Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines – Effective Jan. 1, 2020 ................................................................. 11 Injection and Infusion Services – Effective Feb. 1, 2020 ...................................................................................................................................... 11 Injection and Infusion Services (CES) – Effective Feb. 1, 2020 ............................................................................................................................. 11 Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions – Effective Jan. 1, 2020 ......................................................... 11 Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Procedures – Effective Jan. 1, 2020 .......................... 11 Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging – Effective Jan. 1, 2020 ................................................................................ 12 Multiple Procedures Payment Reduction (MPPR) for Medical and Surgical Services – Effective Jan. 1, 2020 ................................................................ 12 Nonphysician Health Care Codes – Effective Jan. 21, 2020 ................................................................................................................................... 12 Occipital Neuralgia and Headache Treatment – Effective Jan. 1, 2020 ................................................................................................................... 12 Omnibus Codes – Effective Jan. 1, 2020 ............................................................................................................................................................ 13 Outpatient Surgical Procedures – Site of Service – Effective Jan. 1, 2020 .............................................................................................................. 13 Oxford's Outpatient Imaging Self-Referral – Effective Jan. 1, 2020 ....................................................................................................................... 13 Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction – Effective Jan. 1, 2020 ........................................................................... 13 Precertification Exemptions for Outpatient Services – Effective Jan. 1, 2020 .......................................................................................................... 13 Preventive Care Services – Effective Jan. 1, 2020 ............................................................................................................................................... 14 Procedure and Place of Service – Effective Jan. 21, 2020 ..................................................................................................................................... 14 Professional/Technical Component (CES) – Effective Jan. 1, 2020 ......................................................................................................................... 14 Prolonged Services – Effective Jan. 21, 2020 ..................................................................................................................................................... 15 Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs – Effective Jan. 1, 2020 ......................................................................... 15 Radiology Procedures Requiring Precertification for eviCore healthcare Arrangement – Effective Jan. 1, 2020 ............................................................ 15 Radiopharmaceuticals and Contrast Media – Effective Jan. 1, 2020 ....................................................................................................................... 15 Replacement Codes – Effective Jan. 1, 2020 ...................................................................................................................................................... 15 Services and Modifiers Not Reimbursable to Healthcare Professionals – Effective Jan. 1, 2020 .................................................................................. 15 Site of Service Differential – Effective Jan. 1, 2020 ............................................................................................................................................. 15 Speech Therapy and Early Intervention Programs/Birth to Three – Effective Jan. 1, 2020 ........................................................................................ 15 T Status Codes – Effective Jan. 1, 2020 ............................................................................................................................................................. 16 T Status Codes (CES) – Effective Jan. 1, 2020.................................................................................................................................................... 16 Telehealth and Telemedicine – Effective Feb. 1, 2020 .......................................................................................................................................... 16 Telehealth and Telemedicine (CES) – Effective Feb. 1, 2020 ................................................................................................................................ 17 Time Span Codes – Effective Jan. 21, 2020 ........................................................................................................................................................ 17 Total Artificial Disc Replacement for the Spine – Effective Jan. 1, 2020 .................................................................................................................. 17 Transcatheter Heart Valve Procedures – Effective Jan. 1, 2020 ............................................................................................................................. 17 Zulresso™ (Brexanolone) – Effective Jan. 1, 2020 .............................................................................................................................................. 17
Clinical Policy Updates
TAKE NOTE
Effective Date Postponed for MRI and CT Scan – Site of Service ........................................................................................................................... 18
3 Oxford® Policy Update Bulletin: January 2020
Oxford
NEW
Reblozyl® (Luspatercept-Aamt) – Effective Feb. 1, 2020 ...................................................................................................................................... 18 Tysabri® (Natalizumab) – Effective Apr. 1, 2020 ................................................................................................................................................. 19 Vertebral Body Tethering for Scoliosis – Effective Mar. 1, 2020 ............................................................................................................................ 21
Ambulance – Effective Feb. 1, 2020 .................................................................................................................................................................. 83 Injection and Infusion Services – Effective Feb. 1, 2020 ...................................................................................................................................... 85 Injection and Infusion Services (CES) – Effective Feb. 1, 2020 ............................................................................................................................. 87 Maximum Frequency Per Day – Effective Feb. 1, 2020 ........................................................................................................................................ 89 Maximum Frequency Per Day (CES) – Effective Feb. 1, 2020 ............................................................................................................................... 92 Modifier Reference – Effective Feb. 1, 2020 ....................................................................................................................................................... 94 Modifier Reference (CES) – Effective Feb. 1, 2020 .............................................................................................................................................. 95 Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Procedures – Effective Feb. 1, 2020 .......................... 96 Reduced Services (CES) – Effective Feb. 1, 2020 ................................................................................................................................................ 98 Supply Policy – Effective Feb. 1, 2020 ............................................................................................................................................................... 98 Telehealth and Telemedicine – Effective Feb. 1, 2020 ......................................................................................................................................... 100 Telehealth and Telemedicine (CES) – Effective Feb. 1, 2020 ............................................................................................................................... 106
8 Oxford® Policy Update Bulletin: January 2020
Take Note
Oxford
ANNUAL CDT®, CPT®, AND HCPCS CODE UPDATES
The following Clinical, Administrative, and Reimbursement Policies have been modified to reflect the 2020 Current Dental Terminology (CDT®), Current Procedural Terminology (CPT®), and Healthcare Common Procedure Coding System (HCPCS) code additions, revisions, and deletions. Refer to the following sources for information on the 2020 code updates:
American Dental Association®. Current Dental Terminology: CDT®
American Medical Association. Current Procedural Terminology: CPT®
Centers for Medicare & Medicaid Services. Healthcare Common Procedure Coding System: HCPCS Level II
Policy Title Policy Type Effective Date Summary of Changes
Clinical Jan. 1, 2020 Added 15769, 15771, 15772, 15773, and 15774 Removed 19304 and 20926
Genetic Testing for
Hereditary Cancer
Clinical Jan. 1, 2020 Multi-Gene Panel
Added 0162U
Global Days Reimbursement Jan. 21, 2020 Global Days Assignment: Global Period 000 Added 0563T, 0564T, 0565T, 0566T, 0567T, 0568T, 0569T, 0571T, 0572T, 0573T, 0574T,
Removed 96150, 96151, 96152, 96153, 96154, and 96155
Occipital Neuralgia and Headache Treatment
Clinical Jan. 1, 2020 Revised description for 64405
13 Oxford® Policy Update Bulletin: January 2020
Take Note
Oxford
ANNUAL CDT®, CPT®, AND HCPCS CODE UPDATES
Policy Title Policy Type Effective Date Summary of Changes
Omnibus Codes Clinical Jan. 1, 2020 Evacuation of meibomian glands
Added 0563T
Fallopian tube occlusion with a degradable biopolymer implant Added 0567T
Islet cell transplantation
Added 0584T, 0585T, and 0586T
Pupillometry
Removed 0341T
Injectable bulking agents
Removed 0377T
Leadless pacemakers
Revised description for 33275
Outpatient Surgical Procedures – Site of Service
Clinical Jan. 1, 2020 Eye/Ocular Adnexa System Revised description for 66982 and 66984
Oxford's Outpatient
Imaging Self-
Referral
Clinical Jan. 1, 2020 Cardiologists, Including Pediatric; OB/GYNs; and Maternal and Fetal Medicine and
Neonatal/Perinatal Medicine
Removed 76930
Nuclear Medicine Removed 78205, 78206, 78320, 78607, 78647, 78710, 78805, 78806, and 78807
Physical Medicine & Rehabilitation: Multiple Therapy Procedure Reduction
Reimbursement Jan. 1, 2020 Multiple Therapy Reducible Codes Revised PE RVU value for CPT codes 92521 and 92609 Revised Total RVU value for CPT code 97140 Revised PE RVU and Total RVU values for CPT/HCPCS codes 92507, 92508, 92522, 92523,
Reimbursement Jan. 1, 2020 Procedures Eligible for a Site of Service Differential Removed 64402, 64405, 64410, 64413, 90911, 92225, 92226, 95831, 95832, 95833,
95834, 96150, 96151, 96152, 96153, and 96154
Speech Therapy and Early Intervention Programs/Birth to
Three
Administrative Jan. 1, 2020 Removed 96153 Revised description for 92626 and 92627
16 Oxford® Policy Update Bulletin: January 2020
Take Note
Oxford
ANNUAL CDT®, CPT®, AND HCPCS CODE UPDATES
Policy Title Policy Type Effective Date Summary of Changes
T Status Codes Reimbursement Jan. 1, 2020 Payable Service Codes
EFFECTIVE DATE POSTPONED FOR MRI AND CT SCAN – SITE OF SERVICE
The Clinical Policy titled Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan – Site of Service will not be effective on Feb. 1, 2020, as previously announced. Implementation of the new site of service medical necessity review guidelines has been postponed for UnitedHealthcare Oxford commercial benefit plans until further notice.
Policy Title Effective Date Coverage Rationale
NEW
Reblozyl®
(Luspatercept-Aamt)
Feb. 1, 2020
Reblozyl is proven and/or medically necessary for the treatment of anemia in adult patients with beta
thalassemia who meet ALL of the following criteria:
Initial Therapy
Diagnosis of beta thalassemia including beta+ thalassemia, beta0 thalassemia, and hemoglobin E/beta thalassemia; and
Patient is 18 years of age or older; and Patient is transfusion dependent as evidenced by both of the following in the previous 24 weeks:
o Has required regular transfusion of at least six units of packed red blood cells (PRBC); and o No transfusion free period greater than 35 days
and Reblozyl is prescribed by, or in consultation with, a hematologist, or other specialist with expertise in the
diagnosis and management of beta thalassemia; and Reblozyl dosing is in accordance with the United States Food and Drug Administration approved labeling: starting
dose of 1 mg/kg every 3 weeks by subcutaneous injection, with maximum dose of 1.25 mg/kg every 3 weeks; and
Initial authorization will be for no more than 6 months. Continuation of Therapy
Diagnosis of beta thalassemia including beta+ thalassemia, beta0 thalassemia, and hemoglobin E/beta thalassemia; and
Reblozyl is prescribed by, or in consultation with, a hematologist, or other specialist with expertise in the diagnosis and management of beta thalassemia;and
Patient has experienced a reduction in transfusion requirements from pretreatment baseline of at least 2 units PRBC while receiving Reblozyl; and
Reblozyl dosing is in accordance with the United States Food and Drug Administration approved labeling: starting dose of 1 mg/kg every 3 weeks by subcutaneous injection, with maximum dose of 1.25 mg/kg every 3 weeks; and
Reauthorization will be for no more than 12 months.
19 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Coverage Rationale
NEW
Reblozyl®
(Luspatercept-Aamt) (continued)
Feb. 1, 2020 Reblozyl is not proven or medically necessary for:
The treatment of non-transfusion dependent beta thalassemia; or The treatment of beta thalassemia in pediatric patients; or The treatment of sickle beta thalassemia (hemoglobin S [HbS]/beta thalassemia);or The treatment of alpha thalassemia; or
The treatment of myelodisplastic syndromes with or without ring siderobalsts; or The treatment of myeloproliferative neoplasm (MPN)-associated myelofibrosis.
Tysabri® (Natalizumab)
Apr. 1, 2020
Tysabri (natalizumab) is proven for: Relapsing Forms of Multiple Sclerosis
Tysabri (natalizumab) is medically necessary for the treatment of relapsing forms of multiple sclerosis (MS) when ALL of the following are met:
Initial Therapy
Diagnosis of relapsing forms of multiple sclerosis (MS) (e.g., relapsing-remitting MS, secondary-progressive MS with relapses, progressive-relapsing MS with relapses); and
Patient is not receiving Tysabri in combination with any of the following (used as monotherapy): o Disease modifying therapy (e.g., interferon beta preparations, glatiramer acetate, fingolimod, cladribine,
siponimod, or teriflunomide) o B cell targeted therapy (e.g., rituximab, belimumab, ofatumumab) o Lymphocyte trafficking blockers (e.g., alemtuzumab, mitoxantrone) and
Tysabri is dosed according to the US FDA labeled dosing: 300 mg intravenous infusion every 4 weeks; and Initial authorization is for no more than 6 months.
Continuation of Therapy
Patient has previously received treatment with Tysabri; and
Documentation of positive clinical response to Tysabri therapy; and
Patient is not receiving Tysabri in combination with any of the following (used as monotherapy): o Disease modifying therapy (e.g., interferon beta preparations, glatiramer acetate, fingolimod, cladribine,
siponimod, or teriflunomide) o B cell targeted therapy (e.g., rituximab, belimumab, ofatumumab) o Lymphocyte trafficking blockers (e.g., alemtuzumab, mitoxantrone) and
Tysabri is dosed according to the US FDA labeled dosing: 300 mg intravenous infusion every 4 weeks; and Authorization is for no more than 12 months.
20 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Coverage Rationale
NEW
Tysabri®
(Natalizumab) (continued)
Apr. 1, 2020 Crohn’s Disease
Tysabri (natalizumab) is medically necessary for inducing and maintaining clinical response and remission in patients with moderate to severe Crohn's disease (CD) when all of the following are met:
Initial Therapy
Diagnosis of moderately to severely active Crohn's disease; and
Evidence of inflammation (e.g., elevated C-reactive protein [CRP], elevated erythrocyte sedimentation rate, presence of fecal leukocytes); and
History of inadequate response or intolerance to conventional Crohn’s disease therapies and inhibitors of TNF-α.
Conventional Crohn’s disease therapies may include aminosalicylates (such as mesalamine and sulfasalazine), corticosteroids, immunomodulators (such as azathioprine, 6-mercaptopurine, and methotrexate) and TNF-inhibitors [e.g., infliximab (Remicade®), adalimumab (Humira®), or certolizumab pegol (Cimzia®)]; and
Patient is not receiving concomitant treatment with immunosuppressants (e.g., 6-MP, azathioprine, cyclosporine, or methotrexate) OR TNF-inhibitors [e.g., infliximab (Remicade), adalimumab (Humira), or certolizumab pegol (Cimzia)]; and
Tysabri is dosed according to the US FDA labeled dosing: 300 mg intravenous infusion every 4 weeks; and Initial authorization is for no more than 6 months.
Continuation of Therapy
Patient has previously received treatment with Tysabri; and Documentation of positive clinical response to Tysabri therapy; and
Diagnostic and/or clinical documentation (e.g. improved disease activity index) that indicates patient has experienced clinical benefit from receiving (induction) natalizumab therapy by week 12; and
Patients with Crohn’s disease who start natalizumab while on chronic oral corticosteroids must discontinue chronic steroids within 6 months of starting natalizumab therapy or natalizumab therapy should be discontinued; and
Patient is not receiving concomitant treatment with immunosuppressants (e.g., 6-MP, azathioprine, cyclosporine, or methotrexate) OR TNF-inhibitors [e.g., Enbrel (etanercept), Humira (adalimumab), or Remicade
(infliximab)]; and Tysabri is dosed according to the US FDA labeled dosing: 300 mg intravenous infusion every 4 weeks; and Initial authorization is for no more than 12 months. Natalizumab is unproven for the treatment of other conditions or diseases, including types of MS other than relapsing forms.
Statistically robust randomized controlled trials are needed to address the issue of whether natalizumab has sufficient superiority in clinical efficacy compared to other available treatments to justify the substantial inherent clinical risk in its use.
21 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Coverage Rationale
NEW
Vertebral Body
Tethering for Scoliosis
Mar. 1, 2020 Vertebral body tethering for the treatment of scoliosis is unproven and not medically necessary due to
Added language to clarify: o Spinal procedures for the treatment of spine pain are proven and medically necessary in certain
circumstances o For medical necessity clinical coverage criteria for the spinal procedures listed in the policy, see the
applicable MCG™ Care Guidelines, 23rd edition, 2019
Techniques for Lumbar Interbody Fusion (LIF)
Updated language to clarify the following techniques for lumbar interbody fusion (LIF) are proven and medically necessary: o Anterior LIF (ALIF) including lateral approaches [e.g., extreme lateral interbody fusion (XLIF®), Direct
Lateral Interbody Fusion (DLIF)] o Posterior LIF (PLIF), including Transforaminal Lumbar Interbody Fusion (TLIF)
Definitions
Added definition of: o Anterior Lumbar Spine Surgery o Arthrodesis o Axial Lumbar Interbody Fusion (ALIF) o Direct Lateral Interbody Fusion (DLIF) o Dynamic Stabilization
o Facet Arthroplasty
o Facet Fusion o Facet Syndrome o Image-Guided Minimally Invasive Lumbar Decompression (mild®) o Interlaminar Lumbar Instrumented Fusion (ILIF) o Interlaminar Stabilization Device o Interspinous Process Decompression (IPD) o Laparoscopic Anterior Lumbar Interbody Fusion (LALIF)
o Lumbar Spinal Stenosis (LSS)
22 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes
UPDATED
Surgical Treatment
for Spine Pain (continued)
Jan. 1, 2020 o Percutaneous or Endoscopic Lumbar Fusion
o Posterior Lumbar Spine Surgery o Sacroplasty o Spinal Fusion o Spinal Stabilization
o Spondylolisthesis o Spondylolysis o Total Facet Joint Arthroplasty
o Transforaminal Lumbar Interbody Fusion (TLIF) o X-STOP Interspinous Process Decompression (IPD) System
Applicable Codes
Revised description for 0202T, 0274T, and 0275T
Supporting Information Updated Description of Services, Clinical Evidence, and References sections to reflect the most current
information
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Actemra® (Tocilizumab) Injection for Intravenous
Infusion
Feb. 1, 2020
Conditions of Coverage Revised list of applicable sites of
service; added “home” Revised precertification
guidelines; added language to indicate: o Home infusion of Actemra
requires additional precertification for the home care services
o Participating providers in
the office setting: Precertification is required for services performed in the office of a participating provider
o Non-participating/out-of-network providers in the
office setting: Precertification is not
Refer to the policy for complete details on the coverage guidelines for Actemra® (Tocilizumab) Injection for Intravenous Infusion.
