The AAN’s Role in the Development of Model Medical Coverage Policies

The AAN has developed systematic reviews (SRs) and clinical practice guidelines (CPGs) for decades. SRs and CPGs are valued by both practicing neurologists and health insurers (payers) such as the Centers for Medicare and Medicaid Services (CMS) in the development of their coverage and payment policies.  Such policies draw not only on evidence but also on regulations as well as values held by physicians, patients, and society at large, to set guidance for health practices for the average patient circumstance or health setting. Coverage and payment policies should not impinge on provider autonomy in care practices for unusual circumstances or variant patient presentations. It is within this context that the AAN Payment Policy Subcommittee (PPS) develops separate medical coverage policy documents to help payers and AAN members better define appropriate use of specific technologies or treatments.

To date, there is no clear process for model policy topic selection. There must be interest among either an insurer and/or volunteer members of the PPS to initiate document development for a given topic. In the case of intraoperative monitoring (IOM) services, the AAN responded to frequent requests from public and private payers for guidance on AMA Current Procedural Terminology (CPT) code 95920* by creating a model coverage policy for payer consideration. Payer concerns related to an apparent rapid increase in use and possible misuse of the code. There was also interest among PPS members to define more clearly these services amid evolving practice models, thereby helping payers shape coverage and payment policies that ensure patient access to needed care.

The AAN’s model policy documents typically include the following information for a given procedure or technology:

• Background information
• Published literature that demonstrates usefulness
• Pertinent, specific coding instructions
• A nonexclusive list of medically necessary diagnoses

There is a process for developing a model medical policy:

1. Among the PPS members and identified topic experts, a volunteer work group (including supporting AAN staff) is formed that is responsible for the creation of the document. The group comprises individuals with expertise in a majority of the following areas wherever possible: the procedure or technology being explored, medical policy development in general, health care economics, CPT coding, CMS local coverage decisions, and private insurer relations.
2. Project work progresses by means of email discussion and a series of conference calls to define the project scope and compose policy drafts.  The group reviews relevant peer-reviewed literature and any existing coverage policies; discusses current real-world practices, including coding implications; and agrees upon medically necessary diagnoses surrounding the technology/procedure.
3. When the group has drafted and circulated a policy document by email, additional conference calls are held to complete work on the document.
4. Work group members vote by email to approve the document. The approval process can take several months to a year, depending on the dynamics of the work group, need for the statement, and degree of agreement on what constitutes a typical scenario.
5. When the work group approves the document, the coverage policy is routed for final approval to the AAN PPS, Medical Economics and Management Committee, and Board of Directors.
6. Upon the document’s approval, the work group will either publish the policy as a document available at www.aan.com or seek publication in the AAN’s journal, Neurology® Clinical Practice. The AAN also distributes the document to its network of public and private insurers, in conjunction with any available AAN SRs or CPGs related to use of the procedure or technology.

To access the IOM policy, visit www.aan.com/go/practice/policy. 

*[Intraoperative neurophysiology testing, per hour (List separately in addition to code for primary procedure)]

Periodically, this blog will feature insights from other areas within the AAN Center for Health Policy. Today’s post was written by Katie M. Shepard, Senior Manager in Medical Economics. She can be reached by email (kshepard@aan.com) or through the comments area of this blog post. Given the development of model medical policies is relatively new to us, we welcome feedback from other associations, particularly if those associations develop model medical policies or other documents targeted to public and private payers and association membership.