AETNA Insurance and NxStage

[PKDSTGV]

Hi all! First off let me say that I might be making this more difficult for myself than it really is and that's mostly due to the fact that I'm a Clinical Case Manager and have worked as a Utilization Review nurse. When I used to work in the hospital as a Case Manager, the process to start dialysis started with the doctor writing the order. Once the order was written, I had to fax every piece of clinical information that patient preferred dialysis center wanted, then set up their first dialysis session.

A few weeks ago, my neph told me it was time to start (I feel like crap) but she doesn't do dialysis anymore (she's primarily a research neph) and so I'd need to change docs. I had originally told her that I would go to a group closer to my house and that I had two options....DaVita or FMC. She said that she would like me to do Extended Home hemo because of it's long term benefits and I agreed. (I had already done extensive research into my options and had a beautifully functioning fistula). The practice with the best reputation goes to the FMC site so I did a tour of their center and asked them about NxStage. At the time, they were trying to get certified for NxStage (that's fallen through as of this writing) but they explained that they did offer a nocturnal home hemo program. The only drawback was the larger machines and the modifications that need to be made to accommodate them in my house plus I really liked the docs that go to that center. However, I wanted to give DaVita a fair shake and after learning that FMC would not be able to use the NxStage equipment, I thought I'd go ahead and tour their facility.

The tour went really well and I liked the way they set up the teaching area for the home hemo patients. I also really liked the NxStage machine. It's so small and portable!!! I thought, this is exactly what I need! So after speaking with the Clinical Educator we decided to have me get an appointment with their doc. I thought things were gonna go pretty smooth after that.....even if DaVita doesn't do Extended (nocturnal) I wanted the smaller equipment so I was willing to start out on daily hemo.

When I got home I decided to check back in with my insurance carrier. We have really good coverage so I wasn't really worried, but I wanted to make sure there weren't any glitches. The first thing I did was search for any Policy Bulletins that AETNA has on Home Hemo and low and behold I found one. They agree that home hemo is a great modality but then they said they didn't cover NxStage because it was considered experimental!!

Has anyone had this problem with NxStage and AETNA (or any other insurance company)? Does Medicare cover the NxStage machine and if so, why wouldn't AETNA?  Any help I could get would be greatly appreciated! I have spoken with a Members Services person and she said that the Policy Bulletin is what it is and that we could send a pre-determination letter and maybe they'd approve! I also requested Case Management through my Insurance so I'm hoping someone from their office will call me. Just so you know, I've also requested info via DaVita with absolutely NO LUCK....no one there wants to call me back and the only person who did, doesn't know a thing about Insurance!

Sorry this post is so long, as you can see, I'm a little frustrated. I hope someone with experience on this site can give me some info! Thanks!!

Tami

[tyefly]

 Hemodoc wrote about another person in the same situation.....  You can find the article here....


http://www.hemodoc.com/2011/02/buyer-beware-group-health-of-seattle-does-not-cover-home-hemodialysis.html

He also has many other interesting subjects on his web page....http://www.hemodoc.com/

[vcarmody]

My husband has Aetna as his secondary insurance company, they always pay, but I also noticed when the center bills it bills as home dialysis there is not mention that it is NxStage.  I had also read on the site that Nxstage was considered experimental and not covered so I was worried they would not pay.  Good luck, I hope it all works out for you. 

[lmunchkin]

 When hubby started on NxStage last year he had M'care primary and Aetna 2nd.  Both covered EVERYTHING.  But after retiring at first of year, he is with BCBS of Ill. and they are suppose to pay, but havent as of yet.  We are 6 months in already and they havent paid a thing!  I wish that he still had AETNA!

lmunchkin     

P.S. I do recall Aetna was slow about paying, but they had to wait for Medicare to pay, which is very slow in these parts!  Also, with BCBS there will be a large Deductible with an out-of-pocket exspense, BUMMER!!!!!