23 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Actemra®
(Tocilizumab) Injection for Intravenous Infusion
(continued)
Feb. 1, 2020
required, but encouraged for
out-of-network services performed in the office; if precertification is not obtained, Oxford will review
for out-of-network benefits and medical necessity after the service is rendered
Benlysta® (Belimumab)
Feb. 1, 2020
Template Update Reorganized policy template;
relocated Background and FDA sections
Conditions of Coverage
Revised list of applicable sites of service; replaced “all” with “office, outpatient, home”
Revised precertification
guidelines; added language to indicate: o Participating providers in
the office setting: Precertification is required for services performed in the office of a participating
provider o Non-participating/out-of-
network providers in the office setting:
Precertification is not required, but encouraged for out-of-network services
performed in the office; if precertification is not obtained, Oxford will review for out-of-network benefits and medical necessity after the service is rendered
o Home infusion of Benlysta
This policy refers only to Benlysta (belimumab) injection for intravenous infusion for the treatment of systemic lupus erythematosus (SLE). Benlysta (belimumab) for self-administered subcutaneous injection is obtained under the pharmacy benefit and is indicated systemic lupus erythematosus.
Benlysta (belimumab) is proven and medically necessary for the treatment of systemic lupus erythematosus when ALL of the following criteria are met:
For initial therapy, all of the following: o Diagnosis of active systemic lupus erythematosis without severe
active lupus nephritis or severe active central nervous system lupus; and
o Laboratory testing has documented the presence of autoantibodies [e.g., ANA, Anti-dsDNA, Anti-Sm, AntiRo/SSA, Anti-La/SSB]; and
o Currently receiving at least one standard of care treatment for active systemic lupus erythematosus (e.g., antimalarials, corticosteroids, or immunosuppressants); that is not a biologic or intravenous cyclophosphamide; and
o Benlysta is initiated and titrated according to US Food and Drug Administration labeled dosing for SLE up to a maximum of 10mg/kg
every 4 weeks; and o Initial authorization is for no more than 12 months.
For continuation of therapy, all of the following: o Patient has previously received Benlysta injection for intravenous
infusion; and
o Documentation of positive clinical response; and o Currently receiving at least one standard of care treatment for active
systemic lupus erythematosus (e.g., antimalarials, corticosteroids, or immunosuppressants; that is not a biologic or intravenous
24 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Benlysta®
(Belimumab) (continued)
Feb. 1, 2020
requires additional
precertification for the home care services
Coverage Rationale
Revised coverage criteria for:
Initial Therapy o Added criterion requiring:
Laboratory testing has
documented the presence of autoantibodies [e.g., ANA, Anti-dsDNA, Anti-Sm, Anti-Ro/SSA, Anti-La/SSB]
Initial authorization is for no more than 12 months
o Removed criterion requiring
one of the following: Anti-nuclear antibody
(ANA) titer ≥ 1:80 Anti-double-stranded
DNA (anti-dsDNA) level ≥ 30 IU/mL]
o Replaced criterion requiring: “Diagnosis of active
systemic lupus erythematosus” with “diagnosis of active
systemic lupus
erythematosus, without severe active lupus nephritis or severe active central nervous system lupus”
“[Patient is] currently receiving at least one standard of care treatment for active
cyclophosphamide; and
o Benlysta is dosed according to US Food and Drug Administration labeled dosing for SLE up to a maximum of 10mg/kg every 4 weeks; and
o Authorization is for no more than 12 months.
Benlysta is unproven and not medically necessary for: Severe active lupus nephritis
Severe active central nervous system (CNS) lupus Use in combination with other biologics or intravenous cyclophosphamide Waldenström macroglobulinemia Sjögren's syndrome Rheumatoid arthritis
25 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Benlysta®
(Belimumab) (continued)
Feb. 1, 2020
systemic lupus
erythematosus (e.g., antimalarials, corticosteroids, or immunosuppressants)”
with “[patient is] currently receiving at least one standard of
care treatment for active systemic lupus erythematosus (e.g., antimalarials, corticosteroids, or immunosuppressants)
that is not a biologic or intravenous cyclophosphamide”
Continuation of Therapy
o Added criteria requiring all of the following: Patient has previously
received Benlysta injection for intravenous infusion
Documentation of positive clinical response
Currently receiving at least one standard of care treatment for active
systemic lupus erythematosus (e.g.,
antimalarials, corticosteroids, or immunosuppressants) that is not a biologic or intravenous cyclophosphamide
Benlysta is dosed
26 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Benlysta®
(Belimumab) (continued)
Feb. 1, 2020 according to US Food
and Drug Administration labeled dosing for SLE up to a maximum of 10mg/kg every 4 weeks
Authorization is for no more than 12 months
Breast Reconstruction Post Mastectomy
Feb. 1, 2020 Coverage Rationale Revised list of procedures that
may be utilized during breast reconstruction; added “mastopexy or breast reduction when required prior to mastectomy to preserve the
viability of the nipple”
Refer to the policy for complete details on the coverage guidelines for Breast Reconstruction Post Mastectomy.
Breast Reduction
Surgery
Feb. 1, 2020
Coverage Rationale
Added language for plans that include breast reduction surgery benefits to indicate breast reduction surgery is
eligible for coverage as reconstructive and medically necessary when performed prior to mastectomy to preserve the viability of the nipple
Indications for Coverage
Most Oxford plans have a specific exclusion for breast reduction surgery except as required by the Women's Health and Cancer Rights Act of 1998 (WHCRA). Refer to the Coverage Limitations and Exclusions section of the policy. For plans that include breast reduction surgery benefits, the
following are eligible for coverage as reconstructive and medically necessary when the criteria are met: Following mastectomy to achieve symmetry (per WHCRA); or Prior to the mastectomy to preserve the viability of the nipple. Macromastia is the primary etiology of the member’s Functional
Impairments.
o The following are examples of Functional Impairments that must be
attributable to Macromastia to be considered (not an all-inclusive list): Severe skin excoriation/intertrigo unresponsive to medical
management Severe restriction of physical activities that meets the definition
of Functional Impairment below Signs and symptoms of nerve compression that are unresponsive
to medical management (e.g., ulnar paresthesias)
27 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Breast Reduction
Surgery (continued)
Feb. 1, 2020
Acquired kyphosis that is attributed to Macromastia
Chronic breast pain due to weight of the breasts Upper back, neck, or shoulder pain Shoulder grooving from bra straps Headache;
and o The amount of tissue to be removed:
Plots above the 22nd percentile; or
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 o The proposed procedure is likely to result in significant improvement
of the Functional Impairment.
Coverage Limitations and Exclusions
Oxford excludes Cosmetic Procedures from coverage including but not
limited to the following: Breast reduction surgery when done to improve appearance without
improving A Functional/Physiologic Impairment. Liposuction as the sole procedure for breast reduction surgery. 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.
Procedures that do not meet the reconstructive criteria in the Indications
for Coverage section of the policy (e.g., psychological or social reasons,
breast size asymmetry unless post mastectomy, exercise). 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.
28 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Breast Reduction
Surgery (continued)
Feb. 1, 2020
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/body-surface-area-calculator.html (Use Du Bois formula): or
Du Bois formula:
o BSA = 0.007184 × W0.425 × H0.725 Du Bois D, Du Bois EF. A formula to estimate the approximate surface area if height and weight be known. Arch Intern Med. 1916; 17(6):863-871.
Modified Schnur Nomogram Chart
Body Surface (m2) Lower 5th Percentile Lower 22nd Percentile
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Breast Reduction
Surgery (continued)
Feb. 1, 2020 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
Complement Inhibitors (Soliris® & Ultomiris™)
Feb. 1, 2020
Conditions of Coverage Revised precertification
guidelines:
o Added language to indicate: Participating
providers in the office
setting: Precertification is required for services performed in the office
of a participating provider
Non-participating/out-of-network providers in the office setting: Precertification is not
required, but encouraged for out-of-
network services performed in the office; if precertification is not obtained, Oxford will review for out-of-
network benefits and medical necessity after the service is rendered
o Removed language
Refer to the policy for complete details on the coverage guidelines for Complement Inhibitors (Soliris® & Ultomiris™).
30 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Complement
Inhibitors (Soliris® & Ultomiris™) (continued)
Feb. 1, 2020
indicating Soliris and
Ultomiris require precertification with review by a Medical Director or their designee in all sites of
service
Coverage Rationale
Added language to indicate Ultomiris is: o Proven for the treatment of
atypical Hemolytic Uremic
Syndrome (aHUS) o Medically necessary for the
treatment of aHUS when all of the [listed] criteria are met
o Unproven and not medically
necessary for treatment of
Shiga Toxin E. Coli-related Hemolytic Uremic Syndrome (STEC-HUS)
Revised medical necessity criteria for:
Atypical Hemolytic Uremic
Syndrome (aHUS)
Initial Therapy
o Added criterion requiring “patient is treatment naïve
with both Soliris and Ultomiris”
o Replaced criterion requiring:
“Soliris is initiated and titrated according to the US FDA labeled dosing for aHUS, up to a maximum of 1200 mg every 2 weeks” with “Soliris or Ultomiris are
31 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Complement
Inhibitors (Soliris® & Ultomiris™) (continued)
Feb. 1, 2020
dosed according to the
US FDA labeled dosing for aHUS”
“Soliris is prescribed by a hematologist or
nephrologist” with “Soliris or Ultomiris is prescribed by, or in
consultation with, a hematologist or nephrologist”
Continuation of Therapy
o Replaced criterion requiring: “Patient has previously
been treated with Soliris” with “patient has previously been treated
with Soliris or Ultomiris”
“Soliris is dosed according to the US FDA labeled dosing for aHUS: 1200 mg every 2 weeks” with “Soliris or Ultomiris are dosed according to
the US FDA labeled dosing for aHUS”
“Soliris is prescribed by a hematologist or nephrologist” with
“Soliris or Ultomiris is prescribed by, or in
consultation with, a hematologist or oncologist”
Paroxysmal Nocturnal
Hemoglobinuria (PNH) o Replaced criterion requiring
“Soliris is prescribed by a
32 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Complement
Inhibitors (Soliris® & Ultomiris™) (continued)
Feb. 1, 2020
hematologist or
nephrologist” with “Soliris or Ultomiris is prescribed by, or in consultation with, a hematologist or oncologist”
Generalized Myasthenia
Gravis o Replaced criterion requiring
“Soliris or Ultomiris is prescribed by a neurologist” with “Soliris or Ultomiris is
prescribed by, or in consultation with, a neurologist”
o Replaced initial therapy criterion requiring “history of failure of at least one
immunosuppressive agent
over the course of at least 12 months” with “history of failure of at least two immunosuppressive agents over the course of at least 12 months”
Neuromyelitis Optica Spectrum Disorder (NMOSD) o Replaced criterion requiring
“Soliris or Ultomiris is
prescribed by a neurologist”
with “Soliris or Ultomiris is prescribed by, or in consultation with, a neurologist”
Applicable Codes
Added maximum dosage requirements for Ultomiris (ravulizumab-cwvz):
Maximum Allowed Quantities
33 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Complement
Inhibitors (Soliris® & Ultomiris™) (continued)
Feb. 1, 2020 by HCPCS Units
o Maximum Dosage per Administration: 3,600 mg total dose
o HCPCS Code: J1303
o Maximum Allowed: 360 HCPCS units (10 mg per unit)
Maximum Allowed Quantities by National Drug Code (NDC) Units
o How Supplied: 300 mg/30 mL solution in vials
o National Drug Code: 25682-0022-01
o Maximum Allowed: 360 mL
Supporting Information
Updated Clinical Evidence, FDA, and References sections to reflect the most current information
Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes
Apr. 1, 2020
Coverage Rationale Replaced language indicating
“continuous glucose monitoring (CGM) is proven and medically necessary for long-term personal use at home for managing
individuals with type 1 diabetes
who meet all of the [listed] criteria” with “continuous glucose monitoring (CGM) is proven and medically necessary for long-term personal use at home for managing individuals
with diabetes who meet all of the [listed] criteria”
Removed language indicating long-term CGM for managing
Insulin Delivery
External insulin pumps that deliver insulin by continuous
subcutaneous infusion are proven and medically necessary for managing individuals with type 1 or insulin-requiring type 2 diabetes. For medical necessity clinical coverage criteria, see MCG™ Care Guidelines, 23rd edition, 2019, Insulin Infusion Pump ACG: A-0339 (AC).
Click here to view the MCG™ Care Guidelines. Note: Programmable disposable external insulin pumps (e.g., Omnipod) are considered clinically equivalent to standard insulin pumps. Due to insufficient evidence of efficacy, the following devices are unproven and not medically necessary for managing individuals with
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Continuous Glucose
Monitoring and Insulin Delivery for Managing Diabetes (continued)
Apr. 1, 2020 individuals with type 2 or
gestational diabetes is unproven and not medically necessary
Applicable Codes
Removed notation indicating
procedure codes for continuous glucose monitoring (CGM) are unproven and not medically necessary when reported with diagnosis codes for type 2 diabetes or gestational diabetes
CGM is proven and medically necessary for managing individuals with diabetes in the following circumstances: Short-term use (3-7 days) by a healthcare provider for diagnostic
purposes. Long-term use for personal use at home for managing individuals with
diabetes who meet all of the following criteria: o Have demonstrated adherence to a physician ordered diabetic
treatment plan; and o Are on an intensive insulin regimen (3 or more insulin injections per
day or insulin pump therapy) Due to insufficient evidence of efficacy, the following services and/or
devices are unproven and not medically necessary for managing individuals with diabetes: CGM using an implantable glucose sensor (e.g., Eversense) CGM using a noninvasive device
Cosmetic and Reconstructive
Procedures
Feb. 1, 2020
Coverage Rationale and Applicable Codes
Replaced language indicating “sclerotherapy in excess of 3 sessions per leg is considered cosmetic” with “sclerotherapy in excess of 3 sessions per leg
within 12 months from the date
of the ablation procedure is considered cosmetic”
Some states require benefit coverage for services that Oxford considers Cosmetic Procedures, such as repair of external congenital anomalies in the
absence of a Functional Impairment. Refer to the member specific benefit plan document. Indications for Coverage
For plans that include benefits for Cosmetic Procedures, the
following are eligible for coverage as reconstructive and medically necessary when all of the following criteria are met: There is documentation that the physical abnormality and/or
physiological abnormality is causing a Functional Impairment that
requires correction; and The proposed treatment is of proven efficacy and is deemed likely to
significantly improve or restore the patient’s physiological function
Microtia Microtia repair is reconstructive; although no Functional Impairment may
35 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Cosmetic and
Reconstructive Procedures (continued)
Feb. 1, 2020 be documented for Microtia, this has been deemed Reconstructive
Surgery.
Coverage Limitations and Exclusions
Oxford excludes Cosmetic Procedures from coverage including but not
limited to the following: 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
Procedures that do not meet the reconstructive criteria in the Indications for Coverage section of the policy o Pharmacological regimens, nutritional procedures or treatments o Scar or tattoo removal or revision procedures (such as salabrasion,
chemosurgery and other such skin abrasion procedures) o Skin abrasion procedures performed as a treatment for acne o Liposuction or removal of fat deposits considered undesirable,
including fat accumulation under the male breast and nipple o Treatment for skin wrinkles or any treatment to improve the
appearance of the skin
o Treatment for spider veins o Sclerotherapy treatment of veins (Note: Sclerotherapy in excess of 3
sessions per leg within 12 months from the date of the ablation procedure is considered cosmetic)
o Hair removal or replacement by any means
Drug Coverage
Criteria – New and Therapeutic Equivalent Medications
Feb. 1, 2020
Related Policies
Added reference link to the Clinical Policy titled Drug Coverage Guidelines
Coverage Rationale
Revised list of medications requiring precertification through the pharmacy benefit manager (PBM): o Added Amzeeq, Brukinsa,
Refer to the policy for complete details on Drug Coverage Criteria – New and
Therapeutic Equivalent Medications.
