March 2018
policy update bulletin Medical & Administrative Policy Updates
UnitedHealthcare respects the expertise of the physicians, health care professionals, and their staff who participate in our network. Our goal is to support you and your patients in making the most informed decisions regarding the choice of quality and cost-effective care, and to support practice staff with a simple and predictable administrative experience. The Policy Update Bulletin was developed to share important information regarding Oxford® Medical and Administrative Policy.* *Where information in this bulletin conflicts with applicable state and/or federal law, UnitedHealthcare follows such applicable federal and/or state law
Oxford
Oxford® Medical and Administrative Policy Updates
Overview This bulletin provides complete details on Oxford® Clinical, Administrative and Reimbursement Policy updates. The inclusion of a health service (e.g., test, drug, device or procedure) in this bulletin indicates only that UnitedHealthcare has recently adopted a new policy and/or updated, revised, replaced or retired an existing policy; it does not imply that Oxford® provides coverage for the health service. In the event of an inconsistency or conflict between the information provided in this bulletin and the posted policy, the provisions of the posted policy will prevail. Note that most benefit plan documents exclude from benefit coverage health services identified as investigational or unproven/not medically necessary. Physicians and other health care professionals may not seek or collect payment from a member for services not covered by the applicable benefit plan unless first obtaining the member’s written consent, acknowledging that the service is not covered by the benefit plan and that they will be billed directly for the service. A complete library of Oxford® Medical and Administrative Policies is available at OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies.
Tips for using the Policy Update Bulletin:
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From the table of contents, click the policy title to be directed to the corresponding policy update summary.
From the policy updates table, click the policy title to view a complete copy of a new, updated, or revised policy.
Oxford® Policy Update Bulletin: March 2018
Policy Update Classifications New New clinical coverage criteria and/or documentation review requirements have been adopted for a health service (e.g., test, drug, device or procedure) Updated An existing policy has been reviewed and changes have not been made to the clinical coverage criteria or documentation review requirements; however, items such as the clinical evidence, FDA information, and/or list(s) of applicable codes may have been updated Revised An existing policy has been reviewed and revisions have been made to the clinical coverage criteria and/or documentation review requirements Replaced An existing policy has been replaced with a new or different policy Retired The health service(s) addressed in the policy are no longer being managed or are considered to be proven/medically necessary and are therefore not excluded as unproven/not medically necessary services, unless coverage guidelines or criteria are otherwise documented in another policy Note: The absence of a policy does not automatically indicate or imply coverage. As always, coverage for a health service must be determined in accordance with the member’s benefit plan and any applicable federal or state regulatory requirements. Additionally, UnitedHealthcare reserves the right to review the clinical evidence supporting the safety and effectiveness of a medical technology prior to rendering a coverage determination.
Oxford
Oxford® Medical and Administrative Policy Updates
In This Issue Clinical Policy Updates
Page
NEW
Denosumab (Prolia® & Xgeva®) – Effective Mar. 1, 2018 ....................................................................................................................................... 7
UPDATED
Actemra® (Tocilizumab) Injection for Intravenous Infusion – Effective Apr. 1, 2018 ................................................................................................ 10 Balloon Sinus Ostial Dilation – Effective Apr. 1, 2018 .......................................................................................................................................... 11 Blepharoplasty, Blepharoptosis and Brow Ptosis Repair – Effective Apr. 1, 2018 ..................................................................................................... 12 Breast Reduction Surgery – Effective Apr. 1, 2018 .............................................................................................................................................. 12 Cytological Examination of Breast Fluids for Cancer Screening – Effective Apr. 1, 2018 ........................................................................................... 15 Epidural Steroid and Facet Injections for Spinal Pain – Effective Mar. 1, 2018 ........................................................................................................ 16 Fecal Calprotectin Testing – Effective Mar. 1, 2018 ............................................................................................................................................. 17 Glaucoma Surgical Treatments – Effective Apr. 1, 2018....................................................................................................................................... 17 Home Hemodialysis – Effective Mar. 1, 2018 ...................................................................................................................................................... 18 Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion – Effective Apr. 1, 2018 ......................... 19 Orencia® (Abatacept) Injection for Intravenous Infusion – Effective Mar. 1, 2018 ................................................................................................... 20 Outpatient Physical & Occupational Therapy for Self-Funded Groups – Effective Mar. 1, 2018 .................................................................................. 22 Outpatient Physical and Occupational Therapy (OptumHealth Care Solutions Arrangement) – Effective Mar. 1, 2018 .................................................. 25 Panniculectomy and Body Contouring Procedures – Effective Apr. 1, 2018 ............................................................................................................. 28 Rhinoplasty and Other Nasal Surgeries – Effective Apr. 1, 2018 ........................................................................................................................... 30
REVISED
3
Abnormal Uterine Bleeding and Uterine Fibroids – Effective Apr. 1, 2018 ............................................................................................................... 34 Attended Polysomnography for Evaluation of Sleep Disorders – Effective Apr. 1, 2018 ............................................................................................ 35 Buprenorphine (Probuphine® & Sublocade™) – Effective Apr. 1, 2018 ................................................................................................................... 38 Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes – Effective Apr. 1, 2018 ......................................................................... 42 Denosumab (Prolia® & Xgeva®) – Effective Jun. 1, 2018...................................................................................................................................... 47 Drug Coverage Criteria - New and Therapeutic Equivalent Medications – Effective Apr. 1, 2018 ................................................................................ 51 Drug Coverage Guidelines – Effective Mar. 1, 2018 ............................................................................................................................................. 51 o Prolia, Xgeva (Denosumab) ........................................................................................................................................................................ 51 o Symdeko (Tezacaftor/Ivacaftor) ................................................................................................................................................................. 52 Drug Coverage Guidelines – Effective Apr. 1, 2018 ............................................................................................................................................. 52 o Arymo ER (Morphine Sulfate) ..................................................................................................................................................................... 52 o Avinza (Morphine Sulfate Controlled Release) (Brand Only) ............................................................................................................................ 52 o Baxdela (Delafloxacin) ............................................................................................................................................................................... 52
Oxford® Policy Update Bulletin: March 2018
Oxford
Oxford® Medical and Administrative Policy Updates
In This Issue
4
o Cabometyx (Cabozantinib) ......................................................................................................................................................................... 52 o Dolophine (Methadone).............................................................................................................................................................................. 52 o Duragesic (Brand Only) (Fentanyl) .............................................................................................................................................................. 52 o Embeda (Morphine Sulphate and Naltrexone HCL)......................................................................................................................................... 52 o Entresto (Valsartan-Sacubitril) .................................................................................................................................................................... 52 o Exalgo (Hydromorphone) ........................................................................................................................................................................... 53 o Flolipid (Simvastatin Suspension) ................................................................................................................................................................ 53 o Hemlibra (Emicizumab-Kxwh) ..................................................................................................................................................................... 53 o Hysingla ER (Hydrocodone Bitartrate) .......................................................................................................................................................... 53 o Impoyz (Clobetasol Propionate) .................................................................................................................................................................. 53 o Kadian (Morphine Sulfate Extended Release) ................................................................................................................................................ 53 o Morphabond ER (Morphine Sulfate) ............................................................................................................................................................. 53 o Morphine Sulfate Controlled-Release (Generic MS Contin) .............................................................................................................................. 53 o MS Contin ................................................................................................................................................................................................ 53 o Noctiva (Desmopressin Acetate) ................................................................................................................................................................. 53 o Nucynta ER (Tapentadol Extended Release) ................................................................................................................................................. 53 o Opana ER (Oxymorphone Extended Release) ................................................................................................................................................ 54 o Oxycontin (Oxycodone Extended Release) .................................................................................................................................................... 54 o Oxycodone ER 12hr Tablet ......................................................................................................................................................................... 54 o Oxymorphone Extended Release ................................................................................................................................................................. 54 o Probuphine (Buprenorphine)....................................................................................................................................................................... 54 o Steglujan (Ertugliflozin/Sitagliptin) .............................................................................................................................................................. 54 o Sublocade (Buprenorphine Extended-Release) .............................................................................................................................................. 54 o Trintellix (Vortioxetine) .............................................................................................................................................................................. 54 o Troxyca ER (Oxycodone HCL and Naltrexone) ............................................................................................................................................... 54 o Vantrela ER (Hydrocodone Bitartrate) .......................................................................................................................................................... 54 o Xeljanz (Tofacitinib) .................................................................................................................................................................................. 54 o Xeljanz XR ............................................................................................................................................................................................... 55 o Xtampza ER (Oxycodone) .......................................................................................................................................................................... 55 o Zohydro ER (Hydrocodone Bitartrate Extended Release) ................................................................................................................................ 55 Elbow Replacement Surgery (Arthroplasty) – Effective Apr. 1, 2018 ...................................................................................................................... 55 Electrical and Ultrasound Bone Growth Stimulators – Effective Apr. 1, 2018 ........................................................................................................... 56 Functional Endoscopic Sinus Surgery (FESS) – Effective Apr. 1, 2018.................................................................................................................... 56 Hip Resurfacing and Replacement Surgery (Arthroplasty) – Effective Apr. 1, 2018 .................................................................................................. 56 Hysterectomy for Benign Conditions – Effective Apr. 1, 2018 ............................................................................................................................... 57 Implanted Electrical Stimulator for Spinal Cord – Effective Apr. 1, 2018 ................................................................................................................ 57 Luxturna™ (Voretigene Neparvovec-Rzyl) – Effective May 1, 2018 ........................................................................................................................ 58 Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions – Effective Apr. 1, 2018 ......................................................... 58 Observation Care – Effective Apr. 1, 2018 ......................................................................................................................................................... 63
Oxford® Policy Update Bulletin: March 2018
Oxford
Oxford® Medical and Administrative Policy Updates
In This Issue
Obstructive Sleep Apnea Treatment – Effective Apr. 1, 2018 ................................................................................................................................ 64 Office Based Program – Effective Apr. 1, 2018 ................................................................................................................................................... 66 Omnibus Codes – Effective Apr. 1, 2018 ............................................................................................................................................................ 67 Orthognathic (Jaw) Surgery – Effective Apr. 1, 2018 ........................................................................................................................................... 70 Orthopedic Services – Effective Apr. 1, 2018 ...................................................................................................................................................... 73 Outpatient Cardiac Telemetry – Effective Apr. 1, 2018 ........................................................................................................................................ 75 Pneumatic Compression Devices – Effective Apr. 1, 2018 .................................................................................................................................... 76 Preventive Care Services – Effective Apr. 1, 2018 ............................................................................................................................................... 76 Respiratory Interleukins (Cinqair®, Fasenra®, and Nucala®) – Effective Apr. 1, 2018 ............................................................................................... 77 Shoulder Replacement Surgery (Arthroplasty) – Effective Apr. 1, 2018 ................................................................................................................. 84 Site of Service Guidelines for Certain Outpatient Surgical Procedures – Effective Apr. 1, 2018 .................................................................................. 84 Sodium Hyaluronate – Effective Apr. 1, 2018 ..................................................................................................................................................... 86 Specialty Medication Administration - Site of Care Review Guidelines – Effective Apr. 1, 2018 .................................................................................. 89 Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins – Effective Apr. 1, 2018 ...................................................................... 90 Surgical Treatment for Spine Pain – Effective Apr. 1, 2018 .................................................................................................................................. 94 Temporomandibular Joint Disorders – Effective Apr. 1, 2018 ................................................................................................................................ 96 Total Knee Replacement Surgery (Arthroplasty) – Effective Apr. 1, 2018 ............................................................................................................... 97 Transcranial Magnetic Stimulation – Effective Apr. 1, 2018 .................................................................................................................................. 97
