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1 Oxford® Policy Update Bulletin: February 2020

February 2020

policy update bulletin Medical & Administrative Policy Updates

In This Issue

Clinical Policy Updates Page

NEW

• Adakveo® (Crizanlizumab-Tmca) – Effective Mar. 1, 2020 ..................................................................................................................................... 4 • Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing for Infectious Diarrhea – Effective Apr. 1, 2020 ........................................................... 5 • Genitourinary Pathogen Nucleic Acid Detection Panel Testing – Effective May 1, 2020 ............................................................................................... 5 • Givlaari™ (Givosiran) – Effective Mar. 1, 2020 ..................................................................................................................................................... 5 • Inhaled Nitric Oxide for Infants – Effective Apr. 1, 2020 ........................................................................................................................................ 7 • Percutaneous Patent Foramen Ovale (PFO) Closure – Effective May 1, 2020............................................................................................................. 7

REVISED

• Cardiac Event Monitoring – Effective Feb. 1, 2020 ................................................................................................................................................ 7 • Cardiology Procedures Requiring Precertification for eviCore healthcare Arrangement – Effective Feb. 1, 2020 ............................................................. 8 • Drug Coverage Criteria – New and Therapeutic Equivalent Medications – Effective Mar. 1, 2020 ................................................................................. 8 • Drug Coverage Guidelines – Effective Feb. 1, 2020 ............................................................................................................................................... 9

o Avsola (Infliximab-Axxq) .............................................................................................................................................................................. 9 o Inflectra (Infliximab) ................................................................................................................................................................................... 9 o Ixifi (Infliximab-Qbtx) .................................................................................................................................................................................. 9 o Levemir (Insulin Detemir) ............................................................................................................................................................................ 9 o Remicade (Infliximab) ................................................................................................................................................................................. 9 o Renflexis (Infliximab) .................................................................................................................................................................................. 9 o Stelara (Ustekinumab): Intravenous Infusion ................................................................................................................................................. 9

• Drug Coverage Guidelines – Effective Mar. 1, 2020 ................................................................................................... Error! Bookmark not defined. o Absorica (Isotretinoin) ............................................................................................................................................................................... 10 o Absorica LD (Isotretinoin) .......................................................................................................................................................................... 10 o Adakveo (Crizanlizumab-Tmca) .................................................................................................................................................................. 10 o Addyi (Flibanserin) .................................................................................................................................................................................... 10 o Anastrozole (Generic) ................................................................................................................................................................................ 10 o Arimidex (Brand Only) (Anastrozole) ........................................................................................................................................................... 10 o Arymo ER (Morphine Sulfate) ..................................................................................................................................................................... 10 o Budesonide/Formoterol (Symbicort Authorized Generic) ................................................................................................................................ 10

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o Consensi (Amlodipine and Celecoxib) .......................................................................................................................................................... 11 o Dapsone (Aczone) ..................................................................................................................................................................................... 11 o Divigel 1.25g (Estradiol Gel) ....................................................................................................................................................................... 11 o Embeda (Morphine Sulphate and Naltrexone Hcl) .......................................................................................................................................... 11 o Evista (Raloxifene) (Brand Only) ................................................................................................................................................................. 11 o Exemestane (Generic) ............................................................................................................................................................................... 11 o Genotropin (Somatropin) ........................................................................................................................................................................... 11 o Genotropin Miniquick (Somatropin) ............................................................................................................................................................. 11 o Givlaari (Givosiran) ................................................................................................................................................................................... 12 o Humatrope (Somatropin) ........................................................................................................................................................................... 12 o Ibsrela (Tenapanor) .................................................................................................................................................................................. 12 o Increlex (Mecasermin) ............................................................................................................................................................................... 12 o Jatenzo (Testosterone Undecanoate) ........................................................................................................................................................... 12 o Kanjinti (Trastuzumab-Anns) ...................................................................................................................................................................... 12 o Letrozole (Generic) ................................................................................................................................................................................... 12 o Lorbrena (Lorlatinib) ................................................................................................................................................................................. 12 o Norditropin (Somatropin) ........................................................................................................................................................................... 13 o Norditropin AQ (Somatropin) ...................................................................................................................................................................... 13 o Norditropin Flexpro (Somatropin) ................................................................................................................................................................ 13 o Norditropin Nordiflex (Somatropin).............................................................................................................................................................. 13 o Nourianz (Istradefylline) ............................................................................................................................................................................ 13 o Nuspin (Somatropin) ................................................................................................................................................................................. 13 o Omnitrope (Somatropin) ............................................................................................................................................................................ 13 o Oxbryta (Voxelotor) .................................................................................................................................................................................. 13 o Praluent (Alirocumab) ................................................................................................................................................................................ 13 o Raloxifene (Generic) .................................................................................................................................................................................. 13 o Saizen (Somatropin) ................................................................................................................................................................................. 13 o Secuado (Asenapine) ................................................................................................................................................................................. 13 o Serostim (Somatropin) .............................................................................................................................................................................. 14 o Simvastatin Oral Suspension (Flolipid Authorized Generic) ............................................................................................................................. 14 o Soltamox (Tamoxifen Citrate) ..................................................................................................................................................................... 14 o Sucraid (Sacrosidase) ................................................................................................................................................................................ 14 o Takhzyro (Lanadelumab-Flyo) .................................................................................................................................................................... 14 o Talicia (Omeprazole Magnesium, Amoxicillin and Rifabutin) ............................................................................................................................ 14 o Talzenna (Talazoparib) .............................................................................................................................................................................. 14 o Tamoxifen 20mg (Generic) ......................................................................................................................................................................... 14 o Tetrabenazine (Generic) ............................................................................................................................................................................ 14 o Trulance (Plecanatide) ............................................................................................................................................................................... 14 o Valtoco (Diazepam) ................................................................................................................................................................................... 15 o Vosevi (Sofosbuvir/Velpatasvir/Voxilaprevir) ................................................................................................................................................ 15 o Wakix (Pitolisant) ...................................................................................................................................................................................... 15 o Xenazine (Tetrabenazine) (Brand) ............................................................................................................................................................... 15 o Yupelri (Revefenacin) ................................................................................................................................................................................ 15 o Zelnorm (Tegaserod Maleate) ..................................................................................................................................................................... 15

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o Ziextenzo (Pegfilgrastim-Bmez) .................................................................................................................................................................. 15 o Zirabev (Bevacizumab-Bvzr) ...................................................................................................................................................................... 15 o Zomacton (Somatropin) ............................................................................................................................................................................. 16 o Zorbtive (Somatropin) ............................................................................................................................................................................... 16

• Infliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®) – Effective Feb. 1, 2020 ................................................................................................ 16 • Infliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®) – Effective May 1, 2020 ................................................................................................ 19 • Outpatient Surgical Procedures - Site of Service – Effective Apr. 6, 2020 ............................................................................................................... 19 • Provider Administered Drugs – Site of Care – Effective Apr. 1, 2020 ..................................................................................................................... 21 • Rituximab (Rituxan®, Ruxience™ & Truxima®) – Effective Feb. 1, 2020 .................................................................................................................. 23 • White Blood Cell Colony Stimulating Factors – Effective Mar. 1, 2020 .................................................................................................................... 27 • White Blood Cell Colony Stimulating Factors – Effective May 1, 2020 .................................................................................................................... 29

Administrative Policy Updates

RETIRED

• Hospice Care – Effective Feb. 1, 2020 ............................................................................................................................................................... 30

Reimbursement Policy Updates

UPDATED

• Co-Surgeon/Team Surgeon – Effective Jan. 21, 2020 .......................................................................................................................................... 31 • Co-Surgeon/Team Surgeon (CES) – Effective Jan. 21, 2020 ................................................................................................................................. 31

REVISED

• Drug Testing – Effective Mar. 1, 2020 ............................................................................................................................................................... 31 • Maximum Frequency Per Day – Effective Feb. 1, 2020 ........................................................................................................................................ 33 • Maximum Frequency Per Day (CES) – Effective Feb. 1, 2020 ............................................................................................................................... 35 • Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Procedures – Effective Feb. 1, 2020 .......................... 38 • Nonphysician Health Care Professionals Billing Evaluation and Management Codes – Effective Mar. 1, 2020 ............................................................... 41 • Procedure and Place of Service – Effective Mar. 1, 2020 ...................................................................................................................................... 42 • Supply Policy – Effective Feb. 1, 2020 ............................................................................................................................................................... 43

Clinical Policy Updates

Oxford


Policy Title Effective Date Coverage Rationale

NEW

Adakveo®

(Crizanlizumab-Tmca)

Mar. 1, 2020

Adakveo (crizanlizumab-tmca) has been added to the Review at Launch program. Some members may

not be eligible for coverage of this medication at this time. Refer to the policy titled Review at Launch for New to Market Medications for additional details. Adakveo is proven and/or medically necessary to reduce the frequency of vasoocclusive crises in

patients with sickle cell disease who meet ALL of the following criteria:

