Rheumatologist Advocacy Wins Reprieve on Viscosupplementation "Ban"

Prompt action by Alabama rheumatologists has caused Blue Cross Blue Shield to rethink a policy denying all claims for injections into knees with osteoarthritis. But a similar "ban" on hyaluronic acid in neighboring Florida takes effect today.

Blue Cross Blue Shield (BCBS) of Alabama was set to reject all claims for all forms of viscosupplementation for knee osteoarthritis (OA), as of today. But intensive advocacy efforts by Alabama rheumatologists have won at least a temporary reprieve.

Meanwhile Florida BCBS is reportedly standing firm on a similar "ban" on payments for treatments such as hyaluronic acid (HA) injections, due to take effect today (April 1, 2015). The insurer bases the new policy on 2013 revised clinical practice guidelines from the American Academy of Orthopaedic Surgeons, which state that viscosupplementation for knee OA is not recommended and that its efficacy is unsupported by research.

According to Norman Gaylis MD, a Florida-based rheumatologist, the proposed denial of payments only adds to the “hostile environment” within the medical community. Facing already decreasing reimbursements, “the amount of pressure on the practice is getting progressively worse,” he says.

Gaylis argues that the injections are indeed supported by multiple studies, and that BCBS has chosen to follow the AAOS guidelines to circumvent payment.

The options for patients who cannot afford out-of-pocket payments for expensive HA injections: Less-safe steroid injections, even more costly (and invasive) knee replacement surgery, or potentially limited function and continued pain.

When BCBS of Alabama announced this past February that it intended to stop reimbursement for viscosupplementation, a group of rheumatologists belonging to the Alabama Society for the Rheumatic Diseases (ASRD) decided to take action.

Members quickly pooled their individual knowledge to counter and disprove the inefficacy claims that BCBS was using to support the new policy. The team of seven wrote a three-page response to BCBS of Alabama,citing detailed research in support of HA injections, as well as the detrimental outcomes the policy would have on the subspecialty as a whole.

They sent the document not only to the insurance company, but also to influential figures within the state, including the insurance commissioner, the governor, the state medical society, and the state medical board. All members of the ASRD were notified and encouraged to contact BCBS individually, expressing their disapproval of the policy change.  

The outcry led BCBS of Alabama to retract the new policy last month, “based on feedback.”

"[I]mplementation of the non-coverage policy will be delayed to allow time to review comments received,” it stated. Furthermore, BCBS released a proposed policy revision along with updated treatment guidelines, including restrictive criteria for prior authorization and a quantity limit.

Although this revision has been released, Alabama providers have been unable to confirm an effective date with BCBS.

The outlook is quite different in Florida. Currently, the Florida Society of Rheumatology (FSR) is attempting to meet with the state’s BCBS administrators to discuss the implications of the ban and seek an alternate resolution. Despite the proactive stance of the FSR, today's effective date for the viscosupplementation "ban" still stands.

The incidents in Alabama and Florida certainly caught providers off-guard, largely due to the fact that the injections are FDA-approved and their efficacy is supported by some clinical trials and guidelines. It’s worth noting that other states may see these same types of broad-brush treatment denials by payers in the future.

The Alabama experience offers a useful lesson, ASRD representatives say:  Advocacy, by physicians is an exceedingly powerful weapon that can be deployed to combat inefficient, and sometimes harmful, policy changes.

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