A ruling that bolsters one of the country's toughest anti-self-referral laws was cheered by radiologist groups but jeered by orthopedic surgeons in the latest legislative scrap over one of medicine's thorniest issues.

The Maryland Court of Appeals upheld a lower court's ruling that the state's anti-self-referral law prevents orthopedic surgeons, and by extension most nonradiologists, from referring patients for CT, MRI and radiation therapy services on machines in their own offices.

In a ruling issued Jan. 24 that took into account the law's texts and the murky world of lawmaker's intent, the court decided that the 1993 law's various exemptions don't apply to these modalities.

Radiologist and radiation oncologist lobbies, which had filed friend-of-the-court briefs against the appeal, welcomed the news. "Today's ruling represents a victory for patients in Maryland," said Laura I. Thevenot, CEO of ASTRO, in a statement.

These groups have long argued that self-referral by doctors on equipment they own leads to overutilization of imaging and the waste of health care dollars on unnecessary treatments or exams.

However, supporters of self-referral defend it for its convenience for the patient and because it ensures access to proper care in rural or other underserved areas. They also believe it's critical for comprehensive patient management by specialists.

The American Academy of Orthopaedic Surgeons, which filed an amicus brief in support of the appeal, said it was "disappointed."

"Significant technological advances have been made in our field so that patients can receive timely and accessible screenings from the comfort of their doctor’s office," AAOS president Dr. John J. Callaghan said in a statement e-mailed to DOTmed News. "This ruling could have a dramatic effect on the treatment and quality of care of Maryland patients."

At issue in the current case was the Maryland State Board of Physician's 2006 decision that exemptions allowing doctors to self-refer services under certain conditions don't apply to radiation therapy and the two advanced imaging modalities.

That decision prompted a lengthy court battle, with 12 medical practices in orthopedics, oncology and emergency medicine filing suit against the state medical board, in Potomac Valley Orthopaedic Associates, et. al. v. Maryland State Board of Physicians.

The Circuit Court for Montgomery County, which heard the case, sided with the medical board, in a ruling upheld this week by the Appeals Court.

The courts ruled that the three exceptions to self-referral prohibitions included in the 1993 law could not apply to CT, MRI and radiation therapy.

They judged the "within-office" exception largely applies to patients being transferred to another physician in the facility if, say, one was out of town, and not for referral on imaging tests. They also noted that the so-called "supervision" exception, which lets doctors self-refer for tests they run or oversee, only applies to procedures in outside facilities, and not in the doctor's own offices. The appeals court said this interpretation was in line with American Medical Association policy.

The court also found the "in-office ancillary services" exception was meant for certain routine tests, but that the law specifically ruled out by name MRI, CT and radiation therapy. The court further said it was "highly improbable" and would make "no common sense" for the legislature to intend to permit those services under the other exemptions but ban it in this one.

"Ghosts" of intent

The court based its ruling on a mix of close reading of the law's language and what it called "hunting the ghost of legislative intent."

The Appeals Court noted one indication that state lawmakers wanted to include MRI and CT scans in the self-referral bans was they repeatedly resisted attempts to amend the self-referral law to include these procedures. The state's General Assembly rejected both a 2007 bill to amend the self-referral law to permit rural group practices to perform MRI and CT scans and a 2008 bill that would have let the in-office ancillary services exception explicitly include MRI and CT scans.

Maryland's laws are generally held to be tougher than the federal legislation, known as the Stark Law. These are actually three separate laws that first took effect in 1992. These laws ban self-referral for some Medicare and Medicaid patients, though they provide broader in-office ancillary exceptions.

For years, the radiologist and radiation oncologist groups have petitioned Congress to pass laws that would block these exceptions. "The Maryland law is a model to which other states should look -- to maintain quality, curtail inappropriate utilization and ensure that health care dollars are spent effectively," said Dr. John A. Patti, chair of the ACR Board of Chancellors.

Though ACR failed to get language in the health reform legislation passed last spring which would have nixed the in-office ancillary exemptions, it did manage to get a new disclosure rule through. The rule, which took effect this year, requires referring doctors to give Medicare and Medicaid patients a written notice of at least five rival groups within a 25 mile radius of the doctor's office.