Initial Therapy

• Patient is 16 years of age or older; and • Diagnosis of a sickle cell disease, including, but not limited to, homozygous hemoglobin S [HbSS], sickle

hemoglobin C disease [HbSC], sickle beta0 thalassemia, and sickle beta+ thalassemia; and • Patient has previously experienced 2 or more sickle cell-related vasoocclusive crises within the previous 12

months; and • One of the following:

o Patient is currently receiving hydroxyurea therapy o Patient has a history of treatment failure, intolerance, or contraindication to hydroxyurea therapy and

• Patient is not receiving concomitant chronic, prophylactic blood transfusion therapy; and • Patient is not receiving concomitant Oxbryta (voxelotor) therapy; and • Adakveo is prescribed by, or in consultation with, a hematologist, or other specialist with expertise in the

diagnosis and management of sickle cell disease; and • Adakveo initial dosing is in accordance with the United States Food and Drug Administration approved labeling:

5 mg/kg by intravenous infusion on week 0, week 2, and every 4 weeks thereafter; and

• Initial authorization will be for no more than 6 months. Continuation Therapy

• Diagnosis of a sickle cell disease, including, but not limited to, homozygous hemoglobin S [HbSS], sickle hemoglobin C disease [HbSC], sickle beta0 thalassemia, and sickle beta+ thalassemia; and

• Patient has experienced a reduction in sickle cell-related vasoocclusive crises and/or a decrease in severity of sickle cell-related vasoocclusive crises from pretreatment baseline while on Adakveo; and

• Patient is not receiving concomitant chronic, prophylactic blood transfusion therapy; and • Patient is not receiving concomitant Oxbryta (voxelotor) therapy; and

• Adakveo is prescribed by, or in consultation with, a hematologist, or other specialist with expertise in the diagnosis and management of sickle cell disease; and

• Adakveo maintenance dosing is in accordance with the United States Food and Drug Administration approved labeling: 5 mg/kg by intravenous infusion every 4 weeks; and

• Reauthorization will be for no more than 12 months.


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NEW

Adakveo®

(Crizanlizumab-Tmca) (continued)

Mar. 1, 2020 Adakveo is not proven or medically necessary for the treatment of:

• Pediatric patients less than 16 years of age with sickle cell disease • Myelofibrosis

Gastrointestinal

Pathogen Nucleic Acid Detection

Panel Testing for Infectious Diarrhea

Apr. 1, 2020 The following are proven and medically necessary:

• Multiplex polymerase chain reaction (PCR) panel testing of gastrointestinal pathogens of up to 5 targets when performed as part of an evaluation that includes blood cultures for an individual with any of the following:

o Diarrhea for more than 7 days with fever and suspected bacteremia; or o Suspected enteric fever (i.e., typhoid or paratyphoid) in an individual with a history of recent travel to an

endemic region (e.g., south-central Asia, Southeast Asia, and southern Africa) or who has consumed foods prepared by people with recent endemic exposure

• Multiplex PCR panel testing of gastrointestinal pathogens of up to 11 targets for the evaluation of persistent diarrhea in an individual with any of the following: o Diarrhea for more than 7 days with fever and suspected bacteremia, and the individual is at risk for

Clostridium difficile (C. difficile) colitis; or o Acquired Immune Deficiency Syndrome (AIDS); or o On immunosuppressive medications following an organ transplant; or

o Other condition causing immunosuppression and other stool diagnostic studies have failed to yield a pathogenic organism

Due to insufficient evidence of efficacy, multiplex PCR panel testing of gastrointestinal pathogens is

unproven and not medically necessary for evaluating all other indications not listed above as proven and medically necessary.

Genitourinary Pathogen Nucleic Acid Detection Panel Testing

May 1, 2020 The following are proven and medically necessary to evaluate symptomatic women for Vaginitis: • Direct and amplified DNA probe testing for Trichomoniasis vaginalis • Direct probe testing for Candida sp

Due to insufficient evidence of efficacy, the following are unproven and not medically necessary:

• Amplified DNA probe testing for vulvovaginitis due to Candida sp • Direct and amplified DNA probe testing for bacterial Vaginosis (i.e., Gardnerella vaginalis) • Multiplex polymerase chain reaction (PCR) panel testing of genitourinary pathogens, including but not limited to

pathogens commonly associated with Vaginitis

Note: This policy does not apply to tests for gonorrhea and chlamydia.

Givlaari™ (Givosiran)

Mar. 1, 2020

Givlaari (givosiran) has been added to the Review at Launch program. Some members may not be eligible for coverage of this medication at this time. Refer to the Clinical Policy titled Review at Launch for New to Market Medications for additional details.


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NEW

Givlaari™

(Givosiran) (continued)

Mar. 1, 2020 Givlaari is proven and/or medically necessary for the treatment of acute hepatic porphyrias:

Initial Therapy

• Diagnosis of an acute hepatic porphyria (AHP) [i.e., acute intermittent porphyria, hereditary coproporphyria, variegate porphyria, ALA dehydratase deficient porphyria]; and

• One of the following: o Patient has active disease as defined in the clinical trial by having at least 2 documented porphyria attacks

within the past 6 months; or o Patient is currently receiving treatment with prophylactic hemin to prevent porphyria attacks and

• Provider attestation that the patient’s baseline (before givosiran is initiated) hemin administration requirements (prophylactic or treatment) and rate and/or number of porphyria attacks has been documented; and

• Patient has not had a liver transplant; and • Patient will not receive concomitant prophylactic hemin treatment while on Givlaari; and • Prescribed by, or in consultation with, a hematologist, or a specialist with expertise in the diagnosis and

management of AHPs; and • Givlaari dosing is in accordance with the United States Food and Drug Administration approved labeling: up to a

maximum of 2.5 mg/kg (body weight) subcutaneously once monthly; and • Initial authorization will be for no more than 6 months. Continuation Therapy

• Patient has previously received Givlaari for the treatment of AHP; and • Documentation that the patient has experienced a positive clinical response while on Givlaari by demonstrating

all of the following from pre-treatment baseline: o Reduction in hemin administration requirements (if previously required, including prophylactic and/or

treatment doses)

o Reduction in the rate and/or number of porphyria attacks o Improvement of signs and symptoms of AHPs (e.g., pain, neurological, gastrointestinal, renal, quality of life,

etc.) and

• Patient has not had a liver transplant; and • Patient will not receive concomitant prophylactic hemin treatment while on Givlaari; and

• Prescribed by, or in consultation with, a hematologist, or a specialist with expertise in the diagnosis and management of AHPs; and

• Givlaari dosing is in accordance with the United States Food and Drug Administration approved labeling: up to a maximum of 2.5 mg/kg (body weight) subcutaneously once monthly; and

• Reauthorization will be for no more than 12 months.


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NEW

Inhaled Nitric

Oxide for Infants

Apr. 1, 2020 Inhaled nitric oxide (iNO) is proven and medically necessary for treating term or near-term infants (at

least 34 weeks gestation at birth) with hypoxic respiratory failure or echocardiographic evidence of persistent pulmonary hypertension of the newborn (PPHN) and ALL of the following: • Absence of congenital diaphragmatic hernia (CDH) • Failure of conventional treatments (e.g., mechanical ventilation)

Note: In the postoperative management of pulmonary hypertension associated with heart or lung surgery in infants, iNO is a clinically accepted option and will be covered as bridge therapy during the acute recovery phase.

Due to insufficient evidence of efficacy, iNO is unproven and not medically necessary for treating ALL other newborns including but not limited to: • Newborns with CDH • Preterm newborns who are less than 34 weeks gestation at birth

Percutaneous

Patent Foramen Ovale (PFO) Closure

May 1, 2020 Note: This policy does not apply to individuals <18 years of age.

Percutaneous patent foramen ovale closure for the prevention of recurrent ischemic stroke is proven and medically necessary 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: • History of cryptogenic stroke confirmed by imaging; and • A cardiologist and a neurologist agree that the stroke is likely embolic in nature; and • Other causes of ischemic stroke have been ruled out including, but not limited to, carotid disease,

hypercoagulable states or atrial fibrillation; and • Individual is 18–60 years of age. Due to insufficient evidence of efficacy, percutaneous patent foramen ovale closure is unproven and not medically necessary for all other stroke or related neurological indications including, but not limited to, primary prevention of stroke, transient ischemic attacks, and migraine prevention.

Policy Title Effective Date Summary of Changes Coverage Rationale

REVISED

Cardiac Event Monitoring

Feb. 1, 2020

Conditions of Coverage • Updated list of CPT codes that

do not require referral or precertification in the office or

outpatient setting; added 93268, 93270, 93271, and 93272

• Updated list of CPT/HCPCS codes that require precertification with

Cardiac event monitoring is proven and medically necessary for evaluating suspected cardiac arrhythmias as outlined below. • Ambulatory Event Monitoring

o Holter monitor

o Event monitor o Patch-type monitor

• Outpatient Cardiac Telemetry for any of the following indications: o Suspected cardiac arrhythmia and non-diagnostic Ambulatory Event


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REVISED

Cardiac Event

Monitoring (continued)

Feb. 1, 2020 review by a Medical Director

when performed in an inpatient, outpatient, or participating provider office setting to reflect annual code edits:

o Added G2066 o Removed 93299

Monitoring after a minimum of 3 weeks

o Cryptogenic stroke with suspected occult atrial fibrillation as the cause of the stroke

o Monitoring arrhythmia status following an ablation procedure • Implantable Loop Recorder in certain circumstances. For medical

necessity clinical coverage criteria, see MCG™ Care Guidelines, 23rd edition, 2019, Loop Recorder (Cardiac Event Monitor), Implantable, A-0122 (AC).

