AVF: Making a Difference Through Collaboration

The dynamic changes occurring in the United States healthcare environment are reflected in the constant modifications being made to payers’ reimbursement policies. Tracking these changes, identifying issues that potentially affect patients with venous and lymphatic diseases, and ensuring that our patients continue to have the option of high-quality, evidence-based care are a daily challenge. Because promoting venous and lymphatic health is our mission, the American Venous Forum (AVF) cannot be a passive observer. Last year, we extended the charter of the Government Relations & Reimbursement Issues Task Force to open constructive dialogue with medical insurance companies regarding policy issues that could adversely affect patient treatment. Within just a few months, the Task Force identified three significant policy changes and reached out to the relevant medical insurance companies.

In April we became aware of a suggested policy change that would consider venous stenting as “investigational and not medically necessary” for “chronically occluded iliac veins, iliac vein compression syndrome (also known as May-Thurner syndrome), ilio-femoral venous thrombosis and any other conditions...” The Task Force created an expert panel including Drs. Raju and Comerota to
address this issue. In collaboration with the Society for Vascular Surgery (SVS) and the Society of Interventional Radiology (SIR), the Task Force responded by stating that “denial of reimbursement for stenting of iliac vein lesions and vena cava lesions following catheter- directed thrombolysis for extensive iliofemoral venous thrombosis will put patients at great risk for harm,” and by advocating for venous stents to be considered medically necessary for treating iliac vein compression syndrome or post-thrombotic vein stenosis. The letter opened a constructive dialogue between all parties and resulted in policy revision based on the collaborative advice and evidence provided. The policy now states that venous angioplasty (with or without stent placement) is medically necessary for treatment of iliac vein compression syndrome (May-Thurner).

in the Coverage Determination Guidelines (CDG) for Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins by expressing concerns about coverage of patients with reflux, ablative therapy for accessory veins, and using venous diameter as a criterion for treatment. Following a teleconference discussion with AVF and with responses from collaborating societies, the insurers revised the Coverage Determination Guidelines to exclude requirements for a trial of compression stockings prior to
treatment and for photographic documentation. They also excluded a segment of the policy change regarding sclerotherapy, ligation, and/or stripping on varicose veins or endovenous ablation therapy for patients on anticoagulation therapy, pregnant women, and other conditions.

Finally, the Task Force reviewed a policy revision that stated pneumatic compression pumps (PCDs) were now considered “not medically necessary” for the treatment of venous leg ulcers (VLU) for any patients. A response letter was issued in collaboration with SVS and the American College of Phlebology (ACP). The letter detailed a history of PCD use in VLU treatment, and provided supporting evidence for the necessity for PCD use in patients with venous ulcers when standard forms of compression are ineffective, or are not a viable treatment option. Our recommendation was to revise the medical coverage policy for pneumatic compression devices to allow for their use on patients with a nonhealing venous leg ulcer.

The key to success of the AVF Task Force was collaboration with other professional societies and coordination of responses with SVS, SIR, and ACP. Perhaps our main achievement was establishing a working relationship with major insurance companies. We see this as an opportunity to impact reimbursement policymaking by providing high-quality evidence and by discussing the potential impact of policy changes on the venous health of our patient population.

AVF Task Force members participated in direct communication with the senior medical officers of insurance companies to ensure constructive bilateral dialogue, and we invited them to attend the AVF Annual Meeting to further strengthen communication and share knowledge. Going forward, we will work toward extending our relationships to continue meaningful collaboration, to provide needed evidence by research, writing and refining evidence-based practice guidelines, and by educating professionals and the public on related issues.