Administrative Policy Updates NEW
New York & Connecticut Participating Surgeons Using Non- Participating Providers for Intraoperative Neuro-Monitoring (IONM) – Effective Jun. 1, 2018 ....................................................................................................................................................................................100
UPDATED
Non-Participating Provider Consent Form Protocol – Effective Mar. 1, 2018 ...........................................................................................................102
REVISED
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Formula & Specialized Food – Effective Apr. 1, 2018 ..........................................................................................................................................104 In-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy – Effective Apr. 1, 2018 .................................................................107 Newborns – Effective Apr. 1, 2018 ...................................................................................................................................................................107 Precertification Exemptions for Outpatient Services – Effective Apr. 1, 2018 .........................................................................................................108 Referrals – Effective Apr. 1, 2018 ....................................................................................................................................................................108
Oxford® Policy Update Bulletin: March 2018
Oxford
Oxford® Medical and Administrative Policy Updates
In This Issue Reimbursement Policy Updates NEW
Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging – Effective Apr. 1, 2018 ...............................................................................111
UPDATED
After Hours and Weekend Care – Effective Apr. 1, 2018 .....................................................................................................................................112 Evaluation and Management (E/M) – Effective Mar. 1, 2018 ................................................................................................................................113 Increased Procedural Services – Effective Mar. 1, 2018 ......................................................................................................................................115 Modifier SU – Effective Apr. 1, 2018.................................................................................................................................................................117 Nonphysician Health Care Codes – Effective Apr. 1, 2018 ...................................................................................................................................117 Observation Care Evaluation and Management Codes – Effective Apr. 1, 2018 ......................................................................................................118 Obstetrical Policy – Effective Apr. 1, 2018 .........................................................................................................................................................120 Standby Services – Effective Apr. 1, 2018 ........................................................................................................................................................121 Wrong Surgical or Other Invasive Procedures – Effective Mar. 1, 2018 .................................................................................................................121
REVISED
B Bundle Codes – Effective Apr. 1, 2018 ...........................................................................................................................................................123 Drug Testing – Effective Mar. 1, 2018 ..............................................................................................................................................................124 Reimbursement for Comprehensive and Component CPT Codes (CES) – Effective Mar. 1, 2018 ...............................................................................125
RETIRED/REPLACED
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Advanced Practice Provider Evaluation and Management Procedures – Effective Mar. 1, 2018 .................................................................................128 Multiple Imaging Rules – Effective Apr. 1, 2018 .................................................................................................................................................128
Oxford® Policy Update Bulletin: March 2018
Oxford
Clinical Policy Updates Policy Title
Effective Date
Coverage Rationale
Mar. 1, 2018
This policy refers to the following denosumab products: Prolia Xgeva
NEW Denosumab (Prolia® & Xgeva®)
Proven Prolia (denosumab) is proven and medically necessary for:
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The treatment of postmenopausal patients with osteoporosis, or to increase bone mass in patients with osteoporosis at high risk for fracture who meet ALL of the following criteria: o Diagnosis of osteoporosis; and o One of the following: BMD T-score ≤ -2.5 based on BMD measurements from lumbar spine (at least two vertebral bodies), hip (femoral neck, total hip), or radius (one-third radius site); or History of one of the following resulting from minimal trauma: Vertebral compression fracture Fracture of the hip Fracture of the distal radius Fracture of the pelvis Fracture of the proximal humerus or Both of the following: BMD T-score between -1 and -2.5 (BMD T-score greater than-2.5 and less than or equal to -1) based on BMD measurements from lumber spine (at least two vertebral bodies), hip (femoral neck, total hip), or radius (one-third radius site); and One of the following: FRAX 10-year fracture probabilities: major osteoporotic fracture at 20% or more FRAX 10-year fracture probabilities: hip fracture at 3% or more; and and o History of failure, contraindication, or intolerance to oral or intravenous bisphosphonate therapy; and o Prolia dosing is in accordance with the United States Food and Drug Administration approved labeling: maximum dosing of 60 mg every 6 months; and o Authorization is for no more than 12 months.
To increase bone mass in patients at high risk for fracture receiving androgen deprivation therapy for non-metastatic prostate cancer in patients who meet ALL of the following criteria: o Diagnosis of non-metastatic prostate cancer; and o Patient is receiving androgen deprivation therapy; and o History of failure, contraindication, or intolerance to oral or intravenous bisphosphonate therapy; and o Prolia dosing is in accordance with the United States Food and Drug Administration approved labeling:
Oxford® Policy Update Bulletin: March 2018
Oxford
Clinical Policy Updates Policy Title
Effective Date
Coverage Rationale
NEW Denosumab (Prolia® & Xgeva®) (continued)
Mar. 1, 2018 o
maximum dosing of 60 mg every 6 months; and Authorization is for no more than 12 months.
To treat patients at high risk for fracture receiving adjuvant aromatase inhibitor therapy for breast cancer in patients who meet ALL of the following criteria: o Diagnosis of breast cancer; and o Patient is receiving aromatase inhibitor therapy; and o History of failure, contraindication, or intolerance to oral or intravenous bisphosphonate therapy; and o Prolia dosing is in accordance with the United States Food and Drug Administration approved labeling: maximum dosing of 60 mg every 6 months; and o Authorization is for no more than 12 months.
Xgeva (denosumab) is proven and medically necessary for:
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The prevention of skeletal-related events in patients with multiple myeloma and with bone metastases from solid tumors when ALL of the following criteria are met: o Patient is one of the following: Patient is ≥ 18 years of age; or Patient is a skeletally mature adolescent as defined by having at least 1 mature long bone (e.g., closed epiphyseal growth plate of the humerus) and o One of the following: Diagnosis of multiple myeloma; or Presence of metastatic disease secondary to a solid tumor (e.g., bladder, kidney, lung, ovarian, thyroid, etc.) and o Individual has an expected survival of 3 months or greater; and o Refractory (within the past 30 days), contraindication (including renal insufficiency), or intolerance to treatment with intravenous bisphosphonate therapy (e.g., pamidronate, zoledronic acid) ; and o Xgeva dosing is in accordance with the United States Food and Drug Administration approved labeling: maximum dosing of 120 mg every 4 weeks; and o Authorization is for no more than 12 months.
The treatment of giant cell tumor of the bone when ALL of the following criteria are met: o Patient is one of the following: Patient is ≥ 18 years of age; or Patient is a skeletally mature adolescent as defined by having at least 1 mature long bone (e.g., closed epiphyseal growth plate of the humerus) and
Oxford® Policy Update Bulletin: March 2018
Oxford
Clinical Policy Updates Policy Title
Effective Date
Coverage Rationale
NEW Denosumab (Prolia® & Xgeva®) (continued)
Mar. 1, 2018
o o
o
o
Diagnosis of localized or metastatic giant cell tumor of the bone; and Disease is one of the following: Unresectable; or Surgical resection is likely to result in severe morbidity and Xgeva dosing is in accordance with the United States Food and Drug Administration approved labeling: maximum dosing of 120 mg every 4 weeks (additional 120 mg doses allowed on Day 8 and 15 in the first month of therapy); and Authorization is for no more than 12 months.
The treatment of hypercalcemia of malignancy when ALL of the following criteria are met: o Patient is one of the following: Patient is ≥ 18 years of age; or Patient is a skeletally mature adolescent as defined by having at least 1 mature long bone (e.g., closed epiphyseal growth plate of the humerus) and o Diagnosis of hypercalcemia of malignancy as defined as: albumin-corrected serum calcium level greater than 12.5 mg/dL (3.1 mmol/L); and o No pre-existing hypocalcemia (i.e., serum calcium or corrected calcium within normal limits per laboratory reference); and o Refractory (within the past 30 days), contraindication (including renal insufficiency), or intolerance to treatment with intravenous bisphosphonate therapy (e.g., pamidronate, zoledronic acid); and o Xgeva dosing is in accordance with the United States Food and Drug Administration approved labeling: maximum dosing of 120 mg every 4 weeks (additional 120 mg doses allowed on Day 8 and 15 in the first month of therapy); and o Authorization is for no more than 12 months.
Unproven Xgeva is unproven and not medically necessary for the following indications: Combination therapy of denosumab and intravenous bisphosphonates Bone loss associated with hormone-ablation therapy (other than aromatase inhibitors) in breast/prostate cancer Cancer pain Central giant cell granuloma Hyper-parathyroidism Immobilization hypercalcemia Osteogenesis imperfecta Osteopenia
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Oxford® Policy Update Bulletin: March 2018
Oxford
Clinical Policy Updates Policy Title
Effective Date
Summary of Changes
Coverage Rationale
Apr. 1, 2018
Please refer to Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines for updated information based upon the National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium® (NCCN Compendium®) for oncology indications.
UPDATED Actemra® (Tocilizumab) Injection for Intravenous Infusion
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Updated coverage rationale; replaced language indicating “this policy refers to Actemra (tocilizumab) injection for intravenous infusion” with “this policy refers only to Actemra (tocilizumab) injection for intravenous infusion for the treatment of rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, systemic juvenile idiopathic arthritis, and cytokine release syndrome; Actemra for self-administered subcutaneous injection is obtained under the pharmacy benefit and is indicated in the treatment of rheumatoid arthritis and giant cell arteritis”
Oxford® Policy Update Bulletin: March 2018
This policy refers only to Actemra (tocilizumab) injection for intravenous infusion for the treatment of rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, systemic juvenile idiopathic arthritis, and cytokine release syndrome. Actemra for self-administered subcutaneous injection is obtained under the pharmacy benefit and is indicated in the treatment of rheumatoid arthritis and giant cell arteritis. Actemra is proven and medically necessary for the treatment of:
Polyarticular juvenile idiopathic arthritis when ALL of the following criteria are met: o Diagnosis of polyarticular juvenile idiopathic arthritis (PJIA); and o Actemra is initiated and titrated according to US Food and Drug Administration labeled dosing for polyarticular juvenile idiopathic arthritis up to a maximum of (or equivalent dose and interval schedule): 10mg/kg every 4 weeks for patients weighing < 30kg 8mg/kg every 4 weeks for patients weighing ≥ 30kg; and o Patient is not receiving Actemra in combination with either of the following: Biologic disease-modifying antirheumatic drug (DMARD) [e.g., Enbrel (etanercept), Humira (adalimumab), Cimzia (certolizumab), Simponi (golimumab)] Janus kinase inhibitor [e.g., Xeljanz (tofacitinib)]
Rheumatoid arthritis when ALL of the following criteria are met: o Diagnosis of moderate to severely active rheumatoid arthritis (RA); and o History of failure, contraindication, or intolerance to at least one non-biologic DMARD [e.g., methotrexate, leflunomide, sulfasalazine, hydroxychloroquine, minocycline, etc.]; and o Actemra is initiated and titrated according to US Food and Drug Administration labeled dosing for rheumatoid arthritis up to a
Oxford
Clinical Policy Updates Policy Title
Effective Date
Summary of Changes
Coverage Rationale
UPDATED Actemra® (Tocilizumab) Injection for Intravenous Infusion (continued)
Balloon Sinus Ostial Dilation
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Apr. 1, 2018 o
Apr. 1, 2018
Updated list of applicable CPT codes; added 31298
Oxford® Policy Update Bulletin: March 2018
maximum of 800mg every 4 weeks (or equivalent dose and interval schedule); and Patient is not receiving Actemra in combination with either of the following: Biologic DMARD [e.g., Enbrel (etanercept), Humira (adalimumab), Cimzia (certolizumab), Simponi (golimumab)] Janus kinase inhibitor [e.g., Xeljanz (tofacitinib)]
Systemic juvenile idiopathic arthritis when ALL of the following criteria are met: o Diagnosis of systemic juvenile idiopathic arthritis (SJIA); and o Actemra is initiated and titrated according to US Food and Drug Administration labeled dosing for systemic juvenile idiopathic arthritis up to a maximum of (or equivalent dose and interval schedule): 12mg/kg every 2 weeks for patients weighing < 30kg 8mg/kg every 2 weeks for patients weighing ≥ 30kg; and o Patient is not receiving Actemra in combination with either of the following: Biologic DMARD [e.g., Enbrel (etanercept), Humira (adalimumab), Cimzia (certolizumab), Simponi (golimumab)] Janus kinase inhibitor [e.g., Xeljanz (tofacitinib)]
Cytokine release syndrome when ALL of the following criteria are met: o Diagnosis of chimeric antigen receptor (CAR) T cell-induced cytokine release syndrome (CRS); and o Actemra is prescribed according to US Food and Drug Administration labeled dosing for CRS: 12mg/kg for patients weighing < 30kg 8mg/kg for patients weighing ≥ 30kg; up to a maximum of 800mg per infusion and o Actemra is prescribed for a maximum of 4 doses
Balloon sinus ostial dilation is proven and/or medically necessary for treating Chronic Rhinosinusitis (defined as rhinosinusitis lasting longer than 12 weeks) when all of the following are met: Chronic Rhinosinusitis of the sinus to be dilated is confirmed on computed tomography (CT) scan. CT scan findings of Chronic
Oxford
Clinical Policy Updates Policy Title
Effective Date
Summary of Changes
Coverage Rationale
UPDATED Balloon Sinus Ostial Dilation (continued)
Apr. 1, 2018
Rhinosinusitis include one or more of the following: o Mucosal thickening, o Bony remodeling, o Bony thickening, or o Obstruction of the ostiomeatal complex. Balloon sinus ostial dilation is limited to the frontal, maxillary or sphenoid sinuses. Balloon sinus ostial dilation is performed either as a stand-alone procedure or as part of Functional Endoscopic Sinus Surgery (FESS). Balloon sinus ostial dilation is performed in persons whose symptoms persist despite medical therapy with one or more of the following: o Nasal lavage o Antibiotic therapy, if bacterial infection is suspected o Intranasal corticosteroids
Balloon sinus ostial dilation is unproven and/or not medically necessary for treating nasal polyps or tumors. There is insufficient published clinical evidence to conclude that balloon sinus ostial dilation is safe and effective for treating nasal polyps or tumors.
