Private Payer Advocacy: United Healthcare Guideline Rhinoplasty, Septoplasty, Turbinate Resection
Michael Setzen, MD, Richard W. Waguespack, MD, and Udo Kaja In August 2010, the Academy’s Health Policy (HP) department learned from members and the American Rhinologic Society (ARS) that United Healthcare (UHC) had released a problematic guideline draft for Rhinoplasty, Septoplasty, Turbinate Resection (http://tinyurl.com/2g6v26v) that did not align with current medical practice and evidence. The guideline’s purpose was to provide UHC subscribers and providers with conditions of coverage for reconstructive septoplasty and turbinate resection. Currently, the insurer does not cover these procedures for cosmetic indications. Our response to the policy was a joint effort of coordination and collaboration among a number of stakeholders. The Academy’s Health Policy (HP) staff disseminated the policy draft to the Rhinology and Paranasal Sinus (RPS), Plastic & Reconstructive Surgery (PRS) committees and the Physician Payment Policy (3P) workgroup for comment. The committees systematically reviewed this policy and 3P provided strategic oversight and recommendations for our final response to UHC. Our major concerns in the initial guideline draft included: A requirement for a formal, signed computed tomography (CT) scan, which UHC would use to determine whether the rhinoplasty, septoplasty or turbinate resection was performed for reconstructive or cosmetic purposes. Trial of medical treatment including decongestants for septal deviation. Before the Academy drafted a response to UHC, staff from the California Medical Association (CMA) and Lionel M. Nelson, MD, (an Academy member in California) contacted the medical director of UHC in California to address the CT scan requirement. As a result, the insurer removed this condition if the physician or patient declined the CT scan. As soon as the updated policy was released, the HP staff disseminated it to the RPS, PRS, and 3P to determine if there were still requirements that did not align with current medical practice or were unsupported by published guidelines. Based on their review and comments, staff drafted a response to UHC requesting removal of the two-year requirement for office notes. Staff also asked for clarification defining criteria for moderate to severe septal deviations; broadening the definition of reconstructive surgery to reflect evidence-based medicine; and allowing the physician to determine whether a patient needs a diagnostic trial of decongestive therapy, rather than requiring this for all septoplasty and rhinoplasty cases. You may view a copy of the letter we sent to UHC (http://tinyurl.com/2df3aga). We made the effort collaborative because we realize the strength and effectiveness of alliances. We also obtained feedback and input from the ARS, the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), the American Society of Plastic Surgeons (ASPS), and the American Society of Aesthetic Plastic Surgery (ASAPS). These societies collaborated in creating and signing the final letter, which was sent to UHC on September 22, 2010. In the future, we will use this strategy when national coverage issues arise, whether of an intra- or inter-specialty nature. In August, 3P members Bradley F. Marple, MD, Richard W. Waguespack, MD, and HP staff joined a conference call with Aetna’s medical directors and physician liaisons and successfully overturned Aetna’s previous coverage position. That position allowed bundling CPT code 30930 (Fracture nasal inferior turbinate(s), therapeutic) when it was performed on the same date of service as CPT code 30520 (Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft). Before the implementation date of the policy (December 1, 2010), we followed up with UHC to find out whether they had made any changes based on our recommendations. Due to our advocacy, UHC removed the two-year requirement for office notes in lieu of CT scans, limited the photograph requirements for nasal deformity to only one, and modified the requirement for the CT report for nasal deformities. While we appreciate these changes, we are disappointed that UHC has not completed review of the other recommendations we made in our letter. We plan to have a conference call with Richard A. Justman, MD, the National Medical Director of UHC this month to follow up on the other outstanding issues and will update members as soon as we hear more from UHC. This case highlights how Academy members can make a difference and be their own advocates. It also shows the importance of alerting your state societies of any coverage issues you come across. As you work to resolve your local coverage issues, please refer to the resources available on the website, including a step-by-step list: Determine whether the insurer denied the claim because of billing errors. (Contact the Academy’s coding hotline at 1-800-584-7773. This is a FREE service for members. You may also visit the Academy’s website [http://www.entnet.org/conferencesandevents/codingworkshops.cfm] to obtain information on Karen Zupko coding workshops and webinars held by the Coding Institute under our Business of Medicine program). Determine whether you submitted the appropriate supporting medical documentation. After you have determined there was no billing or documentation error, please appeal the denial, using the Academy’s resources (http://www.entnet.org/Practice/Private-Payer-Resources.cfm). Report the issue to your state medical or otolaryngology society if you determine the issue is state-wide. If you determine that the coverage issue is nation-wide, contact Udo Kaja, program manager for private payer advocacy at 1-703-535-3727. The Academy is able to respond to payers as they draft coverage guidelines contrary to Academy guidelines and Position Statements. To learn more about the Academy’s latest private payer advocacy efforts, see the weekly The News, our website (http://www.entnet.org/Practice/News-and-Updates-from-Private-Payers.cfm), or contact Healthpolicy@entnet.org.