36 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Drug Coverage
Criteria – New and Therapeutic Equivalent Medications
(continued)
Feb. 1, 2020
Pantoprazole (Camber
Products), and Ziextenzo o Removed Abilify, Acanya,
Sprinkle, Prilosec Suspension, Protonix (brand only), and Protonix Granules for Suspension
Removed language/notations
pertaining to select medications (listed as removed above) with additional precertification requirements; refer to the
37 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Drug Coverage
Criteria – New and Therapeutic Equivalent Medications
(continued)
Feb. 1, 2020 Clinical Policy titled Drug
Coverage Guidelines for applicable coverage guidelines
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage Guidelines
Jan. 1, 2020 Chantix (Varenicline Tartrate)
Revised Revised coverage guidelines for New York plans to indicate precertification is not required
Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Tobacco Cessation for Health Care Reform for complete details
Nicotrol Inhaler
(Nicotine) Revised Revised coverage guidelines for New York plans to indicate
precertification is not required Revised prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: Tobacco Cessation for Health Care Reform for complete details
Nicotrol NS (Nicotine) Revised Revised coverage guidelines for New York plans to indicate precertification is not required
Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Tobacco Cessation for Health Care Reform for complete details
Drug Coverage Guidelines
Feb. 1, 2020 Description of Services Revised guidelines for New FDA-Approved Drugs:
o Added guidelines for oral chemotherapy; refer to Oral Chemotherapeutic Agents for complete details
Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Abstral (Fentanyl) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Abstral (Fentanyl) for complete details
38 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Feb. 1, 2020 Acanya (Clindamycin
Phosphate 1.2% and Benzoyl Peroxide 2.5%)
Revised Added prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage
Criteria - New and Therapeutic Equivalent Medications
Actemra (Tocilizumab):
Injection
Revised Added notation to indicate precertification is required in all sites of
service; additional precertification may be required for the site of care of the injection
Actiq (Brand Only) (Fentanyl Citrate)
Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Actiq (Fentanyl Citrate) for complete details
Adynovate
(Antihemophillic Factor)
Removed Removed coverage guidelines
Ambien (Zolpidem Tartrate)
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic
Equivalent Medications for complete details Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage
Criteria - New and Therapeutic Equivalent Medications
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage
Criteria - New and Therapeutic Equivalent Medications
Amzeeq (Minocycline
Topical)
New Added language to indicate precertification is required through the
Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details
Aplenzin (Bupropion)
Revised
Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed prior authorization/medical necessity guidelines and corresponding reference link to the policy titled Prior
39 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Drug/Medication Status Summary of Changes
Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Arymo ER for complete details
Asacol HD (Mesalamine) Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic
Equivalent Medications for complete details Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Ativan (Brand Only) (Lorazepam)
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic
Equivalent Medications for complete details Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage
Criteria - New and Therapeutic Equivalent Medications
Auvi-Q (Epinephrine) Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic
Equivalent Medications for complete details Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Avinza (Morphine Sulfate Controlled Release)
(Brand Only)
Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Arymo ER for complete
details
Azor (Amlodipine
Besylate and Olmesartan Medoxomil)
Revised Added prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage
Criteria - New and Therapeutic Equivalent Medications
Belbuca (Buprenorphine) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Belbuca for complete details
Benlysta (Belimumab)
Revised
Added notation to indicate precertification is required in all sites of service; additional precertification may be required for the site of care of
40 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Feb. 1, 2020 Benlysta (Belimumab)
(continued)
Revised the injection
Brukinsa (Zanubrutini) New Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)
Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent
Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details
Butrans (Buprenorphine) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Butrans for complete details
Celexa (Citalopram) (Brand Only)
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed prior authorization/medical necessity guidelines and
corresponding reference link to the policy titled Prior authorization/medical necessity guidelines: Select Brand Medications
Compounds and Bulk
Powders: Various Drugs
Revised Revised prior authorization/notification guidelines; refer to Prior
Authorization/Notification Guidelines: Compounds and Bulk Powders for complete details
Continuous Glucose Monitor
Revised Revised prior authorization/medical necessity guidelines and title of reference link; refer to Prior Authorization/Medical Necessity Guidelines: Guardian Connect Sensor and Transmitter for Continuous Glucose Monitoring for complete details
Copaxone (Brand Only)(Glatiramer
Acetate)
Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Copaxone for complete details
Copiktra (Duvelisib) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Copiktra for complete details
Corlanor (Ivabradine) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Corlanor for complete details
Cotellic (Cobimetinib) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Cotellic for complete details
Cymbalta (Duloxetine) (Brand Only)
Revised
Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage
41 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Feb. 1, 2020 Cymbalta (Duloxetine)
(Brand Only) (continued)
Revised Criteria - New and Therapeutic Equivalent Medications
Daliresp (Roflumilast) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Daliresp for complete details
Delzicol (Mesalamine Delayed Release
Capsule)
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic
Equivalent Medications for complete details Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Diovan (Valsartan) (Brand Only)
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic
Equivalent Medications for complete details Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage
Criteria - New and Therapeutic Equivalent Medications
Diovan HCT (Valsartan) (Brand Only)
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic
Equivalent Medications for complete details Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Dolophine (Methadone) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Dolophine for complete
details
Dulera (Mometasone
Furoate/ Formoterol Fumarate Dihydrate)
Revised Revised step therapy guidelines; refer to Step Therapy Guidelines:
Dulera for complete details
Duragesic (Brand Only) (Fentanyl)
Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Duragesic for complete
details Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
42 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Feb. 1, 2020 Dymista (Fluticasone)
(Flonase)
Revised Added prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage
Criteria - New and Therapeutic Equivalent Medications
Effexor XR (Venlafaxine)
(Brand Only)
Revised Added prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed prior authorization/medical necessity guidelines and corresponding reference link to the policy titled Prior authorization/medical necessity guidelines: Select Brand Medications
Embeda (Morphine
Sulphate and Naltrexone HCL)
Revised Revised prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: Embeda for complete details
Entyvio (Vedolizumab) Revised Added notation to indicate precertification is required in all sites of service; additional precertification may be required for the site of care of the injection
Erleada (Apalutamide) Revised Revised prior authorization/notification guidelines; refer to Prior
Authorization/Notification Guidelines: Erleada for complete details
Esbriet (Pirfenidone) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Esbriet (Pirfenidone) for
complete details
Exalgo (Hydromorphone) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Exalgo for complete details
Extavia (Interferon B-1b)
Revised Revised step therapy guidelines; refer to Step Therapy Guidelines: Extavia (Interferon B-1b) for complete details
Fasenra (Benralizumab)
Revised
Revised coverage guidelines to indicate precertification is required through the PBM if obtained at a pharmacy (for coverage provided under the pharmacy benefit)
Added prior authorization/medical necessity guidelines; refer to Prior
43 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Feb. 1, 2020 Fasenra (Benralizumab)
(continued)
Revised Authorization/Medical Necessity Guidelines: Fasenra for complete details
Fentanyl Citrate (Generic Actiq)
Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Actiq (Fentanyl Citrate) for complete details
Fentanyl Citrate Bulk Powder
Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Fentora (Fentanyl) for
complete details
Fentanyl Transdermal Patch (37.5, 62.5 and 87.5 Mcg/Hr Strengths Only)
Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Fentanyl Transdermal Patch for complete details
Fentora (Fentanyl Buccal)
Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Fentora (Fentanyl) for complete details
Firdapse
(Amifampridine)
Revised Added prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: Firdapse for complete details Removed prior authorization/notification guidelines and corresponding
reference link to the policy titled Prior Authorization/Notification Guidelines: Firdapse
Forfivo XL (Bupropion HCL)
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed prior authorization/medical necessity guidelines and
corresponding reference link to the policy titled Prior Authorization/Medical Necessity Guidelines: Select Brand Medications
Galafold (Migalastat) Revised Revised prior authorization/notification guidelines; refer to Prior
Authorization/Notification Guidelines: Galafold for complete details
Gleevec (Imatinib Mesylate)
Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Gleevec for complete details
Hemlibra (Emicizumab-Kxwh)
Removed Removed coverage guidelines
Hemophilia Drugs
Revised
Added therapeutic equivalent guidelines for Adynovate; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details
Revised prior authorization/medical necessity guidelines; refer to the
44 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Feb. 1, 2020 Hemophilia Drugs
(continued)
Revised following policies for complete details:
o Prior Authorization/Medical Necessity Guidelines: Advate o Prior Authorization/Medical Necessity Guidelines: Adynovate o Prior Authorization/Medical Necessity Guidelines: Recombinate
Hycamtin (Topotecan
Hydrochloride)
Revised Revised prior authorization/notification guidelines; refer to Prior
Authorization/Notification Guidelines: Hycamtin for complete details
Hysingla ER
(Hydrocodone Bitartrate)
Revised Revised prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: Hysingla ER for complete details
Iclusig (Ponatinib) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Iclusig for complete details
Immune Globulin (IVIG
and SCIG)
Revised Added coverage guidelines for Xembify™:
o Added language to indicate: Precertification is not required however it is strongly
recommended While no penalty will be imposed for failure to request a pre-
service review, if one is not requested, a medical necessity review will be conducted post-service to determine coverage
It is the referring physician’s responsibility to provide medical
documentation to demonstrate clinical necessity for the medication
Beginning Apr. 1, 2020, precertification will be required o Added precertification guidelines; refer to Precertification Guidelines:
Review at Launch for New to Market Medications for complete details Revised coverage guidelines for Asceniv™ and Cutaquig®; removed
reference link to the policy titled Precertification Guidelines: Review at
Launch for New to Market Medications Updated reference link to related policy to reflect title change for
Precertification Guidelines: Immune Globulin Site of Care
Inflectra (Infliximab) Revised Added notation to indicate precertification is required in all sites of service; additional precertification may be required for the site of care of the injection
Inrebic (Fedratinib) Revised Added prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Inrebic for complete details
Intron-A (Interferon Alfa-2b)
Revised
Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Intron-A (interferon Alfa-2b) for
45 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Feb. 1, 2020 Intron-A (Interferon
Alfa-2b) (continued)
Revised complete details
Intuniv (Guanfacine) (Brand Only)
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic
Equivalent Medications for complete details Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Janumet (Sitagliptin and Metformin Hydrochloride)
Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Diabetes Medications DPP4 Inhibitors (CT/NY) for complete details
Revised step therapy guidelines; refer to Step Therapy Guidelines:
Diabetes Medications DPP4 Inhibitors (NJ) for complete details
Inhibitors (CT/NY) for complete details Revised step therapy guidelines; refer to Step Therapy Guidelines:
Diabetes Medications DPP4 Inhibitors (NJ) for complete details
Januvia (Sitagliptin) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Diabetes Medications DPP4 Inhibitors (CT/NY) for complete details
Revised step therapy guidelines; refer to Step Therapy Guidelines: Diabetes Medications DPP4 Inhibitors (NJ) for complete details
Kadian (Morphine
Sulfate Extended Release)
Revised Revised prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: Kadian for complete details
Lantus (Insulin Glargine) Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Lantus Solostar (Insulin Glargine)
Revised
Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
46 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Feb. 1, 2020 Lantus Solostar (Insulin
Glargine) (continued)
Revised Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Lenvima (Lenvatinib) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Lenvima for complete details
Lescol XL (Fluvastatin) (Brand and Generic)
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic
Equivalent Medications for complete details Revised step therapy guidelines; refer to Step Therapy Guidelines: Lescol
for complete details Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Lipitor (Brand Only) (Atorvastatin)
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Livalo (Pitavastatin) Revised Revised step therapy guidelines; refer to Step Therapy Guidelines: Livalo for complete details
Lotronex (Alosetron) (Brand)
Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Lotronex (Alosteron) for complete details
Lovaza (Brand Only) (Omega-3-Acid Ethyl Esters)
Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Lovaza for complete details
Lovaza (Generic) (Omega-3-Acid Ethyl Esters)
Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Lovaza for complete details
Lucemyra (Lofexidine) Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Lucemyra for complete details
Lunesta (Eszopicione) (Brand Only)
Revised
Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
47 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Feb. 1, 2020 Lunesta (Eszopicione)
(Brand Only) (continued)
Revised Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Mavenclad (Cladribine) Revised Added step therapy guidelines; refer to Step Therapy Guidelines: Mavenclad for complete details
Removed prior authorization/medical necessity guidelines and corresponding reference link to the policy titled Prior
Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Mavyret for complete details
Morphabond ER (Morphine Sulfate)
Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: MorphaBond ER for complete details
Morphine Sulfate Controlled-Release (Generic MS Contin)
Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Morphine Sulfate for complete details
MS Contin Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: MS Contin for complete
details
Mulpleta (Lusutrombopag)
Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Mulpleta for complete details
Myrbetriq (Mirabegron) Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Nucynta ER (Tapentadol Extended Release)
Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Nucynta ER for complete details
Nuplazid (Pimavanserin Tartrate)
Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Nuplazid for complete details
Ofev (Nintedanib) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Ofev (Nintedanib) for complete details
48 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Drug/Medication Status Summary of Changes
Authorization/Medical Necessity Guidelines: Orenitram for complete details
Oxycodone ER 12hr Tablet
Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Oxycodone ER for complete
details
Oxycontin (Oxycodone
Extended Release)
Revised Revised prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: Oxycontin for complete details
Oxymorphone Extended Release
Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Oxymorphone for complete details
Pantoprazole (Camber Products)
New Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)
Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent
Medications for complete details
Pegasys (Peginterferon
Alfa-2a)
Revised Revised prior authorization/notification guidelines; refer to Prior
Authorization/Notification Guidelines: Pegasys (Peginterferon Alfa-2a) for complete details
Peg-Intron (Peginterferon Alfa-2b)
Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: PEG-Intron (Peginterferon Alfa-2b) for complete details
Pennsaid 1.5% Drops
(Diclofenac Sodium)
Revised Added prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Pennsaid 2% (Diclofenac
Sodium)
Revised Added prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
49 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Drug/Medication Status Summary of Changes
Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage
Criteria - New and Therapeutic Equivalent Medications
Percocet
(Acetaminophen and Oxycodone) (Brand Only)
Revised Added prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Pexeva (Paroxetine
Mesylate)
Revised Added prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed prior authorization/medical necessity guidelines and
corresponding reference link to the policy titled Prior authorization/medical necessity guidelines: Select Brand Medications
Promacta (Eltrombopag) Revised Revised prior authorization/notification guidelines; refer to Prior
Authorization/Notification Guidelines: Promacta for complete details
Prozac (Fluoxetine) (Brand Only)
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Rayos (Delayed-Release Prednisone)
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic
Equivalent Medications for complete details Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Rebif (Interferon Beta-1a)
Revised Revised step therapy guidelines; refer to Step Therapy Guidelines: Rebif for complete details
Reblozyl (Luspatercept-Aamt)
New
Added coverage guidelines to indicate coverage is provided under the medical benefit
50 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Feb. 1, 2020 Reblozyl (Luspatercept-
Aamt) (continued)
New o Precertification is not required however it is strongly recommended
o While no penalty will be imposed for failure to request a pre-service review, if one is not requested, a medical necessity review will be conducted post-service to determine coverage
o It is the referring physician’s responsibility to provide medical
documentation to demonstrate clinical necessity for the medication o Beginning Jul. 1, 2020, precertification will be required
Added precertification guidelines; refer to the following policies for
complete details: o Precertification Guidelines: Reblozyl (Luspatercept-Aamt) o Precertification Guidelines: Review at Launch for New to Market
Medications
Remicade (Infliximab) Revised Added notation to indicate precertification is required in all sites of service; additional precertification may be required for the site of care of
the injection
Rozlytrek (Entrectinib) New Added language to indicate precertification is required through the
Authorization/Notification Guidelines: Rozlytrek for complete details
Ruxience (Rituximab-Pvvr)
New Added coverage guidelines to indicate coverage is provided under the medical benefit o Precertification is not required however it is strongly recommended o While no penalty will be imposed for failure to request a pre-service
review, if one is not requested, a medical necessity review will be conducted post-service to determine coverage
o It is the referring physician’s responsibility to provide medical
documentation to demonstrate clinical necessity for the medication o Beginning Apr. 1, 2020, precertification will be required
Added precertification guidelines; refer to Precertification Guidelines: Rituximab (Rituxan®, Ruxience® & Truxima®) for complete details
Sprycel (Dasatinib) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Sprycel for complete details
Stelara (Ustekinumab): Sub-Cutaneous Injection
Revised
Added notation to indicate precertification is required in all sites of service; additional precertification may be required for the site of care of the injection
Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Stelara Injection for Subcutaneous
51 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Feb. 1, 2020 Stelara (Ustekinumab):
Sub-Cutaneous Injection (continued)
Revised Use for complete details
Subsys (Fentanyl Sublingual Spray)
Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Subsys for complete details
Sylatron (Peginterferon Alfa-2b)
Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Sylatron for complete details
Synribo (Omacetaxine) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Synribo for complete details
Tagrisso (Osimertinib) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Tagrisso for complete details
Tarceva (Erlotinib) Revised Revised prior authorization/notification guidelines; refer to Prior
Authorization/Notification Guidelines: Tarceva for complete details
Tasigna (Nilotinib) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Tasigna for complete details
Revised step therapy guidelines; refer to Step Therapy Guidelines:
Tasigna for complete details
Tavalisse (Fostamatinib Disodium Hexahydrate)
Revised Revised step therapy guidelines; refer to Step Therapy Guidelines: Tavalisse for complete details
Treximet (Sumatriptan Naproxen)
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Trikafta (Elexacaftor/ Tezacaftor/Ivacaftor)
New Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)
Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Trikafta for complete details
Turalio (Pexidartinib) New Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)
Added prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Turalio for complete details
Uptravi (Selexipag) Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Uptravi for complete details
52 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Feb. 1, 2020 Valium (Diazepam)
(Brand Only)
Revised Added prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage
Criteria - New and Therapeutic Equivalent Medications
Valtrex (Valacyclovir)
(Brand Only)
Revised Added prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Vascepa (Omega-3-Acid
Ethyl Esters)
Revised Revised prior authorization/notification guidelines; refer to Prior
Authorization/Notification Guidelines: Vascepa for complete details
Vascepa 0.5 Gram Only (Omega-3-Acid Ethyl
Esters)
Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Vascepa for complete details
Vemlidy (Tenofovir Alafenamide)
Revised Revised step therapy guidelines; refer to Step Therapy Guidelines: Vemlidy for complete details
Vesicare (Solifenacin) Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Vizimpro (Dacomitinib) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Vizimpro for complete details
Votrient (Pazopanib) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Votrient for complete details
Authorization/Medical Necessity Guidelines: Vyleesi for complete details
Wakix (Pitolisant) Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Wakix for complete details
Weight Loss
Revised
Removed coverage guidelines for Apidex P Added language to indicate brand and generic versions and all
formulations are included unless otherwise noted
53 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Feb. 1, 2020 Weight Loss
(continued)
Revised Updated list of applicable drugs; added generic product drug name for:
o Belviq XR o Contrave o Qsymia o Saxenda
o Xenical
Wellbutrin SR (Brand
Only) (Bupropion)
Revised Added prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Wellbutrin XL (Bupropion
Extended Release)
Revised Added prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Xadago (Safinamide) Revised Revised coverage guidelines to indicate precertification is no longer
required Removed prior authorization/medical necessity guidelines and
corresponding reference link to the policy titled Prior Authorization/Medical Necessity Guidelines: Xadago
Xanax (Alprazolam) (Brand Only)
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage
Criteria - New and Therapeutic Equivalent Medications
Xanax XR (Alprazolam) (Brand Only)
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Xpovio (Selinexor)
New
Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)
54 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Feb. 1, 2020 Xpovio (Selinexor)
(continued)
New Added prior authorization/notification guidelines; refer to Prior
Authorization/Notification Guidelines: Xpovio for complete details
Xtampza ER (Oxycodone)
Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Xtampza ER for complete
details
Ziextenzo (Pegfilgrastim-
Bmez)
New Added language to indicate precertification is required through the
Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details
Zohydro ER (Hydrocodone Bitartrate
Extended Release)
Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Zohydro ER for complete
details
Zoloft (Sertraline) (Brand Only)
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic
Equivalent Medications for complete details Removed therapeutic equivalent guidelines and corresponding reference
link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage
Criteria - New and Therapeutic Equivalent Medications
Zovirax Cream (Acyclovir)
Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: New and Therapeutic Equivalent Medications for complete details
Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage
Criteria - New and Therapeutic Equivalent Medications
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Entyvio®
(Vedolizumab) (continued)
Feb. 1, 2020
Revised list of applicable sites of
service; added “home” Revised precertification
guidelines; added language to indicate:
o Home infusion of Entyvio requires additional precertification for the home
care services o Participating providers in
the office setting: Precertification is required for services performed in the office of a participating
provider o Non-participating/out-of-
network providers in the
office setting: Precertification is not required, but encouraged for out-of-network services
performed in the office; if precertification is not obtained, Oxford will review for out-of-network benefits and medical necessity after the service is rendered
and
o One of the following: History of failure, contraindication, or intolerance to at least one
of the following conventional therapies: - Tumor necrosis factor (TNF) blocker [e.g., Humira
Tysabri (natalizumab); and o Initial authorization will be for no more than 14 weeks
For continuation of therapy, all of the following: o Documentation of positive clinical response to Entyvio; and o Entyvio dosing for Crohn’s disease is in accordance with the FDA
labeled dosing up to a maximum of 300mg every 8 weeks (or equivalent dose and interval schedule); and
o Reauthorization will be for no more than 12 months.
