Over the past year or two, there have been some rather substantial changes in policies and Local Coverage Determinations (LCD). Of note has been Blues of North Carolina restricting ablations to one per limb per lifetime. This was not a medical policy change but a coverage change enacted by Blues to save money.
Currently there is a draft LCD put forward by Novitas which would limit coverage to C4b and higher CEAP scores only. CEAP 2 and 3 would no longer be allowed to be treated if this draft policy remains in place. I would like to use this policy as an example for everyone, regardless of location, as similar policies and LCDs could impact you and your area as well.
Draft Policy Posting:
Some of the payers have specific dates posted on their website noting when the next review may happen. Others seem to leave it as a mystery. We recommend about once a month checking your top three of four payers to see if there has been a policy change or a draft policy put forward. If you save the link on your computer, this check takes about one minute per payer.
Short Meeting Notice:
To give you an idea, Novitas posted their draft policy on January 19th. The Notice of Open Meeting was posted the next day on the 20th. The registration deadline for the meeting was the 24th. You had four days to discover that the policy has been posted and to register to attend the meeting! The meeting itself was held on the 26th in Mechanicsburg, PA. One had less than a week to even make plans to attend the meeting. While not all payers give such short notice, some do not hold open meeting either. It is important to note how one can give feedback on a draft policy or a new policy.
Comment Period:
Novitas is allowing comments to be emailed or mailed to them until March 9th. You have almost a month and a half to comment. Of note here is that Novitas already has a list of studies and articles they are ostensibly referencing to support their clinical decision making. If you do comment, they either want new studies or you can cite the list they already have. I would make sure you reference specific pages if it is a study they already have on their bibliography. Each payer has different commentary submission guidelines. Be sure to pull those and abide by them or they will reject your thoughts out of hand.
Publication of the Policy:
Once the policy or LCD has been published with an implementation date, it is usually quite difficult to cause changes to the policy to take place. It is possible however. Some of the Medicare administrators and commercial plan policies have processes listed for submitting information and reference materials .
Policy Review:
When a draft or new policy is published, try to be realistic in what changes the payer is likely to implement. In the Novitas draft policy they still have conservative therapy requirements. It is unlikely they will suddenly stop requiring conservative therapy. What IS important is the non-coverage of C2 and C3 disease. For some, the exclusion of MOCA treatment will also be important despite new specific codes being available. Our recommendation is to target what is critical and not what is desired.
Broadcast the Policy:
If you happen to note a policy change that is going to greatly impact the phlebology community, be sure to bring it to the attention of the ACP, SIR, AVF or someone. Send it to us if you are not sure what else to do with it. We will be happy to review the policy or draft policy and then contact the appropriate association.
Arm Yourself:
You should consider maintaining a ‘library’ of references, various articles and publications that support your clinical position on how venous disease should be treated. There is a lot of information being published each year. Keeping some of this at your fingertips would be very beneficial in pushing back against bad policies.
Fight Back:
Bad policies not only impact us but your patients as well. Drafting cogent arguments that are supported by peer reviewed literature and ensuring they reach the payer during their comment window is the best way to push back. If we passively accept more and more restrictive policies, at some point there will be few if any circumstances in which the patient will be covered for their venous disease.
If each of us is routinely reviewing the policies and LCD’s that impact our area, then we should never be surprised after the fact. Typically the time to contest any ridiculous changes is when the policy is still in a draft format which takes an active and concerted effort in a very timely fashion. With the various payers confused about where healthcare is heading, I expect to see further degradation in what is covered and not covered in the treatment of venous disease.
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