Private Payer Advocacy Spotlight: Wins and Recent Actions
The AAO-HNS is actively engaged in private payer advocacy efforts to maximize coverage and reimbursement of procedures provided by our members.
Throughout the past year, the Academy has been active on several private payer coverage and reimbursement issues. Much of the Health Policy Advocacy team’s efforts have related to coverage issues surrounding surgical treatment of obstructive sleep apnea, imaging requirements for sinus surgeries, balloon dilation for treatment of chronic rhinosinusitis, and balloon dilation of the eustachian tube. Additionally, following an extensive review process by multiple AAO-HNS Committees and the Physician Payment Policy (3P) Workgroup, the AAO-HNS submitted responses to two Blue Cross Blue Shield Association’s (BCBSA) Evidence Street evidence summaries: Balloon Dilation of the Eustachian Tube and Surgical Treatment of Snoring and Obstructive Sleep Apnea. By providing clinical input on these evidentiary summaries, the AAO-HNS has an opportunity to directly impact the clinical input that is assessed by BCBSA to inform future medical coverage policies by Blue Cross plans.
Obstructive Sleep Apnea Treatment
In June 2020, the AAO-HNS sent comments to Cigna opposing their medical policy on “Obstructive Sleep Apnea Treatment Services,” which designated hypoglossal nerve stimulation (HGNS) as investigational. Based on coverage by all the Medicare Administrative Contractors, other private insurers, and strong evidence demonstrating HGNS’s efficacy, the Academy requested that Cigna amend its policy to include coverage of this procedure. In response to the Academy’s submission, Cigna updated its policy to include coverage of HGNS when specific clinical criteria are met.
Balloon Sinus Ostial Dilation for Treatment of Chronic Rhinosinusitis (BSOD)
In July 2020, following the Academy’s advocacy efforts and submission of clinical input, the Blue Cross Blue Shield Federal Employee Program updated its medical policy on “Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis.” The procedure is now considered medically necessary for the treatment of chronic rhinosinusitis when specific criteria are met.
Similarly in October 2020, following extensive advocacy efforts by the AAO-HNS, the Iowa Academy of Otolaryngology, and other stakeholders, Wellmark revised its medical policy “Functional Endoscopic Dilation of the Sinuses and Sinus Implantable Devices.” Wellmark, which operates commercial insurance plans in Iowa and South Dakota, now includes coverage of balloon ostial dilation for chronic rhinosinusitis in adults when specific clinical criteria are met. Wellmark previously deemed the procedure investigational for this patient population.
Image Upload Requirement for FESS and BSOD
In December 2020, following Academy review and input, UnitedHealthcare (UHC) amended its proposed medical policies on “Functional Endoscopic Sinus Surgeries (FESS) and BSOD.” The proposed policies contained an onerous requirement that mandated the uploading of CT images for every patient undergoing FESS or BSOD. The Academy strongly disagreed with this mandatory submission requirement and highlighted significant concerns regarding the utility, interpretation, and labeling of individual patient’s CT scans. In response to the Academy’s policy review, the final FESS and BSOD medical policies (effective February 1, 2021) were amended to state that the CT images are not required in all cases but, for certain patients, may be requested.
Balloon Dilation of the Eustachian Tube
Throughout 2020 and 2021, the Academy has been engaging in advocacy efforts with Cigna to reverse the insurer’s negative coverage policy on balloon dilation of the eustachian tube. In April 2021, in response to these efforts, Cigna revised its “Balloon Sinus Ostial Dilation for Chronic Sinusitis and Eustachian Tube Dilation” medical coverage policy to state that unilateral or bilateral eustachian tube balloon dilation is considered medically necessary once per lifetime for the treatment of chronic obstructive eustachian tube dysfunction.
Members experiencing inappropriate coverage and reimbursement denials are encouraged to reach out to the Academy’s Health Policy Advocacy staff at healthpolicy@entnet.org with the relevant medical policy and denial letter(s).
