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The reimbursement policy team at UnitedHealth Group's UnitedHealthcare unit is preparing to get tough on coverage for allergy testing.
The team told the doctors in the UnitedHealthcare commercial plan networks that it will put tight limits on allergy testing coverage services for adults seen during routine office visits starting Sept. 1.
The health insurer will consider covering one type of test — a test that measures the amount of immunoglobulin E in a patient's blood — for patients ages 20 or older who have moderate to severe asthma or who seem to have breathing problems caused by mold spores.
The insurer will also consider covering tests that screen the blood of patients ages 20 or older for antibodies to up to 20 specific allergens per year.
The insurer will not cover reimbursements for some other types of allergy tests, such as antigen leukocyte antibody testing and allergen-specific immunoglobulin E tests that do not identify a specific allergen.
UnitedHealthcare is also putting new restrictions on coverage for other types of tests, such as tests for liver damage and blood testosterone levels for patients who have no symptoms, or only vague symptoms.
For liver fibrosis testing, for example, the insurer will consider reimbursement of testing up to once every six months to distinguish liver cirrhosis from other types of liver problems, but it will stop covering some similar types of liver tests.
The new rules do not apply to patients treated in hospital emergency rooms, hospital inpatient wards or hospital observation units.
UnitedHealthcare is also making the lab test rule changes for the providers in its Medicare Advantage plan networks and individual and family plan networks.
UnitedHealthcare said in the reimbursement policy change notice that it will begin applying the new rules in most states in which it operates in September. The insurer will put off trying to apply the rules in Arkansas, Colorado, Kentucky, Nebraska, North Carolina, Ohio and Rhode Island.
"We will issue a later notification for these states," the company said.
What it means: UnitedHealthcare has been reducing the scope of prior authorization programs, but it's also editing the list of services that it covers.
Employers and their benefits advisors may get fewer participant complaints about prior authorization fights and more about outright denials of coverage for lab tests.
The backdrop: Some patients may be more interested in finding out why they have symptoms than in getting treatments, especially when treatments are expensive, inconvenient or potentially dangerous.
But, from the perspective of many physicians and health care cost specialists, insurance coverage for low-value diagnostic testing may increase the cost of care, and decrease the quality, by increasing direct testing costs, causing testing-related infections or injuries, and leading to unnecessary, potentially harmful follow-up tests and treatment efforts.
Cheryl Lau and Dr. Christopher Naugler argued in a paper published in the Cleveland Clinic Journal of Medicine in 2016 that immunoglobulin E testing, for example, is convenient but is not very reliable and is ordered far more often than it should be. False positive results may cause patients to give up healthy foods that they like, and false negative tests could lead patients to eat foods that could hurt them, the researchers warned.
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