News and Updates from Private Payers

*NEW* Private Payers Dropping Physicians from Medicare Advantage Plans (10/30/2013)

It has been reported that United Healthcare (UHC) has been dropping physicians, without notice, from one or more of its Medicare Advantage Plans. As a result, the Academy signed onto an AMA letter to CMS urging that proper notice and guidance are provided to patients and physicians regarding any future changes. With the help of the Board of Governors SEGR Regional Reps and Association of Otolaryngology Administrators (AOA), the Academy received feedback that physicians have been impacted in Connecticut, Florida, Indiana, New Jersey and Rhode Island. Any affected member should consider appealing the decision directly to UHC at:

United Healthcare 
Attn: NCQ Appeals Coordinator 
9050 Center Pointe Drive, #400 
West Chester, Ohio 45069. 

If you or any of your colleagues have been affected by this issue, please also contact healthpolicy@entnet.org, so that the Academy may continue tracking this issue.



Academy Achieves Revisions to Aetna Policy on Rhinoplasty and Septoplasty (10/15/2013)
In response to Academy advocacy efforts over the past 6 months, Aetna has revised its Clinical Policy Bulletin on Septoplasty and Rhinoplasty.  Among other changes, Aetna accepted Academy recommendations to change the minimum required time frame for medical therapy prior to performing a Rhinoplasty from "3 months or greater" to "4 weeks or greater." In addition, under its indications for Rhinoplasty, Aetna has changed its requirement from "an average of 50% obstruction or greater of nares" to "significant obstruction of one or both nares." To view Aetna's updated Clinical Policy Bulletin, click here. Changes are summarized below:

Academy Requested Aetna Modify the Following Provisions of their Policy: Aetna Changes to Rhinoloplasty/Septoplasty Policy as of 8/19/13:
Request that Aetna more clearly define “appropriate medical therapy” under criterion D. Specifically, Academy requested that Aetna consider 4 weeks of prior medical therapy, at the discretion of the physician, as constituting “appropriate medical therapy” unless there is failure to respond due to some side effect. Accept: Aetna accepted 4 weeks of prior medical therapy as their timeframe constituting “appropriate medical therapy” prior to performing Septoplasty.
Requested that Aetna consider obstruction of airflow that persists following reasonable medical therapy that can be correlated with documented anatomical abnormalities evident during the physical examination of the nasal interior and exterior be considered appropriate criteria to proceed with Rhinoplasty. We noted that assigning specific percentages is, at best, an arbitrary practice. Accept: Eliminated specific obstruction % requirements for nares. New language reads: “Significant obstruction of one or both nares documented by nasal endoscopy, CT, or other imaging modality.”
Requested that Aetna revise the policy to accept 4 weeks or greater at the discretion of the physician as an acceptable requirement for conservative medical management instead of their previously stated 3 month requirement. Accept: Aetna accepted 4 weeks or more as an appropriate time frame constituting conservative medical management prior to performing Rhinoplasty.
Requested that Aetna include a reference in the coverage policy that any traumatic and functional reconstruction is covered. Also asked that the benefits policy reflect a timeframe which spans two years to include the year in which the injury occurred and the year following the injury. No Change
Requested that Aetna revise the section of their policy which requires a photograph for diagnoses to demonstrate external nasal trauma or deformity. In other cases, a CT scan or an endoscopy, coupled with documented anatomic symptoms and a physical exam, should suffice. No Change: criteria remains: “Photographs demonstrate an external nasal deformity.”





Aetna Clarifies Allergy Immunotherapy Policy (8/8/13)
Through the joint advocacy efforts of the Academy, AAOA and AOA, we have received clarification from Aetna Medical Directors regarding their new Allergy Immunotherapy Policy for CPT 95165.  To view the joint letter sent to Aetna in July, click here. We are particularly pleased that Aetna has chosen to accept our request to allow 120 units during the first year of escalation, and 90 units for years thereafter, for maintenance.  For more information, access the response from Aetna on August 8th.

UHC Clarifies Requirements for Peer to Peer Reviews for Cone Beam Scanners  (07/29/2013)
The Academy is pleased to announce that through joint efforts with the Association of Otolaryngology Administrators (AOA), we have obtained confirmation from UHC, in the states of KY and TX, that the policy of requiring peer to peer reviews for all cone beam scan requests has been corrected as of July 29th.  Moving forward, UHC will ask whether a cone beam scanner is being utilized and will document the response during prior authorization, but will not require a peer to peer review solely based on the use of a cone beam scanner.  The Academy will continue to track this issue and encourage members to contact us at: healthpolicy@entnet.org if they continue to experience issues.

