirements for outlier professionals when ordering advanced diagnostic imaging.

The statutory language of the program also required real-time claims-based reporting of the ordering professionals’ AUC consultation information to receive payment for these services. In 2022, the AUC program was delayed indefinitely as the reporting requirement proved to be an “insurmountable barrier” to full implementation.

In the 2024 Medicare PFS final rule, CMS advised that the current claims system cannot perform this function effectively, noting that an extraordinary number of inappropriately denied claims for advanced diagnostic imaging would result if the AUC program were implemented under the current system. This would pose a severe administrative and financial burden to providers and inevitably lead to inappropriately delayed or denied care to Medicare beneficiaries.

Due to these concerns, CMS has finalized their proposal to pause the AUC program for reevaluation and to rescind current regulations, ending the current educational and operations testing period for the time being. The agency has not established a timeline for recommencement of the program to date.

As the AUC program is required by statute, CMS cannot permanently abandon the effort. The agency will reevaluate the AUC program under its current mandates and will address congressional updates or changes to the program if they occur in future rulemaking.

CMS noted the value of CDSMs while warning of the technical limitations of the program: “We welcome and encourage the continued voluntary use of AUC and/or clinical decision support tools in a style and manner that most effectively and efficiently fit the needs and workflow of the clinician user.”

CMS also added that programs like the Quality Payment Program, Merit-Based Incentive Payment System and Alternative Payment Models, while not specifically addressing advanced diagnostic imaging, meet many of the AUC program’s goals by incentivizing higher quality, more efficient care.