Cardiology Procedures Requiring Precertification for eviCore healthcare Arrangement

Feb. 1, 2020 Applicable Codes • Revised list of CPT codes

requiring precertification; added

0501T, 0502T, 0503T, and 0504T (effective for claims with dates of service on or after Jan. 1, 2019)

Supporting Information

• Updated Description of Services section to reflect the most current information

Refer to the policy for complete details on Cardiology Procedures Requiring Precertification for eviCore healthcare Arrangement.

Drug Coverage

Criteria – New and Therapeutic Equivalent Medications

Mar. 1, 2020 Coverage Rationale

• Revised list of medications requiring precertification through the pharmacy benefit manager (PBM): o Added Absorica LD,

Budesonide/Formoterol (Symbicort authorized

generic), Consensi, Dapsone

7.5% Gel (Aczone 7.5% authorized generic), Divigel 1.25g, Jatenzo, Oxbryta, Secuado, Simvastatin Oral Suspension (Flolipid

authorized generic), Talicia, and Valtoco

o Removed Zelnorm

Refer to the policy for complete details on Drug Coverage Criteria – New and

Therapeutic Equivalent Medications.


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Policy Title Effective Date Drug/Medication Status Summary of Changes

REVISED

Drug Coverage Guidelines

Feb. 1, 2020

Avsola (Infliximab-Axxq)

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 May 1, 2020, precertification will be required

• Added precertification guidelines; refer to the following policies for complete details: o Precertification Guidelines: Infliximab (Avsola™, Remicade®,

Inflectra™, Renflexis™) o Precertification Guidelines: Review at Launch for New to Market

Medications

Inflectra (Infliximab) Revised • Revised notation pertaining to precertification requirements to indicate precertification is required in all sites of service; additional

precertification may be required for the site of care of the injection • Updated reference link to reflect title change for Precertification

Guidelines: Infliximab (Avsola™, Remicade®, Inflectra™, Renflexis™)

Ixifi (Infliximab-Qbtx) Updated • Updated reference link to reflect title change for Precertification Guidelines: Infliximab (Avsola™, Remicade®, Inflectra™, Renflexis™)

Levemir (Insulin Detemir)

Revised • Revised coverage guidelines to indicate precertification is not required • Removed prior authorization/notification guidelines and corresponding

reference link to the policy titled to Prior Authorization/Notification

Guidelines: Levemir

Remicade (Infliximab) Revised • Revised notation pertaining to precertification requirements to indicate precertification is required in all sites of service; additional

precertification may be required for the site of care of the injection • Updated reference link to reflect title change for Precertification

Guidelines: Infliximab (Avsola™, Remicade®, Inflectra™, Renflexis™)

Renflexis (Infliximab) Updated • Updated reference link to reflect title change for Precertification Guidelines: Infliximab (Avsola™, Remicade®, Inflectra™, Renflexis™)

Stelara (Ustekinumab): Intravenous Infusion

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


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REVISED

Drug Coverage

Guidelines

Mar. 1, 2020 Absorica (Isotretinoin) Updated • Updated prior authorization/medical necessity guidelines; refer to Prior

Authorization/Medical Necessity Guidelines: Absorica for complete details

Absorica LD (Isotretinoin)

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

Adakveo (Crizanlizumab-Tmca)

New • Added language 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 Jul. 1, 2020, precertification will be required

• Added precertification guidelines; refer to the following policies for complete details: o Precertification Guidelines: Adakveo® (Crizanlizumab-Tmca) o Precertification Guidelines: Review at Launch for New to Market

Medications

Addyi (Flibanserin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Addyi for complete details

Anastrozole (Generic) New • Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)

• Added prior authorization/regulatory guidelines; refer to Prior

Authorization/Regulatory Guidelines: Anastrozole for complete details

Arimidex (Brand Only)

(Anastrozole)

Updated • Updated list of applicable HCPCS codes; replaced J8499 with S0170

Arymo ER (Morphine Sulfate)

Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Arymo ER for complete

details

Budesonide/Formoterol (Symbicort Authorized Generic)

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


Oxford



REVISED

Drug Coverage

Guidelines (continued)

Mar. 1, 2020 Budesonide/Formoterol

(Symbicort Authorized Generic) (continued)

New Medications for complete details

Consensi (Amlodipine

and Celecoxib)

New • Added language to indicate precertification is required through the

Pharmacy Benefit Manager (PBM) • Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent


Dapsone (Aczone) New • Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)


Medications for complete details

Divigel 1.25g (Estradiol Gel)


• Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details

Embeda (Morphine Sulphate and Naltrexone Hcl)

Removed • Removed coverage guidelines

Evista (Raloxifene) (Brand Only)

Revised • Removed prior authorization/regulatory guidelines and corresponding reference link to the policy titled Prior Authorization/Regulatory Guidelines: Evista

Exemestane (Generic) New • Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)

• Added prior authorization/regulatory guidelines; refer to Prior Authorization/Regulatory Guidelines: Exemestane for complete details

Genotropin (Somatropin)

Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Genotropin (Somatropin) for

complete details

Genotropin Miniquick (Somatropin)

Revised • Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Genotropin MiniQuick for complete details


Oxford



REVISED

Drug Coverage


Mar. 1, 2020 Givlaari (Givosiran) New • Added language 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 Jul. 1, 2020, precertification will be required • Added precertification guidelines; refer to the following policies for

complete details: o Precertification Guidelines: Givlaari™ (Givosiran) o Precertification Guidelines: Review at Launch for New to Market

Medications

Humatrope (Somatropin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Humatrope (Somatropin) for complete details

Ibsrela (Tenapanor) 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: Ibsrela for complete details

Increlex (Mecasermin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Increlex (Mecasermin) for complete details

Jatenzo (Testosterone Undecanoate)

Revised • Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent


Kanjinti (Trastuzumab-

Anns)

Updated • Updated list of applicable HCPCS codes; replaced J9999 with Q5117

Letrozole (Generic) New • Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)

• Added prior authorization/regulatory guidelines; refer to Prior Authorization/Regulatory Guidelines: Letrozole for complete details

Lorbrena (Lorlatinib) Revised • Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Lorbrena for complete details


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REVISED

Drug Coverage


Mar. 1, 2020 Norditropin (Somatropin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior

Authorization/Medical Necessity Guidelines: Norditropin (Somatropin) for complete details

Norditropin AQ (Somatropin)

Removed • Removed coverage guidelines

Norditropin Flexpro (Somatropin)

Revised • Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Norditropin FlexPro for

complete details

Norditropin Nordiflex (Somatropin)

Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: NordiFlex (Somatropin) for complete details

Nourianz (Istradefylline) Revised • Added prior authorization/medical necessity guidelines; refer to Prior

Authorization/Medical Necessity Guidelines: Nourianz for complete details

Nuspin (Somatropin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: NuSpin (Somatropin) for complete details

Omnitrope (Somatropin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Omnitrope (Somatropin) for

complete details

Oxbryta (Voxelotor) New • Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)


Praluent (Alirocumab) Updated • Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Praluent (Alirocumab) for complete details

Raloxifene (Generic) Revised • Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Raloxifene for complete details

Saizen (Somatropin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Saizen (Somatropin) for complete details

Secuado (Asenapine)

New

• Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)

• Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent


Oxford



REVISED

Drug Coverage


Mar. 1, 2020 Secuado (Asenapine)

(continued)

New Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent


Serostim (Somatropin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Serostim (Somatropin) for complete details

Simvastatin Oral Suspension (Flolipid

Authorized Generic)



Soltamox (Tamoxifen Citrate)

Revised • Removed prior authorization/regulatory guidelines and corresponding reference link to the policy titled Prior Authorization/Regulatory Guidelines: Soltamox

Sucraid (Sacrosidase) Revised • Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Sucraid for complete details

• Removed prior authorization/notification guidelines and corresponding

reference link to the policy titled Prior Authorization/Notification Guidelines: Sucraid

Takhzyro (Lanadelumab-Flyo)

Updated • Updated list of applicable HCPCS code; replaced J3490 with J0593

Talicia (Omeprazole Magnesium, Amoxicillin and Rifabutin)




Talzenna (Talazoparib) Revised • Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Talzenna for complete details

Tamoxifen 20mg (Generic)

Updated • Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Tamoxifen for complete details

• Updated medication/drug name; added “20mg (Generic)”

Tetrabenazine (Generic) Updated • Updated medication/drug name; previously listed as Xenazine (Tetrabenazine)

Trulance (Plecanatide) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Trulance for complete details


Oxford



REVISED

Drug Coverage


Mar. 1, 2020 Valtoco (Diazepam) New • Added language to indicate precertification is required through the

Pharmacy Benefit Manager (PBM) • Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent


Vosevi (Sofosbuvir/ Velpatasvir/Voxilaprevir)

Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Vosevi for complete details

Wakix (Pitolisant) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Wakix for complete details

Xenazine (Tetrabenazine) (Brand)

Revised • Added prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Tetrabenazine for complete details

Yupelri (Revefenacin) Updated • Updated list of applicable HCPCS codes; replaced J3490 with J7677