Ulcerative colitis when all of the following criteria are met:
For initial therapy, all of the following: o Diagnosis of moderately to severely active ulcerative colitis (UC);
and o One of the following:
History of failure, contraindication, or intolerance to at least one
of the following conventional therapies: - Tumor necrosis factor (TNF) blocker [e.g., Humira
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Entyvio®
(Vedolizumab) (continued)
Feb. 1, 2020 - Corticosteroid
Corticosteroid dependent (e.g., unable to successfully taper corticosteroids without a return of the symptoms of UC)
and o Entyvio is initiated and titrated according to US Food and Drug
Administration labeled dosing for ulcerative colitis up to a maximum of 300mg every 8 weeks (or equivalent dose and interval schedule); and
o Patient is not receiving Entyvio in combination with either of the following: Tumor necrosis factor (TNF) blocker [e.g., Humira (adalimumab),
Simponi (golimumab)] Tysabri (natalizumab); and
o Initial authorization will be for no more than 14 weeks.
For continuation of therapy, all of the following: o Documentation of positive clinical response to Entyvio; and o Entyvio dosing for ulcerative colitis is in accordance with the FDA
labeled dosing up to a maximum of 300mg every 8 weeks (or equivalent dose and interval schedule); and
o Reauthorization will be for no more than 12 months.
Immune checkpoint inhibitor-related toxicities when all of the following criteria are met for initial and continuation of therapy: Diagnosis of severe (G3-4) immunotherapy-related diarrhea or colitis;
and Patient is receiving a checkpoint inhibitor [e.g., Keytruda
(pembrolizumab), Opdivo (nivolumab)]; and History of failure, contraindication, or intolerance to infliximab; and
Authorization will be for no more than 3 doses of Entyvio.
Immune Globulin (IVIG and SCIG)
Feb. 1, 2020
Conditions of Coverage Added language to indicate
precertification is not required, however it is strongly recommended for Xembify:
o While no penalty will be imposed for failure to request a pre-service review, if one is not
Refer to the policy for complete details on the coverage guidelines for Immune Globulin (IVIG and SCIG).
57 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Immune Globulin
(IVIG and SCIG) (continued)
Feb. 1, 2020
requested, a medical
necessity review will be conducted post-service to determine coverage
o It is the referring physician’s
responsibility to provide medical documentation to demonstrate clinical
necessity for the medication o Beginning Feb. 1, 2020,
precertification will be required; refer to the Clinical Policy titled Review at Launch for New to Market
Medications
Coverage Rationale Revised list of applicable FDA
approved subcutaneous (SC)
immune globulin (IG) products; added “Xembify™”
Revised coverage criteria:
General Requirements
o Added medical necessity criterion to indicate authorization for initial or continuation of therapy will be for no more than 12 months
o Added notation to indicate
Xembify is not medically necessary for the treatment of any diagnosis addressed within this policy
Diagnosis-Specific
Requirements o Added language to indicate
immune globulin is: Proven and medically
58 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Immune Globulin
(IVIG and SCIG) (continued)
Feb. 1, 2020
necessary for multiple
myeloma (prevention of infection in multiple myeloma)
Medically necessary for
the prevention of infection in multiple myeloma when all of the
following criteria are met: - Diagnosis of multiple
myeloma - One of the following:
Documented
hypogammaglobulinemia (IgG < 500 mg/dL)
History of bacterial infection(s) associated with
multiple myeloma - IVIG dose does not
exceed 400 mg/kg every 3 to 4 weeks
o Updated medical necessity criteria for: Asthma (severe,
persistent, high-dose
steroid-dependent) Feto-neonatal
alloimmune thrombocytopenia (AIT), for pregnant women
Multiple sclerosis, relapsing forms
Neuromyelitis optica Rasmussen syndrome
59 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Immune Globulin
(IVIG and SCIG) (continued)
Feb. 1, 2020 Stiff-person syndrome
o Added medical necessity criterion requiring immune globulin is prescribed by, or in consultation with, a
neurologist for the following diagnoses: Chronic inflammatory
Added language to indicate immune globulin is unproven
and not medically necessary for:
o Isolated IgE deficiency o Isolated IgM deficiency
Applicable Codes
Added ICD-10 diagnosis codes C90.00, C90.01, and C90.02
Supporting Information
Updated Clinical Evidence and References sections to reflect the most current information
60 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Immune Globulin
(IVIG and SCIG)
Apr. 1, 2020 Conditions of Coverage
Revised precertification guidelines to indicate precertification is required for Xembify
Refer to the policy for complete details on the coverage guidelines for
Immune Globulin (IVIG and SCIG).
Infliximab (Remicade®,
Inflectra™, Renflexis™)
Feb. 1, 2020
Conditions of Coverage Added language to indicate:
o Home infusion of infliximab requires additional precertification for the home care services
o Participating providers in the office setting: Precertification is required
for services performed in the office of a participating provider
o Non-participating/out-of-network providers in the office setting: Precertification is not
required, but encouraged for out-of-network services performed in the office; if precertification is not obtained, Oxford will review for out-of-network benefits
and medical necessity after the service is rendered
Removed language indicating: o A referral is required in the
office setting o Precertification with review
by a Medical Director or their
designee is required for Remicade and Inflectra in the home or outpatient setting; no precertification is
Refer to the policy for complete details on the coverage guidelines for Infliximab (Remicade®, Inflectra™, Renflexis™).
61 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Infliximab
(Remicade®, Inflectra™, Renflexis™) (continued)
Feb. 1, 2020 required for Remicade and
Inflectra administered in the office setting
o Precertification with review by a Medical Director or their
designee is required for Renflexis in all settings/sites of service
Negative Pressure Wound Therapy
Feb. 1, 2020
Coverage Rationale Added language to indicate:
o The proven and medically necessary coverage statements in this policy apply to the use of negative
pressure wound therapy (NPWT) in the outpatient setting
o The unproven and not medically necessary coverage statements in this policy apply to all settings
Supporting Information Updated Clinical Evidence and
References sections to reflect
the most current information
Note: The proven and medically necessary coverage statements in this policy
apply to the use of negative pressure wound therapy (NPWT) in the outpatient setting.
The unproven and not medically necessary coverage statements apply to all settings.
NPWT, in an outpatient setting or upon discharge from an inpatient setting, is proven and medically necessary for treating individuals
who have undergone a complete wound therapy program and meet indication-specific criteria as noted below. A complete wound therapy program, meeting the following criteria, must
have been tried or considered and ruled out prior to initiation of NPWT: Documentation of evaluation, care and wound measurements; and Application of dressings to maintain a moist wound environment; and Debridement of necrotic tissue, if present; and Evaluation of and provision for adequate nutritional status; and Documentation, by provider, of indication for NPWT; and
Documentation that open wound has not responded to conventional treatment after 30 days.
Indications
Pressure ulcer (Stage III or IV) with documentation of the following: o Complete wound therapy program, as outlined above; and o Appropriate turning and positioning; and o Use of a pressure-reducing support surface; and o Moisture and incontinence management.
Neuropathic ulcer (e.g., diabetic ulcer) with documentation of the
62 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Negative Pressure
Wound Therapy (continued)
Feb. 1, 2020
following:
o Complete wound therapy program, as outlined above; and o Comprehensive diabetic management program; and o Reduction in pressure on ulcer.
Venous insufficiency ulcer with documentation of the following: o Complete wound therapy program, as outlined above; and o Compression bandages and/or garments have been used
consistently, for at least 30 days; and o Leg elevation and ambulation.
Open surgical wound with documentation of the following:
o Post-operative dehiscence (separation of a previously closed surgical incision) with documentation of a complete wound therapy program,
as outlined above; or o Open, non-healing amputation site in diabetics; or o Post-sternotomy infection (mediastinitis); or
o Delayed healing or non-healing of skin graft is likely due to irregularly contoured or inadequate blood flow of the graft bed.
High-risk open fracture (Gustilo grade III)
The following indications and devices are unproven and not medically necessary due to insufficient evidence of efficacy: NPWT for treating ALL other indications, including but not limited to:
o Closed surgical wounds o Pilonidal disease o Disposable/single-use NPWT systems
Contraindications to NPWT
Active bleeding or exposed vasculature in wound Eschar or necrotic tissue present in wound
Exposed bone, nerves or organs in vicinity of wound Malignancy present in wound Uncontrolled soft tissue infection or osteomyelitis within vicinity of wound Presence of an open fistula to body organs or cavities within vicinity of
wound
63 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Negative Pressure
Wound Therapy (continued)
Feb. 1, 2020 NPWT should be discontinued when any of the following criteria are present:
Documentation of weekly assessment of the wound's dimensions and characteristics by the provider indicate failure of progressive wound healing (i.e., wound is not diminishing in size [either surface area or depth] within 30 days); or
The depth of the wound is 1 mm or less; or Uniform granulation tissue has been obtained.
Outpatient Surgical Procedures - Site of Service
Apr. 6, 2020
Notice of Revision and Implementation Delay (Jan. 1, 2020): The following changes will not be effective on Feb. 1, 2020, as previously announced. Implementation of the revised policy has been postponed until Apr. 6,
2020. Revisions to the original policy update announcement are outlined in red below. Please take
note of the amended guidelines to be applied beginning Apr. 6, 2020. Related Policies
Updated list of related policies Coverage Rationale Corrected clerical errors in list of
medically necessary indications; replaced: o “Coronary artery disease
cardiac ischemia requiring medical management recently placed [within 1 year] drug eluting stent)” with “coronary artery
disease ([CAD]/peripheral vascular disease [PVD]) (ongoing cardiac ischemia requiring medical
UnitedHealthcare® Oxford members may choose to receive surgical procedures in an ambulatory surgical center (ASC) or other locations. We are conducting site of service medical necessity reviews, however, to determine whether the outpatient hospital department is medically necessary, in accordance with the terms of the member’s benefit plan. If the outpatient hospital department is not considered medically necessary, this location will not be covered under the member’s plan.
Certain planned surgical procedures performed in a hospital outpatient department are considered medically necessary for an
individual who meets ANY of the following criteria: Advanced liver disease (MELD Score > 8) Advance surgical planning determines an individual requires overnight
recovery and care following a surgical procedure
Anticipated need for transfusion Bleeding disorder requiring replacement factor or blood products or
special infusion products to correct a coagulation defect Brittle Diabetes Cardiac arrhythmia (symptomatic arrhythmia despite medication) Chronic obstructive pulmonary disease (COPD) (FEV1 <50%)
Coronary artery disease (CAD)/peripheral vascular disease (PVD) (ongoing cardiac ischemia requiring medical management or recently
placed [within 1 year] drug eluting stent) Developmental stage or cognitive status warranting use of a hospital
outpatient department End stage renal disease ([hyperkalemia above reference range] receiving
peritoneal or hemodialysis)
History of cerebrovascular accident (CVA) or transient ischemic attack (TIA) (recent event [< 3 months])
History of myocardial infarction (MI) (recent event [< 3 months]) Individuals with drug eluting stents (DES) placed within one year or bare
64 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Outpatient Surgical
Procedures - Site of Service (continued)
Apr. 6, 2020 management or recently
placed [within 1 year] drug eluting stent)”
o “End stage renal disease ([hyperkalemia above
reference range] peritoneal or hemodialysis)” with “end stage renal disease
([hyperkalemia above reference range] receiving peritoneal or hemodialysis)”
Documentation Requirements
Added reference link to the applicable Clinical Policy for CPT codes with additional documentation requirements
Applicable Codes
Reformatted content Added 1,084 1,015 CPT/HCPCS
codes (see list for details; revised Jan. 1, 2020)
Revised description for CPT codes 66982 and 66984 to reflect annual code edits
Definitions
Updated definition of “ASA Physical Status Classification System Risk Scoring Tool”
metal stents (BMS) or plain angioplasty within 90 days unless
acetylsalicylic acid and antiplatelet drugs will be continued by agreement of surgeon, cardiologist and anesthesia
Less than 19 years of age Ongoing evidence of myocardial ischemia
Poorly Controlled asthma (FEV1 < 80% despite medical management) Pregnancy Prolonged surgery (> 3 hours)
Resistant hypertension (Poorly Controlled) Significant Severe valvular heart disease Sleep apnea (moderate to severe Obstructive Sleep Apnea (OSA) Uncompensated chronic heart failure (CHF) (NYHA class III or IV) A planned surgical procedure performed in a hospital outpatient
department is considered medically necessary if there is an inability to access an ambulatory surgical center for the procedure due to ANY one of the following:
There is no geographically accessible ambulatory surgical center that has the necessary equipment for the procedure; or
There is no geographically accessible ambulatory surgical center available at which the individual’s physician has privileges; or
An ASC’s specific guideline regarding the individual’s weight or health conditions that prevents the use of an ASC
Planned Surgical Procedures List
Site of service medical necessity reviews will be conducted for surgical procedures on the Applicable Codes List only when performed in an
outpatient hospital setting.
Preventive Care Services
Feb. 1, 2020
Applicable Codes
Preventive Care Services
Updated service description for:
Bacteriuria Screening
o Removed July 2008 USPSTF “A” rating
o Added September 2019 USPSTF “A” rating to indicate the USPSTF
Refer to the policy for complete details on the coverage guidelines for Preventive Care Services.
