Cardiologists lead push for Aetna to reconsider ‘restrictive,’ ‘inconsistent’ reimbursement proposals

Five leading U.S. medical societies have joined together to urge Aetna, a CVS Health company, to reconsider multiple policy proposals.

The Society for Cardiovascular Angiography and Interventions (SCAI) , American College of Cardiology (ACC), Society of Interventional Radiology (SIR), Society for Vascular Surgery and Outpatient Endovascular and Interventional Society all signed on to two different letters addressed to Aetna’s executive medical officer and chief medical officer. SCAI took the lead on both letters, which are dated Nov. 27.

Aetna is one of the largest insurance providers in the United States. According to the company’s website, “an estimated 39 million people rely on Aetna, a CVS Health company, to help them make decisions about their healthcare and their healthcare spending.”

Aetna's atherectomy policies

The first letter—available here—is focused on changes Aetna proposed to Policy 0295 Peripheral Atherectomy and Thrombectomy Devices, which details when atherectomy and thrombectomy devices are considered medically necessary, experimental or investigational. SCAI and the other groups wrote that the proposed changes are both “restrictive to best patient care” and “inconstant with current guidelines and research.”

For example, Aetna wrote that many therapies, including the use of drug-eluting balloons for in vein grafts and dialysis/vascular access, have not yet been proven to be effective on a long-term basis. Several uses of Shockwave Medical’s intravascular lithotripsy technology were also included in the proposal.

“We do not believe categorizing these interventions as experimental or investigational is appropriate,” the groups wrote.

The groups also shared concerns about the eviCore policy Aetna is using for prior authorization, noting that its small scope could lead to a high number of denials. In addition, they noted that Aetna’s proposed lesion length restriction is “too specific,” saying there are certain instances when even lesions larger than 20 cm require treatment to salvage a limb.

Aetna's intravascular ultrasound policies

The second letter—available here—is focused on changes Aetna proposed to Policy 0382 Intravascular Ultrasound (IVUS), which details when IVUS is considered medically necessary, experimental or investigational.

The groups explained that one of their primary concerns is the patient population Aetna believes should be targeted for IVUS.

“The medical policy states that the first criterion for IVUS to be used as a clinical decision-making tool to evaluate the need for an intracoronary interventional procedure in a symptomatic member whose angiogram shows 50 to 70% stenosis(es) is restrictive for intermediate stenosis,” according to the letter. “It is important to note that three recent studies define intermediate stenosis as 40-70% and we feel this range would be a more reasonable requirement as it provides clinicians with decision-making tools before advancing disease leaves fewer clinical options.”

SCAI and the other societies “strongly disagree” with Aetna’s decision, noting that IVUS should not still be seen as an “experimental or investigational” therapy for screening patients for coronary artery disease, diagnosing vulnerable plaques or other key coronary procedures.

“Our organizations would like to work with you to narrow the scope of the statement to avoid unintended denials of patient care for procedures when IVUS is appropriate,” the groups wrote.

Michael Walter
Michael Walter, Managing Editor

Michael has more than 16 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.

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