Zelnorm (Tegaserod Maleate)

Revised • Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Zelnorm 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

Ziextenzo (Pegfilgrastim-

Bmez)

Revised • Revised coverage guidelines to indicate:

o Coverage is provided under the PBM benefit when purchased from a pharmacy and self-administered; precertification is required

o Coverage is provided under the medical benefit when administered by a provider: ▪ 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 May 1, 2020, precertification will be required

• Added eviCore guidelines; refer to eviCore Guidelines: White Blood Cell Colony Stimulating Factors for complete details

Zirabev (Bevacizumab-Bvzr)

Updated • Updated list of applicable HCPCS codes; replaced J9999 with Q5118


Oxford



REVISED

Drug Coverage


Mar. 1, 2020 Zomacton (Somatropin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior

Authorization/Medical Necessity Guidelines: Zomacton for complete details

Zorbtive (Somatropin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Zorbtive (Somatropin) for

complete details


REVISED

Infliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®)

Feb. 1, 2020

Title Change • Previously titled Infliximab

(Remicade®, Inflectra™, Renflexis™)

Conditions of Coverage • Added language to indicate

precertification is not required,

however it is strongly recommended for Avsola

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 May 1, 2020, precertification will be required

Coverage Rationale • Revised list of applicable

infliximab products; added

Refer to the policy for complete details on the coverage guidelines for Infliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®).


Oxford



REVISED

Infliximab

(Avsola™, Inflectra®, Remicade®, & Renflexis®)

(continued)

Feb. 1, 2020

Avsola™ (infliximab-axxq)

• Added language to indicate: o Avsola (infliximab-axxq) has

been added to the Review at Launch program and some

members may not be eligible for coverage of this medication at this time;

refer to the Medical Benefit Drug Policy titled Review at Launch for New to Market Medications for additional details

Preferred Product: Medical Necessity Plans o Coverage for Avsola™

(infliximab-axxq) will be

provided contingent on the

criteria in this section and the coverage criteria in the Diagnosis-Specific Criteria section [of the policy]

o In order to continue coverage, members already

on Avsola will be required to change therapy to Inflectra or Remicade unless they meet the criteria in [the Preferred Product Criteria]

section [of the policy] o Treatment with Avsola is

medically necessary for the indications specified in the policy when both of the [Preferred Product Criteria listed in the policy] are met

• Replaced Preferred Product criterion requiring:


Oxford



REVISED

Infliximab


(continued)

Feb. 1, 2020

o “History of a trial of at least

14 weeks of Remicade and Inflectra resulting in minimal clinical response to therapy and residual disease activity”

with “history of a trial of at least 14 weeks of both Inflectra and Remicade

resulting in minimal clinical response to therapy and residual disease activity”

o “Physician attests that in their clinical opinion, the clinical response would be

expected to be superior with [a non-preferred] infliximab biosimilar product, than

experienced with Remicade or Inflectra” with “physician attests that in their clinical opinion, the clinical response

would be expected to be superior with [a non-preferred] infliximab biosimilar product, than experienced with Inflectra and Remicade”

o “Patient has not developed

neutralizing antibodies to

any infliximab biosimilar product that has led to an attenuation of efficacy of therapy” with “patient has not developed neutralizing

antibodies to any infliximab product that has led to an attenuation of efficacy of therapy”


Oxford



REVISED

Infliximab


(continued)

Feb. 1, 2020 Applicable Codes • Added HCPCS codes J3490 and

J3590

Supporting Information • Updated FDA and References

sections to reflect the most current information

Infliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®)

May 1, 2020 Conditions of Coverage • Revised precertification

requirements to indicate precertification with review by a Medical Director or their designee is required for Avsola

Coverage Rationale • Removed reference link to the

Clinical Policy titled Review at

Launch for New to Market

Medications for Avsola (prior authorization requirements apply May 1, 2020)

Refer to the policy for complete details on the coverage guidelines for Infliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®).

Outpatient Surgical Procedures - Site of Service

Apr. 6, 2020

Notice of Revision (Feb. 1, 2020): The following summary of changes has been modified. Revisions to the

previous policy update announcement are outlined in red below. Please take note of the amended guidelines to be applied on 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 ([CAD]/peripheral vascular

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


Oxford



REVISED

Outpatient Surgical

Procedures - Site of Service (continued)

Apr. 6, 2020

disease [PVD]) (ongoing

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 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 1,015 991 CPT/HCPCS

codes (see list for details; revised Feb. 1, 2020)

Definitions • Updated definition of “ASA

Physical Status Classification System Risk Scoring Tool”

• 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

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


Oxford



REVISED

Outpatient Surgical

Procedures - Site of Service (continued)

Apr. 6, 2020 Planned Surgical Procedures List

Site of service medical necessity reviews will be conducted for surgical procedures on the Applicable Codes List from this policy only when

performed in an outpatient hospital setting.

Provider

Administered Drugs – Site of Care

Apr. 1, 2020

Related Policies

• Added reference link to the Clinical Policy titled Reblozyl®

(Luspatercept-Aamt)

Coverage Rationale • Revised list of specialty

medications requiring healthcare provider administration; added Reblozyl® (luspatercept-aamt)

Definitions • Updated definition of “Site of

Care”

Applicable Codes • Added list of applicable HCPCS

codes: J0129, J0180, J0221,

J0222, J0256, J0257, J0490, J0584, J0638, J1300, J1301, J1303, J1322, J1428, J1458, J1602, J1743, J1745, J1746, J1786, J1931, J2350, J2840, J3060, J3245, J3262, J3380, J3385, J3397, J3590, Q5103,

and Q5104

This policy addresses the criteria for consideration of allowing hospital

outpatient facility specialty medication infusion services. This includes claim submission for hospital based services with the following CMS/AMA Place of Service codes: • 19 Off-Campus - Outpatient Hospital; and

• 22 On-Campus - Outpatient Hospital Alternative sites of care, such as non-hospital outpatient infusion, physician office, ambulatory infusion or home infusion services are well accepted places of service for medication infusion therapy. If an individual does not meet criteria for outpatient hospital facility infusion, alternative sites of care may be used.

Outpatient hospital facility-based intravenous medication infusion is medically necessary for individuals who meet at least ONE of the following criteria (submission of medical records is required): • Documentation that the individual is medically unstable for

administration of the prescribed medication at the alternative sites of care as determined by any of the following:

o The individual’s complex medical status or therapy requires enhanced monitoring and potential intervention above and beyond the capabilities of the office or home infusion setting; or

o The individual’s documented history of a significant comorbidity (e.g., cardiopulmonary disorder) or fluid overload status that

precludes treatment at an alternative Site Of Care; or

o Outpatient treatment in the home or office setting presents a health risk due to a clinically significant physical or cognitive impairment; or

o Difficulty establishing and maintaining patent vascular access o To initiate, re-initiate products for a short duration (e.g., 4 weeks) or

• Documentation (e.g., infusion records, medical records) of episodes of severe or potentially life-threatening adverse events (e.g., anaphylaxis,

seizure, thromboembolism, myocardial infarction, renal failure) that have not been responsive to acetaminophen, steroids, diphenhydramine,


Oxford



REVISED

Provider

Administered Drugs – Site of Care (continued)

Apr. 1, 2020

fluids, infusion rate reductions, or other pre-medications, thereby

increasing risk to the individual when administration is in the home or office setting; or

• Initial infusion or re-initiation of therapy after more than 6 months; or • Homecare or infusion provider has deemed that the individual, home

caregiver, or home environment is not suitable for home infusion therapy (if the prescriber cannot infuse in the office setting).

Ongoing outpatient hospital facility-based infusion duration of therapy will be no more than 6 months to allow for reassessment of the individual’s ability to receive therapy at an alternative Site Of Care.

This policy applies to these specialty medications that require healthcare provider administration: • Actemra® (Tocilizumab) • Aldurazyme® (Laronidase)

• Aralast NP™ (A1-PI) • Benlysta® (Belimumab) • Cerezyme® (Imiglucerase) • Crysvita® (Burosumab) • Elaprase® (Idursulfase) • Elelyso® (Taliglucerase)

• Entyvio® (Vedolizumab) • Exondys 51™ (Eteplirsen) • Fabrazyme® (Agalsidase beta) • Glassia™ (A1-PI) • Ilaris® (Canakinumab) • Ilumya™ (Tildrakizumab-asmn)

• Inflectra™ (Infliximab-dyyb)

• Kanuma® (Sebelipase alfa) • Lumizyme® (Alglucosidase alfa) • Mepsevii™ (Vestronidase alfa-vjbk) • Naglazyme® (Galsulfase) • Ocrevus™ (Ocrelizumab) • Onpattro™ (Patisiran) • Orencia® (Abatacept)

• Prolastin®-C™ (A1-PI)


Oxford



REVISED

Provider

Administered Drugs – Site of Care (continued)

Apr. 1, 2020 • Radicava™ (Edaravone)

• Reblozyl® (Luspatercept-aamt) • Remicade® (Infliximab) • Renflexis™ (Infliximab-abda) • Revcovi™ (Elapegademase-lvlr)

• Simponi Aria® (Golimumab) • Soliris® (Eculizumab) • Trogarzo™ (Ibalizumab)

• Ultomiris™ (Ravulizumab-cwvz) • Vimizim® (Elosulfase alfa) • VPRIV® (Velaglucerase) • Zemaira® (A1-PI)

Rituximab (Rituxan®,

Ruxience™ & Truxima®)

Feb. 1, 2020

Notice of Revision: The following summary of changes has been

modified. Revisions to the previous policy update announcement are outlined in red below. Please take

note of the additional updates to be applied on 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

Refer to the policy for complete details on the coverage guidelines for Rituximab (Rituxan®, Ruxience™ & Truxima®).


