Highmark’s decision last month to stop covering power morcellation for laparoscopic hysterectomies generated headlines across the country, but as of this writing, other insurers have not followed suit, preferring, for the most part, to let providers handle the issue.
The personal struggles of two physicians, husband and wife, sparked concern. In October 2013, Amy Reed, MD, underwent the procedure. What happened as a result — the metastasizing of a rare and deadly cancer — prodded Reed and her husband, Hooman Noorchashm, MD, PhD, to launch a tireless campaign against morcellation. Their story continues to make national headlines.
“Dr. Reed was the first to report to the FDA that this procedure may not be safe,” explains Virginia Calega, MD, Highmark’s vice president for medical management and policy. “What they’ve done is just fantastic, because it’s led to a number of actions.”
“I have been contacted by other insurers who want to understand how we came to this decision,” says Virginia Calega, MD, Highmark’s vice president for medical management and policy.
Those actions included FDA hearings, and in mid-July, the agency discussed changing the classification of the device as well as issuing a black-box warning. Johnson & Johnson, the biggest manufacturer of power morcellators, stopped selling them in April and asked physicians to return any that they have.
Reed’s story may have helped bring this matter to Highmark’s attention faster but, says Calega, “We review our policies yearly. What would accelerate that review would be things like the FDA announcement about this device and then subsequent literature reviews. If something is a hot topic, for lack of a better word, that would accelerate the process and would have us look at something a bit sooner rather than later.” Highmark, she adds, never spoke to Reed.
Highmark notified providers in June that it would no longer cover the procedure after August 31.
Several other health plans have no intention, so far, of changing their policies, but they are willing to let providers take the lead. “Ultimately, we leave the decision about which particular surgical procedure is safest and most appropriate for any individual patient in the hands of the operating surgeon and expect her or him to engage in appropriate shared decision,” says Don Liss, MD, a medical director at Independence Blue Cross.
Aetna spokesman Ethan Slavin says his plan looks to guidance from medical associations, such as the American Association of Gynecologic Laparoscopists. “We support the guidance of these medical organizations, which currently are deferring to the treating physician and the patient in determining if the procedure is appropriate while the safety issues are being examined,” says Slavin. “Currently, Aetna [pays] for services identified by the surgical procedure [CPT] code submitted by the provider (e.g., uterine fibroid removal or hysterectomy — abdominal, laparoscopic, vaginal). The power morcellator is supplied by the hospital and may or may not be listed on the provider’s claim. Therefore, use of the power morcellator may be difficult for an insurer to identify. Of note, tissue morcellation is used in other surgical procedures that are outside the scope of the FDA review.”
Highmark’s Calega notes, “There are other options for women who need to have hysterectomies. You can have an open abdominal hysterectomy, you can have a vaginal hysterectomy, and you can still do a laparoscopic hysterectomy, just not using this particular device.”
The difference in cost “depends on the region and the provider’s contracted reimbursement rates. For us, this decision was not about payment. It is really about what’s in the patient’s best interest.”