Updates on Private Payer Policies on Balloon Dilation

humana policy
Humana’s Policy on Balloon Dilation: AAOHNS was alerted by Entellus reimbursement staff that Humana was reviewing their Balloon Dilation policy. Health Policy staff quickly contacted the Humana Medical Director who appreciated receiving our policy statement on the issue and asked us about appropriate patient selection On April 12th, the Academy delivered comments to Humana regarding their Balloon Dilation Policy. The Academy believes that the use of a balloon as a tool in a standard approach to a sinus ostial dilation along with other indicated endoscopic surgery is acceptable and an appropriate therapeutic option for selected patients with sinusitis. The letter expressed the disagreement with the Humana policy designating stand-alone ostial dilations as "Investigational/ Not Medically Necessary," and provided evidence showing the wide spread use and clinical experience of the procedure. The Humana letter was the lead story for the April 26th News and received 800 clicks out of 1300 members who opened the News, the highest amount of views ever received for a health policy update.
In response to comments submitted by the Academy, Humana amended its policy and now supports physician choice when treating chronic sinusitis. The updated policy allows the use of balloon ostial dilation as a standalone and as a hybrid procedure when deemed clinically appropriate by the surgeon. This will be in the May 3rd News item.

blue cross policy
Blue Cross Blue Shield’s Policy on Balloon Dilation: We were also alerted about HCSC, Health Care Service Corporation, the Blue Cross insurer for TX, NM, OK, and IL also recently reviewed their policies that were not covering stand alone balloon procedures. AAOHNS contacted the Medical Director(s) to let them know of the support of these procedures, based on Academy and ARS policies. We have heard that as a result, the will allow stand alone balloon procedures as well as hybrid procedures, similar to Humana. HCSC covers roughly 12.3 Million lives, the largest Blues group after Anthem so this is an important development for our members. We are waiting to hear when the policy goes in place and will keep our members updated with the latest information via the News and website.

Revised 05/06/2012
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