Oxford



REVISED

Rituximab

(Rituxan®, Ruxience™ & Truxima®) (continued)

Feb. 1, 2020

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 Home infusion of rituximab

requires additional precertification for the home care services

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]”


Oxford



REVISED

Rituximab


Feb. 1, 2020

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:

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

../../../../AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/AL%20Final/rituxan-ohp-020120.doc#Autoimmune_hemolytic_anemia



../../../../AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/AL%20Final/rituxan-ohp-020120.doc#Multiple_sclerosis

../../../../AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/AL%20Final/rituxan-ohp-020120.doc#Neuromyelitis_optica

../../../../AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/AL%20Final/rituxan-ohp-020120.doc#Pemphigus_vulgaris

../../../../AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/AL%20Final/rituxan-ohp-020120.doc#PTLD



../../../../AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/AL%20Final/rituxan-ohp-020120.doc#TTP



Oxford



REVISED

Rituximab


Feb. 1, 2020 (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

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: o Chronic graft-versus-host

disease o Multiple sclerosis

Applicable Codes

• Added HCPCS codes J3590, J9311, and J9999

• Added ICD-10 diagnosis code G35

Supporting Information • Updated Clinical Evidence, FDA,

and References sections to reflect the most current information


../../../../AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/AL%20Final/rituxan-ohp-020120.doc#ITP

../../../../AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/AL%20Final/rituxan-ohp-020120.doc#ITP

../../../../AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/AL%20Final/rituxan-ohp-020120.doc#Rheumatoid_arthritis

../../../../AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/AL%20Final/rituxan-ohp-020120.doc#Wegeners





Oxford



REVISED

White Blood Cell

Colony Stimulating Factors

Mar. 1, 2020

Conditions of Coverage

• Added language to indicate precertification is not required, however, it is strongly recommended for Ziextenzo

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 May 1, 2020,

precertification will be required

Coverage Rationale • Revised list of applicable long-

acting pegfilgrastim agents;

added Ziextenzo™ (pegfilgrastim-bmez)

• Added language to indicate:

Long-Acting Pegfilgrastim Agents (Fulphila, Neulasta,

Udenyca, Ziextenzo): Preferred Product o Coverage for Ziextenzo will

be provided contingent on the criteria in [the Preferred

Product Criteria] section and the coverage criteria in the Diagnosis-Specific Criteria section [of the policy]

Refer to the policy for complete details on the coverage guidelines for White

Blood Cell Colony Stimulating Factors.


Oxford



REVISED

White Blood Cell

Colony Stimulating Factors (continued)

Mar. 1, 2020

o In order to continue

coverage, members already on Ziextenzo will be required to change therapy to Neulasta unless they meet

the criteria in [the Preferred Product Criteria] section [of the policy]

o Treatment with Ziextenzo is medically necessary for the indications specified in the policy when one of the [Preferred Product Criteria listed in the policy] is met

Diagnosis-Specific Criteria o Ziextenzo is proven for:

▪ Hematopoietic Syndrome

of Acute Radiation

Syndrome ▪ Neutropenia Associated

with Cancer Chemotherapy – Dose Dense Chemotherapy

▪ Primary Prophylaxis of

Chemotherapy-Induced Febrile Neutropenia (FN)

▪ Secondary Prophylaxis of Febrile Neutropenia (FN)

▪ Treatment of Febrile

Neutropenia (Off-Label) o Ziextenzo is medically

necessary when the criteria listed in the policy are met

Applicable Codes • Added HCPCS codes J3490 and

J3590

Supporting Information • Updated Background, FDA, and


Oxford



REVISED

White Blood Cell

Colony Stimulating Factors (continued)

Mar. 1, 2020 References sections to reflect

the most current information

White Blood Cell

Colony Stimulating Factors

May 1, 2020 Conditions of Coverage

• Revised precertification requirements to indicate

precertification with review by a Medical Director or their designee is required for Ziextenzo

Refer to the policy for complete details on the coverage guidelines for White

Blood Cell Colony Stimulating Factors.

Administrative Policy Updates

Oxford


Policy Title Effective Date Summary of Changes

RETIRED

Hospice Care Feb. 1, 2020 • Policy retired; refer to the member specific benefit plan document for applicable coverage guidelines


Oxford


Policy Title Effective Date Summary of Changes

UPDATED

Co-Surgeon/Team Surgeon

Jan. 21, 2020 Applicable Codes • Updated Co-Surgeon Eligible List to reflect annual code edits; added CPT codes 21601, 21602, 21603, 34717,

34718, 35702, 35703, 33858, 33859, 33871, 66987, and 66988 • Updated Team Surgeon Eligible List to reflect annual code edits; added CPT codes 66987 and 66988

Co-Surgeon/Team

Surgeon (CES)

Jan. 21, 2020 Applicable Codes

• Updated Co-Surgeon Eligible List to reflect annual code edits; added CPT codes 21601, 21602, 21603, 34717, 34718, 35702, 35703, 33858, 33859, 33871, 66987, and 66988

• Updated Team Surgeon Eligible List to reflect annual code edits; added CPT codes 66987 and 66988

Policy Title Effective Date Summary of Changes Reimbursement Guidelines

REVISED

Drug Testing

Mar. 1, 2020

Overview and Reimbursement Guidelines • Revised language addressing

applicable CPT codes for

definitive drug

testing/Proprietary Laboratory Analysis; removed references to “0082U”

Applicable Codes

• Reformatted content • Revised list of applicable

CPT/HCPCS codes for definitive drug testing; removed 0082U

Questions and Answers (Q&A) • Updated Q&A #2 pertaining to

separate reimbursement for laboratory services; added

reference to the Reimbursement Policy titled Modifier Reference for additional information

This policy enforces the code description for presumptive and definitive drug testing in that the service should be reported once per day and it includes Specimen Validity Testing.

Clinical drug testing is used in pain management and in substance abuse

screening and treatment programs. The testing may be used to detect prescribed, therapeutic drugs, prescription drugs of abuse, illicit drugs, and/or other substances such as nicotine. Presumptive drug testing, also known as drug screening, is used when necessary to determine the presence or absence of drugs or a Drug Class.

Results are expressed as negative or positive. The methodology is considered when coding presumptive procedures. Per Current Procedural Terminology (CPT®) guidelines each presumptive drug testing code represents all drug and Drug Class tests performed by the respective methodology per date of service. The test is a single per patient service that should only be reported once irrespective of the number of Drug Class

procedures or results on any date of service. Definitive drug testing, also known as confirmation testing, is used when it is necessary to identify specific medications, illicit substances and metabolites. Definitive urine drug test (UDT) reports the results of drugs absent or present in concentrations of ng/ml. Definitive drug testing is qualitative or quantitative to identify possible use or non-use of a drug. These tests

identify specific drugs and associated metabolites. A presumptive drug test is not required to be provided prior to a definitive drug test. Consistent with CMS, definitive drug testing CPT codes 80320-80377 are considered non-


Oxford



REVISED

Drug Testing

(continued)

Mar. 1, 2020 reimbursable and the appropriate HCPCS G0480-G0483 and G0659 should

be reported. The HCPCS codes describe a per-day service that represents the total number of different Drug Classes performed. When applicable, Proprietary Laboratory Analysis CPT Codes 0006U, 0007U or 0011U may be reported and are considered under the policy guidelines pertaining to

definitive drug testing. Some examples of drugs or a Drug Class that are commonly assayed by

presumptive tests, followed by definitive testing are: alcohols, amphetamines, barbiturates/sedatives, benzodiazepines, cocaine and metabolites, methadone, antihistamines, stimulants, opioid analgesics, salicylates, cardiovascular drugs, antipsychotics, and cyclic antidepressants. In accordance with the code descriptions and the CPT and CMS guidelines,

Oxford will only allow one drug test within the presumptive Drug Class and one drug test within the definitive Drug Class per date of service by the same or different provider.

Specimen Validity Testing to assure that a specimen has not been compromised or that a test has not been adulterated may be required. However, Specimen Validity Testing is included in the presumptive and

definitive drug testing CPT and HCPCS code descriptions and is considered a quality control which is an integral part of the collection process and is not separately reimbursable. Oxford will deny Specimen Validity Testing when performed on the same date of service as a presumptive and/or definitive drug test by the same or different provider. A modifier may be appropriate when a service commonly used for Specimen Validity Testing is performed distinctly separate from the drug test service and the documentation

supports the service was not related to the drug testing.

Drug testing services that are determined to be court ordered and/or funded by a county, state or federal agency will continue to be denied. For additional information, refer to the Reimbursement Policy titled Services and Modifiers Not Reimbursable to Healthcare Professionals.