Michael Setzen, MD, Richard W. Waguespack, MD, and Udo Kaja
In August 2010, the Academy’s Health Policy (HP) department learned from members and the American Rhinologic Society (ARS) that United Healthcare (UHC) had released a problematic guideline draft for Rhinoplasty, Septoplasty, Turbinate Resection (http://tinyurl.com/2g6v26v) that did not align with current medical practice and evidence.
The guideline’s purpose was to provide UHC subscribers and providers with conditions of coverage for reconstructive septoplasty and turbinate resection. Currently, the insurer does not cover these procedures for cosmetic indications. Our response to the policy was a joint effort of coordination and collaboration among a number of stakeholders. The Academy’s Health Policy (HP) staff disseminated the policy draft to the Rhinology and Paranasal Sinus (RPS), Plastic & Reconstructive Surgery (PRS) committees and the Physician Payment Policy (3P) workgroup for comment. The committees systematically reviewed this policy and 3P provided strategic oversight and recommendations for our final response to UHC.
Our major concerns in the initial guideline draft included:
- A requirement for a formal, signed computed tomography (CT) scan, which UHC would use to determine whether the rhinoplasty, septoplasty or turbinate resection was performed for reconstructive or cosmetic purposes.
- Trial of medical treatment including decongestants for septal deviation.
Before the Academy drafted a response to UHC, staff from the California Medical Association (CMA) and Lionel M. Nelson, MD, (an Academy member in California) contacted the medical director of UHC in California to address the CT scan requirement. As a result, the insurer removed this condition if the physician or patient declined the CT scan.
As soon as the updated policy was released, the HP staff disseminated it to the RPS, PRS, and 3P to determine if there were still requirements that did not align with current medical practice or were unsupported by published guidelines. Based on their review and comments, staff drafted a response to UHC requesting removal of the two-year requirement for office notes. Staff also asked for clarification defining criteria for moderate to severe septal deviations; broadening the definition of reconstructive surgery to reflect evidence-based medicine; and allowing the physician to determine whether a patient needs a diagnostic trial of decongestive therapy, rather than requiring this for all septoplasty and rhinoplasty cases. You may view a copy of the letter we sent to UHC (http://tinyurl.com/2df3aga).
We made the effort collaborative because we realize the strength and effectiveness of alliances. We also obtained feedback and input from the ARS, the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), the American Society of Plastic Surgeons (ASPS), and the American Society of Aesthetic Plastic Surgery (ASAPS). These societies collaborated in creating and signing the final letter, which was sent to UHC on September 22, 2010. In the future, we will use this strategy when national coverage issues arise, whether of an intra- or inter-specialty nature.
In August, 3P members Bradley F. Marple, MD, Richard W. Waguespack, MD, and HP staff joined a conference call with Aetna’s medical directors and physician liaisons and successfully overturned Aetna’s previous coverage position. That position allowed bundling CPT code 30930 (Fracture nasal inferior turbinate(s), therapeutic) when it was performed on the same date of service as CPT code 30520 (Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft).
Before the implementation date of the policy (December 1, 2010), we followed up with UHC to find out whether they had made any changes based on our recommendations. Due to our advocacy, UHC removed the two-year requirement for office notes in lieu of CT scans, limited the photograph requirements for nasal deformity to only one, and modified the requirement for the CT report for nasal deformities. While we appreciate these changes, we are disappointed that UHC has not completed review of the other recommendations we made in our letter. We plan to have a conference call with Richard A. Justman, MD, the National Medical Director of UHC this month to follow up on the other outstanding issues and will update members as soon as we hear more from UHC.
This case highlights how Academy members can make a difference and be their own advocates. It also shows the importance of alerting your state societies of any coverage issues you come across. As you work to resolve your local coverage issues, please refer to the resources available on the website, including a step-by-step list:
- Determine whether the insurer denied the claim because of billing errors. (Contact the Academy’s coding hotline at 1-800-584-7773. This is a FREE service for members. You may also visit the Academy’s website [http://www.entnet.org/conferencesandevents/codingworkshops.cfm] to obtain information on Karen Zupko coding workshops and webinars held by the Coding Institute under our Business of Medicine program).
- Determine whether you submitted the appropriate supporting medical documentation.
- After you have determined there was no billing or documentation error, please appeal the denial, using the Academy’s resources (http://www.entnet.org/Practice/Private-Payer-Resources.cfm).
- Report the issue to your state medical or otolaryngology society if you determine the issue is state-wide.
- If you determine that the coverage issue is nation-wide, contact Udo Kaja, program manager for private payer advocacy at 1-703-535-3727.
The Academy is able to respond to payers as they draft coverage guidelines contrary to Academy guidelines and Position Statements. To learn more about the Academy’s latest private payer advocacy efforts, see the weekly The News, our website (http://www.entnet.org/Practice/News-and-Updates-from-Private-Payers.cfm), or contact Healthpolicy@entnet.org.