AETNA Clinical Bulletin

Some Clarification by the Plan
by Cheryl Nash
There has been an interesting new paragraph added to Aetna’s Clinical Policy Bulletin number 0050, treatment of varicose veins. The addition states that one treatment session of endovenous catheter ablation per leg is generally considered medically necessary, as endovenous ablation of the entire incompetent saphenous vein usually can be accomplished in a single treatment session. This is being translated by both providers and authorization personnel to literally mean that you may only treat each leg one time for ablation. If the patient has reflux in both the great and short saphenous veins, then do they have to be done on the same day?This seems to be the important question.

After discussing this with an assistant to the Medical Director’s office at Aetna, there is some understandable confusion. Regardless of what the policy actually says, the stand taken by Aetna is if the patient truly needs services performed for both short and great saphenous veins, you may stage the procedures into two sessions. However, before you release a big sigh of relief, do note there will be some small hurdles to jump through at the claim processing level.

It was explained that due to this one session criteria, any additional services will be flagged for medical necessity. This will require medical records to be sent to verify the necessity of the additional services, and may cause slight to significant delay of payment. Though the insurance company tries to ensure consistent results from the reviews, ultimately the end result is subject to the individual’s interpretation of the medical policy. It may also cause the claims to go through several reviewers and even into appeals prior to payment being issued. Unfortunately, there is no way of knowing exactly how easy or difficult it may be to receive payment until you provide the services.

Another option is to space out additional sessions per leg to ensure the claims do not duplicate each other at the processing level. A waiting period of six months for the additional services, with a new authorization number, may eliminate any confusion prior to payment. The policy does have an additional exception stating repeat sessions of endovenous catheter ablation or stripping/division/ligation are considered medically necessary for persons with persistent or recurrent junctional reflux. However you choose to treat your patients, we highly recommend exact documentation or recordings of all conversations with the authorization department as this may become a key element in resolving any claims payment issues. Medical necessity should always supersede any payment considerations when deciding how to treat the patient.

American Physician has requested that an update to the policy clarifying exactly what Aetna is requiring be released to the public. We will keep you informed of any changes as they happen.

Some Clarification by the Plan
by Cheryl Nash
There has been an interesting new paragraph added to Aetna’s Clinical Policy Bulletin number 0050, treatment of varicose veins. The addition states that one treatment session of endovenous catheter ablation per leg is generally considered medically necessary, as endovenous ablation of the entire incompetent saphenous vein usually can be accomplished in a single treatment session. This is being translated by both providers and authorization personnel to literally mean that you may only treat each leg one time for ablation. If the patient has reflux in both the great and short saphenous veins, then do they have to be done on the same day?This seems to be the important question.

After discussing this with an assistant to the Medical Director’s office at Aetna, there is some understandable confusion. Regardless of what the policy actually says, the stand taken by Aetna is if the patient truly needs services performed for both short and great saphenous veins, you may stage the procedures into two sessions. However, before you release a big sigh of relief, do note there will be some small hurdles to jump through at the claim processing level.

It was explained that due to this one session criteria, any additional services will be flagged for medical necessity. This will require medical records to be sent to verify the necessity of the additional services, and may cause slight to significant delay of payment. Though the insurance company tries to ensure consistent results from the reviews, ultimately the end result is subject to the individual’s interpretation of the medical policy. It may also cause the claims to go through several reviewers and even into appeals prior to payment being issued. Unfortunately, there is no way of knowing exactly how easy or difficult it may be to receive payment until you provide the services.

Another option is to space out additional sessions per leg to ensure the claims do not duplicate each other at the processing level. A waiting period of six months for the additional services, with a new authorization number, may eliminate any confusion prior to payment. The policy does have an additional exception stating repeat sessions of endovenous catheter ablation or stripping/division/ligation are considered medically necessary for persons with persistent or recurrent junctional reflux. However you choose to treat your patients, we highly recommend exact documentation or recordings of all conversations with the authorization department as this may become a key element in resolving any claims payment issues. Medical necessity should always supersede any payment considerations when deciding how to treat the patient.

American Physician has requested that an update to the policy clarifying exactly what Aetna is requiring be released to the public. We will keep you informed of any changes as they happen.