Academy Works with WellPoint to Revise WellPoint’s Policy on Tonsillectomy for Children (11/15/2012)
On October 16th the Academy submitted a letter to WellPoint regarding the WellPoint policy on Tonsillectomy in Children that inappropriately incorporated some statements from the AAO-HNS’s Clinical Practice Guideline (CPG). On November 5th, a conference call was held with WellPoint physician executives, Academy Research and Health Policy leaders and staff, to further discuss these concerns. The conversation was very collegial and the WellPoint executive leaders attentively listened to comments made by the Academy leaders. The Academy’s comments from the call and the October 16th letter were reviewed by the Medical Policy and Technology Assessment Committee (MPTAC) during their November 7-8 meeting. On November 12th, WellPoint revised the policy on Tonsillectomy for Children, incorporating many of the Academy’s comments. This change will affect all of the WellPoint affiliated plans – Anthem BCBS of CT, NH, ME, VA, OH, KY, IN, WI, MO, CO, NV, Anthem Blue Cross (CA), Empire BCBS (NY), BCBS of Georgia, and Unicare.

 

The revisions to the Clinical Indications section of the WellPoint policy on Tonsillectomy in Children are noted in bold underline below. The full revised policy can be found here: http://www.anthem.com/medicalpolicies/guidelines/gl_pw_c148461.htm.

Tonsillectomy is considered medically necessary for individuals less than 18 years of age who meet one or more of the criteria below:

A. …(see policy)
B. …(see policy)
C. A diagnosis of sleep-disordered breathing (SDB) with documentation of all of the following:
     o …(see policy)
     o Abnormalities of respiratory pattern or the adequacy of ventilation during sleep, including but not limited to snoring, mouth breathing, and pauses in breathing*; and
     o …(see policy) OR
D. A diagnosis of SDB for a child less than 3 years of age with documentation of all of the following:

       a. Tonsillar hypertrophy; and
       b. SDB is chronic (more than 3 months in duration); and
       c. Child's parent or caregiver reports regular episodes of nocturnal choking, gasping, apnea, or breath holding. (Note:   the Academy provided WellPoint with this recommended language.) OR

E. A diagnosis of obstructive sleep apnea (OSA) with documentation of all of the following:
         a. Tonsillar hypertrophy; and
         b. A polysomnogram with an Apnea-Hypopnea Index (AHI) greater than 1.0. OR


F. …(see policy)

* NOTE: Documentation of SDB can be made on the basis of physical and history only, and does not require polysomnography. A history of snoring alone is not sufficient to make a diagnosis of SDB.
 

Academy Leads Balloon Dilation Advocacy Efforts (6/7/2012)

Over the last year, the Physician Payment Policy (3P) work group members, supported by Health Policy staff, have been tirelessly working with insurers and advocating for changes to restrictive policies that limit the use of a balloon as a tool in a standard approach to a sinus ostial dilation. On June 1, Health Care Service Corporation (Blue Cross insurer for IL, TX, NM and OK) announced that they amended their coverage policy and now support the '[u]se of a catheter-based inflatable device (balloon sinus ostial dilation) for the treatment of medically refractory chronic sinusitis … as a minimally invasive alternative to functional endoscopic sinus surgery."

Multiple other plans across the country have reviewed and changed their policy. Wellmark and Blue Cross Blue Shield Montana both now allow a hybrid approach and allow the use of a balloon catheter in FESS. Blue Cross Blue Shield Louisiana, CGS Medicare, Blue Cross Blue Shield North Dakota, Blue Cross Blue Shield Western New York, Blue Cross Blue Shield Wyoming, and Network Health Plan now all allow the stand alone use of a balloon catheter as an alternative to FESS.With these changes, payer policies across the nation now cover balloon dilation only procedures for roughly 194 million lives.

On April 12th, the Academy delivered comments to Humana regarding their Balloon Dilation Policy. The Academy believes that the use of a balloon as a tool in a standard approach to a sinus ostial dilation along with other indicated endoscopic surgery is acceptable and an appropriate therapeutic option for selected patients with sinusitis. You can see the Academy's official policy statement
here. The letter expressed the disagreement with the Humana policy designating stand-alone ostial dilations as "Investigational/ Not Medically Necessary," and provided evidence showing the wide spread use and clinical experience of the procedure. See the Letter. In response to comments submitted by the Academy, Humana amended its policy and now supports physician choice when treating chronic sinusitis. The updated policy allows the use of balloon ostial dilation as a standalone and as a hybrid procedure when deemed clinically appropriate by the surgeon.


