HRS/ACC have beef with Aetna's CIED pre-authorization program
Despite two society's concerns, Aetna will launch a nationwide Cardiac Rhythm Implant Pre-Authorization program for certain cardiac implantable electronic device (CIED) procedures. The program kicked off June 15; however, the Heart Rhythm Society (HRS) and the American College of Cardiology (ACC) said they are worried the program may result in delays in clinical care.
The pre-authorization program will include four CIED procedures: insertion, removal and upgrades for implantable cardiac pacemakers and defibrillators, and cardiac resynchronization therapy (CRT) performed on an outpatient basis.
As a follow-up to a meeting held May 16, ACC and HRS expressed concerns in a letter sent to Lonny Reisman, MD, senior vice president and chief medical officer of Aetna, on June 12. In the letter, the society heads said that the pre-authorization program has the potential to limit care and said that if left unchanged, the program will require close monitoring in terms of data capture and data sharing.
Additionally, the societies said that they were concerned that the program could result in delays in clinical care. ACC and HRS said that it will be important for them to have timely access to data.
ACC and HRS also expressed concern with the varied philosophies on the pre-authorization of generator replacements.
“We accept CareCore’s process to determine if the request is a generator change and verify the reason for the change,” the letter read. “However, we question the validity of MedSolutions’ justification to further manage and limit generator replacement cases for patients with end-of-life concerns, comorbidities, dementia, pacemaker dependence and other indications.”
To date, no published guidelines exist that outline recommendations for appropriate generator replacement. “This delicate decision is one that is best made by the patient and his or her treating physician,” the letter stated.
Lastly, ACC/HRS said that they are worried that vendors may attempt to adjudicate implantable cardioverter-defibrillator (ICD) mode selection in qualified patients.
“As you may know, there are no clinical practice guidelines to direct the selection of a single or dual-chamber device for a patient with an ICD. ABIM [American Board of Internal Medicine] Board-certified physicians rely on expert opinion and their experience when clinical guidelines do not exist,” the letter stated. The authors went on to say that benefit managers have a conflict of interest “and (are) thus unsuited to make a determination of this magnitude.”
HRS/ACC said that they will release an updated consensus statement on pacemaker mode selection soon and would like to review certain aspects within the program’s data from the first three months. The societies requested that Aetna send data at least 10 days prior to the next meeting.
The pre-authorization program will include four CIED procedures: insertion, removal and upgrades for implantable cardiac pacemakers and defibrillators, and cardiac resynchronization therapy (CRT) performed on an outpatient basis.
As a follow-up to a meeting held May 16, ACC and HRS expressed concerns in a letter sent to Lonny Reisman, MD, senior vice president and chief medical officer of Aetna, on June 12. In the letter, the society heads said that the pre-authorization program has the potential to limit care and said that if left unchanged, the program will require close monitoring in terms of data capture and data sharing.
Additionally, the societies said that they were concerned that the program could result in delays in clinical care. ACC and HRS said that it will be important for them to have timely access to data.
ACC and HRS also expressed concern with the varied philosophies on the pre-authorization of generator replacements.
“We accept CareCore’s process to determine if the request is a generator change and verify the reason for the change,” the letter read. “However, we question the validity of MedSolutions’ justification to further manage and limit generator replacement cases for patients with end-of-life concerns, comorbidities, dementia, pacemaker dependence and other indications.”
To date, no published guidelines exist that outline recommendations for appropriate generator replacement. “This delicate decision is one that is best made by the patient and his or her treating physician,” the letter stated.
Lastly, ACC/HRS said that they are worried that vendors may attempt to adjudicate implantable cardioverter-defibrillator (ICD) mode selection in qualified patients.
“As you may know, there are no clinical practice guidelines to direct the selection of a single or dual-chamber device for a patient with an ICD. ABIM [American Board of Internal Medicine] Board-certified physicians rely on expert opinion and their experience when clinical guidelines do not exist,” the letter stated. The authors went on to say that benefit managers have a conflict of interest “and (are) thus unsuited to make a determination of this magnitude.”
HRS/ACC said that they will release an updated consensus statement on pacemaker mode selection soon and would like to review certain aspects within the program’s data from the first three months. The societies requested that Aetna send data at least 10 days prior to the next meeting.