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Blepharoplasty, Blepharoptosis and Brow Ptosis Repair
Apr. 1, 2018
Updated supporting information; replaced reference to “MCG™ Care Guidelines, 21st edition, 2017” with “MCG™ Care Guidelines, 22nd edition, 2018”
Refer to the policy for complete details on the coverage guidelines for Blepharoplasty, Blepharoptosis and Brow Ptosis Repair.
Breast Reduction Surgery
Apr. 1, 2018
Updated supporting information; replaced reference to “MCG™ Care Guidelines, 21st edition, 2017” with “MCG™ Care Guidelines, 22nd edition, 2018”
Indications for Coverage Criteria for a Coverage Determination as Reconstructive Breast reduction surgery is considered reconstructive and medically necessary when the following criteria are met and a physiologic functional impairment is identified: Macromastia is the primary etiology of the member’s functional impairment or impairments (as defined in the Definitions section of the policy). The following are examples of functional impairments that must be attributable to Macromastia to be considered (not an all-inclusive list): o Severe skin excoriation/intertrigo unresponsive to medical management o Severe restriction of physical activities that meets the definition of functional impairment o Signs and symptoms of nerve compression that are unresponsive to
Oxford® Policy Update Bulletin: March 2018
Oxford
Clinical Policy Updates Policy Title
Effective Date
Summary of Changes
Coverage Rationale
UPDATED Breast Reduction Surgery (continued)
Apr. 1, 2018
medical management, e.g., ulnar paresthesias o Acquired kyphosis that is attributed to Macromastia o Chronic breast pain due to weight of the breasts o Upper back, neck, or shoulder pain o Shoulder grooving from bra straps o Headache and The amount of tissue to be removed plots above the 22nd percentile; or If the amount of tissue to be removed plots between the 5th and 22nd percentiles, the procedure may be either reconstructive or cosmetic; the determination is based on the review of the information provided; and The proposed procedure is likely to result in significant improvement of the functional impairment.
The Following Documentation Should be Available for Review Reduction Mammoplasty documentation should include the evaluation and management note for the date of service and the note for the day the decision to perform surgery was made. The member’s medical record must contain, and be available for review on request, the following information: Height and weight Body Surface Area (BSA) Photographs that document Macromastia Coverage Limitations and Exclusions Some states require benefit coverage for services that UnitedHealthcare considers cosmetic procedures, such as repair of external congenital anomalies in the absence of a functional impairment. Please refer to member specific benefit plan documents. Cosmetic Procedures are excluded from coverage. Procedures that correct an anatomical Congenital Anomaly without improving or restoring physiologic function are considered Cosmetic Procedures. The fact that a Covered Person may suffer psychological consequences or socially avoidant behavior as a result of an Injury, Sickness or Congenital Anomaly does not classify surgery (or other procedures done to relieve such consequences or behavior) as a reconstructive procedure. Any procedure that does not meet the reconstructive criteria above in the Indications for Coverage section, e.g., psychological or social reasons, breast size asymmetry unless post mastectomy, exercise. Breast reduction surgery is cosmetic when done to improve appearance
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Oxford® Policy Update Bulletin: March 2018
Oxford
Clinical Policy Updates Policy Title
Effective Date
Summary of Changes
Coverage Rationale
UPDATED Breast Reduction Surgery (continued)
Apr. 1, 2018
without improving a functional/physiologic impairment. The use of liposuction as the sole procedure for breast reduction surgery is considered cosmetic.
Appendix This Schnur chart may be used to assess whether the amount of tissue (per breast) that will be removed is reasonable for the body habitus, and whether the procedure is cosmetic or reconstructive in nature. If the amount plots above the 22nd percentile and the member has a functional impairment, the procedure is reconstructive. If the amount plots below the 5th percentile, the procedure is cosmetic. If the amount plots between the 5th and 22nd percentiles, the procedure may be either reconstructive or cosmetic based on review of information. To calculate body surface area (BSA), see: http://www.calculator.net/bodysurface-area-calculator.html or BSA = (W 0.425 x H 0.725) x 0.007184 (weight is in kilograms and height is in centimeters). Modified Schnur Nomogram Chart
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Oxford® Policy Update Bulletin: March 2018
Body Surface (m2) 1.35
Lower 5th Percentile 127
Lower 22nd Percentile 199
1.40
139
218
1.45
152
238
1.50
166
260
1.55
181
284
1.60
198
310
1.65
216
338
1.70
236
370
1.75
258
404
1.80
282
441
1.85
308
482
1.90
336
527
1.95
367
575
Oxford
Clinical Policy Updates Policy Title
Effective Date
Summary of Changes
Coverage Rationale
UPDATED Breast Reduction Surgery (continued)
Cytological Examination of Breast Fluids for Cancer Screening
Apr. 1, 2018
Apr. 1, 2018
Updated supporting information; replaced reference to “MCG™ Care Guidelines, 21st edition, 2017” with “MCG™ Care Guidelines, 22nd edition, 2018”
2.00
401
628
2.05
439
687
2.10
479
750
2.15
523
819
2.20
572
895
2.25
625
978
2.30
682
1,068
2.35
745
1,167
2.40
814
1,275
2.45
890
1,393
2.50
972
1,522
2.55
1,062
1,662
Breast ductal lavage is unproven and not medically necessary for use in breast cancer screening of either low-risk or high-risk women. There is inadequate clinical evidence that breast ductal lavage either allows for better clinical decision-making or reduces breast cancer mortality. Further studies are necessary to determine the efficacy of cytological examination of ductal fluid in detecting atypical cells to identify women at increased risk of breast cancer as well as comparing the results to established methods of detecting and diagnosing breast cancer. Ductal lavage is intended for use in high-risk women but no definite patient selection criteria for ductal lavage of the breast have been established. Breast ductal fluid aspiration and cytology is unproven and not medically necessary for use in breast cancer screening of either lowrisk or high-risk women. There is inadequate clinical evidence that automated nipple aspiration either allows for better clinical decision-making or reduces breast cancer mortality. Further studies are necessary to determine the efficacy of cytological examination of ductal fluid in detecting atypical cells to identify women at increased risk of breast cancer as well as comparing the results to established methods of detecting and diagnosing breast cancer. Fiberoptic ductoscopy, with or without ductal lavage, is unproven and not medically necessary for use in breast cancer diagnosis or
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Oxford® Policy Update Bulletin: March 2018
Oxford
Clinical Policy Updates Policy Title
Effective Date
Summary of Changes
Coverage Rationale
UPDATED Cytological Examination of Breast Fluids for Cancer Screening (continued)
Apr. 1, 2018
Epidural Steroid and Facet Injections for Spinal Pain
Mar. 1, 2018
screening or as an intraoperative tool to guide surgery. There is insufficient clinical evidence demonstrating that fiberoptic ductoscopy allows for better clinical decision-making, reduces breast cancer mortality or serves as a useful adjunct to or replacement of open surgical excision.
Updated coverage rationale; replaced language indicating: o “[The listed services] are proven and medically necessary” with “[the listed services] are proven and/or medically necessary” o “[The listed services] are unproven and not medically necessary” with “[the listed services] are unproven and/or not medically necessary” Updated supporting information to reflect the most current clinical evidence, FDA information, and references
Note: Epidural steroid injections in this policy apply to the lumbar spine only. This section does not address cervical or thoracic injections. The facet joint injections section of the policy addresses multiple sites, and is not limited to the lumbar spine. Ultrasound Guidance The use of ultrasound guidance for epidural steroid injection(s) and facet joint injection(s) is unproven and/or not medically necessary. There is insufficient clinical evidence regarding its safety and/or efficacy in published peer-reviewed medical literature. Epidural Steroid Injections Epidural steroid injection is proven and/or medically necessary for treating acute and sub-acute sciatica or radicular pain of the low back caused by spinal stenosis, disc herniation or degenerative changes in the vertebrae. Epidural steroid injections have a clinically established role in the short-term management of low back pain when the following two criteria are met: The pain is associated with symptoms of nerve root irritation and/or low back pain due to disc extrusions and/or contained herniations; and The pain is unresponsive to conservative treatment, including but not limited to pharmacotherapy, exercise or physical therapy. Epidural steroid injection is unproven and/or not medically necessary for ALL other indications of the lumbar spine. There is a lack of evidence from randomized controlled trials indicating that epidural steroid injections effectively treat patients with lumbar pain not associated with sciatica or radicular pain. Note: This policy does not apply to obstetrical epidural anesthesia utilized during labor and delivery.
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Clinical Policy Updates Policy Title
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UPDATED Epidural Steroid and Facet Injections for Spinal Pain (continued)
Mar. 1, 2018
Facet Joint Injections Diagnostic facet joint injection and/or facet nerve block (e.g., medial branch block) is proven and/or medically necessary when used to localize the source of pain to the facet joint in persons with spinal pain. Therapeutic facet joint injection is unproven and/or not medically necessary for treating chronic spinal pain. Clinical evidence about the very existence of facet joint syndrome is conflicting, and evidence from studies is inadequate regarding the superiority of periodic facet joint injections compared to placebo in relieving chronic spinal pain (pain lasting more than 3 months). For additional information on facet joint injections as a diagnostic procedure prior to radiofrequency ablation, see the Clinical Evidence section of the policy.
