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  • mikeylikesit33_99 mikeylikesit33_99 Oct 17, 2012 2:32 PM Flag

    UNH update was not a coverage update

    I have all the pdfs downloaded. A PDL (which you may have seen in the title of the doc from Citron's hyperlink to UNH), is a Pharmacy Directory Listing, that is provided to members, just like a doctor listing you may use to find a doctor that takes your insurance.

    ACTH, Acthar, or any other name you want to call it, was never included in the doc. So, in effect, they have been covering it with their current coverage policies and bulletins, but it was never in the member documents.

    The update falls exactly in line with their COVERAGE POLICY, and is simply adding what was missing from the PDL.

    Citron purposely misrepresented the document as a coverage change, in my opinion.

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    • mike

      UNH has a Clinical Policy Update for October. I don't know if you downloaded it but here is the change for ACTH: (effective 11/01/2012)

      Revised authorization approval timeframes for the following ICD-9 diagnosis codes:

      o Multiple Sclerosis (340):

       Changed initial approval period from “3 month initial approval without MD review” to “3 week initial approval without MD review for new acute exacerbations only”
       Changed reauthorization approval period from “MD review required for 6 month reauthorization” to “3 week approval without MD review for new exacerbations; requests for therapy beyond 3 weeks require MD review”

      o Infantile Spasms (345.60 and 345.61):

       Changed initial approval period from “3 month initial approval without MD review” to “4 week initial approval without MD review”
       Changed reauthorization approval period from “MD review required for 6 month reauthorization” to “MD review required for reauthorization”

      • 3 Replies to minxmrphd
      • minxmrphd,

        I wrote an article on that change from one of UNHs subsidiaries, Oxford, last week. I do appreciate that folks who aren't used to reading these insurance documents, may find some of the language changes 'misleading' on the surface. Please do read my article on Seeking Alpha, as I went through each change individually, and stuck to the facts, and just the facts. I think you may find it informative.

        Also of note, is that I mentioned in that article, that I expect to see more insurer's modify their policies, and documentation. The reason I mentioned that is that most of them really don't have Acthar properly added to their documentation. So, with it being in the 'limelight' now, it's bringing their documentation defficiencies to light.

        Yesterday was a prime example, UNH never did add Acthar to their Pharmacy List, and Citron took advantage of their 'update'. I would also venture to say 'misled', as Citron has made it known they are following the insurance coverage in depth, yet couldn't produce an accurate report for readers. Really??? Citron also didn't provide reference for some of the statements UNH supposedly have in the docs. Really??? It makes you long for the time of Walter Cronkite, when a reporter that doesn't provide citations for the fact checkers, were tarred and feathered until they got a paper route, just to stay in the news business.

        Any lawyers on here? Want someone to walk you through the 'misleading' statements and reporting style? Let me know...

      • Infantile, limping Nile, lipid while, pimpin file, aye? lol

      • Read his article on Seeking Alpha regarding this.

    • Good to Bump

      Sentiment: Strong Buy

    • thx for clarifying mikey - you do great work.

    • bumping

 
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