[rsudock]

Hi all! First off let me say that I might be making this more difficult for myself than it really is and that's mostly due to the fact that I'm a Clinical Case Manager and have worked as a Utilization Review nurse. When I used to work in the hospital as a Case Manager, the process to start dialysis started with the doctor writing the order. Once the order was written, I had to fax every piece of clinical information that patient preferred dialysis center wanted, then set up their first dialysis session.

A few weeks ago, my neph told me it was time to start (I feel like crap) but she doesn't do dialysis anymore (she's primarily a research neph) and so I'd need to change docs. I had originally told her that I would go to a group closer to my house and that I had two options....DaVita or FMC. She said that she would like me to do Extended Home hemo because of it's long term benefits and I agreed. (I had already done extensive research into my options and had a beautifully functioning fistula). The practice with the best reputation goes to the FMC site so I did a tour of their center and asked them about NxStage. At the time, they were trying to get certified for NxStage (that's fallen through as of this writing) but they explained that they did offer a nocturnal home hemo program. The only drawback was the larger machines and the modifications that need to be made to accommodate them in my house plus I really liked the docs that go to that center. However, I wanted to give DaVita a fair shake and after learning that FMC would not be able to use the NxStage equipment, I thought I'd go ahead and tour their facility.

The tour went really well and I liked the way they set up the teaching area for the home hemo patients. I also really liked the NxStage machine. It's so small and portable!!! I thought, this is exactly what I need! So after speaking with the Clinical Educator we decided to have me get an appointment with their doc. I thought things were gonna go pretty smooth after that.....even if DaVita doesn't do Extended (nocturnal) I wanted the smaller equipment so I was willing to start out on daily hemo.

When I got home I decided to check back in with my insurance carrier. We have really good coverage so I wasn't really worried, but I wanted to make sure there weren't any glitches. The first thing I did was search for any Policy Bulletins that AETNA has on Home Hemo and low and behold I found one. They agree that home hemo is a great modality but then they said they didn't cover NxStage because it was considered experimental!!

Has anyone had this problem with NxStage and AETNA (or any other insurance company)? Does Medicare cover the NxStage machine and if so, why wouldn't AETNA?  Any help I could get would be greatly appreciated! I have spoken with a Members Services person and she said that the Policy Bulletin is what it is and that we could send a pre-determination letter and maybe they'd approve! I also requested Case Management through my Insurance so I'm hoping someone from their office will call me. Just so you know, I've also requested info via DaVita with absolutely NO LUCK....no one there wants to call me back and the only person who did, doesn't know a thing about Insurance!

Sorry this post is so long, as you can see, I'm a little frustrated. I hope someone with experience on this site can give me some info! Thanks!!

Tami

When you have private insurance they are primary for 36 months then medicare becomes primary. (double check the 36 months though) so you might be in the time period where medicare is secondary still.

xo,
R

[MooseMom]

PKDSTGV, NxStage is not "experimental".  AETNA's underwriters are just making that up.  If it WAS experimental, no insurance company (including Medicare) would cover it.  I would suggest that you request from their underwriters their working definition of "experimental" and go from there. 

Home hemo with NxStage is better for the patient than other home hemo systems because of their ultrapure water system.  So for any insurance company to deny you the best treatment strikes me as unethical.

[cattlekid]

This has just changed recently and the new policy bulletins may not yet be available.  Please google Home Dialyzors United and take a look at the information there.

[amanda100wilson]

Aetna have now changed their policy and no longer consider NxStage experimental.  I believe that Home Dialyzors United were instrumental in achieving this change.  I hope that you can now progress with your desire to switch to NxStage.  Good luck.

[Dannyboy]

Tami,
Sorry to hear you've gotta start D.
RE: Aetna
I have Aetna as Primary and am on NxStage, they have paid just fine, no problems.

Hope you get the issues worked out.
Best wishes,
--Dan

[M3Riddler]

Aetna have now changed their policy and no longer consider NxStage experimental.  I believe that Home Dialyzors United were instrumental in achieving this change.  I hope that you can now progress with your desire to switch to NxStage.  Good luck.