Fecal Calprotectin Testing
Mar. 1, 2018
Glaucoma Surgical Treatments
17
Apr. 1, 2018
Updated non-coverage rationale; replaced language indicating “fecal measurement of calprotectin is unproven and not medically necessary” with “fecal measurement of calprotectin is unproven and/or not medically necessary” Updated supporting information to reflect the most current description of services, clinical evidence, and references
Fecal measurement of calprotectin is unproven and/or not medically necessary for the diagnosis and management of all conditions, including but not limited to the following: Inflammatory bowel disease (IBD) including ulcerative colitis (UC) and Crohn's disease (CD) Colorectal cancer (CRC)
Updated coverage rationale; replaced language indicating: o “[The listed services] are proven and medically necessary” with “[the listed services] are proven and/or medically necessary” o “[The listed services] are
Glaucoma drainage devices, such as the ExPRESS™ mini glaucoma shunt, Molteno implant, Baerveldt tube shunt, Krupin Eye Valve, or the Ahmed glaucoma valve implant, are proven and/or medically necessary for treating refractory glaucoma when conventional medical or surgical treatments have failed or are inappropriate.
Oxford® Policy Update Bulletin: March 2018
There is insufficient evidence that fecal calprotectin (FC) is effective as a biomarker for the diagnosis and management of intestinal disease. Before FC can be incorporated into routine clinical practice, studies in larger and diverse groups of patients will be needed to further clarify its role in clinical decision making and its effect on the outcome of treatment of the condition for which it is being used.
The iStent® Trabecular Micro-Bypass Stent System is proven and/or medically necessary when used in combination with cataract surgery
Oxford
Clinical Policy Updates Policy Title
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Coverage Rationale
UPDATED Glaucoma Surgical Treatments (continued)
Apr. 1, 2018
unproven and not medically necessary” with “[the listed services] are unproven and/or not medically necessary” Updated list of applicable CPT codes; revised description for 66180 Updated supporting information to reflect the most current description of services, clinical evidence, FDA information, and references
for treating mild to moderate open-angle glaucoma and a cataract in adults currently being treated with ocular hypotensive medication. The CyPass® Micro-Stent System is unproven and/or not medically necessary when used in combination with cataract surgery for treating mild-to-moderate primary open-angle glaucoma (POAG). The Xen® Glaucoma Treatment System is unproven and/or is not medically necessary for treating refractory glaucoma when conventional medical or surgical treatments have failed, or in patients with primary open-angle glaucoma, pseudoexfoliative or pigmentary glaucoma with open angles that are unresponsive to maximum tolerated medical therapy. Glaucoma drainage devices, such as Eyepass, DeepLight SOLX® Gold Shunt and other shunts that do not have FDA approval are investigational and unproven and/or not medically necessary for treating glaucoma. Clinical evidence is limited to small studies; therefore, additional studies are needed to establish the safety and efficacy of these devices. Canaloplasty is proven and/or medically necessary for the treatment of primary open-angle glaucoma. Viscocanalostomy is unproven and/or not medically necessary for treating glaucoma. Evidence from the majority of available randomized controlled trials indicates that viscocanalostomy is not as effective as trabeculectomy in reducing intraocular pressure (IOP).
Home Hemodialysis
Mar. 1, 2018
18
Updated and reorganized coverage rationale; replaced language indicating “[the listed services] are medically necessary” with “[the listed services] are proven and/or medically necessary” Updated supporting information to reflect the most current description of services, clinical
Oxford® Policy Update Bulletin: March 2018
Home hemodialysis without professional staff assistance is proven and/or medically necessary as an alternative to facility-based hemodialysis for treating patients with end-stage renal disease who meet ALL of the following criteria: Patient is stable on dialysis with no evidence of complex skilled interventions being necessary during treatments; and Patient or non-professional caregiver has the ability to perform and maintain home hemodialysis and has received comprehensive training regarding proper protocol; and Absence of complications and significant concomitant disease that would
Oxford
Clinical Policy Updates Policy Title
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UPDATED Home Hemodialysis (continued)
Mar. 1, 2018
evidence, FDA information, and references
cause home hemodialysis to be unsafe or unsuitable; and Presence of well-functioning vascular access.
Home hemodialysis with professional staff assistance is proven and/or medically necessary as an alternative to facility-based hemodialysis for treating patients with end-stage renal disease who meet ALL of the following criteria: Patient is stable on dialysis and not at increased risk as a result of having the procedure performed outside a dialysis center venue; and Patient has well-functioning vascular access; and Patient has medical contraindications to leaving home for hemodialysis; and Patient or non-professional caregiver is not capable of performing home hemodialysis; and Staff assisted home hemodialysis protocols generally match those provided in the hemodialysis center (i.e., at least 3 times per week, 3-4 hour treatments). The exact dialysis therapy employed is determined on an individual basis by the attending nephrologist. Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion
Apr. 1, 2018
Updated coverage rationale; added reference link to the policy titled Immune Globulin (IVIG and SCIG) for proven and/or medically necessary clinical uses of immune globulin (relocated from the Clinical Evidence section of the policy) Updated supporting information to reflect the most current references o Replaced reference to “MCG™ Care Guidelines, 21st edition, 2017” with “MCG™ Care Guidelines, 22nd edition, 2018”
Clinical use of Immune Globulin is proven and/or medically necessary, in accordance with the Oxford policy titled Immune Globulin (IVIG and SCIG). This guideline addresses the criteria for consideration of allowing hospital outpatient facility infusion service for Immune Globulin (IVIG and SCIG) therapy. In accordance with CMS, this includes hospital based services with either of the following Place of Service (POS) codes: 19 (Off-Campus - Outpatient Hospital) 22 (On-Campus - Outpatient Hospital) Criteria and Clinical Indications for Hospital Outpatient Site of Care Selection Criteria Hospital outpatient Site of Care may be approved when: The patient’s condition meets any of the Clinical Indications below, and The provider has submitted the appropriate supporting documentation Clinical Indications Initial infusion of Immune Globulin, or re-initiation of therapy after more
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Clinical Policy Updates Policy Title
Effective Date
Summary of Changes
Coverage Rationale
UPDATED Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion (continued)
Apr. 1, 2018
than 6 months off of Immune Globulin Change of Immune gGobulin products History of severe adverse events to Immune Globulin (including but not limited to anaphylaxis, seizure, thromboembolism, myocardial infarction, renal failure) Patient is clinically unstable Episodes of moderate to severe adverse events that have not been responsive to acetaminophen, steroids, diphenhydramine, fluids, infusion rate reductions, or other therapy pre-medications, thereby increasing risk to the patient when administration is in the home or office setting Patient has immunoglobulin A (IgA) deficiency with anti-IgA antibodies Outpatient treatment in the home or ambulatory setting presents a health risk due to a clinically significant physical or cognitive impairment
Note: If more than one of the above criteria are met, then the greatest of the applicable approval time periods will be allowed. Orencia® (Abatacept) Injection for Intravenous Infusion
20
Mar. 1, 2018
Updated supporting information to reflect the most current references; no change to coverage rationale or lists of applicable codes
Oxford® Policy Update Bulletin: March 2018
This policy refers to Orencia (abatacept) injection for intravenous infusion. Orencia is proven and medically necessary for the treatment of:
Polyarticular juvenile idiopathic arthritis when all of the following criteria are met: o Diagnosis of moderately to severely active polyarticular juvenile idiopathic arthritis (PJIA); and o Orencia is initiated and titrated according to US Food and Drug Administration labeled dosing for polyarticular juvenile idiopathic arthritis up to a maximum of (or equivalent dose and interval schedule): 10mg/kg every 4 weeks for patients weighing Clinical Resources > Guidelines/Policies/Manuals > Coverage Determination Guidelines. Some studies have examined the use of transcranial magnetic stimulation for treating disorders such as pain, dystonia, epilepsy, headaches, Parkinson’s disease, stroke, and tinnitus. However, because of limited studies and small sample size there is insufficient data to conclude that transcranial magnetic stimulation is beneficial for treating these conditions. Navigated transcranial magnetic stimulation (nTMS) is unproven and/or not medically necessary for treatment planning or for diagnosing motor neuron diseases or neurological disorders. There is limited information from the peer-reviewed published medical literature to conclude that navigated transcranial magnetic stimulation is an effective clinical diagnostic test. Most published studies involve a small number of patients. Randomized controlled trials with large populations are needed to evaluate how this test can reduce clinical diagnostic uncertainty or impact treatment planning.
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REVISED Transcranial Magnetic Stimulation (continued)
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Apr. 1, 2018
o Added 64999 o Removed 95999 Updated supporting information to reflect the most current clinical evidence, FDA information, and references
Oxford® Policy Update Bulletin: March 2018
Coverage Rationale
Oxford
Administrative Policy Updates Policy Title
Effective Date
Administrative Guidelines
Jun. 1, 2018
NY and CT Participating Providers Using Non-Participating IONM Providers The following procedures and responsibilities apply to Participating Providers located in NY and CT when providing services to members enrolled on NY and/or CT products in an outpatient or inpatient facility setting that involve intraoperative neuro-monitoring (IONM).
NEW New York & Connecticut Participating Surgeons Using Non- Participating Providers for Intraoperative Neuro-Monitoring (IONM)
Services performed by a Participating Provider located in NY or CT and meeting the following criteria must ensure that the IONM provider utlized is participating with the Oxford network. Member is enrolled on a NY or CT product; and Service is being provided in an outpatient or inpatient facility setting; and Involve intraoperative neuro-monitoring (IONM). Outpatient and Inpatient Facility Place Codes Place Code 15
Description Mobile diagnostic unit
19
Off campus - outpatient hospital
21
Inpatient Hospital
22
On campus - outpatient hospital
24
Ambulatory surgical center
99
Other unlisted factilty
If the Participating Provider intends to utilize an IONM provider that does not participate in the Oxford network, the provider is required to:
Verbally discuss options and financial impact with the Member o The Participating Provider must review this policy and the Non-Participating Provider Consent Form with the Member. The discussion must explain Participating and Non-Participating IONM Provider alternatives and provide the Member with an understanding of all the providers involved in the Member’s care. The discussion must include a conversation explaining the financial impact of using a Non-Participating IONM Provider. A copy of the Non-Participating Provider Consent Form must be provided to the Member. o The discussion must occur no more than 90 days, and no less than 14 days before, the scheduled date of the procedure. o If the Member does not sign the form at the end of the discussion, explain that it needs to be completed and returned no less than 14 days before the scheduled date of the procedure. o The discussion must then be noted in the Member’s medical record.
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Administrative Policy Updates Policy Title
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Jun. 1, 2018
NEW New York & Connecticut Participating Surgeons Using Non- Participating Providers for Intraoperative Neuro-Monitoring (IONM) (continued)
Obtain a completed Non-Participating Provider Consent Form o The member will need to agree or disagree to receive IONM services from a Non-Participating Provider by marking the appropriate box on the Non-Participating Provider Consent Form. The member must then sign and date the form and return the form to the Participating Provider no less than 14 days before the scheduled date of the procedure. If the Member: Does not agree to the use of a Non-Participating IONM Provider: Following the discussion, if the Participating Provider: Is unable to locate a Participating IONM Provider, they must contact the health plan for assistance in locating a Participating IONM Provider. Still wants to recommend the Non-Participating IONM Provider, they must contact Oxford to request and initiate an In-Network Exception request. Does agree to the use of a Non-Participating IONM Provider: The Participating Provider must ensure that the Member understands the financial obligations of using a Non-Participating IONM Provider. For Members with out-of-network benefits: Non-Participating IONM Providers will be paid at the out-of-network benefit level. Out-of-network cost shares and deductibles will apply. In addition, Members may be responsible to the Non-Participating IONM Provider for any amount above the amount paid by the health plan, as determined by the Member’s out-of-network benefit; or For Members with only in-network benefits: Non-Participating IONM Provider claims will be denied because the Member has no coverage for services provided by Non-Participating Providers. Members will therefore be responsible for the entire cost of the service(s). o The Participating Provider must then sign and date the form to acknowledge the Member’s decision. o The Non-Participating Provider Consent Form must be kept on file by the Participating Provider. o A separate Non-Participating Provider Consent Form is required for every service when the Participating Provider wants to refer to or involve a Non-Participating IONM Provider in a member’s care. o The Non-Participating Provider Consent Form will only be valid for 90 days from the date of member signature. o Oxford may request a copy of the completed Non-Participating Provider Consent Form from the Participating Provider (who is required to keep the form on file) in order to conduct standard business. When requested, the Participating Provider must provide a copy of the Non-Participating Provider Consent Form within 15 days of the request. If a copy of the completed Non-Participating Provider Consent Form is not received within 15 days of the request, the Participating Provider’s claim will be denied administratively for failure to comply with this protocol. In these instances, the Participating Provider is prohibited from balance billing the Member. Any payment previously made for the surgical service will be subject to recovery. The Participating provider cannot balance bill the member for claims denied for administrative reasons.