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Preventive Care
Services (continued)
Feb. 1, 2020
recommends screening for
asymptomatic bacteriuria using urine culture in pregnant persons
Genetic Counseling and
Evaluation for BRCA Testing; and BRCA Lab Screening o Removed December 2013
USPSTF “B” rating o Added August 2019 USPSTF
“B” rating to indicate the
USPSTF recommends primary care clinicians assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who
have an ancestry associated
with breast cancer susceptibility 1 and 2 (BRCA1/2) gene mutations with an appropriate brief familial risk assessment tool; women with a positive result
on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing
Added coverage guidelines for Perinatal Depression –
Preventive Interventions (Counseling): o Added service description to
indicate: The USPSTF
recommends clinicians provide or refer
66 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Preventive Care
Services (continued)
Feb. 1, 2020
pregnant and
postpartum persons who are at increased risk of perinatal depression to counseling interventions
(February 2019 USPSTF “B” rating)
This policy addresses
coding for interventions from a network medical provider only; for perinatal depression preventive interventions with a mental health
provider, refer to the plan’s mental health plan benefit administrator
For depression screening, refer to the Screening for Depression in Adults and Depression
in Children and Adolescents (Screening) sections of this policy
o Added list of applicable CPT/HCPCS codes:
Code Group 1
Preventive Medicine, Individual Counseling:
99401, 99402, 99403, and 99404
Preventive Medicine, Group Counseling: 99411 and 99412
Prenatal Care Visits: 59425 and 59426
Preventive Medicine Services (Evaluation and
67 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
Evaluation and Management (Office Visits): 99201, 99202, 99203, 99204, 99205,
99211, 99212, 99213, 99214, 99215, and G0463
o Added list of applicable ICD-10 diagnosis codes for Code Group 2: Z13.32, Z39.2, or
a Pregnancy Diagnosis Code
o Added preventive benefit instructions to indicate procedure codes in: Code Group 1 do not
have diagnosis code requirements for the
preventive benefit to apply
Code Group 2 require one of the Code Group 2 diagnosis codes for the
preventive benefit to apply
Expanded Women’s Preventive Health Updated preventive benefit
instructions for Breastfeeding Services and Supplies: Counseling and Education to clarify HCPCS code S9443 does
68 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Preventive Care
Services (continued)
Feb. 1, 2020
not have diagnosis code
requirements for preventive benefits to apply
Rituximab (Rituxan®,
Ruxience™ & Truxima®)
Feb. 1, 2020
Title Change Previously titled Rituximab
(Rituxan® & Truxima®)
Conditions of Coverage
Revised applicable sites of service: o Added “Home” o Removed “Inpatient”
Added language to indicate: o Precertification is not
required, however it is strongly recommended for Ruxience: While no penalty will be
imposed for failure to request a pre-service review, if one is not requested, a medical necessity review will be conducted post-service to determine coverage
It is the referring physician’s responsibility to provide medical documentation to
demonstrate clinical necessity for the medication
As of Apr. 1, 2020, precertification will be required
o Home infusion of rituximab requires additional precertification for the home
care services
Refer to the policy for complete details on the coverage guidelines for Rituximab (Rituxan®, Ruxience™ & Truxima®).
69 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Rituximab
(Rituxan®, Ruxience™ & Truxima®) (continued)
Feb. 1, 2020
Coverage Rationale
Updated list of applicable drug products for rituximab injections for intravenous infusion for non-
oncology conditions; added:
o Rituxan Hycela® (rituximab and hyaluronidase human)
o Ruxience™ (rituximab-pvvr) Replaced language indicating:
o “Rituximab will be used to refer to both Rituxan and
Truxima” with “rituximab will be used to refer to all rituximab products without hyaluronidase”
o “Rituximab is proven and medically necessary for the
treatment of [the listed
conditions]” with “rituximab is proven for the treatment of [the listed conditions]”
o “Rituximab is proven and medically necessary in combination with plasma
exchange therapy and high dose corticosteroids for acute thrombotic thrombocytopenic purpura” with “rituximab is proven for
the treatment of thrombocytopenic purpura
(TTP); rituximab is medically necessary for acute thrombotic thrombocytopenic purpura when all of the [listed] criteria are met”
Added language to indicate:
70 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Rituximab
(Rituxan®, Ruxience™ & Truxima®) (continued)
Feb. 1, 2020
o Rituxan Hycela is unproven
and not medically necessary for the treatment of non-oncology indications
o Rituximab is proven for the
treatment of multiple sclerosis (MS)
Added medical necessity criteria
for initial and continuation of therapy for: o Autoimmune hemolytic
anemia, including chronic cold agglutinin disease
o Multiple sclerosis (MS)
o Neuromyelitis optica o Pemphigus vulgaris o Post-transplant B-
lymphoproliferative disorder (PTLD)
o Thrombotic thrombocytopenic purpura
(TTP) Added medical necessity criteria
for initial therapy dosage, initial authorization, and continuation of therapy for: o Immune thrombocytopenic
purpura (ITP)
o Rheumatoid arthritis
o Wegener’s granulomatosis or microscopic polyangiitis (both ANCA-associated vasculidities)
Revised medical necessity
criteria for immunotherapy-related encephalitis; added criterion requiring: o Rituximab is dosed up to a
71 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Rituximab
(Rituxan®, Ruxience™ & Truxima®) (continued)
Feb. 1, 2020 maximum of 1,225 mg per
dose o Authorization will be for no
more than 3 months Removed language indicating
rituximab is unproven and not medically necessary for the treatment of:
requires additional precertification for the home care services
Participating
Refer to the policy for complete details on the coverage guidelines for Stelara® (Ustekinumab).
72 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Stelara®
(Ustekinumab) (continued)
Feb. 1, 2020 providers in the office
setting: Precertification is required for services performed in the office of a participating
provider Non-participating/
out-of-network
providers in the office setting: Precertification is not required, but encouraged for out-of-network services performed in the office;
if precertification is not obtained, Oxford will review for out-of-
network benefits and medical necessity after the service is rendered
o Removed language
indicating precertification is not required when provided in an office or outpatient setting
Total Artificial Disc Replacement for
the Spine
Mar. 1, 2020
Conditions of Coverage Revised list of applicable sites of
service; replaced “all” with “inpatient, outpatient, office”
Coverage Rationale Revised proven and medically
necessary criteria for lumbar artificial total disc replacement with an FDA-
approved prosthetic intervertebral disc: o Added criterion requiring
“favorable psychosocial-
Cervical artificial total disc replacement with an FDA-approved prosthetic intervertebral disc is proven and medically necessary for
treating one-level or two contiguous levels of cervical Degenerative Disc Disease (C3 to C7), in a Skeletally Mature individual with
symptomatic radiculopathy and/or myelopathy when the following criteria are met: Documented individual history of neck and/or upper extremity pain
and/or a functional/neurological deficit associated with the cervical level to be treated
Imaging studies (i.e., computerized tomography [CT] scan or magnetic resonance imaging [MRI]) confirming herniated nucleus pulposus or osteophyte formation
Failed at least six weeks of non-operative treatment prior to implantation
73 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Total Artificial Disc
Replacement for the Spine (continued)
Mar. 1, 2020
behavioral evaluation to be
conducted by an individual who is professionally recognized as part of a behavioral health discipline
to provide screening and identification of risk factors or potential postoperative
challenges that may contribute to a poor postoperative outcome”
o Removed criterion requiring “favorable face-to-face psychological evaluation
confirming candidacy for surgery”
Documentation Requirements
Updated documentation
requirements for lumbar surgery to reflect changes to the Coverage Rationale
Cervical artificial disc replacement at one level combined with cervical spinal fusion surgery at another level (adjacent or non-adjacent) is unproven and not medically necessary due to insufficient evidence of efficacy.
Lumbar artificial total disc replacement with an FDA-approved prosthetic intervertebral disc is proven and medically necessary for
treating single level lumbar Degenerative Disc Disease with symptomatic intractable discogenic low back pain in a Skeletally Mature individual when ALL of the following criteria are met: Advanced Degenerative Disc Disease (DDD) in only one vertebral level
between L3 and S1 confirmed by complex imaging studies (i.e., computerized tomography [CT] scan or magnetic resonance imaging
[MRI]) that indicate either moderate to severe Degenerative Disease or Modic Changes.
Symptoms correlate with imaging findings
No more than Grade 1 Spondylolisthesis at the involved level or any listhesis at two or more lumbar segments
Presence of symptoms for at least six months Failed at least 6 months of conservative treatment immediately prior to
implantation of artificial disc. Conservative treatment shall include all of the following, unless contraindicated: physical therapy, anti-inflammatory medications, analgesics, muscle relaxants, and epidural steroid injections
Age 18 to 60 years Favorable psychosocial-behavioral evaluation to be conducted by an
individual who is professionally recognized as part of a behavioral health
discipline to provide screening and identification of risk factors or
potential postoperative challenges that may contribute to a poor postoperative outcome
Contraindications to lumbar artificial total disc replacement, including, but not limited to the following:
Moderate or severe facet arthropathy or pars defect at the operative level on a preoperative MRI scan, CT scan or plain radiograph
Lumbosacral spinal fracture Scoliosis of the lumbosacral spine
74 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Total Artificial Disc
Replacement for the Spine (continued)
Mar. 1, 2020 Active systemic infection or infection localized to the site of implantation
Tumor in the peritoneum, retroperitoneum or site of implantation Osteoporosis or osteopenia as defined by recent (within one year) DEXA
scan Isolated radicular compression syndromes especially due to disc
herniation. Spinal stenosis or radiculopathy Previous lumbar spine surgery where the previous surgery destabilized
the spine or where the spine at the level of the previous surgery is an alternate source of pain
Vascular, urological, or other peritoneal or retroperitoneal pathology that may preclude safe and adequate anterior spine exposure as required for the surgery
Lumbar artificial total disc replacement is unproven and not medically in the following situations due to insufficient evidence of efficacy:
More than one spinal level Prior history of lumbar fusion or when combined with a lumbar fusion at
any level Treating any other indications not listed above
Transcatheter Heart Valve Procedures
Mar. 1, 2020
Coverage Rationale Revised list of unproven and not
o “Mitral valve repair or replacement” with “mitral
valve repair, reconstruction, or replacement, except where noted [as proven and medically necessary]”
o “Tricuspid valve repair or
replacement” with “tricuspid valve repair, reconstruction, or replacement”
Aortic Transcatheter aortic heart valve replacement is proven and medically necessary for treating individuals at intermediate or higher surgical risk, when used according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings and precautions, and ALL of the following criteria are met:
Severe calcific native aortic valve stenosis as indicated by one of the following:
o Mean aortic valve gradient ≥ 40 mmHg; or o Peak aortic jet velocity ≥ 4.0 m/s; or o Aortic valve area of ≤ 0.8 cm2.
Individual is symptomatic [New York Heart Association (NYHA) class II or greater] and symptoms are due to aortic valve stenosis.
Individual requires valve replacement surgery but is at intermediate or higher risk for serious surgical complications or death from open valve replacement surgery as determined by an interventional cardiologist and an experienced cardiothoracic surgeon.
75 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Transcatheter
Heart Valve Procedures (continued)
Mar. 1, 2020
Aortic
Replaced language indicating “transcatheter aortic heart valve replacement is proven and
medically necessary for treating
intermediate or higher risk individuals” with “transcatheter aortic heart valve replacement is proven and medically necessary for treating individuals at intermediate or higher surgical
risk” Clarified criterion/list of
indications for severe calcific native aortic valve stenosis; replaced: o “Mean aortic valve gradient
> 40 mmHg” with “mean
aortic valve gradient ≥ 40 mmHg”
o “Peak aortic jet velocity > 4.0 m/s” with “peak aortic jet velocity ≥ 4.0 m/s”
Added language to indicate
requests for transcatheter aortic heart valve replacement for low-flow/low-gradient aortic stenosis will be evaluated on a case-by-case basis
Mitral
Added language to indicate transcatheter mitral valve repair is proven and medically necessary when used according
to FDA labeled indications, contraindications, warnings, and precautions in individuals with one of the following clinical
Note: Requests for transcatheter aortic heart valve replacement for low-
flow/low-gradient aortic stenosis will be evaluated on a case-by-case basis. Society of Thoracic Surgeons (STS) surgical risk categories are as follows (Nishimura et al., 2014):
Intermediate - Predicted Risk of Mortality (PROM) score of 4-8% High - PROM score of > 8%
Mitral Transcatheter mitral valve repair is proven and medically necessary when used according to FDA labeled indications, contraindications, warnings and precautions in individuals with ONE of the following clinical indications for intervention:
Primary (degenerative) mitral regurgitation (MR) when ALL of the following criteria are met: o Moderate-to-severe or severe MR (grade ≥ 3); and
o Symptomatic NYHA class III or IV; and o Prohibitive surgical risk as defined by one of the following:
PROM score of ≥ 8% for patients deemed likely to undergo mitral valve replacement; or
PROM score of ≥ 6% for patients deemed likely to undergo mitral valve repair; or
Predicted risk of death or major morbidity at 1 year of over 50% and
o Care directed by a multidisciplinary heart team which includes a heart failure specialist, interventional cardiologist and cardiothoracic surgeon experienced in the evaluation and treatment of heart failure
and mitral valve disease.
Secondary (functional) MR when ALL of the following criteria are met:
o Moderate-to-severe or severe MR (grade ≥ 3) with LVEF ≥ 20 and ≤ 50; and
o Symptomatic NYHA class II –IV (ambulatory); and
o Optimal evidence-based management which includes pharmacologic therapy plus cardiac resynchronization therapy as indicated; and
o High surgical risk; and o Care directed by a multidisciplinary heart team which includes a
76 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Transcatheter
Heart Valve Procedures (continued)
Mar. 1, 2020
indications for intervention:
o Primary (degenerative) mitral regurgitation (MR) when all of the following criteria are met:
Moderate-to-severe or severe MR (grade ≥ 3); and
Symptomatic NYHA class III or IV; and
Prohibitive surgical risk as defined by one of the following: - PROM score of ≥ 8%
for patients deemed likely to undergo mitral valve
replacement; or - PROM score of ≥ 6%
for patients deemed likely to undergo
mitral valve repair; or - Predicted risk of
death or major morbidity at 1 year of over 50%;
and Care directed by a
multidisciplinary heart
team which includes a heart failure specialist, interventional cardiologist and cardiothoracic surgeon
experienced in the evaluation and treatment of heart failure and mitral valve
heart failure specialist, interventional cardiologist and cardiothoracic
surgeon experienced in the evaluation and treatment of heart failure and mitral valve disease.
Pulmonary
Transcatheter pulmonary heart valve replacement is proven and medically necessary, when used according to FDA labeled indications, contraindications, warnings and precautions, in
individuals with right ventricular outflow tract (RVOT) dysfunction with ONE of the following clinical indications for intervention: Moderate or greater pulmonary regurgitation; and/or Pulmonary stenosis with a mean RVOT gradient ≥ 35 mmHg. The following transcatheter heart valve devices and/or procedures
are unproven and not medically necessary due to insufficient evidence of efficacy: Cerebral protection devices (e.g., Sentinel™)
Mitral valve repair, reconstruction or replacement, except where noted above
Tricuspid valve repair, reconstruction or replacement Valve-in-Valve (ViV) replacement within a failed bioprosthesis
77 Oxford® Policy Update Bulletin: January 2020
Clinical Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Transcatheter
Heart Valve Procedures (continued)
Mar. 1, 2020 disease
o Secondary (functional) MR when ALL of the following criteria are met: Moderate-to-severe or
severe MR (grade ≥ 3) with LVEF ≥ 20 and ≤ 50; and
Symptomatic NYHA class II –IV (ambulatory); and
Optimal evidence-based management which includes pharmacologic therapy plus cardiac
resynchronization therapy as indicated; and
High surgical risk; and
Care directed by a multidisciplinary heart team which includes a heart failure specialist,
interventional cardiologist and cardiothoracic surgeon experienced in the evaluation and treatment of heart failure and mitral valve disease
Applicable Codes
Added CPT codes 0543T, 0544T,
and 0545T
Policy Title Effective Date Summary of Changes
RETIRED/REPLACED
Magnetic Resonance Spectroscopy
Jan. 1, 2020 Policy retired; magnetic resonance spectroscopy (CPT code 76390) will be managed through UnitedHealthcare’s Radiology Notification/Prior Authorization Program
78 Oxford® Policy Update Bulletin: January 2020
Administrative Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Administrative Guidelines
REVISED
Acquired Rare
Disease Drug Therapy Exception Process
Feb. 1, 2020
Conditions of Coverage
Revised precertification guidelines; added language to indicate: o Participating providers in
the office setting: Precertification is required for services performed in the
office of a participating provider
o Non-participating/out-of-network providers in the office setting: Precertification is not
required, but is encouraged for out-of-network services performed in the office; if
precertification is not obtained, Oxford will review for out-of-network benefits and medical necessity after
the service is rendered
After receiving a request for experimental treatment of an Acquired Rare
Disease, an Oxford Medical Director will review the relevant clinical and patient information. As part of that review, the Medical Director, in his/her discretion, will determine whether the disease is an Acquired Rare Disease and whether the proposed drug therapy is clinically reasonable.
For purposes of this policy, clinically reasonable means: The drug is FDA approved and is not contraindicated for the proposed
use. There is evidence of early success with the drug therapy and at least a
small number of patients with the same Acquired Rare Disease have responded to treatment but there is not enough information to have a peer review published study at this time.
The evidence showing early success is from a Center of Excellence which
treats members with the same Acquired Rare Disease. The benefit likely exceeds the risk to the member in receiving the drug
therapy.
The treatment results will be available for use by the medical community by establishment of a patient registry to evaluate the effectiveness of the drug therapy for patients with this Acquired Rare Disease.
The member has not failed a previous course or trial of the drug therapy.
The member does not have any other comorbidity which would preclude the proposed drug therapy.
The member has signed an informed consent. The Medical Director will consult with the specialist who has received early success with use of the proposed treatment if possible and/or an outside consultant. The specialist/consultant must have credentials in the specific
discipline of medicine that treats the member's Acquired Rare Disease. That
specialist or consultant will be asked to certify that the basis of the medical documents submitted that: The member has an Acquired Rare Disease. There have not been, and are not likely to be in the period of time during
which the member must be treated, either clinical trials or articles
published in the peer reviewed medical literature showing that the proposed treatment is likely to benefit patients who have the specific rare disease.
The requested drug therapy protocol is clinically reasonable to treat the
79 Oxford® Policy Update Bulletin: January 2020
Administrative Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Administrative Guidelines
REVISED
Acquired Rare
Disease Drug Therapy Exception Process (continued)
Feb. 1, 2020
member's Acquired Rare Disease, with stated rationales that support
that conclusion. Based on the consultant's opinion, the benefits of the treatment are
likely to outweigh the risks of treatment. The specialist/consultant has treated patients with this condition.
