Humana Moves Towards AEtna’s Policy
by Cheryl Nash
Some of you may have noticed the new changes to the language in Humana’s coverage policy. Along the lines of last year’s changes to Aetna’s guidelines , Humana has also added a notation in their guidelines stating:
Initially, one treatment session of RFA, TIPP or, EVLT™, 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.
Interestingly enough, we agree that ‘staging’ the GSV into more than one session is rarely if ever indicated. The above statement though is being used to state treatment of both the great and short saphenous vein should be treated in the same setting. They want the claim to be billed as a 36475/36478 for the GSV and 36476/36479 for the SSV. While this is of concern, they did allow a small amount of room for leeway in the statement:
Repeat sessions of RFA, TIPP, EVLT™ or stripping/division/ligation may be requested and are subject to medical necessity review. Repeat sessions may be medically necessary for persons with persistent or recurrent junctional reflux.
We have had some varying results on recent authorizations, and like Aetna, it appears to be subject to the medical director’s discretion on how stringently this is being enforced. Also of interest is that Humana excluded the treatment of perforators, tributaries, and accessory veins with either RF or EVLT, stating that these services are considered experimental and investigational. We will be following up on this development as we receive more feedback from the insurance company and our clients.
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