Participating IONM Providers
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Jun. 1, 2018
When a Participating Provider performs services in an outpatient or inpatient facility setting using a Participating IONM Provider, there will be no additional requirements to fulfill. A Non-Participating Provider Consent Form is not required.
NEW New York & Connecticut Participating Surgeons Using Non- Participating Providers for Intraoperative Neuro-Monitoring (IONM) (continued)
Non-Compliance With This Policy Oxford may request a copy of the completed Non-Participating Provider Consent Form from the Participating Provider (who is required to keep the form on file) in order to conduct standard business. When requested: The Participating Provider must provide a copy of the Non-Participating Provider Consent Form within 15 days of the request. If a copy of the completed Non-Participating Provider Consent Form is not received within 15 days of the request, as proof that they discussed the member’s options for selecting a Participating or Non-Participating IONM Provider, in advance of the service, the Participating Provider’s claim will be denied administratively for failure to comply with the protocol. In these instances, the Participating Provider is prohibited from balance billing the member. Any payment previously made for the service will be subject to recovery. The Participating Provider cannot balance bill the member for claims denied for administrative reasons. In-Network Exception Requests If requesting an In-Network Exception to have a Non-Participating IONM Provider covered as if they were participating with the Oxford network, the Participating Provider must make the exception request. The exception request will not be accepted from the Non-Participating IONM Provider. The In-Network Exception request must be made no less than 14 days in advance of the scheduled procedure in order to avoid delays in care and alleviate potential complications with the patient’s required preparations for the procedure. If the Participating Provider requests an In-Network Exception less than 14 days in advance of the scheduled procedure, the In-Network Exception request will be processed per Oxford’s standard guidelines, however the Participating Provider will receive an administrative denial for their claim for failure to follow protocol.
Policy Title
Effective Date
Summary of Changes
Administrative Guidelines
Mar. 1, 2018
In Advance of Any Services Being Rendered You must verbally discuss Provider options and financial impacts with the member: o Review this policy and the Member Advance Notice Form with the member. o Provide participating alternatives and explain the reason for the nonparticipating provider. o Discuss the financial impact of utilizing a non-participating provider.
UPDATED Non-Participating Provider Consent Form Protocol
Reformatted attachments/reference documents; transferred content to embedded PDF format (no change to policy guidelines)
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UPDATED Non-Participating Provider Consent Form Protocol (continued)
Mar. 1, 2018
If the member has out-of-network benefits, they may utilize those benefits to receive services from a non-participating provider, however; they may have higher out-of-pocket costs when using a non-participating provider. Members that do not have out-of-network benefits may be responsible for the entire cost of the service(s) provided by the non-participating provider.
Impacted Provider/Service Types o Ambulatory Surgical Centers (ASC); free-standing and hospital outpatient non-emergent o Assistant surgeon: a physician or other health care professional who is assisting the physician performing a surgical procedure, where the participating surgeon has influence/control over the selection of the assistant surgeon o Home health o Air ambulance; fixed-wing non-emergency transport o Laboratory services; for specimens collected in the physician’s office then sent out to a non-participating laboratory for processing For Oxford New York products members, refer to the Oxford policy New York Participating Provider Laboratory & Pathology Protocol for specific requirements and instructions on nonparticipating laboratory and pathology services. o Outpatient dialysis o Specialty drug vendor
Complete the Member Advance Notice Form If the member elects to use a non-participating provider, complete the Member Advance Notice Form and obtain the member’s signature. o The participating Provider must keep a copy of the signed form on file to present to Oxford upon request. o A separate Member Advance Notice Form is required for each nonparticipating provider/service.
This Protocol does not apply in emergent situations or instances where the care provider or member has obtained an in-network exception to utilize a non-participating physician, facility or other healthcare provider. This Protocol is not intended to deter members from using out-of-network
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Administrative Policy Updates Policy Title
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Summary of Changes
Administrative Guidelines
UPDATED Non-Participating Provider Consent Form Protocol (continued)
Mar. 1, 2018
benefits, if available. Members who have out-of-network benefits can exercise their right to use those benefits at any time.
Policy Title
Effective Date
Summary of Changes
Administrative Guidelines
Apr. 1, 2018
Oxford will cover specialized formula and specialized foods as outlined below.
Administrative Actions for Non-Compliance Oxford will monitor the involvement of the non-participating provider types and services outlined above in our member’s care and may request a copy of the completed Member Advance Notice Form at any time from providers with a pattern of non-participating provider utilization. Compliance with this Protocol will be reviewed by Oxford. Failure to comply with the Protocol may result in appropriate action according to the participation agreement, which may include, but is not limited to, ineligibility for performance based compensation, or termination of your participation agreement.
REVISED Formula & Specialized Food
Revised coverage rationale; updated coverage criteria for: Connecticut (CT) and New Jersey (NJ) Plans o Replaced language indicating “specialized formula will be authorized [for] one of the [listed] conditions” with “specialized formula will be authorized when the specialized formula is medically necessary for the treatment of a disease or condition, including but not limited to one [listed in the policy]” New York (NY) Plans o Replaced language indicating “enteral formulas which are medically necessary and taken under written order from a physician for the treatment of specific
104 Oxford® Policy Update Bulletin: March 2018
Approved authorizations will be issued for one year. CT and NJ Plans Specialized Formula Specialized formula will be authorized when all of the following criteria, one of the conditions, and all of the documentation requirements are met: Criteria: o A physician prescribes the therapy; and o The condition is chronic and is expected to last for an undetermined or prolonged period of time; and o Adequate nutrition is not possible by dietary adjustment; and o Nutritional therapy is provided as replacement therapy; and o The material used is specially formulated as a nutrition replacement; and Individuals who will become malnourished or suffer from severe disorders such as physical disability, mental retardation or death if the medical nutritional therapy is not instituted; and The specialized formula is medically necessary for the treatment of a disease or condition, including but not limited to one of the following:
Oxford
Administrative Policy Updates Policy Title
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REVISED Formula & Specialized Food (continued)
Apr. 1, 2018
diseases shall be distinguished from nutritional supplements taken electively” with “enteral formulas (prescription or nonprescription) which are deemed medically necessary and written under order from a physician for the treatment of specific diseases shall be distinguished from nutritional supplements taken electively” o Added language to indicate nutritional formulas will be authorized for the treatment of phenylketonuria, branched-chain ketonuria, galactosemia, and homocystinuria Updated supporting information to reflect the most current description of services and references
105 Oxford® Policy Update Bulletin: March 2018
Inborn error of metabolism; or Inherited diseases of amino-acid or organic acid metabolism; or Crohn's disease; or Disorders of gastrointestinal motility such as chronic intestinal pseudo-obstruction; or o Severe malabsorptive syndrome; or o Severe food allergies which if left untreated will cause malnourishment, chronic physical disability, mental retardation or death; or Note: See documentation required for severe food allergy. o GE reflux with Failure to Thrive Note: See documentation required for GE reflux with Failure to Thrive. and Required documentation: o For multiple food allergy: Consultation with relevant specialist (Neonatologist, Gastroenterologist or Allergist); and Note: A consultation by a specialist is not required for NJ plans. A requests from the covered infant's physician is sufficient. Diagnosis of multiple food protein allergy; and Note: Multiple food protein intolerance is also acceptable for NJ plans. Office notes indicating failure to tolerate due to severe allergic reaction, or contraindication to available standard: Standard cow milk based formula; and Non-cow milk based formula, (including soybean) o For GE reflux with Failure to Thrive: Consultation with relevant specialist (gastroenterologist or neonatologist); and Note: A consultation by a specialist is not required, for NJ plans. Requests from the covered infant's physician is sufficient. Diagnosis of GE reflux WITH Failure to Thrive. Failure to Thrive is defined as a child: Growing below 3rd or 5th percentile; or Whose decreased growth has crossed 2 major growth percentiles); and Office notes indicating failure to tolerate due to severe allergic reaction or contraindication to available standard: o o o o
Oxford
Administrative Policy Updates Policy Title
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Administrative Guidelines
REVISED Formula & Specialized Food (continued)
Apr. 1, 2018
-
Cow milk based formula; and Non-cow milk based formula, (including soybean)
Specialized Foods Specialized foods (including low protein and amino acid modified food or formula) are covered for inborn errors of metabolism, which includes, but is not limited to, Homocystinuria, Maple syrup urine disease, methylmalonic aciduria, phelylketonuria (PKU), Tyrosinemias, certain inherited diseases of amino acid and organic acid metabolism, and Cystic Fibrosis. Note: Specialized food for members with a diagnosis of Cystic Fibrosis is covered for CT Commercial plans only. NY Plans Enteral Formulas Enteral formulas (prescription or non-prescription) which are deemed medically necessary and written under order from a physician for the treatment of specific diseases shall be distinguished from nutritional supplements taken electively. Enteral formula or modified solid food products will be authorized based on all of the following criteria: Being used as part of disease specific treatment; and Treatment is for one of the following: o Inherited diseases of amino acid and/or organic acid metabolism o Crohn’s Disease o Gastroesophageal reflux disease with Failure to Thrive o Disorders of gastrointestinal motility such as chronic intestinal pseudo-obstruction o Multiple, severe food allergies and One of the following: o Patient is malnourished o Patient will become malnourished without treatment o If patient’s condition is left untreated it will cause one of the following: Chronic physical disability Mental retardation Death
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Administrative Policy Updates Policy Title
Effective Date
Summary of Changes
Administrative Guidelines
REVISED Formula & Specialized Food (continued)
Apr. 1, 2018
In-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy
Apr. 1, 2018
Nutritional Formulas Nutritional formulas will be authorized for the treatment of phenylketonuria, branched-chain ketonuria, galactosemia, and homocystinuria.
Newborns
Apr. 1, 2018
Changed policy type classification from “Clinical” to “Administrative” Revised list of services eligible for in-network exception request; added CPT codes 19330, 19342, and 19355 Reformatted attachment file (Non-Participating Provider Consent Form); transferred content to embedded PDF format
Refer to the policy for complete details on In-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy.
Revised procedures and responsibilities: o Updated language pertaining to New Jersey (NJ) plan members: Changed timeframe for automatic newborn/newly born adopted child coverage with no premium requirement from “first 31 days” to “first 60 days” Changed enrollment period for a newborn/newly born adopted child for members without family or parent/child coverage from “initial 31 day period in order for coverage to continue beyond the 31 days” to
Refer to the policy for complete details on the processes for the enrollment and coverage Newborns.