Precertification will be required for each course of drug therapy. If the member does not respond to the initial prescribed course of drug therapy,
Oxford will not continue to approve the therapy and the therapy will be denied as an Unproven Therapy. Documentation
The following documentation must be submitted to Oxford demonstrating the criteria below have been satisfied. Without all such documentation, Oxford will deny any such request. Necessary Information
The following supporting documentation must be provided by the member and/or the member's provider for consideration of the drug therapy:
Certification from the member's attending physician* which includes: o A statement that the member has an Acquired Rare Disease. o A statement of the evidence relied upon to recommend the proposed
drug therapy and a statement of why any standard therapy available would not be beneficial, would be ineffective or would be inappropriate, including an assessment of the risks and benefits of the proposed treatment.
o A copy of any available medical and scientific evidence, upon which the attending physician based his recommendation for the proposed
treatment.
*The attending physician must be a board certified or board eligible physician qualified to practice in the area of practice appropriate to treat
the member's condition. A written description of the proposed treatment (or protocol if available),
which must include: o Specific goals o A rationale and background for the plan
80 Oxford® Policy Update Bulletin: January 2020
Administrative Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Administrative Guidelines
REVISED
Acquired Rare
Disease Drug Therapy Exception Process (continued)
Feb. 1, 2020 o Criteria for patient selection
o Specific directions for administering the therapy o Specific directions for the monitoring of patients o A definition of quantitative measures for determining treatment or
intervention response
o Methods for documenting and treating adverse reactions to the treatment or intervention
A copy of the member's informed consent form.
A copy of the member's medical and treatment records, including results of tests or studies, showing the member's current condition and any treatment the member has received for the condition.
The available clinical or pre-clinical data that indicate the effectiveness of the proposed drug therapy for treatment of the member's condition and the contact information for the specialist who can discuss the evidence of
early success of the drug therapy with an Oxford Medical Director. Depending upon the nature of the proposed drug therapy and/or the
member's disease, the specialist/consultant or Oxford may require
additional documentation to review the requested therapy. Oxford will also accept and consider any additional pertinent clinical documentation, peer review publications and/or relevant data concerning the
protocol that the member and/or the member's physician would like to provide in support of the request for the drug therapy.
Behavioral Health Services
Feb. 1, 2020
Policy
Added language to indicate Optum uses the following clinical criteria: o American Society of
Addiction Medicine (ASAM) for substance-related disorders
o Level of Care Utilization System (LOCUS) for adults 18 and older
o Child and Adolescent Service Intensity Instrument (CASII) for children and adolescents
ages 6-18
Oxford administers benefit coverage for behavioral health services in coordination with OptumHealth. OptumHealth uses written criteria based on sound clinical evidence to make coverage determinations, as well as to inform discussions about evidence-based practices and discharge planning.
In using its clinical criteria, Optum takes individual circumstances and the local delivery system into account when determining coverage of behavioral
health services. Optum uses the following clinical criteria: American Society of Addiction Medicine (ASAM) for substance-related
disorders Level of Care Utilization System (LOCUS) for adults 18 and older Child and Adolescent Service Intensity Instrument (CASII) for children
and adolescents ages 6-18 Early Childhood Service Intensity Instrument (ECSII) for children ages 0-
5
81 Oxford® Policy Update Bulletin: January 2020
Administrative Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Administrative Guidelines
REVISED
Behavioral Health
Services (continued)
Feb. 1, 2020 o Early Childhood Service
Intensity Instrument (ECSII) for children ages 0-5
Removed language indicating: o For mental health and
wraparound services, Optum: Derives a standard set of
clinical criteria from guidance produced by government sources, professional societies, and published research
Involves appropriate
clinical staff, providers and consumers in developing, adopting,
and reviewing its clinical criteria
o For substance-related disorder services, Optum
standardly uses the ASAM criteria to make coverage determinations
OptumHealth:
Adopts and disseminates clinical practice guidelines relevant to its members for the provision of behavioral health services. The clinical practice guidelines adopted by OptumHealth include those produced by the American Psychiatric Association, and the American Academy of Child
and Adolescent Psychiatry. Develops clinical criteria that supersedes its standard set or adopts
externally-developed clinical criteria when required to do so by contract
or regulation. Annually reviews its clinical criteria and the procedures for applying
them, and updates internally-developed clinical criteria when appropriate.
OptumHealth’s clinical criteria are available to:
Practitioners on the Optum website: www.providerexpress.com. Beneficiaries on the Optum website: www.liveandworkwell.com.
Paper copies are available to providers and members upon request.
Experimental/ Investigational Treatment
Feb. 1, 2020
Conditions of Coverage Revised precertification
guidelines; added language to
indicate: o Participating providers in
the office setting: Precertification is required for services performed in the office of a participating provider
o Non-participating/out-of-network providers in the office setting: Precertification is not
Refer to the policy for complete details on the coverage guidelines for Experimental/Investigational Treatment.
Policy Title Effective Date Summary of Changes Administrative Guidelines
REVISED
Experimental/
Investigational Treatment (continued)
Feb. 1, 2020 required, but is encouraged
for out-of-network services performed in the office; if precertification is not obtained, Oxford will review
for out-of-network benefits and medical necessity after the service is rendered
Experimental/ Investigational Treatment for NJ Plans
Feb. 1, 2020 Conditions of Coverage Removed language indicating a
referral is required Revised precertification
guidelines; added language to indicate:
o Participating providers in the office setting: Precertification is required
for services performed in the office of a participating provider
o Non-participating/out-of-
network providers in the office setting: Precertification is not required, but is encouraged for out-of-network services performed in the office; if
precertification is not obtained, Oxford will review
for out-of-network benefits and medical necessity after the service is rendered
Refer to the policy for complete details on the coverage guidelines for Experimental/Investigational Treatment for NJ Plans.
83 Oxford® Policy Update Bulletin: January 2020
Reimbursement Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Ambulance
Feb. 1, 2020
Applicable Codes
Revised list of Ambulance Bundled Codes; added HCPCS code J0642
Ambulance Suppliers
Oxford considers only an Ambulance Supplier as eligible for reimbursement of ambulance services reported with Healthcare Common Procedure Coding
System (HCPCS) codes A0021 and A0225-A0999.
Other provider specialties, e.g., emergency room physicians, should report the Current Procedural Terminology (CPT®) and/or HCPCS codes that specifically and accurately describe the services and procedures outside of the HCPCS code A0021 and A0225-A0999 range.
Oxford will not reimburse non-Ambulance suppliers for rendering ambulance services. Origin and Destination Modifiers
For ambulance transportation claims, Oxford has adopted the Centers for Medicare and Medicaid Services (CMS) guidelines that require an Ambulance Supplier to report an origin and destination modifier for each trip provided.
Each ambulance modifier is comprised of a single digit alpha character
identifying the origin of the transport in the first position, and a single digit alpha character identifying the destination of the transport in the second position. Example: RH (residence to hospital). Single digit alpha characters used to designate an origin and destination are listed below: D = Diagnostic or therapeutic site other than P or H when these are used
as origin codes
E = Residential, domiciliary, custodial facility (other than 1819 facility) G = Hospital based ESRD facility
H = Hospital I = Site of transfer (e.g. airport or helicopter pad) between modes of
ambulance transport J = Freestanding ESRD facility
N = Skilled nursing facility P = Physician’s office R = Residence S = Scene of accident or acute event X = Intermediate stop at physician’s office on way to hospital
(destination code only)
84 Oxford® Policy Update Bulletin: January 2020
Reimbursement Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Ambulance
(continued)
Feb. 1, 2020
In alignment with CMS, Oxford will reimburse a code on the Ambulance
Transportation Codes List only when reported with a two-digit ambulance modifier on the Ambulance Modifiers List. Ambulance transportation services reported without a valid two-digit ambulance modifier will be denied.
When “X” (Intermediate stop at physician's office en route to the hospital) is present within the 2 digit modifier combination, “X” must be in the second digit position preceded by a valid origin digit in the first position. If “X” is the
first digit of the two digit modifier combination, the ambulance transportation code will be denied. See the Applicable Codes section of the policy for: Ambulance Transportation Codes Ambulance Modifiers Services Included in Ambulance Transportation
Per CMS, services including, but not limited to oxygen, drugs, extra attendants, supplies, EKG, and night differential are not paid separately when reported as part of an ambulance transportation service. In addition,
the ambulance must have customary patient care equipment and first aid supplies, including reusable devices and equipment such as backboards, neckboards and inflatable leg and arm splints. These are all considered part of the general ambulance service and payment for them is included in the payment rate for the transport.
In alignment with CMS, Oxford will not reimburse codes on the Ambulance Bundled Codes list when provided by the Same Ambulance Supplier for the same patient on the same date of service as a code on the Ambulance Transportation Codes list. This applies to network providers only. See the Applicable Codes section of the policy for: Ambulance Transportation Codes
Ambulance Bundled Codes
Advanced Life Support, Level 2 (ALS2) Ambulance Transportation
There are marked differences in resources necessary to furnish the various levels of ground ambulance services. According to CMS, Basic Life Support (BLS) ambulances must be staffed by at least two people, at least one of whom must be certified as an emergency medical technician (EMT) by the State or local authority where the services are being furnished and be legally authorized to operate all lifesaving and life-sustaining equipment on board
85 Oxford® Policy Update Bulletin: January 2020
Reimbursement Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Ambulance
(continued)
Feb. 1, 2020 the vehicle. All Advanced Life Support (ALS) vehicles must be staffed by at
least two people, at least one of whom must be certified by the State or local authority as an EMT-Intermediate or an EMT-Paramedic. In addition, Advanced Life Support, Level 1 (ALS1) must include the provision of an ALS Assessment or at least one ALS Intervention.
CMS defines Advanced Life Support, Level 2 (ALS2) as transportation by ground ambulance vehicle and the provision of medically necessary supplies
and services including (1) at least three separate administrations of one or more medications by intravenous push/bolus or by continuous infusion (excluding crystalloid fluids) or (2) ground ambulance transport, medically necessary supplies and services, and the provision of at least one of the ALS2 procedures listed below: Manual defibrillation/cardioversion
Endotracheal intubation Central venous line Cardiac pacing
Chest decompression Surgical airway or Intraosseous line
In alignment with CMS, reimbursement is based on the level of service provided, not on the vehicle used. Refer to the Definitions section of the policy for more information on ambulance transport.
Injection and
Infusion Services
Feb. 1, 2020
Applicable Codes
Revised list of E&M Codes Applicable When Reported
Injection Codes 96372-96379: o Added CPT codes 99421*,
99422*, 99423*, 99458*, 99473*, and 99474*
o Added HCPCS codes G0508,
G0509, G2082*, and G2083*
(*annual code edit)
Injections (96372-96379) and Evaluation and Management Services by Place of Service
Facility, Emergency Room, and Ambulatory Surgical Center Services
Per CPT and the CMS National Correct Coding Initiative (NCCI) Policy Manual, CPT codes 96372-96379 are not intended to be reported by the physician in the facility setting. Thus, when an E/M service and a therapeutic and
diagnostic Injection service are submitted with CMS Place of Service (POS) codes 19, 21, 22, 23, 24, 26, 51, 52, and 61 for the same patient by the Same Individual Physician or Other Qualified Health Care Professional on the same date of service, only the E/M service will be reimbursed and the therapeutic and diagnostic Injection(s) are not separately reimbursed, regardless of whether a modifier is reported with the Injection(s).
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Injection and
Infusion Services (continued)
Feb. 1, 2020
For additional information, refer to the Questions and Answers section of the policy, Q&A #1. Non-Facility Injection Services
E/M services provided in a non-facility setting are considered an inherent
component for providing an Injection service. CPT indicates these services typically require direct supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service
supervision of staff. When a diagnostic and therapeutic Injection procedure is performed in a POS other than 19, 21, 22, 23, 24, 26, 51, 52, and 61 and an E/M service is provided on the same date of service, by the Same Individual Physician or Other Qualified Health Care Professional only the appropriate therapeutic and diagnostic Injection(s) will be reimbursed and the EM service is not separately reimbursed.
If a significant, separately identifiable EM service is performed unrelated to the physician work (Injection preparation and disposal, patient assessment,
provision of consent, safety oversight, supervision of staff, etc.) required for the Injection service, Modifier 25 may be reported for the E/M service in addition to 96372-96379. If the E/M service does not meet the requirement for a significant separately identifiable service, then Modifier 25 would not be reported and a separate E/M service would not be reimbursed.
Exceptions
CPT 99211: E/M service code 99211 will not be reimbursed when submitted with a diagnostic or therapeutic Injection code, with or without Modifier 25. This very low service level code does not meet the requirement for "significant" as defined by CPT, and therefore should not be submitted in
addition to the procedure code for the Injection.
CPT 99381-99429: The Preventive Medicine codes (99381-99429) do not need Modifier 25 to indicate a significant, separately identifiable service when reported in addition to the diagnostic and therapeutic Injection service. The Preventive Medicine codes include routine services such as the ordering of immunizations or diagnostic procedures. The performance of these services is to be reported in addition to the Preventive Medicine E/M code. Therefore, diagnostic and therapeutic Injections can be reported at the same
time as a Preventive Medicine code without appending Modifier 25.
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REVISED
Injection and
Infusion Services (continued)
Feb. 1, 2020
For additional information, refer to the Questions and Answers section of the policy, Q&A#2, Q&A #3 and Q&A #6. CMS POS Database E/M Codes for Injection Codes 96372-96379
Injection and Infusion Services (96360-96549 and G0498) and HCPCS Supplies
Consistent with CPT guidelines, HCPCS codes identified by code description
as standard tubing, syringes, and supplies are considered included when reported with Injection and Infusion services (CPT codes 96360-96549 and HCPCS code G0498) and will not be separately reimbursed. See the Applicable Codes section of the policy for Injection and Infusion Inclusive Supplies List Drug Codes
Oxford reimbursement policy is aligned with CMS and will separately
reimburse for the HCPCS drug code when submitted with Injection or Infusion codes (CPT codes 96360-96549 and HCPCS code G0498) by the Same Individual Physician or Other Qualified Health Care Professional on the same date of service under the guidelines of this policy.
For additional information, refer to the Questions and Answers section of the policy, Q&A #4.
Injection and
Infusion Services (CES)
Feb. 1, 2020
Applicable Codes
Revised list of E&M Codes Applicable When Reported Injection Codes 96372-96379:
o Added CPT codes 99421*, 99422*, 99423*, 99458*, 99473*, and 99474*
o Added HCPCS codes G0508,
G0509, G2082*, and G2083*
(*annual code edit)
Injections (96372-96379) and Evaluation and Management Services by Place of Service
Facility, Emergency Room, and Ambulatory Surgical Center Services
Per CPT and the CMS National Correct Coding Initiative (NCCI) Policy Manual,
CPT codes 96372-96379 are not intended to be reported by the physician in
the facility setting. Thus, when an E/M service and a therapeutic and diagnostic Injection service are submitted with CMS Place of Service (POS) codes 19, 21, 22, 23, 24, 26, 51, 52, and 61 for the same patient by the Same Individual Physician or Other Qualified Health Care Professional on the same date of service, only the E/M service will be reimbursed and the therapeutic and diagnostic Injection(s) are not separately reimbursed, regardless of whether a modifier is reported with the Injection(s).
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Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Injection and
Infusion Services (CES) (continued)
Feb. 1, 2020
For additional information, refer to the Questions and Answers section of the
policy, Q&A1. Non-Facility Injection Services
E/M services provided in a non-facility setting are considered an inherent
component for providing an Injection service. CPT indicates these services typically require direct supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff. When a diagnostic and therapeutic Injection procedure is performed in a POS other than 19, 21, 22, 23, 24, 26, 51, 52, and 61 and an
E/M service is provided on the same date of service, by the Same Individual Physician or Other Qualified Health Care Professional only the appropriate therapeutic and diagnostic Injection(s) will be reimbursed and the EM service is not separately reimbursed. If a significant, separately identifiable EM service is performed unrelated to the physician work (Injection preparation and disposal, patient assessment,
provision of consent, safety oversight, supervision of staff, etc.) required for the Injection service, Modifier 25 may be reported for the E/M service in addition to 96372-96379. If the E/M service does not meet the requirement for a significant separately identifiable service, then Modifier 25 would not be reported and a separate E/M service would not be reimbursed. Exceptions
CPT 99211: E/M service code 99211 will not be reimbursed when submitted with a diagnostic or therapeutic Injection code, with or without Modifier 25.
This very low service level code does not meet the requirement for "significant" as defined by CPT, and therefore should not be submitted in
addition to the procedure code for the Injection. CPT 99381-99429: The Preventive Medicine codes (99381-99429) do not need Modifier 25 to indicate a significant, separately identifiable service
when reported in addition to the diagnostic and therapeutic Injection service. The Preventive Medicine codes include routine services such as the ordering of immunizations or diagnostic procedures. The performance of these services is to be reported in addition to the Preventive Medicine E/M code. Therefore, diagnostic and therapeutic Injections can be reported at the same time as a Preventive Medicine code without appending Modifier 25.
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Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Injection and
Infusion Services (CES) (continued)
Feb. 1, 2020 For additional information, refer to the Questions and Answers section of the
policy, Q&A2, Q&A3 and Q&A6. CMS POS Database E/M Codes for Injection Codes 96372-96379
Injection and Infusion Services (96360-96549 and G0498) and HCPCS Supplies
Consistent with CPT guidelines, HCPCS codes identified by code description as standard tubing, syringes, and supplies are considered included when reported with Injection and Infusion services (CPT codes 96360-96549 and
HCPCS code G0498) and will not be separately reimbursed. See the Applicable Codes section of the policy for Injection and Infusion Inclusive Supplies List Drug Codes
Oxford reimbursement policy is aligned with CMS and will separately
reimburse for the HCPCS drug code when submitted with Injection or Infusion codes (CPT codes 96360-96549 and HCPCS code G0498) by the
Same Individual Physician or Other Qualified Health Care Professional on the same date of service under the guidelines of this policy. For additional information, refer to the Questions and Answers section of the policy, Q&A4.
