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Health plans' coverage determinations for technology-based interventions: the case of electrical bone growth stimulation.
Am J Manag Care. 2004 Dec; 10(12):957-62.AJ

Abstract

OBJECTIVES

To determine (1) whether commercial health plans' coverage criteria for a costly technology-based medical intervention are consistent with recent clinical effectiveness evidence, (2) whether medical directors adhere to planwide coverage criteria when making coverage determinations for individual patients, and (3) if any organizational characteristics are associated with having more stringent coverage criteria or making more frequent coverage denials.

STUDY DESIGN

Case-based survey of medical directors of US commercial health plans.

METHODS

A close-ended survey was mailed to 346 medical directors meeting eligibility criteria, asking about the criteria specified in their plans' coverage policies for electrical bone growth stimulation (EBGS) and whether they would cover this intervention for a hypothetical patient with abnormal union of long-bone fracture.

RESULTS

Responses from 228 (66%) of the 346 directors indicated that approximately 72% of plans have a formal coverage policy for EBGS for long-bone fractures. More than 30% of plans specify that longer than 4 months must elapse before EBGS is attempted, although clinical studies do not support absolute waiting times. Directors of approximately 61% of plans with policies requiring extended waiting periods would nevertheless authorize EBGS for patients who did not meet this criterion.

CONCLUSIONS

Health plans apply varied criteria in coverage policies for technology-based treatments such as EBGS, but do not always adhere to stated criteria when determining coverage for individual patients. For-profit status, accreditation status, geographic location, and size of plan are not associated with being more or less likely to authorize EBGS.

Authors+Show Affiliations

Center for Health Policy, Stanford University, Stanford, Calif., USA. ajhuan@itsa.ucsf.eduNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

15617371

Citation

Huang, Alison J., et al. "Health Plans' Coverage Determinations for Technology-based Interventions: the Case of Electrical Bone Growth Stimulation." The American Journal of Managed Care, vol. 10, no. 12, 2004, pp. 957-62.
Huang AJ, Gemperli MP, Bergthold L, et al. Health plans' coverage determinations for technology-based interventions: the case of electrical bone growth stimulation. Am J Manag Care. 2004;10(12):957-62.
Huang, A. J., Gemperli, M. P., Bergthold, L., Singer, S. S., & Garber, A. (2004). Health plans' coverage determinations for technology-based interventions: the case of electrical bone growth stimulation. The American Journal of Managed Care, 10(12), 957-62.
Huang AJ, et al. Health Plans' Coverage Determinations for Technology-based Interventions: the Case of Electrical Bone Growth Stimulation. Am J Manag Care. 2004;10(12):957-62. PubMed PMID: 15617371.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Health plans' coverage determinations for technology-based interventions: the case of electrical bone growth stimulation. AU - Huang,Alison J, AU - Gemperli,Marcel P, AU - Bergthold,Linda, AU - Singer,Sara S, AU - Garber,Alan, PY - 2004/12/25/pubmed PY - 2005/2/25/medline PY - 2004/12/25/entrez SP - 957 EP - 62 JF - The American journal of managed care JO - Am J Manag Care VL - 10 IS - 12 N2 - OBJECTIVES: To determine (1) whether commercial health plans' coverage criteria for a costly technology-based medical intervention are consistent with recent clinical effectiveness evidence, (2) whether medical directors adhere to planwide coverage criteria when making coverage determinations for individual patients, and (3) if any organizational characteristics are associated with having more stringent coverage criteria or making more frequent coverage denials. STUDY DESIGN: Case-based survey of medical directors of US commercial health plans. METHODS: A close-ended survey was mailed to 346 medical directors meeting eligibility criteria, asking about the criteria specified in their plans' coverage policies for electrical bone growth stimulation (EBGS) and whether they would cover this intervention for a hypothetical patient with abnormal union of long-bone fracture. RESULTS: Responses from 228 (66%) of the 346 directors indicated that approximately 72% of plans have a formal coverage policy for EBGS for long-bone fractures. More than 30% of plans specify that longer than 4 months must elapse before EBGS is attempted, although clinical studies do not support absolute waiting times. Directors of approximately 61% of plans with policies requiring extended waiting periods would nevertheless authorize EBGS for patients who did not meet this criterion. CONCLUSIONS: Health plans apply varied criteria in coverage policies for technology-based treatments such as EBGS, but do not always adhere to stated criteria when determining coverage for individual patients. For-profit status, accreditation status, geographic location, and size of plan are not associated with being more or less likely to authorize EBGS. SN - 1088-0224 UR - https://www.unboundmedicine.com/medline/citation/15617371/Health_plans'_coverage_determinations_for_technology_based_interventions:_the_case_of_electrical_bone_growth_stimulation_ L2 - https://www.ajmc.com/pubMed.php?pii=2780 DB - PRIME DP - Unbound Medicine ER -