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Administrative Policy Updates Policy Title
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REVISED Newborns (continued)
Apr. 1, 2018
“initial 60 day period in order for coverage to continue beyond the 60 days” o Updated language pertaining to New York (NY) members on OHP and OHI plans when a newborn is not automatically covered as of their date of birth; replaced language indicating “the member must submit the required proof specifically adding the newborn child and the required premium within 30 days of the date of birth” with “the member must submit the required proof specifically adding the newborn child and the required premium within 31 days of the date of birth” Updated supporting information to reflect the most current references
Precertification Exemptions for Outpatient Services
Apr. 1, 2018
Revised list of CPT codes for Pathology and Laboratory services that do not require precertification in the office or outpatient setting; removed 81520 and 81521 (refer to the policy titled Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions for applicable coverage guidelines)
Refer to the policy for complete details on Precertification Exemptions for Outpatient Services.
Referrals
Apr. 1, 2018
Updated list of related policies to reflect title change for Genetic
Refer to the policy for complete details on the administrative guidelines for Referrals.
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Administrative Policy Updates Policy Title
Effective Date
Summary of Changes
REVISED Referrals (continued)
Apr. 1, 2018
Testing for Hereditary Cancer [previously titled Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC)] Revised procedures and responsibilities: o Modified langauge pertaining to how Referrals are submitted to indicate a Referral can be submitted via phone, EDI or online at OxfordHealth.com; refer to the UnitedHealthcare Provider Administrative Guide, including the Oxford Commercial Supplement, for additional details o Updated exceptions to Referral requirements; modified list of related policies for laboratory services that may require precertification: Added reference links to policies titled: Gene Expression Tests for Cardiac Indications Genetic Testing for Hereditary Cancer Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions Pharmacogenetic Testing Whole Exome and
109 Oxford® Policy Update Bulletin: March 2018
Administrative Guidelines
Oxford
Administrative Policy Updates Policy Title
Effective Date
Summary of Changes
REVISED Referrals (continued)
Apr. 1, 2018
Whole Genome Sequencing Removed reference links to policies titled: Gene Expression Tests Genetic Testing Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC) Molecular Profiling to Guide Cancer Treatment Updated supporting information to reflect the most current references
110 Oxford® Policy Update Bulletin: March 2018
Administrative Guidelines
Oxford
Reimbursement Policy Updates Policy Title
Effective Date
Reimbursement Guidelines
Apr. 1, 2018
Multiple Diagnostic Imaging Reductions (MDIR) Oxford utilizes the CMS NPFS MPI of 4 and Non-Facility Total Relative Value Units (RVUs) to determine which radiology procedures are eligible for MDIR. Different MDIR percentages apply to the PC and TC portion of global services.
NEW Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging
MDIR applies when: Multiple diagnostic imaging procedures with a MPI of 4 are performed on the same patient by the Same Group Physician and/or Other Health Care Professional during the Same Session. A single imaging procedure subject to MDIR is submitted with multiple units. For example, code 73702 is submitted with 2 units. MDIR would apply to the second unit. The units are also subject to Oxford's Maximum Frequency Per Day policy. MDIR will not apply when: The diagnostic imaging procedure is the primary procedure as ranked based on the RVU assigned to the code (and modifier, when applicable), compared to other diagnostic imaging procedures billed during the Same Session. Multiple diagnostic imaging procedures are billed, appended with Modifier 59 or Modifier XE to indicate the procedure was performed on the same day but not during the Same Session. Multiple diagnostic imaging procedures are billed for the same patient on the same day but not by the Same Group Physician and/or Other Health Care Professional during the Same Session. The imaging service does not have an MPI of 4. See the Diagnostic Imaging Procedures Subject to Multiple Imaging Reduction Lists in the Attachments section of the policy. Multiple Diagnostic Imaging Reduction Percentages When the TC for two or more imaging procedures subject to MDIR are performed on the same patient by the Same Group Physician and/or Other Health Care Professional during the Same Session, Oxford will reduce the Allowed Amount for the TC of the second and each subsequent procedure by 50%. Oxford will regard the TC portion of the procedure(s) with the lower TC total RVUs, as subject to MDIR. In addition, when the PC for two or more imaging procedures subject to MDIR are performed on the same patient by the Same Group Physician and/or Other Health Care Professional at the Same Session, Oxford will reduce the Allowed Amount for the PC of the second and each subsequent procedure by 5% . The reduction is applied to the Allowed Amount for the PC component of the second and subsequent procedures. Oxford will regard the PC portion of the procedure(s) with the lower PC total RVUs, as subject to MDIR. Multiple Diagnostic Imaging Procedures Billed Globally When a provider bills globally for two or more procedures subject to MDIR, for a patient at the Same Session, the charge for the Global Procedure Codes will be divided into the PC and TC (indicated by modifiers 26 and TC) using Oxford's standard Professional/Technical percentage splits. The RVUs assigned to each component (26 or TC) will
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Reimbursement Guidelines
Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging (continued)
Apr. 1, 2018
determine which code will be ranked as primary, with no reduction applied, and those that will be ranked as secondary or subsequent, with reductions applied in accordance with this policy. The components (26 or TC) will be ranked independently of each other utilizing the CMS Non-Facility Total RVUs.
Policy Title
Effective Date
Summary of Changes
Reimbursement Guidelines
UPDATED After Hours and Weekend Care
Apr. 1, 2018
The Centers for Medicare and Medicaid Services (CMS) considers reimbursement for Current Procedural Terminology (CPT®) codes 99050, 99051, 99053, 99056, 99058 and 99060 to be bundled into payment for other services provided on the same day.
NEW
Updated policy application guidelines; added language to clarify this policy applies to: o Services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form o All products
CPT Codes 99051, 99053, 99056, 99058, or 99060 Consistent with CMS and with the intent of this policy, Oxford will not separately reimburse CPT codes 99051, 99053, 99056, 99058 or 99060. CPT Code 99050 Although CMS considers CPT code 99050 to be bundled into the payment for other services provided on the same day, Oxford will provide additional compensation to participating primary care providers for seeing patients in situations that would otherwise require more costly urgent care or emergency room settings by reimbursing CPT code 99050 in addition to basic service codes. Oxford will reimburse after hours CPT code 99050 to participating primary care providers when reported with basic services in one of the following CMS non-facility place of service (POS) designations only: POS Code 03
112 Oxford® Policy Update Bulletin: March 2018
Description School
05
Indian health service free-standing facility
07
Tribal 638 free-standing facility
11
Office
49
Independent clinic
50
Federally qualified health center
Oxford
Reimbursement Policy Updates Policy Title
Effective Date
Summary of Changes
Reimbursement Guidelines
UPDATED After Hours and Weekend Care (continued)
Apr. 1, 2018
71
State or local public health clinic
72
Rural health clinic
Oxford will reimburse the following participating primary care providers for CPT 99050: Adolescent medicine, pediatric-adolescent, pediatrics Family nurse practitioner, nurse practitioner, pediatric nurse practitioner, advanced registered nurse practitioner Family practice General practice Geriatric medicine Gynecology, obstetrics & gynecology, obstetrics Internal medicine Certified nurse midwife Evaluation and Management (E/M)
Mar. 1, 2018
Routine review; no content changes
All E/M Services When assigning an E/M Level of Service for a patient Encounter, significant factors to consider are the nature of the presenting problem (NoPP) and the complexity of medical decision making (MDM). The expectation of documentation necessary to substantiate the claim as billed will follow the general principles of medical record documentation which apply to all types of medical and surgical services in all settings. While E/M services vary in several ways, such as the nature and amount of physician work required, the following general principles help ensure that medical record documentation for all E/M services is appropriate: The medical record should be complete and legible; The documentation of each patient Encounter should include but not be limited to: o Reason for the Encounter and relevant history, physical examination findings, and prior diagnostic test results; o Assessment, clinical impression, or diagnosis; o Medical plan of care; o Date and legible identity of the observer; o If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred; o Past and present diagnoses should be accessible to the treating and/or consulting physician; o Appropriate health risk factors should be identified;
113 Oxford® Policy Update Bulletin: March 2018
Oxford
Reimbursement Policy Updates Policy Title
Effective Date
Summary of Changes
Reimbursement Guidelines
UPDATED Evaluation and Management (E/M) (continued)
Mar. 1, 2018
o o
o
The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented; The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by documentation in the medical record; Review of past medical records must include a summary of relevant information gleaned from this review in order to receive credit in the Amount and Complexity of Data section.
While there is no prohibition on the use of proprietary templates, documentation from either an electronic health record (EHR) or hard-copy that appears to be cloned (selected information from one source and replicated in another location by copy/paste methods) from another record, including but not limited to history of present illness (HPI), exam, and MDM, would not be acceptable documentation to support the claim as billed. For example, HPI should be the provider’s individual description of the development of the patient’s present illness from the first sign and/or symptom, or from the previous Encounter to the present; the exam should be the individual description of the patient’s exam at the time of the Encounter and MDM should also be individualized to the Encounter for the patient to outline a specific assessment and plan of care. Medical record documentation should be provided upon request. E/M Services Performed in an Emergency Department (ER/ED) Place of Service CPT codes 99281-99285 are used to report E/M services rendered in an ER/ED place of service. Evaluating for level of care appropriateness for these codes in an ER/ED place of service includes a review of the tests and management options that are available to be performed during the initial visit. The 1995 CMS Documentation Guidelines state that the number of diagnoses and management options that must be considered "...is based on the number and types of problems addressed during the Encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician." Additional Work-Up Planned is an element of review which includes a number of diagnoses and management options. The
114 Oxford® Policy Update Bulletin: March 2018
Oxford
Reimbursement Policy Updates Policy Title
Effective Date
Summary of Changes
Reimbursement Guidelines
UPDATED Evaluation and Management (E/M) (continued)
Mar. 1, 2018
Additional Work-Up Planned” element contributes to indicating the complexity of a patient based on the clinician's utilization of diagnostic tests. Oxford utilizes the industry standard guidelines to determine the appropriate level of care is as follows: Number of Diagnoses and Management Options Self-Limiting or Minor Problems (Stable, Improved or Worsening). Max of 2 points can be given
Points Assigned 1
Established Problem – Stable Improved
1
Established Problem – Worsening
2
New Problem – No Additional Work-Up Planned. Max of 1 point can be given
3
New Problem – Additional Work-Up Planned
4
A provider receives 3 points for “New Problem, No Additional Work-Up Planned,” and 4 points for “New Problem, Additional Work-Up Planned.” This one-point difference can affect whether a level 4 or level 5 code is appropriate. Please note that all Encounters with ED patients are considered “New Problem” Encounters for purposes of scoring. An example of Additional Work-Up Planned, is if the physician schedules testing him/herself or communicates directly with the patient’s primary physician or representative the need for testing which is to be done after discharge from the ED, and the appropriate documentation has been recorded. Credit for “Additional Work-up” Planned is granted (4 points assigned). Credit is not given for the work up if it occurs during the ER Encounter. This interpretation is consistent with the level 5 code description that “…Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function…”. Patients admitted to the hospital under the care of a physician other than the ER physician may have testing done as part of the admitting physician’s care for that patient. The ER physician will not receive credit for the Additional WorkUp Planned done under the care of the admitting physician. Routine review; no content changes Increased Procedural Services
Mar. 1, 2018
Updated list of related policies; added reference link to policy titled Robotic Assisted Surgery
115 Oxford® Policy Update Bulletin: March 2018
Oxford's standard for additional reimbursement of Modifier 22 (increased procedural services) and/or Modifier 63 (procedures performed on infants less than 4 kg) is 20% of the Allowable Amount for the unmodified
Oxford
Reimbursement Policy Updates Policy Title
Effective Date
Summary of Changes
Reimbursement Guidelines
UPDATED Increased Procedural Services (continued)
Mar. 1, 2018
procedure, not to exceed the billed charges. Claims submitted with these modifiers must include medical record documentation which supports the use of the modifiers and which will be reviewed by Oxford in accordance with this policy. Note: When both Modifier 22 and Modifier 63 are appended to the same CPT code, reimbursement will be a total of an additional 20% of the Allowable Amount of the unmodified procedure, not to exceed the billed charges, provided the documentation supports use of either Modifier 22 or Modifier 63. Refer to the Obstetrical Policy for information on the use of Modifier 22 with obstetrical services. Modifier 22 - Increased Procedural Services In order to be considered for additional reimbursement when reporting Modifier 22, thorough medical records or reports and a separate document containing a concise statement about how the service differed from the usual service or procedure is required. The documents must indicate the substantial additional work performed and the reason for the additional work which may include, but not be limited to, increased intensity or time, technical difficulty of procedure that is not described by a more comprehensive procedure code, severity of the patient’s condition, or increased physical and mental effort required. Additional reimbursement will only be considered for services appended with Modifier 22 that are assigned a global period of 0, 10, 42 or 90 days. Modifier 22 should not be appended to an evaluation and management service. Refer to the “Global Days Policy” for a listing of those codes with a global day period. Modifier 63 - Procedure Performed on Infants Less Than 4 kg In order to be considered for additional reimbursement when reporting Modifier 63, thorough medical record(s) or report(s) that support the use of the modifier is required. The document(s) must indicate the substantial additional work performed and the reason for the additional work which may include, but not be limited to, increased intensity or time, technical difficulty of procedure that is not described by a more comprehensive procedure code, severity of the patient’s condition, or increased physical and mental effort
116 Oxford® Policy Update Bulletin: March 2018
Oxford
Reimbursement Policy Updates Policy Title
Effective Date
Summary of Changes
Reimbursement Guidelines
UPDATED Increased Procedural Services (continued)
Mar. 1, 2018
Modifier SU
Apr. 1, 2018
required. Unless otherwise designated, this modifier may only be appended to procedures/services listed in the 20005-69990 code series. Modifier 63 should not be appended to any CPT code listed in the Evaluation and Management Services, Anesthesia, Radiology, Pathology/Laboratory, or Medicine sections.
