In Good Company, Aetna, Mark T. Bertolini, opioid

How We Make Coverage Decisions

Dec 12 2017
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We have received significant feedback over the past few days on a story about two individuals and their respective fights against epilepsy.  Both have requested approval for a procedure called laser ablation which, after a thorough review, Aetna has denied.

First, let me state the obvious – our sympathies go out to the millions of people who live with epilepsy every day.  As a physician, I have seen firsthand the debilitating effects of this disorder, and the toll it can take on individuals and families.

The vast majority of people who have reached out to us want to know – how could we deny a procedure that could improve someone’s quality of life?  Our answer is based on scientific data – or lack thereof – and our responsibility to put member safety first.

Laser ablation is an experimental treatment that has not yet been evaluated in any significant clinical trial.  Are there examples of where it has been effective?  Yes, but the rigorous scientific studies we rely on to make our coverage decisions do not exist.  In addition, laser ablation has not been reviewed or approved by the FDA for the treatment of epilepsy.

There has also been confusion around what role cost played in our decision, if any.  Let me be clear – this was not a decision to save money.  In fact, the standard procedure we approved would cost us more than the requested one.

It is never easy to tell an individual or family that a treatment or procedure is not approved – it’s the hardest thing we have to do.  However, our guiding principles will continue to be proven effectiveness and member safety.

We constantly evaluate new published and peer-reviewed studies or additional evidence when developing our clinical policies, and will continue to do so for this procedure.

Harold L. Paz, M.D., M.S.

Executive Vice President and Chief Medical Officer, Aetna