Oxford



REVISED

Maximum

Frequency Per Day

Feb. 1, 2020

Notice of Revision: The following summary of changes has been modified. Revisions to the previous policy update

announcement are outlined in red below. Please take note of the additional updates to be applied on 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 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 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 5,543* MAI2 Indicator Codes (codes previously addressed in the CMS MUE file) (*added 82

codes to reflect annual code edits; revised Feb. 1, 2020)


Oxford



REVISED

Maximum

Frequency Per Day (continued)

Feb. 1, 2020

Codes Restricting Modifiers LT and RT • Added CPT/CDT/HCPCS codes 0139U*, 0140U*, 0141U*, 0142U*, 0143U*, 0144U*, 0145U*, 0146U*, 0147U*,

0148U*, 0149U*, 0150U*, 0151U*, 0152U*, 0153U*, 0154U*, 0155U*, 0156U*, 0157U*, 0158U*, 0159U*, 0160U*, 0161U*, 0162U*, 0563T*, 0564T*, 0565T*, 0566T*, 0567T*, 0568T*, 0569T*, 0570T*, 0571T*,

0572T*, 0573T*, 0574T*, 0575T*, 0576T*, 0577T*, 0578T*, 0579T*, 0580T*, 0581T*, 0582T*, 0584T*,

0585T*, 0586T*, 0587T*, 0588T*, 0589T*, 0590T*, 0591T*, 0592T*, 0593T*, 15769*, 15771*, 15772*, 15773*, 15774*, 20560*, 20561*, 20700*, 20701*, 20702*, 20703*, 20704*, 20705*, 21601*, 21602*, 21603*, 33016*, 33017*, 33018*, 33019*, 33858*, 33859*, 33871*, 34717*, 46948*, 49013*, 49014*, 62328*, 62329*, 64451*, 64454*, 64624*, 64625*, 74221*, 74248*, 78429*, 78430*, 78431*, 78432*, 78433*, 78434*, 78830*, 78831*, 78832*, 78835*, 80145*, 80187*, 80230*, 80235*, 80280*, 80285*, 81277*, 81307*, 81308*, 81309*, 81522*, 81542*, 81552*, 87563*, 90694*, 90912*, 90913*, 92201*,

92202*, 92549*, 93356*, 93985*, 93986*, 95700*, 95705*, 95706*, 95707*, 95708*, 95709*, 95710*, 95711*, 95712*, 95713*, 95714*, 95715*, 95716*, 95717*, 95718*, 95719*, 95720*, 95721*, 95722*, 95723*, 95724*, 95725*, 95726*, 96156*, 96158*, 96159*, 96164*, 96165*, 96167*, 96168*, 96170*, 96171*, 97129*, 97130*, 98970*, 98971*, 98972*, 99421*, 99422*, 99423*, 99458*, 99473*, 99474*, D0419*, A4226*, A9590*, B4187*, G2021*, G2022*, G2058*, G2061*, G2062*, G2063*, G2064*, G2065*, G2066*, G2067*, G2068*, G2069*, G2070*, G2071*, G2072*, G2073*, G2074*, G2075*, G2076*, G2077*,

G2078*, G2079*, G2080*, G2082*, G2083*, G2086*, G2087*, G2088*, J0642, K1001*, K1002*, K1003*,

K1004*, K1005*, L8033*, and P9099*

Maximum Frequency Per Day Code List • Added CPT/CDT/HCPCS codes 0139U*, 0140U*, 0141U*, 0142U*, 0143U*, 0144U*, 0145U*, 0146U*, 0147U*,

0148U*, 0149U*, 0150U*, 0151U*, 0152U*, 0153U*, 0154U*, 0155U*, 0156U*, 0157U*, 0158U*, 0159U*, 0160U*, 0161U*, 0162U*, 0563T*, 0564T*, 0565T*, 0566T*, 0567T*, 0568T*, 0569T*, 0570T*, 0571T*, 0572T*, 0573T*, 0574T*, 0575T*, 0576T*, 0577T*, 0578T*, 0579T*, 0580T*, 0581T*, 0582T*, 0583T*, 0584T*, 0585T*, 0586T*, 0587T*, 0588T*, 0589T*, 0590T*, 0591T*, 0592T*, 0593T*, 15769*, 15771*, 15772*, 15773*, 15774*, 20560*, 20561*, 20700*, 20701*, 20702*, 20703*, 20704*, 20705*, 21601*, 21602*, 21603*, 33016*, 33017*, 33018*, 33019*, 33858*, 33859*, 33871*, 34717*, 34718*, 35702*, 35703*, 46948*, 49013*, 49014*, 62328*, 62329*, 64451*, 64454*, 64624*, 64625*, 66987*, 66988*,

74221*, 74248*, 78429*, 78430*, 78431*, 78432*, 78433*, 78434*, 78830*, 78831*, 78832*, 78835*,

80145*, 80187*, 80230*, 80235*, 80280*, 80285*, 81277*, 81307*, 81308*, 81309*, 81522*, 81542*, 81552*, 87563*, 90694*, 90912*, 90913*, 92201*, 92202*, 92549*, 93356*, 93985*, 93986*, 95700*, 95705*, 95706*, 95707*, 95708*, 95709*, 95710*, 95711*, 95712*, 95713*, 95714*, 95715*, 95716*, 95717*, 95718*, 95719*, 95720*, 95721*, 95722*, 95723*, 95724*, 95725*, 95726*, 96156*, 96158*, 96159*, 96164*, 96165*, 96167*, 96168*, 96170*, 96171*, 97129*, 97130*, 98970*, 98971*, 98972*,

99421*, 99422*, 99423*, 99458*, 99473*, 99474*, D0419*, D1551*, D1552*, D1553*, D1556*, D1557*, D1558*, D2753*, D5284*, D5286*, D6082*, D6083*, D6084*, D6086*, D6087*, D6088*, D6097*, D6098*, D6099*, D6120*, D6121*, D6122*, D6123*, D6195*, D6243*, D6753*, D6784*, D7922*, D8696*, D8697*, D8698*, D8699*, D8701*, D8702*, D8703*, D8704*, D9997*, A4226*, A9590*, B4187*, E0787*, E2398*,


Oxford



REVISED

Maximum

Frequency Per Day (continued)

Feb. 1, 2020 G2021*, G2022*, G2058*, G2061*, G2062*, G2063*, G2064*, G2065*, G2066*, G2067*, G2068*, G2069*,

G2070*, G2071*, G2072*, G2073*, G2074*, G2075*, G2076*, G2077*, G2078*, G2079*, G2080*, G2082*, G2083*, G2086*, G2087*, G2088*, J0179*, J0642, J9199*, J9309*, K1001*, K1002*, K1003*, K1004*, K1005*, L2006*, L8033*, and P9099*

• Revised MFD value for CPT/CDT/HCPCS codes 0093U*, 0546T*, 0550T*, 0553T*, 0560T*, 0562T*, 34713*,

34714*, 34715*, 34716*, 64420*, 76983*, 90284*, 93657*, A0080*, A0090*, A0120*, A0160*, A0170*, A0180*, A0190*, A0380*, A0382*, A0390*, A0394*, A0398*, A0424*, A4207*, A4208*, A4209*, A4211*, A4213*, A4217*, A4218*, A4222*, A4231*, A4244*, A4245*, A4248*, A4280*, A4283*, A4285*, A4305*,

A4306*, A4320*, A4326*, A4327*, A4335*, A4397*, A4400*, A4404*, A4421*, A4455*, A4553*, A4558*, A4605*, A4628*, A4629*, A4630*, A4641*, A4651*, A4657*, A4674*, A4680*, A4690*, A4706*, A4720*, A4736*, A4750*, A4755*, A4766*, A4770*, A4860*, A4890*, A4913*, A4930*, A5055*, A5063*, A5093*, A5121*, A5122*, A5126*, A6021*, A6022*, A6024*, A6025*, A6199*, A6203*, A6204*, A6206*, A6207*, A6209*, A6210*, A6211*, A6213*, A6217*, A6219*, A6220*, A6223*, A6224*, A6230*, A6237*, A6240*, A6245*, A6248*, A6255*, A6256*, A6257*, A6259*, A6260*, A6261*, A6262*, A6266*, A6403*, A6404*,

A6407*, A6413*, A6441*, A6442*, A6448*, A6449*, A6450*, A6451*, A6452*, A6453*, A6455*, A6456*, A6457*, A6512*, A6549*, A6550*, A7008*, A7523*, A9150*, A9153*, A9180*, A9270*, A9273*, A9279*, A9280*, A9300*, A9597*, A9598*, A9699*, A9901*, B4102*, B4104*, B4162*, B4185*, B5100*, B5200*,

B9998*, B9999*, D0411*, D0414*, D0600*, D0999*, D2999*, D3999*, D4346*, D4999*, D5511*, D5512*, D5611*, D5612*, D5621*, D5622*, D5899*, D5999*, D6096*, D6118*, D6119*, D6199*, D6999*, D7296*, D7297*, D7521*, D7899*, D7999*, D8695*, D8999*, D9311*, D9995*, D9996*, D9999*, E0625*, E0700*, E0769*, E1575*, E1699*, E2599*, G0176*, H0033*, H0046*, H0047*, J0130, J2787, J0571*, J0572*, J0573*,