Maximum
Frequency Per Day
Feb. 1, 2020
Reimbursement Guidelines
Maximum Frequency per Day
(MFD) Determination: Part I Replaced language indicating:
o “Where the criteria [listed in the policy] have not defined an MFD value, the Centers for Medicare and Medicaid
Services (CMS) Medically Unlikely Edit (MUE) value, where available, will be utilized to establish an MFD value” with “The CMS MUE
Refer to the policy for complete details on Maximum Frequency Per Day
guidelines.
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Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Maximum
Frequency Per Day (continued)
Feb. 1, 2020
value, where available, may
be utilized to establish an MFD value, including unlisted codes”
o “Where no other definitive
value has been established based on the criteria above, drug HCPCS codes will have
an MFD value of 999 which indicates they are exempt from the MFD policy” with “Where no other definitive value has been established based on the criteria above,
drug HCPCS codes will have an MFD value of 999 which indicates they bypass the
MFD policy” Added language to indicate
when no MUE value has been established for bilateral codes,
the MFD value is one (1) Removed language indicating:
o Where the CPT or HCPCS code description/verbiage references reporting the code once per day, the MFD value is 1
o Where no other definitive
value has been established based on the criteria [listed in the policy], unlisted CPT and HCPCS codes will have an MFD value of 999 which
indicates they are exempt from the MFD policy
MFD Determination: Part II Added language to indicate the
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Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Maximum
Frequency Per Day (continued)
Feb. 1, 2020
limits on code claim occurrences
in a data set excludes HCPCS drug codes
Reimbursement
Removed language indicating
when reporting the same CPT or HCPCS code on multiple and/or separate claim lines, the claim line may be subject to additional Oxford reimbursement policies
Medically Unlikely Edit
Adjudication Indicator (MAI) 2 Added language to indicate
anatomic modifiers may be
considered when appropriate for CPT/HCPCS codes assigned an MAI indicator of “2”
Questions and Answers (Q&A)
Updated Q&A #2, #6, #10, and #11
Removed Q&A pertaining to: o Unlisted CPT and HCPCS
codes with an MFD value of 999
o Clinical circumstances where Oxford would assign a specific MFD value
Applicable Codes
Added list of 5,461 MAI2 Indicator Codes (codes previously addressed in the CMS MUE file)
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Maximum
Frequency Per Day (continued)
Feb. 1, 2020 Added HCPCS code J0642
Revised MFD value for HCPCS codes J0130, J2787, and Q2017
Maximum Frequency Per Day
(CES)
Feb. 1, 2020
Replaced references to “other health care professional” with
“other qualified health care professional”
Reimbursement Guidelines
Maximum Frequency per Day
(MFD) Determination: Part I Replaced language indicating:
o “Where the criteria [listed in the policy] have not defined an MFD value, the Centers
for Medicare and Medicaid Services (CMS) Medically
Unlikely Edit (MUE) value, where available, will be utilized to establish an MFD value” with “The CMS MUE value, where available, may
be utilized to establish an MFD value, including unlisted codes”
o “Where no other definitive value has been established based on the criteria above,
drug HCPCS codes will have
an MFD value of 999 which indicates they are exempt from the MFD policy” with “Where no other definitive value has been established based on the criteria above,
drug HCPCS codes will have an MFD value of 999 which indicates they bypass the MFD policy”
Refer to the policy for complete details on Maximum Frequency Per Day (CES) guidelines.
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Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Maximum
Frequency Per Day (CES) (continued)
Feb. 1, 2020
Added language to indicate
when no MUE value has been established for bilateral codes, the MFD value is one (1)
Removed language indicating:
o Where the CPT or HCPCS code description/verbiage references reporting the
code once per day, the MFD value is 1
o Where no other definitive value has been established based on the criteria [listed in the policy], unlisted CPT
and HCPCS codes will have an MFD value of 999 which indicates they are exempt
from the MFD policy
MFD Determination: Part II
Added language to indicate the limits on code claim occurrences in a data set excludes HCPCS drug codes
Reimbursement
Removed language indicating when reporting the same CPT or HCPCS code on multiple and/or separate claim lines, the claim
line may be subject to additional
Oxford reimbursement policies
Medically Unlikely Edit
Adjudication Indicator (MAI) 2 Added language to indicate
anatomic modifiers may be considered when appropriate for CPT/HCPCS codes assigned an MAI indicator of “2”
Questions and Answers (Q&A)
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Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Maximum
Frequency Per Day (CES) (continued)
Feb. 1, 2020 Updated Q&A #2, #6, #10, and
#11 Removed Q&A pertaining to:
o Unlisted CPT and HCPCS codes with an MFD value of
999 o Clinical circumstances where
Oxford would assign a
specific MFD value
Applicable Codes Added list of 5,461 MAI2
Indicator Codes (codes previously addressed in the CMS MUE file)
Codes Restricting Modifiers LT
and RT Added HCPCS code J0642
Maximum Frequency Per Day
Code List Added HCPCS code J0642 Revised MFD value for HCPCS
codes J0130, J2787, and Q2017
Modifier Reference Feb. 1, 2020 Reimbursement Guidelines Revised list of modifiers
addressed in Oxford Reimbursement Policies: o Added modifiers 95 and G0;
addressed in the
Reimbursement Policy titled Telehealth and Telemedicine
o Removed modifier CP
Supporting Information Updated References section to
reflect the most current
information
Refer to the policy for Modifier Reference guidance.
to modifier SG to indicate no Oxford Reimbursement Policy is applicable; refer to the Questions and Answers section of the policy
Refer to the policy for Modifier Reference (CES) guidance.
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Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Modifier Reference
(CES) (continued)
Feb. 1, 2020 o Removed language
pertaining to industry standards for usage for modifier TC
Supporting Information
Updated References section to reflect the most current information
Multiple Procedure Payment Reduction (MPPR) for
Diagnostic Cardiovascular and Ophthalmology Procedures
Feb. 1, 2020
Overview Removed language indicating:
o Oxford will apply MPPR
cardiovascular reductions to Diagnostic Cardiovascular Procedures identified as Global Test Only Codes assigned an MPI of 6 on the CMS NPFS (CPT codes
93000, 93015, 93040, 93224, 93268 and 93784); these codes will also be considered in ranking other Diagnostic Cardiovascular Procedures assigned an MPI of 6
Reimbursement Guidelines Replaced language indicating
“the MDCR applies to the
Technical Component Only codes
(PC/TC Indicator 3), and to the TC portion of Global Procedure Codes (PC/TC Indicator 1); for Diagnostic Cardiovascular Procedures represented by a Global Test Only code (PC/TC
Indicator 4), the reduction will be 25% of the corresponding Technical Component Only Code(s)” with “the MDCR applies
Refer to the policy for complete details on Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Procedures.
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Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Multiple Procedure
Payment Reduction (MPPR) for Diagnostic Cardiovascular and
Ophthalmology Procedures (continued)
Feb. 1, 2020 to the Technical Component
Only codes (PC/TC Indicator 3), to the TC portion of Global Procedure Codes (PC/TC Indicator 1), and to codes that
represent the TC of Global Test Only Codes (PC/TC Indicator 4)”
Added reference link to the
Applicable Codes section of the policy for a list of PC/TC Indicator 1, 3, and 4 codes
Definitions
Updated definition of: o Gap Fill Codes o Global Service
Applicable Codes
Revised list of Diagnostic
Cardiovascular Procedures Subject to MPPR (PC/TC Indicator 4); updated Non-Facility Total RVU values for CPT
codes 93000, 93015, 93040, 93224, 93268, and 93784
Questions and Answers (Q&A)
Updated Q&A #3 and #5 pertaining to how the TC portion is obtained in order to rank and apply MDCR to the listed
Diagnostic Cardiovascular Procedures
Removed Q&A pertaining to the
Oxford effective date for including the reduction of the TC of multiple Diagnostic Cardiovascular and Ophthalmology Procedures
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Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Reduced Services
(CES)
Feb. 1, 2020 Application
Removed language indicating this policy applies to all products
Overview
• Removed language indicating a
service or procedure is partially reduced or eliminated at the discretion of the hospital or ambulatory surgical center under certain circumstances
There are no industry standards for reimbursement of claims billed with
Modifier 52 from the Centers for Medicare and Medicaid Services (CMS) or other professional organizations. Oxford's standard for reimbursement of Modifier 52 is 50% of the Allowable Amount for the unmodified procedure.
This modifier is not used to report the elective cancellation of a procedure before anesthesia induction, intravenous (IV) conscious sedation, and/or surgical preparation in the operating suite.
Modifier 52 should not be used with an evaluation and management (E/M) service.
Supply Policy
Feb. 1, 2020
Reimbursement Guidelines Updated language to clarify
81, and 99 are considered a non-facility place of service
o 19, 21, 22, 23, and 24 are considered a facility place of
service o 31 and 32 are considered a
skilled nursing facility or nursing facility place of service
Supply Reimbursement in a
Physician’s or Other Qualified
Health Care Professional’s Office and Other Non-Facility Places of Service
Removed references to: o Centers for Medicare and
Medicaid Services (CMS) o The CMS National Physician
Fee Schedule (NPFS) Relative Value File
o Relative Value Unit (RVU)
Supply Reimbursement in a Physician’s or Other Qualified Health Care Professional’s Office and Other Non-Facility Places of Service
Certain HCPCS supply codes are not separately reimbursable as the cost of supplies is incorporated into the Evaluation and Management (E/M) service or procedure code. Oxford will not separately reimburse the HCPCS supply
codes when those supplies are provided on the same day as an E/M service
and/or procedure performed in non-facility places of service by a physician or other qualified health care professional. Refer to the Supply Codes list in this policy. For the purposes of this policy, a nonfacility place of service is considered POS 1, 3, 4, 9, 11, 13, 14, 15, 16, 17, 20, 33, 49, 50, 54, 55, 57, 60, 62,
65, 71, 72, 81, and 99. Casting and Splint Supplies
HCPCS codes A4570, A4580, and A4590 which were previously used for billing of splints and casts are invalid for Medicare use effective July 1, 2001,
and new temporary Q codes were established to reimburse physicians and other practitioners for the supplies used in creating casts. Consistent with CMS, Oxford will no longer reimburse HCPCS codes A4570, A4580, and A4590 for casting and splint supplies. Physicians and other qualified health
care professionals should be using the temporary Q codes (Q4001-Q4051) for reimbursement of casting and splint supplies. Implantable Tissue Markers
CMS clarifies that implantable tissue markers (HCPCS code A4648) and
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Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Supply Policy
(continued)
Feb. 1, 2020
Replaced language indicating
“Oxford will not separately reimburse the HCPCS supply codes when those supplies are provided on the same day as an
Evaluation and Management (E/M) service and/or procedure performed in a physician’s or
other qualified health care professional’s office and other non-facility places of service” with “Oxford will not separately reimburse the HCPCS supply codes when those supplies are
provided on the same day as an E/M service and/or procedure performed in non-facility places
of service by a physician or other qualified health care professional”
HCPCS Code L8680
Revised language to indicate HCPCS code L8680 (implantable neurostimulator electrode), in
alignment with CMS, is denied in: o All facility places of service
because it is considered included in the
reimbursement to the facility (refer to the list of Supply
DME Codes in a Facility Setting)
o Non-facility places of service when reported with CPT code 63650 (percutaneous implantation of neurostimulator electrode
implantable radiation dosimeters (HCPCS code A4650) are separately billable
and payable when used in conjunction with CPT codes 19499, 32553, 49411 or 55876 on a claim for physician services. Consistent with CMS, Oxford will allow separate reimbursement for HCPCS codes A4648 and A4650 when billed on the same date of service with either CPT codes 19499, 32553,
49411 or 55876. If A4648 and A4650 are reported in a facility setting or without CPT codes 19499, 32553, 49411, or 55876 they are not separately reimbursable.
Reimburesment for Supplies, Durable Medical Equipment (DME), Orthotics, Prosthetics, Biologicals and Drugs Reported with a Facility Place of Service 19, 21, 22, 23, and 24
CMS follows a Prospective Payment System (PPS) where Medicare payment is based on a predetermined, fixed amount payable to a facility for inpatient or outpatient hospital services. With these fixed rates all costs associated with supplies, DME, orthotics, Prosthetics, biologicals and drugs are deemed included in the global payment to the facility and are not considered
separately reimbursable when reported on a CMS-1500 claim form by a physician or other qualified healthcare professional. Consistent with CMS, Oxford will not allow separate reimbursement for specific HCPCS supplies, DME, orthotics, prosthetics, biological, and drugs submitted on a CMS-1500 claim form by any physician or other qualified
healthcare professional in the following facility POS 19, 21, 22, 23, and 24. The Oxford Supply Facility J-Code Denial Codes list and Supply DME Codes in a Facility Setting contains the codes that are not separately reimbursable in a facility place of service. For the purposes of this policy, a facility place of service is considered POS
19, 21, 22, 23, and 24.
Durable Medical Equipment, Orthotics, Prosthetics, and Related Supplies Reported with Facility Places of Service 31 and 32
In alignment with the CMS PPS reimbursement methodology, Oxford considers payment for certain DME, orthotics, prosthetics and related supply items on the CMS Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) fee schedule to be included in the payment to a skilled nursing facility (POS 31) and nursing facility (POS 32) and not reimbursed
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Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Supply Policy
(continued)
Feb. 1, 2020 array, epidural) because the
electrodes are considered included in the reimbursement for the procedure
Definitions
Removed definition of: o National Physician Fee
Schedule (NPFS) Relative Value File
o Relative Value Units
Applicable Codes Revised list of:
o Supply Facility J-Code Denial
Codes; added HCPCS code J0642
o Supply DME Codes in a
Facility Setting; added HCPCS code L8680
separately when reported by a physician or other qualified health care
professional on a CMS-1500 claim form. Refer to the Supply DME Codes in a Skilled Nursing Facility list in the Applicable Codes section of the policy. For the purposes of this policy, skilled nursing facility and nursing facility
places of service are considered POS 31 and 32. HCPCS Code L8680
HCPCS code L8680 (implantable neurostimulator electrode) is denied in all facility places of service because it is considered included in the
reimbursement to the facility (refer to the list of Supply DME Codes in a Facility Setting in this policy). Code L8680 is also denied in nonfacility places of service when reported with CPT code 63650 (percutaneous implantation of neurostimulator electrode array, epidural) because the electrodes are considered included in the reimbursement for the procedure. This is in alignment with CMS.
Supply Code 99070
For reimbursement of covered medical and surgical supplies, an appropriate
Level II HCPCS code must be submitted. The non-specific CPT code 99070 (supplies and materials, except spectacles, provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)) is not reimbursable in any setting.
Telehealth and
Telemedicine
Feb. 1, 2020
Overview
Replaced reference to “healthcare professional” with “Qualified Healthcare
Professional”
Reimbursement Guidelines
Codes and Modifiers Replaced language indicating:
o “Oxford recognizes certain additional services which can be effectively performed via Interactive Audio and Video Telecommunications
Codes and Modifiers
Oxford will consider for reimbursement Telehealth services which are recognized by The Centers for Medicare and Medicaid Services (CMS) and
appended with modifiers GT or GQ, as well as services recognized by the
AMA included in Appendix P of CPT and appended with modifier 95. In addition, Oxford recognizes certain additional services which can be effectively performed via Telehealth/Telemedicine. These codes will be considered for reimbursement when reported with modifier GT or GQ: Medical genetics and genetic counseling services (CPT code 96040)
Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum (codes 98960-98962)
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Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Telehealth and
Telemedicine (continued)
Feb. 1, 2020
systems” with “Oxford
recognizes certain additional services which can be effectively performed via Telehealth/Telemedicine”
o “Remote real-time interactive video-conferenced critical care
(reimbursable with or without modifier GT since their description indicates a Telehealth service and the technology used)” with “remote real-time interactive
video-conferenced critical care evaluation and management of the critically
ill or critically injured patient (CPT code 99499)”
o “Oxford recognizes the CMS designated Originating Sites
which are considered eligible for furnishing a Telehealth service to a patient located in such sites via an Interactive Audio and Visual Telecommunications system” with “Oxford recognizes the
CMS designated Originating
Sites which are considered eligible for furnishing a Telehealth service to a patient located in an Originating Site”
Added language to indicate services which can be effectively performed via Telehealth/Telemedicine will be
Alcohol and/or substance abuse screening and brief intervention services
(codes 99408-99409) Remote real-time interactive video-conferenced critical care evaluation
and management of the critically ill or critically injured patient (CPT code 99499)
See the Applicable Codes section of the policy for: Codes Recognized with Modifiers GT or GQ: CPT and HCPCS
Codes Recognized with Modifier 95 Oxford requires one of the following modifiers to be reported when performing a service via Telehealth to indicate the type of technology used and to identify the service as Telehealth. Oxford will consider reimbursement for a procedure code/modifier combination using these modifiers only when
the modifier has been used appropriately.
Modifier Description
GQ Via Asynchronous Telecommunications systems
GT Via Interactive Audio and Video Telecommunications systems
95 Synchronous Telemedicine Service Rendered Via a Real-
Time Interactive Audio and Video Telecommunications system (reported only with codes from Appendix P)
G0 Telehealth services for diagnosis, evaluation, or treatment of symptoms of an acute stroke
Oxford recognizes the CMS designated Originating Sites which are considered eligible for furnishing a Telehealth service to a patient located in
an Originating Site.