Update: Academy Signs on to Letter in Attempt to Warn Consumers About Direct-to-Consumer Hearing Aid Programs
(5/16/12)

On May 15th, the Academy signed on to a letter urging state health departments to advise consumers experiencing hearing loss to seek a comprehensive hearing evaluation by a licensed hearing professional prior to purchasing hearing aids over-the-counter or through the internet. The letter additionally urges each Department of Health to notify consumers of the importance of seeing a physician for hearing loss and that failure to do so skirts state and federal regulations and could potentially be harmful. The Academy along with numerous other organizations including the Academy of Doctors of Audiology (ADA), American Academy of Audiology (AAA), the American Speech Language Hearing Association (ASHA), and the International Hearing Society (IHS), signed on to a letter that was sent to the Department of Health in all 50 states and 6 unincorporated US Territories. The goal of the effort is for all states to issue a statement similar to the Minnesota Department of Health as part of May's Better Hearing and Speech month, stressing the importance of seeing a hearing healthcare professional for hearing loss. To view the Minnesota Department of Health's news release, click here. To view one of the letters, click here. For more background information on this issue, see the 4/26/12 update below.  Stay tuned for more updates.

Update: UnitedHealth Group Hearing Aid Sales Direct-to-Consumers (4/26/2012)

On April 25, 2012, AAO-HNS representatives including physician and audiology volunteers and staff, held a conference call with UHC and hi HealthInnovations (HHI) executives as a follow up to our January in person meeting and 2/21/2012 letter (information below) regarding the direct-to-consumer hearing aid program. A day earlier, the Academy's government affairs team spoke with HHI's legal counsel regarding potential regulatory and statutory issues with the program. AAO-HNS and numerous other hearing health organizations have expressed serious concerns regarding the company's online hearing test. During the call, HHI confirmed that they had removed the self-rendered online hearing test from the company's website. However, HHI continues to distribute air conduction tests to providers. HHI has not made any changes to their program based on our feedback, so the Academy believes it is unlikely anything will change quickly. As a result, we made our position very clear in our discussion with UHC and HHI that while we are supportive of providing patients access to affordable hearing aids, we do not believe the program represents safe and high quality care for patients.

AAO-HNS staff also had a conference call on April 26th with counterparts at the American Academy of Audiology (AAA), the American Speech-Language Hearing Association (ASHA), the Academy of Doctors of Audiology (ADA), and the International Hearing Society (IHS) where each organization discussed its recent interactions with UHC on this issue.

The Academy is formulating plans for communicating our concern to government agencies and the public. We will continue to provide members with updates. Please contact the Health Policy Team at healthpolicy@entnet.org with any questions or feedback you receive from patients' experiences with this program.

Background
On January 30, 2012, Academy representatives including leadership, physician and audiology volunteers and staff, met with leadership members from UHC at the Academy in Alexandria, Virginia to discuss the new hi HealthInnovations (HHI) program. The program was initiated on January 1, 2012, with the following states included in the program’s roll-out: California, Colorado, Florida, Illinois, Kentucky, Missouri, Nevada, New Jersey, New York, North Carolina, Ohio, Oregon, South Carolina, Texas, Tennessee, Virginia, and Wisconsin. During the January meeting, UHC representatives responded to all of the Academy’s concerns set out in our November 2nd comment letter and provided a detailed explanation of their methodology. After gaining a more comprehensive level of insight on the program, the Academy maintains that there continue to be major flaws in HHI’s “direct-to-consumer” approach to dispensing hearing aids. The Academy sent a follow-up letter to UHC on February 21st  outlining outstanding concerns regarding this program including the validity of HHI’s self-rendered, online hearing test, liability issues, UHC’s definition of a “hearing health professional,” and potential non-compliance with Federal and State laws. We also requested to speak with UHC’s legal counsel to discuss the compliance issues.

These concerns were also expressed by participation in a joint statement with the ADA, AAA, ASHA amd IHS detailing concerns about the direct-to-consumer sale of hearing aids and supporting a high quality of care that involves the appropriate specialists when treating hearing loss.


Advocacy Effort Timeline
October 03, 2011 Academy is alerted of Hi Health Innovations’ new hearing aid program.
October 24, 2011 – Academy comments about the program in American Medical News here.
November 2, 2011Comment letter sent to UHC followed by an immediate response from UHC to arrange a conference call.
November 28, 2011 – Several members from the Academy’s physician payment policy group (3P), Board of Governors Chair, and staff hold a brief conference call with UHC.  All parties agree a face to face meeting is necessary.
December 5, 2011 – Academy follows up with UHC, sending a summary of the conference call and suggesting potential dates for a meeting.
January 30, 2012 – Academy leadership, physician and audiologist volunteers, and staff meet with UHC.
February 9, 2012 - Academy signs on to a joint statement emphasizing patient safety with 4 other associations

February 21, 2012 – Academy follows up with a letter to UHC reaffirming Academy requests made in the 01/30 meeting.
April 24, 2012 - Government Affairs staff speak with UHC counsel to discuss regulatory and statutory issues.
April 25, 2012 - Academy leadership, physician and audiologist volunteers, and staff participate in a conference call with UHC as a follow-up to 02/21 letter.
April 26, 2012 - Academy staff participate in conference call with four other organizations concerned with UHC's hearing aid program.
May 15, 2012 - Academy signs on to letter urging state departments in all 50 states and 6 unincorporated US territories to warn consumers about potential health risks of DTC hearing aid programs.

