Increased payer coverage

June 2019 – Vol. 38, No. 5

Advocacy staff constantly monitors improvements and updates to private payer policy decisions. We are happy to announce the following increases in coverage:

Effective August 8, 2018, Aetna offers coverage for hypoglossal nerve neurostimulation for the treatment of moderate to severe obstructive sleep apnea (OSA). Under the policy, FDA-approved hypoglossal nerve neurostimulation devices [such as the Inspire II System and Inspire 3028 system for Upper Airway Stimulation (UAS) Therapy] are considered medically necessary to treat OSA when certain clinical criteria are met. Network-based HMO and/or PPO plans are offered in 40 states and Washington, DC.

Effective February 18, 2019, Highmark updated its commercial medical policies in Delaware, Pennsylvania, and West Virginia to cover standalone balloon sinus ostial dilation (BSOD). Highmark now considers BSOD medically necessary in the sinus being considered for dilation (i.e., frontal, maxillary, or sphenoid) for the treatment of chronic sinusitis when certain clinical indications are present.

Effective April 8, 2019, Highmark Blue Shield now considers eustachian tube balloon dilation medically necessary in adult individuals (22 years and older) when certain clinical criteria are met. This revised coverage policy applies to Highmark BS of Pennsylvania.

To read more on each of these medical policies, visit https://www.entnet.org/content/private-payer-advocacy.