Subspecialists benefit from AAP private payer advocacy
RichardLander, M.D., FAAP
Private Payer Advocacy
One aspect of AAP private payer advocacy is to review insurance carrier policies to
ensure they cover recommended pediatric services and provide payment to primary care
and subspecialty pediatricians. Such review is not an endorsement of a carrier’s policy
but an opportunity to advise the carrier on the policy’s impact on pediatrics and
The policy is shared with the appropriate AAP council, committee or section for review,
and feedback then is forwarded to the carrier. When a carrier's policy is not in alignment
with AAP recommendations, the reviewing group recommends a response from the Academy.
The Academy has facilitated review of the nation’s largest private carriers’ clinical
policies to incorporate pediatric perspective. Recent successes on subspecialty pediatric
issues include the following:
The AAP Committee on Fetus and Newborn and Section on Neonatal-Perinatal Medicine
developed comments on the UnitedHealthcare (UHC) policy on inhaled nitric oxide (INO)
and had a follow-up conference call with its authors. As a result of that discussion,
UHC revised its policy regarding non-coverage for INO in neonates born at less than
Based on input from the AAP Section on Cardiology and Cardiac Surgery, Anthem revised
its policy on implantable cardioverter defibrillators to expand the pediatric indications
for implantation to include all adult indications considered medically necessary when
criteria are met.
Members of the AAP Section on Otolaryngology–Head and Neck Surgery provided clarification
and peer-reviewed published reports supporting digital sound processing for certain
types of hearing loss and urged Anthem and the Blue Cross Blue Shield Association
to provide appropriate benefits coverage. In light of the information provided, clarifications
on medical necessity for bone conducted hearing loss were included in policy templates.
The AAP Section on Urology worked with the AAP Private Payer Advocacy Advisory Committee
(PPAAC) to develop appeal letter templates for its members to advocate for benefits
coverage for biofeedback therapy for lower urinary tract dysfunction, testicular prostheses
and treatment with Deflux for children with vesicoureteral reflux. The templates are
available at http://www2.aap.org/sections/urology/.
Dr. Lander is chair of the AAP Private Payer Advocacy Advisory Committee.