Aetna Policy Update on Home Dialysis Devices/Equipment
 

FYI, Aetna Insurance has updated there policy on home dialysis. The CPB has been revised to state that the NxStage Hemodialysis System is an acceptable alternative to the Standard Home Dialysis Systems. I advise reading the policy change based on many professional references. If you click on additional information on the Aetna Clinical Policy Bulletin Notes on the right hand of the page, it explains what criteria where used in determining the policy change.

Below is a list of references from the actual policy that were used in determining the change.  Other than the National Kidney Foundation, I do not see any other advocacy groups mentioned. .

The above policy is based on the following references: 1.
U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Medicare Coverage Issues Manual §§ 55-1 - 55-3. Baltimore, MD: HCFA; 1999.

2.Tricenturion LLC. Home dialysis supplies and equipment. Durable Medical Equipment Program Safeguard Contractor (DME PSC). Medicare Local Coverage Determination (LCD) No. 11498. Columbia, SC: Tricenturion; revised January 1, 2006.

3.Association for the Advancement of Medical Instrumentation (AAMI), American National Standards Institute. Hemodialysis systems. In: AAMI standards and recommended practices. Volume 3: dialysis. Arlington, VA: AAMI; 1995.
4.Medical Devices Directorate. Haemodialysis equipment: Review issue. London, UK: Department of Health; 1992.
5.U.S. Department of Health and Human Services, National Institutes of Health (NIH), Office of Medical Applications of Research. Morbidity and mortality of dialysis. NIH Consensus Statement. Bethesda, MD: NIH; November 1-3, 1993; 11(2):1-33. Available at: http://odp.od.nih.gov/consensus. Accessed March 20, 2000.
6.National Kidney Foundation (NKF). NKF-DOQI clinical practice guidelines for vascular access. National Kidney Foundation-Dialysis Outcomes Quality Initiative. Am J Kidney Dis. 1997;30(4 Suppl 3):S150-S191.
7.National Kidney Foundation (NKF). NKF-DOQI clinical practice guidelines for hemodialysis adequacy. Am J Kidney Dis. 1997;30(3 Suppl 2):S15-S66.
8.National Kidney Foundation (NKF). NKF-DOQI clinical practice guidelines for peritoneal dialysis adequacy. Am J Kidney Dis. 1997;30(3 Suppl 2):S67-S136.
9.Steuer RR, Harris DH, Conis JM. A new optical technique for monitoring hematocrit and circulating blood volume: Its application in renal dialysis. Dialysis Transplantation. 1993;22(5):260-264.
10.Steuer RR, Leypoldt JK, Cheung AK, et al. Hematocrit as an indicator of blood volume and a predictor of intradialytic morbid events. Am Soc Artificial Internal Organs J. 1994;40(3):M691-M695.
11.Steuer RR, Harris DH, Conis JM. Continuous, in-line monitoring of oxygen saturation in hemodialysis. Dialysis Transplantation. 1995;24(11):615-620, 658.
12.Steuer RR, Leypoldt JK, Cheung AK, et al. Reducing symptoms during hemodialysis by continuously monitoring the hematocrit. Am J Kidney Dis. 1996;17(4):525-532.
13.Agraharkar M, Barclay C, Agraharkar A. Staff-assisted home hemodialysis in debilitated or terminally ill patients. Int Urol Nephrol. 2002;33(1):139-144.
14.National Institute for Clinical Excellence (NICE). Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure. Technology Appraisal Guidance 48. London, UK: NICE; September 2002. Available at: http://www.nice.org.uk/Docref.asp?d=36748. Accessed February 4, 2004.
15.Mowatt G, Vale L, MacLeod A. Systematic review of the effectiveness of home versus hospital or satellite unit hemodialysis for people with end-stage renal failure. Int J Technol Assess Health Care. 2004;20(3):258-268.
