Region of Interest: ROI Column Wal-Mart: A Case of Advocating for Patients for Appropriate DXA Coverage

John Goldman, MD, CCD
OsteoFlash® Editor

Dr. Michael R. Saitta, MD, FACR, CCD, an ISCD member and ISCD Certified Clinical Densitometrist (CCD), is a rheumatologist in Fayetteville, Arkansas. Dr. Saitta’s office is near the Arkansas national headquarters of Wal-Mart Stores, Inc. The Wal-Mart Associates Medical Plan is administrated by Blue Advantage Administrators of Arkansas (Blue Cross/Blue Shield (BC/BS)). After practicing in Fayetteville for over nine years and helping treat and care for Wal-Mart employees, he discovered that the Wal-Mart Plan was denying coverage for DXA examinations for any type of estrogen deficiency. His office contacted the Claims Coordinator from BC/BS who informed them that they would consider bone mineral density studies for coverage for most of the Bone Mass Measurement Act (BMMA) indications but only for postmenopausal women who presented with fractures. This was in direct opposition of the Arkansas BC/BS Coverage Policy Manual which listed the first coverage category for Bone Mineral Density Study “(1) Women who are deficient in estrogen; used as means of identifying those with low bone mass…” Further discussions with BC/BS over the next 5 months failed to uncover the rationale for the policy change.

In December 2004 Dr. Saitta spoke with the Director of Benefits at Wal-Mart Stores, the payer for the plan. Dr. Saitta was invited to send a letter outlining the arguments for paying for the eliminated diagnoses. In his letter he pointed out that waiting until fractures occurred is not a wise health policy. He sent documents from various organizations, including ISCD, clearly outlining the approach to treat patients with estrogen deficiency before they get to that late stage in osteoporosis and that “estrogen deficiency states” are explicitly endorsed by some organizations as appropriate diagnoses for bone density testing.

In May 2005, Dr. Saitta found out that Wal-Mart’s new policy effectively restores estrogen deficiency as a covered state. He still must appeal the unpaid claims but was told they will then be paid.

What can we learn from this case?
1. Keeping current on changes in health care plan coverage requires eternal vigilance.
2. When refusals occur, appeal them to the administrator. If this is not effective go to the payer.
3. Do not be reluctant to involve the patient, your state insurance commissioner, ISCD and your specialty society. We must not allow arbitrary and capricious policies or policy changes to harm our patients.
4. Although this process took a long time, it should not have. For example, in Georgia when payment is refused, the State Insurance Commissioner has deemed that insurance companies must inform by written correspondence within 15 days or have to pay an eighteen percent per annum penalty for a clean claim not paid within 15 days.

Last modified: December 17, 2012