J0574*, J0575*, J0638*, J7311*, J7401*, J7665*, K0108*, K0552*, K0603*, L0999*, L2840*, L2999*, L3320*, L3649*, L3999*, L5999*, L7499*, L8699*, L9900*, Q2017, Q2026*, Q2049*, Q4005*, Q4007*, Q4008*, Q4009*, Q4011*, Q4016*, Q4017*, Q4018*, Q4023*, Q4032*, Q4034*, Q4035*, Q4036*, Q4039*, Q4041*, Q4042*, Q4043*, Q4044*, Q4045*, Q4048*, Q4049*, Q4100*, S0207*, S0209*, S0270*, S0271*, S0272*, S0320*, S0354*, S0400*, S1015*, S1016*, S2095*, S2409*, S4026*, S4027*, S4993*, S5000*, S5001*, S5010*, S5170*, S5199*, S5521*, S8040*, S8189*, S8301*, S8415*, S8431*, S8940*, S9110*, S9430*, S9434*, S9435*, S9977*, S9982*, S9986*, T1010*, T1014*, T1999*, T2003*, T2025*, T2049*,

T4521*, T4536*, T4543*, T5999*, V2799*, and V5274*

(*annual code edit)

Maximum Frequency Per Day (CES)

Feb. 1, 2020

Notice of Revision: The following summary of changes has been modified. Revisions to the previous policy update announcement are outlined in red below. Please take note of the additional updates to be applied on 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


Oxford



REVISED

Maximum

Frequency Per Day (CES) (continued)

Feb. 1, 2020

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”

• 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) • 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 5,543* MAI2 Indicator Codes (codes previously addressed in the CMS MUE file) (*added 82 codes to reflect annual code edits; revised Feb. 1, 2020)

Codes Restricting Modifiers LT and RT • Added CPT/CDT/HCPCS codes 0139U*, 0140U*, 0141U*, 0142U*, 0143U*, 0144U*, 0145U*, 0146U*, 0147U*,

0148U*, 0149U*, 0150U*, 0151U*, 0152U*, 0153U*, 0154U*, 0155U*, 0156U*, 0157U*, 0158U*, 0159U*, 0160U*, 0161U*, 0162U*, 0563T*, 0564T*, 0565T*, 0566T*, 0567T*, 0568T*, 0569T*, 0570T*, 0571T*,

0572T*, 0573T*, 0574T*, 0575T*, 0576T*, 0577T*, 0578T*, 0579T*, 0580T*, 0581T*, 0582T*, 0584T*, 0585T*, 0586T*, 0587T*, 0588T*, 0589T*, 0590T*, 0591T*, 0592T*, 0593T*, 15769*, 15771*, 15772*, 15773*, 15774*, 20560*, 20561*, 20700*, 20701*, 20702*, 20703*, 20704*, 20705*, 21601*, 21602*,


Oxford



REVISED

Maximum


Feb. 1, 2020

21603*, 33016*, 33017*, 33018*, 33019*, 33858*, 33859*, 33871*, 34717*, 46948*, 49013*, 49014*,

62328*, 62329*, 64451*, 64454*, 64624*, 64625*, 74221*, 74248*, 78429*, 78430*, 78431*, 78432*, 78433*, 78434*, 78830*, 78831*, 78832*, 78835*, 80145*, 80187*, 80230*, 80235*, 80280*, 80285*, 81277*, 81307*, 81308*, 81309*, 81522*, 81542*, 81552*, 87563*, 90694*, 90912*, 90913*, 92201*, 92202*, 92549*, 93356*, 93985*, 93986*, 95700*, 95705*, 95706*, 95707*, 95708*, 95709*, 95710*,

95711*, 95712*, 95713*, 95714*, 95715*, 95716*, 95717*, 95718*, 95719*, 95720*, 95721*, 95722*, 95723*, 95724*, 95725*, 95726*, 96156*, 96158*, 96159*, 96164*, 96165*, 96167*, 96168*, 96170*, 96171*, 97129*, 97130*, 98970*, 98971*, 98972*, 99421*, 99422*, 99423*, 99458*, 99473*, 99474*,

D0419*, A4226*, A9590*, B4187*, G2021*, G2022*, G2058*, G2061*, G2062*, G2063*, G2064*, G2065*, G2066*, G2067*, G2068*, G2069*, G2070*, G2071*, G2072*, G2073*, G2074*, G2075*, G2076*, G2077*, G2078*, G2079*, G2080*, G2082*, G2083*, G2086*, G2087*, G2088*, J0642, K1001*, K1002*, K1003*, K1004*, K1005*, L8033*, and P9099*

Maximum Frequency Per Day Code List • Added CPT/CDT/HCPCS codes 0139U*, 0140U*, 0141U*, 0142U*, 0143U*, 0144U*, 0145U*, 0146U*, 0147U*,

0148U*, 0149U*, 0150U*, 0151U*, 0152U*, 0153U*, 0154U*, 0155U*, 0156U*, 0157U*, 0158U*, 0159U*, 0160U*, 0161U*, 0162U*, 0563T*, 0564T*, 0565T*, 0566T*, 0567T*, 0568T*, 0569T*, 0570T*, 0571T*, 0572T*, 0573T*, 0574T*, 0575T*, 0576T*, 0577T*, 0578T*, 0579T*, 0580T*, 0581T*, 0582T*, 0583T*,

0584T*, 0585T*, 0586T*, 0587T*, 0588T*, 0589T*, 0590T*, 0591T*, 0592T*, 0593T*, 15769*, 15771*,

15772*, 15773*, 15774*, 20560*, 20561*, 20700*, 20701*, 20702*, 20703*, 20704*, 20705*, 21601*, 21602*, 21603*, 33016*, 33017*, 33018*, 33019*, 33858*, 33859*, 33871*, 34717*, 34718*, 35702*, 35703*, 46948*, 49013*, 49014*, 62328*, 62329*, 64451*, 64454*, 64624*, 64625*, 66987*, 66988*, 74221*, 74248*, 78429*, 78430*, 78431*, 78432*, 78433*, 78434*, 78830*, 78831*, 78832*, 78835*, 80145*, 80187*, 80230*, 80235*, 80280*, 80285*, 81277*, 81307*, 81308*, 81309*, 81522*, 81542*, 81552*, 87563*, 90694*, 90912*, 90913*, 92201*, 92202*, 92549*, 93356*, 93985*, 93986*, 95700*,

95705*, 95706*, 95707*, 95708*, 95709*, 95710*, 95711*, 95712*, 95713*, 95714*, 95715*, 95716*, 95717*, 95718*, 95719*, 95720*, 95721*, 95722*, 95723*, 95724*, 95725*, 95726*, 96156*, 96158*, 96159*, 96164*, 96165*, 96167*, 96168*, 96170*, 96171*, 97129*, 97130*, 98970*, 98971*, 98972*, 99421*, 99422*, 99423*, 99458*, 99473*, 99474*, D0419*, D1551*, D1552*, D1553*, D1556*, D1557*, D1558*, D2753*, D5284*, D5286*, D6082*, D6083*, D6084*, D6086*, D6087*, D6088*, D6097*, D6098*,

D6099*, D6120*, D6121*, D6122*, D6123*, D6195*, D6243*, D6753*, D6784*, D7922*, D8696*, D8697*, D8698*, D8699*, D8701*, D8702*, D8703*, D8704*, D9997*, A4226*, A9590*, B4187*, E0787*, E2398*,

G2021*, G2022*, G2058*, G2061*, G2062*, G2063*, G2064*, G2065*, G2066*, G2067*, G2068*, G2069*, G2070*, G2071*, G2072*, G2073*, G2074*, G2075*, G2076*, G2077*, G2078*, G2079*, G2080*, G2082*, G2083*, G2086*, G2087*, G2088*, J0179*, J0642, J9199*, J9309*, K1001*, K1002*, K1003*, K1004*, K1005*, L2006*, L8033*, and P9099*

• Revised MFD value for CPT/CDT/HCPCS codes 0093U*, 0546T*, 0550T*, 0553T*, 0560T*, 0562T*, 34713*, 34714*, 34715*, 34716*, 64420*, 76983*, 90284*, 93657*, A0080*, A0090*, A0120*, A0160*, A0170*, A0180*, A0190*, A0380*, A0382*, A0390*, A0394*, A0398*, A0424*, A4207*, A4208*, A4209*, A4211*,


Oxford



REVISED

Maximum


Feb. 1, 2020 A4213*, A4217*, A4218*, A4222*, A4231*, A4244*, A4245*, A4248*, A4280*, A4283*, A4285*, A4305*,

A4306*, A4320*, A4326*, A4327*, A4335*, A4397*, A4400*, A4404*, A4421*, A4455*, A4553*, A4558*, A4605*, A4628*, A4629*, A4630*, A4641*, A4651*, A4657*, A4674*, A4680*, A4690*, A4706*, A4720*, A4736*, A4750*, A4755*, A4766*, A4770*, A4860*, A4890*, A4913*, A4930*, A5055*, A5063*, A5093*, A5121*, A5122*, A5126*, A6021*, A6022*, A6024*, A6025*, A6199*, A6203*, A6204*, A6206*, A6207*,