Updated policy application guidelines; added language to clarify this policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form
The Centers for Medicare and Medicaid Services (CMS) indicates that the Health Care Common Procedure Coding System (HCPCS) modifier SU, Procedure performed in physician's office (to denote use of facility and equipment), is not payable. CMS establishes Relative Value Units (RVU) for CPT and HCPCS codes that include the costs of running an office (such as rent, equipment, supplies and non-physician staff costs) which are referred to as the practice expense RVU. In accordance with CMS, Oxford does not allow reimbursement for services appended with modifier SU in an office place of service, since the use of the office facility and equipment is included in the practice expense RVU, or the costs associated with operating an office. If the charges associated with the use of the modifier SU are submitted by a different provider than the physician performing the office procedure, they will not be considered for separate reimbursement since these practice expenses are considered included in the reimbursement for the physician performing the service.
Nonphysician Health Care Codes
Apr. 1, 2018
Updated policy application guidelines; added language to clairfy this policy applies to: o Services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form o All products
117 Oxford® Policy Update Bulletin: March 2018
The American Medical Association Current Procedural Terminology (CPT®) Professional Edition gives the following instruction for code selection: “Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided.” The American Medical Association (AMA) has developed specific CPT codes intended for use by qualified health care professionals who are not Physicians to report their services. In some instances the intended use of a procedure or service is within the description of the code. For example CPT 98960 describes education and training for patient self-management by a qualified, nonphysician health care professional. In other instances the AMA has included parenthetical information in the CPT book as with CPT 96040 which says “These services are provided by trained genetic counselors and may include obtaining a structured family genetic history, pedigree construction,
Oxford
Reimbursement Policy Updates Policy Title
Effective Date
Summary of Changes
Reimbursement Guidelines
UPDATED Nonphysician Health Care Codes (continued)
Apr. 1, 2018
analysis for genetic risk assessment, and counseling of the patient and family.” Conversely, the AMA instructs Physicians who provide genetic counseling and education, risk factor reduction intervention or medical nutrition therapy to use the appropriate evaluation and management codes to report these services. Existing evaluation and management codes include services such as taking a patient’s health and family history and counseling. Therefore, in accordance with correct coding guidelines, Oxford will not reimburse nonphysician health care professional service codes (listed in the Applicable Codes section of the policy) when reported by a Physician, because these codes are intended for use by nonphysician health care professionals. Physicians who provide genetic counseling, health and behavior assessment/intervention, medical nutrition therapy or education and training for patient self-management should report these services using evaluation and management codes.
Observation Care Evaluation and Management Codes
Apr. 1, 2018
Updated policy application guidelines; added language to clarify: o This policy applies to: Services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form All products o This policy does not apply to claims billed on the UB-04 form
118 Oxford® Policy Update Bulletin: March 2018
Initial Observation Care The physician supervising the care of the patient designated as "observation status" is the only physician who can report an initial Observation Care CPT code (99218-99220). It is not necessary that the patient be located in an observation area designated by the hospital, although in order to report the Observation Care codes the physician must: Indicate in the patient's medical record that the patient is designated or admitted as observation status; Clearly document the reason for the patient to be admitted to observation status; and Initiate the observations status, assess, establish and supervise the care plan for observation and perform periodic reassessments. The CPT codebook states that "When "observation status" is initiated in the course of an encounter in another site of service (e.g., hospital emergency department, office, nursing facility) all evaluation and management services provided by the supervising physician or other qualified health care professional in conjunction with initiating "observation status" are considered part of the initial Observation Care when performed on the same date. The Observation Care level of service reported by the supervising physician should include the services related to initiating "observation status" provided in the other sites of services as well as in the observation setting."
Oxford
Reimbursement Policy Updates Policy Title
Effective Date
Summary of Changes
Reimbursement Guidelines
UPDATED Observation Care Evaluation and Management Codes (continued)
Apr. 1, 2018
Oxford follows the Centers for Medicare and Medicaid Services' (CMS) Claims Processing Manual which provides the instructions, "for a physician to bill the initial Observation Care codes [99218-99220], there must be a medical observation record for the patient which contains dated and timed physician's admitting orders regarding the care the patient is to receive while in observation, nursing notes, and progress notes prepared by the physician while the patient was in observation status. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter." Consistent with CMS guidelines, Oxford requires that an Initial Observation Care CPT code (99218-99220) should be reported for a patient admitted to Observation Care for less than 8 hours on the same calendar date. Subsequent Observation Care In the instance that a patient is held in observation status for more than two calendar dates, the supervising physician should utilize a subsequent Observation Care CPT code (99224-99226). Physicians other than the supervising physician providing care to a patient designated as "observation status" should report subsequent Observation Care. According to the CPT codebook, “All levels of subsequent Observation Care include reviewing the medical record and reviewing the results of diagnostic studies and changes in the patient's status (i.e., changes in history, physical conditions, and response to management) since the last assessment.” Observation Care Discharge Services Per CPT, Observation Care discharge day management CPT code 99217 "includes final examination of the patient, discussion of the hospital stay, instructions for continuing care and preparation of discharge records." Observation Care discharge services include all E/M services on the date of discharge from observation services and should only be reported if the discharge from observation status is on a date other than the date of initial Observation Care. Oxford follows CMS guidelines that physicians should not report an Observation Care discharge Service when the Observation Care is a minimum of 8 hours and less than 24 hours and the patient is discharged on
119 Oxford® Policy Update Bulletin: March 2018
Oxford
Reimbursement Policy Updates Policy Title
Effective Date
Summary of Changes
Reimbursement Guidelines
UPDATED Observation Care Evaluation and Management Codes (continued)
Apr. 1, 2018
the same calendar date. Observation Care Admission and Discharge Services on Same Date Physicians who admit a patient to Observation Care for a minimum of 8 hours, but less than 24 hours and subsequently discharge on the same calendar date shall report an Observation or Inpatient Care Service (Including Admission and Discharge Services) CPT code (99234-99236). In accordance with CMS' Claims Processing Manual, when reporting an Observation Care admission and discharge service CPT code (99234-99236) the medical record must include: Documentation meeting the E/M requirements for history, examination and medical decision making; Documentation stating the stay for hospital treatment or Observation Care status involves 8 hours but less than 24 hours; Documentation identifying the billing physician was present and personally performed the services; and Documentation identifying that the admission and discharge notes were written by the billing physician. Observation Care Services During a Surgical Period Observation Care codes are not separately reimbursable services when performed within the assigned global period as these codes are included in the global package. Refer to the Oxford policy titled Global Days for guidelines on reporting services during a global period.
Obstetrical Policy
Apr. 1, 2018
Updated policy application guidelines; added language to clarify this policy applies to: o Services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form o All products Updated Questions & Answers (Q&A):
120 Oxford® Policy Update Bulletin: March 2018
Refer to the Obstetrical Policy for complete details on applicable coverage guidelines.
Oxford
Reimbursement Policy Updates Policy Title
Effective Date
Summary of Changes
Reimbursement Guidelines
UPDATED Obstetrical Policy (continued)
Apr. 1, 2018
o
o
Standby Services
Apr. 1, 2018
Modified Q&A #7; updated list of CPT codes for contraceptive management services that are separately reimbursable during the postpartum period: Added 11981 Removed 11975 Modified Q&A #9; replaced reference to “provider” with “physician”
Updated policy application guidelines; removed language indicating this policy applies to: o Services reported using the UB-04 Claim Form o Hospitals and ambulatory surgical centers
Centers for Medicare and Medicaid Services The Centers for Medicare and Medicaid Services (CMS) does not reimburse for physician standby services. These services are considered by CMS to be included in the payment to a facility as part of providing quality care and are not separately reimbursable. Standby Services In accordance with CMS, Oxford does not reimburse physician or other qualified health care professional standby services submitted with CPT code 99360. If a specific service is directly rendered to the patient by the standby physician or other qualified health care professional (i.e., tissue examination of frozen section biopsy), the service or procedure would be reported under the appropriate CPT code (i.e., 88331). Mandated Hospital On-Call Service Oxford does not reimburse for hospital mandated on-call services billed under CPT codes 99026 and 99027 because they do not involve direct patient contact.