Academy Advocacy Leads to Blue Shield of Northeastern New York (HealthNOW) Changing Balloon Dilation Policy (3/29/2012)

Since 
In 2010, Dr. Gavin Setzen, a member of the Academy’s Board of Directors who serves on the Medical Management Clinical Committee in for Blue Shield Northeastern New York (BSNENY, also known as HealthNow, representing roughly 500,000 lives in NY), began advocating for review of and removal of the “experimental” and “not medically necessary” designation the policy for balloon sinus dilation sinus surgery. In the course of the last year and half, Dr. Setzen gathered and presented clinical data demonstrating safety and efficacy for the use of balloon sinuplasty as a minimally invasive alternative to endoscopic sinus surgery.

In the March 2012 meeting of the Medical Management Clinical Committee, HealthNow reviewed their policy designating balloon sinus dilation surgery as “experimental” and “not medically necessary,” and in light of the new research presented by Dr. Setzen and others, decided to change the designation to “medically necessary.”

In the new policy, effective May 1st, 2012, HealthNow will now consider the use of a catheter-based inflatable device (balloon sinuplasty) in the treatment of medically refractory chronic sinusitis medically necessary as a minimally invasive alternative to endoscopic sinus surgery. The policy also states when balloon sinuplasty is performed in conjunction with a medically necessary functional endoscopic sinus surgery (FESS) in the same sinus, balloon sinuplasty is considered to be not medically necessary as it would be an integral part of FESS and therefore not separately payable.

This victory shows how important it is for Academy members to advocate at the local level.  local advocacy for all members of the Academy is. It is important to nurture good relationships with Medical Directors and decision makers, get involved in the committee structures and be well prepared to present a cogent argument supported by clinical data. “Persistence beats resistance” in most cases, according to Dr. Setzen.

Update: Academy Representatives Communicate with Blue Cross Blue Shield Association (BCBSA) Regarding Balloon Sinus Ostial Dilation Reference Medical Policy

Since the beginning of 2011 members of the Physician Payment Policy (3P) work group and Academy staff have been in communication with staff from the Blue Cross Blue and Shield Association regarding their balloon sinus ostial dilation reference medical policy. The Academy’s Rhinology and Paranasal Sinus CMTE provided valuable input during the process.  These communications included a letter from Academy Executive Vice President and CEO Dr. David Nielsen responding to the draft reference medical policy and a conference call with members from 3P and Academy staff on the final reference policy. In all of these communications, the Academy expressed disagreement with the classification of balloon sinus ostial dilation as “Investigational/ Not Medically Necessary” and provided evidence supporting the safety and effectiveness of the procedure. Despite these efforts, BCBSA decided to keep the “Investigational/ Not Medically Necessary” designation until future studies could meet the research criteria necessary for the policy to be changed.  One study submitted by the Academy (Plaza, et al) was acknowledged to be the type of literature needed to revise coverage determinations but was, unfortunately, deemed insufficiently powered to change this BCBSA policy.

Note that the BCBSA Reference Policies are available for use by each BCBS Plan in making independent decisions about medical policy. Each Plan may adopt the reference policy in whole or in part, may modify it, or may reject it. These reference policies are developed by BCBSA staff and then reviewed by a BCBSA Medical Policy Panel (MPP) comprised of senior Plan medical directors.

The Academy has been, and remains, ready to cooperate with appropriate industry and other groups to develop requested prospective studies that could evaluate the efficacy and safety of devices and raise the level of evidence. The BCBSA Medical Director stated that there was no reference policy on denying payment for an entire surgical session when one portion or element was considered “Investigational/ Not Medically Necessary”. The Academy will continue to work with BCBS plans, and any others with similar policies, to allow the balloon to be used as a tool to complement a procedure without the entire procedure being denied. The 3P work group strongly believes that the use of a balloon as a tool in a standard approach to a sinus ostial dilation is acceptable. If you receive this type of denial, please forward information including an EOB/Explanation of Benefits (HIPAA information redacted), indicating whether or not the full session is being denied and in what setting the procedure is being denied to healthpolicy@entnet.org so we can continue to track these. Please also let us know if your local BCBSA Plan is covering and paying for balloon sinuplasty.

 

Page Last Updated: November 15th, 2012