Health plans' coverage determinations for technology-based interventions: the case of electrical bone growth stimulation.
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.



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



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.



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.



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.
Huang
Alison J
AJ
Center for Health Policy, Stanford University, Stanford, Calif., USA. ajhuan@itsa.ucsf.edu
Gemperli
Marcel P
MP
Bergthold
Linda
L
Singer
Sara S
SS
Garber
Alan
A
D003659:Decision Making, Organizational; D019317:Evidence-Based Medicine; D019538:Health Care Surveys; D006801:Humans; D019458:Insurance Coverage; D008329:Managed Care Programs / Q000145:classification / Q000191:economics* / Q000458:organization & administration; D020380:Needs Assessment; D016134:Organizational Policy; D010012:Osteogenesis; D008486:Physician Executives; D013673:Technology Assessment, Biomedical; D013978:Tibial Fractures / Q000628:therapy*; D004561:Transcutaneous Electric Nerve Stimulation / Q000191:economics* / Q000706:statistics & numerical data; D014481:United States