Wrong Surgical or Other Invasive Procedures
Mar. 1, 2018
Routine review; no content changes
Similar to any other patient population, Oxford members experience serious injury and/or death if wrong surgeries are performed and may require additional healthcare in order to correct adverse outcomes resulting from such errors. This Oxford reimbursement policy is based on information stated by CMS in its National Coverage Decision (NCD) 140.6 for Wrong Surgical or Other Invasive Procedure Performed on a Patient and is in alignment with the Leapfrog Group and the National Quality Forum (NQF) position on Serious
121 Oxford® Policy Update Bulletin: March 2018
Oxford
Reimbursement Policy Updates Policy Title
Effective Date
Summary of Changes
Reimbursement Guidelines
UPDATED Wrong Surgical or Other Invasive Procedures (continued)
Mar. 1, 2018
Reportable Events in Healthcare. For more information see the NQF and Leapfrog Group websites in the References section of the policy. Oxford will not reimburse for a Wrong Surgical or Other Invasive Procedure Performed on a Patient when the physician or other healthcare professional erroneously performs: 1) a different procedure altogether; 2) the correct procedure but on the wrong body part; or 3) the correct procedure but on the wrong patient. Oxford will not reimburse for related services associated with these Wrong Surgical or Other Invasive Procedures Performed on a Patient. Related services which will not be reimbursed include: All services provided in the operating room related to the error All providers in the operating room when the error occurs, who could bill individually for their services All related services provided during the same hospitalization in which the error occurred The rendering physician and all other providers performing services related to the erroneously performed procedure are expected to waive all costs associated with the Wrong Surgical or Other Invasive procedure. Participating providers may not bill or collect payment from Oxford members for any amounts not paid due to the application of this reimbursement policy. Related services do not include: Services provided following hospital discharge, regardless of whether they are related to the surgical error Performance of the correct procedure Submission of Claims Consistent with CMS billing requirements, Oxford requires the reporting of these Wrong Surgery or Other Invasive Procedures Performed on a Patient in the manner described below. Hospital Inpatient Claims Hospitals are required to submit a no-pay claim (Type of Bill 110) to report all charges associated with the erroneous surgery. However, if there are also non-related services/procedures provided during the same stay as the erroneous surgery, hospitals are then required to submit two claims, one
122 Oxford® Policy Update Bulletin: March 2018
Oxford
Reimbursement Policy Updates Policy Title
Effective Date
Summary of Changes
Reimbursement Guidelines
UPDATED Wrong Surgical or Other Invasive Procedures (continued)
Mar. 1, 2018
claim with services or procedures unrelated to the erroneous surgery and the other claim with the erroneous services/procedures as a no-pay claim. The non-covered Type of Bill 110 must have one of the following ICD-10-CM diagnosis codes reported on the hospital claim to identify the type of erroneous surgery performed. These codes shall not be reported in the External Cause of Injury (E-code) field. Y65.51 - Performance of wrong procedure (operation) on correct patient Y65.52 - Performance of procedure (operation) on patient not scheduled for surgery Y65.53 - Performance of correct procedure (operation) on wrong side of body parts Hospital Outpatient, Ambulatory Surgery Center (ASC), and Professional/1500 Claims Outpatient, ASCs and physicians or other health care professionals must report the applicable HCPCS modifier(s) with the associated charges on all lines related to the surgical error: PA: Surgery Wrong Body Part PB: Surgery Wrong Patient PC: Wrong Surgery on Patient
Policy Title
Effective Date
Summary of Changes
Reimbursement Guidelines
Apr. 1, 2018
All codes published on the NPFS Relative Value File are assigned a status code. The status code indicates whether the code is separately payable if the service is covered. Per the public use file that accompanies the NPFS Relative Value File, the following is stated for the status code B: "Payment for covered services is always bundled into payment for other services not specified. If RVUs are shown, they are not used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. (An example is a telephone call from a hospital nurse regarding care of a patient)."
REVISED B Bundle Codes
Revised B Bundle Code List (attachment file listing codes assigned status code “B” and included in Oxford’s B Bundle Codes Policy); removed CPT code 99091
Consistent with CMS, Oxford will not separately reimburse for specific Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes assigned a status code “B” on the NPFS Relative Value File indicating a bundled procedure. B Bundle Codes are not
123 Oxford® Policy Update Bulletin: March 2018
Oxford
Reimbursement Policy Updates Policy Title
Effective Date
Summary of Changes
Reimbursement Guidelines
REVISED B Bundle Codes (continued)
Apr. 1, 2018
Drug Testing
Mar. 1, 2018
reimbursable services regardless of whether they are billed alone or in conjunction with other services. The codes which Oxford has included in this policy (for which separate reimbursement is not made) can be found in the Attachments section of the policy. Notice of Revision: The following summary of changes has been modified. The revisions noted in red below will not be applied on Mar. 1, 2018 as previously announced. Please take note of the amended guidelines to be implemented on Mar. 1, 2018.
This policy enforces the code description for presumptive and definitive drug testing in that the service should be reported once per day and it includes specimen validity testing.
Presumptive drug testing, also known as drug screening, is used when necessary to determine the presence or absence of drugs or a Drug Class. Results are expressed as negative or positive. The methodology is considered when coding presumptive procedures. Per CPT guidelines each presumptive drug testing code represents all drug and Drug Class tests performed by the respective methodology per date of service. The test is a single per patient service that should only be reported once irrespective of the number of Drug Class procedures or results on any date of service.
Updated policy overview; added language to indicate this policy defines daily and annual limits for presumptive (CPT® codes 80305, 80306, and 80307) and definitive drug testing (HCPCS codes G0480, G0481, G0482, G0483 and G0659) and addresses Specimen Validity Testing Revised reimbursement guidelines; added language to indicate: o This policy provides annual units of service (UOS) limits o For Connecticut (CT) Small and Large Group plans, an annual frequency UOS limitation of 18 dates of service will be applied for presumptive drug testing In addition, an annual frequency UOS limitation of 18 dates of service will be applied for definitive drug testing
124 Oxford® Policy Update Bulletin: March 2018
Clinical drug testing is used in pain management and in substance abuse screening and treatment programs. The testing may be used to detect prescribed, therapeutic drugs, prescription drugs of abuse, illicit drugs, and/or other substances such as nicotine.
Definitive drug testing, also known as confirmation testing, is used when it is necessary to identify specific medications, illicit substances and metabolites. Definitive urine drug test (UDT) reports the results of drugs absent or present in concentrations of ng/ml. Definitive drug testing is qualitative or quantitative to identify possible use or non-use of a drug. These tests identify specific drugs and associated metabolites. A presumptive drug test is not required to be provided prior to a definitive drug test. Consistent with CMS, definitive drug testing CPT codes 80320-80377 and H0003 are considered non-reimbursable and the appropriate HCPCS G0480G0483,G0659, 0006U, 0007U, 0011U and 0020U should be reported. The HCPCS codes describe a per day service that represents the total number of different Drug Classes performed. Some examples of drugs or a Drug Class that are commonly assayed by presumptive tests, followed by definitive testing are: alcohols, amphetamines, barbiturates/sedatives, benzodiazepines, cocaine and metabolites, methadone, antihistamines, stimulants, opioid analgesics,
Oxford
Reimbursement Policy Updates Policy Title
Effective Date
Summary of Changes
Reimbursement Guidelines
REVISED Drug Testing (continued)
Apr. 1, 2018
Reimbursement for Comprehensive and Component CPT Codes (CES)
Mar. 1, 2018
These limits are applied whether services are applied by the same or different providers o Drug testing services that are determined to be court ordered and/or funded by a county, state or federal agency will continue to be denied; for additional information refer to the policy titled Services and Modifiers Not Reimbursable to Healthcare Professionals Updated Questions & Answers (Q&A); added Q&A #4 addressing reimbursement for multiple presumptive and/or definitive drug tests submitted on the same date of service for CT members
salicylates, cardiovascular drugs, antipsychotics, and cyclic antidepressants.
Revised procedures and responsibilities: o Replaced language indicating “to rebundle a claim, Oxford claims system utilizes a software package assembled by IntelliClaim (owned by McKesson Health Solutions)” with “to rebundle a claim, Oxford claims system utilizes a claims editing software product called Optum™ Claims Editing System (CES)” o Removed language indicating:
When two or more related procedures are performed on a patient during a single session or visit, Oxford will reimburse the provider for the comprehensive code and deny or adjust the component, incidental or Mutually Exclusive Procedure performed during the same session. The Rebundling guidelines in this policy are based on The Correct Coding Initiative administered through the Centers for Medicare & Medicaid Services (CMS), AMA Current Procedural Terminology (CPT Code) and additional general industry accepted guidelines.
125 Oxford® Policy Update Bulletin: March 2018
In accordance with the code descriptions and the CPT and CMS guidelines, Oxford will only allow one drug test within the presumptive Drug Class and one drug test within the definitive Drug Class per date of service by the same or different provider. Specimen Validity Testing to assure that a specimen has not been compromised or that a test has not been adulterated may be required. However, Specimen Validity Testing is included in the presumptive and definitive drug testing CPT and HCPCS code descriptions and is considered a quality control which is an integral part of the collection process and is not separately reimbursable. Oxford will deny Specimen Validity Testing when performed on the same date of service as a presumptive and/or definitive drug test by the same or different provider. A modifier may be appropriate when a service commonly used for Specimen Validity Testing is performed distinctly separate from the drug test service and the documentation supports the service was not related to the drug testing. Drug testing services that are determined to be court ordered and/or funded by a county, state or federal agency will continue to be denied. For additional information, refer to the policy titled Services and Modifiers Not Reimbursable to Healthcare Professionals.
To rebundle a claim, Oxford claims system utilizes a claims editing software product called Optum™ Claims Editing System (CES). Optum™ Claims Editing provides an extensive set of core rules that utilize historical data to maximize auditing capabilities for claims. This system features flexible editing functions and complete customization capabilities that allow Oxford to develop, customize and update our payment guidelines as necessary. CES contains edits for both professional and facility claims that are specific to
Oxford
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Effective Date
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REVISED Reimbursement for Comprehensive and Component CPT Codes (CES) (continued)
Mar. 1, 2018
IntelliClaim's product provides a platform on which two off-the-shelf and widely used products (referenced below) are combined with a flexible environment that allows Oxford to develop, customize & update our payment guidelines as necessary Through their product, the efficiency, accuracy and speed with which millions of edits can be applied, the detailed documentation supporting the logic behind the rules, and the clear explanations for claim adjustments result in more automated claim processing, faster turnaround, more consistent and understandable results, and improved customer service As part of the IntelliClaim package, IntelliClaim has incorporated two software packages to rebundle codes; these software packages are the Correct Coding Initiative Software by The National Technical
126 Oxford® Policy Update Bulletin: March 2018
each claim type. The NTIS software provides Oxford with the Correct Coding Rules used by CMS. This software is the same software product used by fiscal intermediaries that process Medicare Fee for Service claims for CMS. The Correct Coding Rules can be found on CMS's website at www.cms.gov. The CES software incorporates the quarterly updates that CMS makes to the Correct Coding rules into Oxford's claims processing system. CES contains rules consisting of, among other things, characterizes coding relationships on provider medical bills. CES provides information that allows claims submitters, claims processors and adjudicators to identify potentially incorrect or inappropriate coding relationships by a single provider, for a single patient, on a single date of service. Examples of the rules include incidental, mutually exclusive, Unbundling and visit edits. Sources of the workbook rules include the AMA and CPT publications, CMS andspecialty societies. Please note this Reimbursement policy is subject to Oxford's reimbursement policies and rules. Refer to the Modifier Reference policy for additional information.
Oxford
Reimbursement Policy Updates Policy Title
Effective Date
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REVISED Reimbursement for Comprehensive and Component CPT Codes (CES) (continued)
Mar. 1, 2018
Information Service (NTIS) and effective October 6, 2006, ClaimsXten™ by McKesson o Added language to indicate: Optum™ Claims Editing provides an extensive set of core rules that utilize historical data to maximize auditing capabilities for claims This system features flexible editing functions and complete customization capabilities that allow Oxford to develop, customize and update our payment guidelines as necessary CES contains edits for both professional and facility claims that are specific to each claim type o Replaced references to: “IntelliClaim” and “ClaimsXten” with “CES” “KnowledgePacks” with “rules/workbook rules” o Updated list of sources for workbook rules; removed “McKesson physician consultants” Updated supporting information to reflect the most current references
127 Oxford® Policy Update Bulletin: March 2018
Reimbursement Guidelines
Oxford
Reimbursement Policy Updates Policy Title
Effective Date
Summary of Changes
RETIRED/REPLACED Advanced Practice Provider Evaluation and Management Procedures
Mar. 1, 2018
This policy is being retired, as it is currently under review. If the policy is reinstated in the future, it will follow our standard new policy notification guidelines.
Multiple Imaging Rules
Apr. 1, 2018
This policy is being replaced; refer to the policy titled Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging for applicable reimbursement guidelines effective Apr. 1, 2018.
128 Oxford® Policy Update Bulletin: March 2018
