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- CAP Advocacy Win: Wellmark BCBS Rescinds Blanket Denials for Certain Pathology Tests
As a result of CAP advocacy, the private insurer Wellmark Blue Cross Blue Shield is rescinding provisions of their immunohistochemistry (IHC) policy that limited coverage with blanket reimbursement denials of IHC when the claim includes certain ICD 10 codes.
On January 30, Wellmark notified the CAP it would rescind medical necessity reviews of IHC, and reverse prior adverse determinations processed under the policy effective October 1, 2023. The policy had affected pathologists and laboratories practicing in Iowa and South Dakota. The CAP worked with the Iowa Association of Pathologists and others to resolve this issue.
On December 12, the CAP expressed serious concern about Wellmark’s recent policy that limited coverage for certain IHC services. In a letter that lists the 10 ICD codes, the CAP wrote: “These policies have the potential to inappropriately limit physician and other health care provider decision-making in the provision of patient care, as such policies improperly impinge on the practice of medicine by encumbering medically necessary laboratory and pathology services.”
The CAP also wrote: “Pathologists know that the right stain at the right time can make all the difference in a patient’s diagnosis, treatment, and outcome. The decision to use a certain stain should be left to the pathologist responsible for diagnosis of the case, who is best positioned to know what is needed to make that determination.”
The CAP continues to advocate with private insurers to protect access to pathology services for patients. For more information: https://www.cap.org/advocacy/payments-for-pathology-services/private-sector-advocacy.