Examples of Originating Sites are listed below: The office of a physician or practitioner A hospital (inpatient or outpatient) A critical access hospital (CAH) A rural health clinic (RHC)
A federally qualified health center (FQHC) A hospital-based or critical access hospital-based renal dialysis center
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Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Telehealth and
Telemedicine (continued)
Feb. 1, 2020
considered for reimbursement
when reported with modifier GQ Added language to clarify the
applicable CPT codes for the listed services:
o Education and training for patient self-management by a qualified, nonphysician
health care professional using a standardized curriculum (CPT codes 98960-98962)
o Alcohol and/or substance abuse screening and brief
intervention services (CPT codes 99408-99409)
Revised list of applicable
Telehealth/Telemedicine modifiers; added G0 (telehealth services for diagnosis, evaluation, or treatment of
symptoms of an acute stroke) Updated list of examples of
Originating Sites; added: o Notation language indicating
independent renal dialysis facilities are not eligible Originating Sites
o Mobile Stroke Unit
o Patient home - only for monthly end stage renal, ESRD-related clinical assessments, and for purposes of treatment of a
substance use disorder or a co-occurring mental health disorder
(including satellites)
Note: Independent renal dialysis facilities are not eligible Originating Sites
A skilled nursing facility (SNF) A community mental health center (CMHC)
Mobile Stroke Unit Patient home - only for monthly end stage renal, ESRD-related clinical
assessments, and for purposes of treatment of a substance use disorder
or a co-occurring mental health disorder
Oxford recognizes the CMS-designated practitioners eligible to be reimbursed for Telehealth services. Examples of practitioners are listed below: Physician Nurse practitioner
Clinical psychologist Clinical social worker Certified Registered Nurse Anesthetists Registered dietitian or nutrition professional
Oxford recognizes but does not require Place of Service (POS) code 02 for reporting Telehealth services rendered by a physician or practitioner from a Distant Site. Modifiers GT, GQ, or 95 are required instead to identify Telehealth services.
POS Description
02
Telehealth – The location where health services and
health related services are provided or received, through
a telecommunication system. (Note: This Telehealth POS code does not apply to Originating Site facilities billing a facility fee.)
Oxford recognizes federal and state mandates regarding Telehealth and Telemedicine.
103 Oxford® Policy Update Bulletin: January 2020
Reimbursement Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Telehealth and
Telemedicine (continued)
Feb. 1, 2020
Telehealth Transmission
Revised language to indicate Oxford follows CMS guidelines which do not allow
reimbursement for Telehealth
transmission, per minute, professional services bill separately reported with HCPCS code T1014; they are non-reimbursable codes according to the CMS Physician Fee Schedule
(PFS) and are considered included in Telehealth services
Telephone Services
Revised language to indicate Oxford follows CMS guidelines and does not allow
reimbursement for telephone services which are non-face-to face evaluation and management services by a
Physician or Other Qualified Health Care Professional reported with CPT codes 98966-98968 or 99441-99443; they are non-reimbursable codes according to the CMS Physician Fee Schedule (PFS) and are
considered an integral part of
other services provided
On-Line Medical Evaluation
Revised language to indicate Oxford follows CMS guidelines and does not reimburse for an on-line medical evaluation, an internet response to a patient’s on-line question, reported with CPT codes 98970, 98971 and
Telehealth Transmission
Oxford follows CMS guidelines which do not allow reimbursement for Telehealth transmission, per minute, professional services bill separately reported with HCPCS code T1014.
Telephone Services
Oxford follows CMS guidelines and does not allow reimbursement for telephone services which are non-face-to face evaluation and management services by a Physician or Other Qualified Health Care Professional reported with CPT codes 98966-98968 or 99441-99443. They are non-reimbursable codes according to the CMS Physician Fee Schedule (PFS) and are considered an integral part of other services provided.
On-Line Medical Evaluation
Oxford follows CMS guidelines and does not reimburse for an on-line medical evaluation, an internet response to a patient’s on-line question, reported
with CPT codes 98970, 98971 and 98972. They are non-reimbursable codes
according to the CMS Physician Fee Schedule (PFS).
Oxford follows CMS guidelines effective for services rendered on or after
January 1, 2019, which considers interprofessional telephone/Internet assessment and management services reported with CPT codes 99446-99449 and 99451-99452 eligible for reimbursement according to the CMS Physician Fee Schedule (PFS). Digitally Stored Data Services/Remote Physiologic Monitoring Oxford follows CMS guidelines effective for services rendered on or after
January 1, 2019, which considers digitally stored data services or remote physiologic monitoring services reported with CPT codes 99453, 99454, 99457, and 99091 eligible for reimbursement according to the CMS Physician Fee Schedule (PFS). Brief Communication Technology-Based Service
Oxford follows CMS guidelines effective for services rendered on or after January 1, 2019, which considers brief communication technology-based service, e.g., virtual check-in, by a Physician or Other Qualified Health Care
104 Oxford® Policy Update Bulletin: January 2020
Reimbursement Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Telehealth and
Telemedicine (continued)
Feb. 1, 2020
98972; they are non-
reimbursable codes according to the CMS Physician Fee Schedule (PFS)
Interprofessional Telephone/
Internet Consultations Revised language to indicate
Oxford follows CMS guidelines effective for services rendered on or after January 1, 2019, which considers interprofessional
telephone/Internet assessment and management services reported with CPT codes 99446-99449 and 99451-99452 eligible for reimbursement according to the CMS Physician Fee Schedule
(PFS)
Digitally Stored Data Services/Remote Physiologic Monitoring (new to policy)
Added language to indicate Oxford follows CMS guidelines effective for services rendered on or after January 1, 2019, which considers digitally stored data services or remote physiologic monitoring services
reported with CPT codes 99453,
99454, 99457, and 99091 eligible for reimbursement according to the CMS Physician Fee Schedule (PFS)
Brief Communication
Technology-Based Service (new to policy) Added language to indicate
Oxford follows CMS guidelines
Professional who can report evaluation and management services, provided to
an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion reported with HCPCS code G2012 eligible for reimbursement
according to the CMS qualified Fee Schedule (PFS).
105 Oxford® Policy Update Bulletin: January 2020
Reimbursement Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Telehealth and
Telemedicine (continued)
Feb. 1, 2020
effective for services rendered on
or after January 1, 2019, which considers brief communication technology-based service (e.g., virtual check-in) by a Physician
or Other Qualified Health Care Professional who can report evaluation and management
services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within
the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
reported with HCPCS code G2012 eligible for reimbursement according to the CMS qualified Fee Schedule (PFS)
Definitions Added definition of “Physician or
Other Qualified Health Care
Professional” Updated definition of:
o Distant Site o Telehealth/Telemedicine
Removed definition of
“Interactive Audio and Video Telecommunication, Interactive
Audio and Visual Transmissions, Audio-Visual Communication Technology”
Applicable Codes
Non-Reimbursable CPT Codes (regardless of appended modifier)
106 Oxford® Policy Update Bulletin: January 2020
Reimbursement Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
99244, 99245, 99251, 99252, 99253, 99254, and 99255
(*annual code edit)
Questions and Answers (Q&A)
Updated Q&A #4
Telehealth and Telemedicine (CES)
Feb. 1, 2020
Related Policies Added reference link to the
Reimbursement Policy titled: o Procedure to Modifier (CES) o Procedure/Technical
Component (CES)
Overview
Replaced reference to “healthcare professional” with “Qualified Healthcare Professional”
Reimbursement Guidelines
Codes and Modifiers
Replaced language indicating: o “Oxford recognizes certain
Codes and Modifiers
Oxford will consider for reimbursement Telehealth services which are recognized by The Centers for Medicare and Medicaid Services (CMS) and appended with modifiers GT or GQ, as well as services recognized by the
AMA included in Appendix P of CPT and appended with modifier 95.
In addition, Oxford recognizes certain additional services which can be effectively performed via Telehealth/Telemedicine .These codes will be considered for reimbursement when reported with modifier GT or GQ: Medical genetics and genetic counseling services (CPT code 96040) Education and training for patient self-management by a qualified,
nonphysician health care professional using a standardized curriculum (CPT codes 98960-98962)
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Telehealth and
Telemedicine (CES) (continued)
Feb. 1, 2020
additional services which can
be effectively performed via Interactive Audio and Video Telecommunications systems” with “Oxford
recognizes certain additional services which can be effectively performed via
Telehealth/Telemedicine” o “Remote real-time
interactive video-conferenced critical care (reimbursable with or without modifier GT since
their description indicates a Telehealth service and the technology used)” with
“remote real-time interactive video-conferenced critical care evaluation and management of the critically
ill or critically injured patient (CPT code 99499)”
o “Oxford recognizes the CMS designated Originating Sites which are considered eligible for furnishing a Telehealth service to a patient located
in such sites via an
Interactive Audio and Visual Telecommunications system” with “Oxford recognizes the CMS designated Originating Sites which are considered
eligible for furnishing a Telehealth service to a patient located in an Originating Site”
Remote real-time interactive video-conferenced critical care evaluation
and management of the critically ill or critically injured patient (CPT code 99499)
See the Applicable Codes section of the policy for:
Codes Recognized with Modifiers GT or GQ: CPT and HCPCS Codes Recognized with Modifier 95
Oxford requires one of the following modifiers to be reported when performing a service via Telehealth to indicate the type of technology used and to identify the service as Telehealth. Oxford will consider reimbursement for a procedure code/modifier combination using these modifiers only when the modifier has been used appropriately. Coding relationships for modifier GQ and modifier 95 are administered through the Reimbursement Policy
titled Procedure to Modifier (CES).
Modifier Description
GQ Via Asynchronous Telecommunications systems
GT Via Interactive Audio and Video Telecommunications systems
95 Synchronous Telemedicine Service Rendered Via a Real-
Time Interactive Audio and Video Telecommunications system (reported only with codes from Appendix P)
G0 Telehealth services for diagnosis, evaluation, or treatment of symptoms of an acute stroke
Oxford recognizes the CMS designated Originating Sites which are considered eligible for furnishing a Telehealth service to a patient located in
an Originating Site. Examples of Originating Sites are listed below: The office of a physician or practitioner A hospital (inpatient or outpatient)
A critical access hospital (CAH) A rural health clinic (RHC) A federally qualified health center (FQHC) A hospital-based or critical access hospital-based renal dialysis center
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Telehealth and
Telemedicine (CES) (continued)
Feb. 1, 2020
Added language to indicate:
o Services which can be effectively performed via Telehealth/Telemedicine will be considered for
reimbursement when reported with modifier GQ
o Coding relationships for
modifier GQ and modifier 95 are administered through the UnitedHealthcare Rembursement Policy titled Procedure to Modifier
Added language to clarify the
applicable CPT codes for the listed services: o Education and training for
patient self-management by a qualified, nonphysician health care professional using a standardized
curriculum (CPT codes 98960-98962)
o Alcohol and/or substance abuse screening and brief intervention services (CPT codes 99408-99409)
Revised list of applicable
Telehealth/Telemedicine
modifiers; added G0 (telehealth services for diagnosis, evaluation, or treatment of symptoms of an acute stroke)
Updated list of examples of
Originating Sites; added: o Notation language indicating
independent renal dialysis facilities are not eligible
(including satellites)
Note: Independent renal dialysis facilities are not eligible Originating Sites
A skilled nursing facility (SNF) A community mental health center (CMHC)
Mobile Stroke Unit • Patient home - only for monthly end stage renal, ESRD-related clinical
assessments, and for purposes of treatment of a substance use disorder
or a co-occurring mental health disorder Oxford recognizes the CMS-designated practitioners eligible to be reimbursed for Telehealth services. Examples of practitioners are listed below: Physician Nurse practitioner
Clinical psychologist Clinical social worker Certified Registered Nurse Anesthetists Registered dietitian or nutrition professional
Oxford recognizes but does not require Place of Service (POS) code 02 for reporting Telehealth services rendered by a physician or practitioner from a Distant Site. Modifiers GT, GQ, or 95 are required instead to identify Telehealth services.
POS Description
02
Telehealth – The location where health services and
health related services are provided or received, through a telecommunication system. (Note: This Telehealth POS code does not apply to Originating Site facilities billing a facility fee.)
Oxford recognizes federal and state mandates regarding Telehealth and Telemedicine. Telehealth Transmission
Oxford follows CMS guidelines which do not allow reimbursement for
109 Oxford® Policy Update Bulletin: January 2020
Reimbursement Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Telehealth and
Telemedicine (CES) (continued)
Feb. 1, 2020
Originating Sites
o Mobile Stroke Unit o Patient home - only for
monthly end stage renal, ESRD-related clinical
assessments, and for purposes of treatment of a substance use disorder or a
co-occurring mental health disorder
Telehealth Transmission
Revised language to indicate Oxford follows CMS guidelines which do not allow reimbursement for Telehealth transmission, per minute, professional services bill
separately reported with HCPCS
code T1014; they are non-reimbursable codes according to the CMS Physician Fee Schedule (PFS) and are considered included in Telehealth services
Telephone Services
Revised language to indicate Oxford follows CMS guidelines and does not allow reimbursement for telephone
services which are non-face-to
face evaluation and management services by a Physician or Other Qualified Health Care Professional reported with CPT codes 98966-
98968 or 99441-99443; they are non-reimbursable codes according to the CMS Physician Fee Schedule (PFS) and are
Telehealth transmission, per minute, professional services bill separately
reported with HCPCS code T1014. They are non-reimbursable codes according to the CMS Physician Fee Schedule (PFS) and are considered included in Telehealth services.
Telephone Services
Oxford follows CMS guidelines and does not allow reimbursement for telephone services which are non-face-to face evaluation and management services by a Physician or Other Qualified Health Care Professional reported with CPT codes 98966-98968 or 99441-99443. They are non-reimbursable codes according to the CMS Physician Fee Schedule (PFS) and are considered an integral part of other services provided.
On-Line Medical Evaluation
Oxford follows CMS guidelines and does not reimburse for an on-line medical evaluation, an internet response to a patient’s on-line question, reported
with CPT codes 98970, 98971 and 98972. They are non-reimbursable codes according to the CMS Physician Fee Schedule (PFS). Interprofessional Telephone/Internet Consultations
Oxford follows CMS guidelines effective for services rendered on or after January 1, 2019, which considers interprofessional telephone/Internet assessment and management services reported with CPT codes 99446-99449
and 99451-99452 eligible for reimbursement according to the CMS Physician Fee Schedule (PFS). Digitally Stored Data Services/Remote Physiologic Monitoring
Oxford follows CMS guidelines effective for services rendered on or after
January 1, 2019, which considers digitally stored data services or remote physiologic monitoring services reported with CPT codes 99453, 99454, 99457, and 99091 eligible for reimbursement according to the CMS Physician Fee Schedule (PFS).
Brief Communication Technology-Based Service
Oxford follows CMS guidelines effective for services rendered on or after January 1, 2019, which considers brief communication technology-based service, e.g., virtual check-in, by a Physician or Other Qualified Health Care
110 Oxford® Policy Update Bulletin: January 2020
Reimbursement Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Telehealth and
Telemedicine (CES) (continued)
Feb. 1, 2020
considered an integral part of
other services provided
On-Line Medical Evaluation Revised language to indicate
Oxford follows CMS guidelines
and does not reimburse for an on-line medical evaluation, an internet response to a patient’s on-line question, reported with CPT codes 98970, 98971 and 98972; they are non-
reimbursable codes according to the CMS Physician Fee Schedule (PFS)
Interprofessional
Telephone/Internet Consultations
Revised language to indicate Oxford follows CMS guidelines effective for services rendered on or after January 1, 2019,
which considers interprofessional telephone/Internet assessment and management services reported with CPT codes 99446-99449 and 99451-99452 eligible for reimbursement according to the CMS Physician Fee Schedule
(PFS)
Digitally Stored Data Services/Remote Physiologic
Monitoring (new to policy) Added language to indicate
Oxford follows CMS guidelines effective for services rendered on or after January 1, 2019, which considers digitally stored data services or remote
Professional who can report evaluation and management services, provided
to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion reported with HCPCS code G2012 eligible for
reimbursement according to the CMS qualified Fee Schedule (PFS).
111 Oxford® Policy Update Bulletin: January 2020
Reimbursement Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Telehealth and
Telemedicine (CES) (continued)
Feb. 1, 2020
physiologic monitoring services
reported with CPT codes 99453, 99454, 99457, and 99091 eligible for reimbursement according to the CMS Physician
Fee Schedule (PFS)
Brief Communication
Technology-Based Service (new to policy) Added language to indicate
Oxford follows CMS guidelines
effective for services rendered on or after January 1, 2019, which considers brief communication technology-based service (e.g., virtual check-in) by a Physician or
Other Qualified Health Care
Professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the
previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical
discussion reported with HCPCS code G2012 eligible for
reimbursement according to the CMS qualified Fee Schedule (PFS)
Definitions
Added definition of “Physician or Other Qualified Health Care Professional”
112 Oxford® Policy Update Bulletin: January 2020
Reimbursement Policy Updates
Oxford
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Telehealth and
Telemedicine (CES) (continued)
Feb. 1, 2020 Updated definition of:
o Distant Site o Telehealth/Telemedicine
Removed definition of “Interactive Audio and Video
Telecommunication, Interactive Audio and Visual Transmissions, Audio-Visual Communication
Technology”
Applicable Codes
Non-Reimbursable CPT Codes
(regardless of appended modifier) Added 98970*, 98971*, and