16.Vale L, Cody J, Wallace S, et al. Continuous ambulatory peritoneal dialysis (CAPD) versus hospital or home haemodialysis for end-stage renal disease in adults. Cochrane Database Syst Rev. 2004;(4):CD003963.
17.Rabindranath KS, Strippoli GF, Daly C, et al. Haemodiafiltration, haemofiltration and haemodialysis for end-stage kidney disease. Cochrane Database Syst Rev. 2006;(4):CD006258.
18.Rabindranath KS, Adams J, Ali TZ, et al. Continuous ambulatory peritoneal dialysis versus automated peritoneal dialysis for end-stage renal disease. Cochrane Database Syst Rev. 2007;(2):CD006515.
19.Topfer LA. Portable home hemodialysis. Emerging Technology List. No. 25. Ottawa, ON: Canadian Coordinating Office for Health Technology Assessment (CCOHTA); March 2005.
20.Suri RS, Nesrallah GE, Mainra R, et al. Daily hemodialysis: A systematic review. Clin J Am Soc Nephrol. 2006;1(1):33-42.
21.Danish Centre for Evaluation and Health Technology Assessment (DACEHTA). Dialysis in chronic renal failure - a health technology assessment. Danish Health Technology Assessment. Copenhagen, Denmark: DACEHTA; 2006;8(3).
22.McFarlane PA, Bayoumi AM, Pierratos A, Redelmeier DA. The impact of home nocturnal hemodialysis on end-stage renal disease therapies: A decision analysis. Kidney Int. 2006;69(5):798-805.
23.Al-Hilali N, Al-Humoud H, Nampoory M, et al. Outcome and survival in different peritoneal dialysis modalities. Ther Apher Dial. 2007;11(2):101-106.
24.Kraus M, Burkart J, Hegeman R, et al. A comparison of center-based vs. home-based daily hemodialysis for patients with end-stage renal disease. Hemodial Int. 2007;11(4):468-477.
25.Davenport A, Gura V, Ronco C, et al. A wearable haemodialysis device for patients with end-stage renal failure: A pilot study. Lancet. 2007;370(9604):2005-2010.
26.Scott A. Portable home hemodialysis for kidney failure. Issues in Emerging Health Technologies Issue 108. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2007. Available at: http://cadth.ca/media/pdf/E0046_Portable-Home-Hemodialysis_cetap_e.pdf. Accessed June 25, 2008.
27.National Horizon Scanning Centre (NHSC). Tap water home haemodialysis systems for end stage renal failure: Horizon scanning technology briefing. Birmingham, UK: NHSC; 2007.
28.Purins A, Hiller JE. NxStage System One home dialysis for patients waiting for kidney transplantation. Australia and New Zealand Horizon Scanning Network. Prioritising Summary. Canberra, ACT: Australian Government; November 2008;22:1-5.
29.Jaber BL, Finkelstein FO, Glickman JD, et al. Scope and design of the Following Rehabilitation, Economics and Everyday-Dialysis Outcome Measurements (FREEDOM) Study. Am J Kidney Dis. 2009;53(2):310-320.
30.Mundy L, Hiller JE. Wearable artificial kidney (WAK): Portable dialysis for patients with chronic kidney disease. Adelaide, SA: Adelaide Health Technology Assessment (AHTA). Horizon Scanning Prioritising Summary; 2009;25.
31.Jaber BL, Lee Y, Collins AJ, et al. ; FREEDOM Study Group. Effect of daily hemodialysis on depressive symptoms and postdialysis recovery time: Interim report from the FREEDOM (Following Rehabilitation, Economics and Everyday-Dialysis Outcome Measurements) Study. Am J Kidney Dis. 2010;56(3):531-539.
32.Gossage-Worrall R, Armstrong J, Clift M. Portable haemodialysis devices. Evidence Review. CEP10053. London, UK: National Health Service, Purchasing and Supply Agency, Centre for Evidence-based Purchasing; 2010.
33.Weinhandl ED, Liu J, Gilbertson DT, et al. Survival in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients. J Am Soc Nephrol. 2012;23(5):895-904.



Here is a llink to the Entire Policy Change:

http://www.aetna.com/cpb/medical/data/500_599/0541.html