A6209*, A6210*, A6211*, A6213*, A6217*, A6219*, A6220*, A6223*, A6224*, A6230*, A6237*, A6240*, A6245*, A6248*, A6255*, A6256*, A6257*, A6259*, A6260*, A6261*, A6262*, A6266*, A6403*, A6404*, A6407*, A6413*, A6441*, A6442*, A6448*, A6449*, A6450*, A6451*, A6452*, A6453*, A6455*, A6456*,

A6457*, A6512*, A6549*, A6550*, A7008*, A7523*, A9150*, A9153*, A9180*, A9270*, A9273*, A9279*, A9280*, A9300*, A9597*, A9598*, A9699*, A9901*, B4102*, B4104*, B4162*, B4185*, B5100*, B5200*, B9998*, B9999*, D0411*, D0414*, D0600*, D0999*, D2999*, D3999*, D4346*, D4999*, D5511*, D5512*, D5611*, D5612*, D5621*, D5622*, D5899*, D5999*, D6096*, D6118*, D6119*, D6199*, D6999*, D7296*, D7297*, D7521*, D7899*, D7999*, D8695*, D8999*, D9311*, D9995*, D9996*, D9999*, E0625*, E0700*, E0769*, E1575*, E1699*, E2599*, G0176*, H0033*, H0046*, H0047*, J0130, J2787, J0571*, J0572*, J0573*,

J0574*, J0575*, J0638*, J7311*, J7401*, J7665*, K0108*, K0552*, K0603*, L0999*, L2840*, L2999*, L3320*, L3649*, L3999*, L5999*, L7499*, L8699*, L9900*, Q2017, Q2026*, Q2049*, Q4005*, Q4007*, Q4008*, Q4009*, Q4011*, Q4016*, Q4017*, Q4018*, Q4023*, Q4032*, Q4034*, Q4035*, Q4036*, Q4039*,

Q4041*, Q4042*, Q4043*, Q4044*, Q4045*, Q4048*, Q4049*, Q4100*, S0207*, S0209*, S0270*, S0271*, S0272*, S0320*, S0354*, S0400*, S1015*, S1016*, S2095*, S2409*, S4026*, S4027*, S4993*, S5000*, S5001*, S5010*, S5170*, S5199*, S5521*, S8040*, S8189*, S8301*, S8415*, S8431*, S8940*, S9110*, S9430*, S9434*, S9435*, S9977*, S9982*, S9986*, T1010*, T1014*, T1999*, T2003*, T2025*, T2049*,

T4521*, T4536*, T4543*, T5999*, V2799*, and V5274* (*annual code edit)

Multiple Procedure Payment Reduction (MPPR) for Diagnostic

Cardiovascular and Ophthalmology

Procedures

Feb. 1, 2020

Notice of Revision: The following summary of changes has been modified. Revisions to the previous policy update announcement are

outlined in red below. Please take note of the additional updates to be

applied on Feb. 1, 2020. Overview • Removed language indicating:

o Oxford will apply MPPR

cardiovascular reductions to Diagnostic Cardiovascular Procedures identified as Global Test Only Codes

Multiple Diagnostic Cardiovascular Reductions (MDCR)

Oxford utilizes the CMS NPFS MPI of 6 and Non-Facility Total Relative Value Units (RVUs) to determine which Diagnostic Cardiovascular Procedures are eligible for MDCR to the TC portion of the procedure.

When the TC for two or more Diagnostic Cardiovascular Procedures are

performed on the same patient by the Same Group Physician and/or Other Health Care Professional on the same day, Oxford will apply a MDCR to reduce the Allowable Amount for the TC of the second and each subsequent procedure by 25%. No reduction is taken on the TC with the highest TC Non-facility Total RVU according to the NPFS. 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) and codes that represent the TC of Global Test Only Codes (PC/TC Indicator 4).


Oxford



REVISED

Multiple Procedure

Payment Reduction (MPPR) for Diagnostic Cardiovascular and

Ophthalmology Procedures (continued)

Feb. 1, 2020

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 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

The MDCR will apply when: • Multiple Diagnostic Cardiovascular Procedures with an MPI of 6 are

performed on the same patient by the Same Group Physician and/or Other Health Care Professional on the same day.

• A single Diagnostic Cardiovascular Procedure subject to the MDCR is

submitted with multiple units. For example, code 78445 is submitted

with 2 units. A MDCR would apply to the TC of the second unit. The units allowed are also subject to Oxford's Maximum Frequency Per Day policy.

The MDCR will not apply when: • Multiple Diagnostic Cardiovascular Procedures are billed, appended with

modifier 26 for the Professional Component (PC) only. MDCRs will not be applied to the PC.

• The procedure does not have an MPI of 6 and is not included on the Diagnostic Cardiovascular Procedures Subject to MPPR lists in the Applicable Codes section of the policy.

Refer to the Applicable Codes section of the policy for a listing of PC/TC Indicator 1, 3, and 4 codes.

Multiple Diagnostic Ophthalmology Reductions (MDOR)

Oxford utilizes the CMS NPFS MPI of 7 and Non-Facility Total RVUs to

determine which Diagnostic Ophthalmology Procedures are eligible for MDOR to the TC portion of the procedure. When the TC for two or more Diagnostic Ophthalmology Procedures are performed on the same patient by the Same Group Physician and/or Other Health Care Professional on the same day, Oxford will apply a MDOR to

reduce the Allowable Amount for the TC of the second and each subsequent procedure by 20%. No reduction is taken on the TC with the highest TC Non-Facility Total RVU according to the NPFS. The MDOR applies to TC only services and the TC portion of Global Procedure Codes.

The MDOR will apply when: • Multiple Diagnostic Ophthalmology Procedures with an MPI of 7 are

performed on the same patient by the Same Group Physician and/or


Oxford



REVISED

Multiple Procedure



Feb. 1, 2020

Applicable Codes • Revised list of Diagnostic

Ophthalmology Procedures Subject to MPPR (PC/TC

Indicator 1) to reflect annual

code edits; added CPT code 0508T with TC Non-Facility Total RVU value 0.63

• 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

Other Health Care Professional on the same day.

• A single Diagnostic Ophthalmology Procedure subject to MDOR is submitted with multiple units. For example, code 92060 is submitted with 2 units. A MDOR would apply to the TC of the second unit. The units allowed are also subject to Oxford's Maximum Frequency Per Day policy.

The MDOR will not apply when: • Multiple Diagnostic Ophthalmology Procedures are billed, appended with

modifier 26 for the PC only. MDORs will not be applied to the PC. • The procedure does not have an MPI of 7 and is not included on the

Diagnostic Ophthalmology Procedures Subject to MPPR list in the Applicable Codes section of the policy.

Multiple Diagnostic Cardiovascular and Ophthalmology Procedures

Billed Globally

When the Same Group Physician and/or Other Health Care Professional bills multiple Diagnostic Cardiovascular Procedure Global Procedure Codes (PC/TC

indicator 1) and/or Global Test Only Codes (PC/TC indicator 4); or multiple Diagnostic Ophthalmology Procedure Global Procedure Codes (PC/TC indicator 1) the procedures will be ranked to determine which procedure(s) are considered secondary or subsequent as indicated below: For Diagnostic Cardiovascular or Diagnostic Ophthalmology Global Procedure

Codes (assigned PC/TC Indicator 1): • When a provider bills globally for two or more procedures subject to

multiple diagnostic cardiovascular or ophthalmology reduction, the charge for the Global Procedure Codes will be divided into the PC and TC (indicated by modifiers 26 and TC) using Oxford's standard Professional/Technical percentage splits. Refer to the Reimbursement

Policy titled Professional/Technical Component for applicable PC/TC

splits. Ranking is based on the TC Non-Facility Total RVU and a reduction of 25% will be applied for MDCR and 20% will be applied for MDOR.

For Diagnostic Cardiovascular Procedures Global Test Only Codes (PC/TC Indicator 4): • When a provider bills for two or more Diagnostic Cardiovascular

Procedures represented by a Global Test Only code, a reduction of 25%

will be applied to the corresponding Technical Component Only Code(s)


Oxford



REVISED

Multiple Procedure



Feb. 1, 2020 (PC/TC Indicator 3). No reduction will apply to the corresponding

Professional Component Only Code(s). Refer to Q&A #3 for an example of how the MDCR reduction is applied.

Diagnostic Cardiovascular and Ophthalmology Procedures with No

Assigned CMS RVU

Services that CMS indicates may be carrier-priced, or those for which CMS does not develop RVUs are considered Gap Fill Codes and are addressed as follows: • Gap Fill Codes: When data is available for Gap Fill Codes, Oxford uses

the RVUs published in the first quarter update of the Optum The Essential RBRVS publication for the current calendar year. A Diagnostic Cardiovascular Procedure or Diagnostic Ophthalmology Procedure assigned a gap value, will be denoted with an asterisk (*) next to the code in the applicable list.

• 0.00 RVU Codes: Some codes cannot be assigned a gap value or remain without an RVU due to the nature of the service (example:

unlisted codes). Codes assigned an RVU value of 0.00 will not be included in the Diagnostic Cardiovascular Procedures or Diagnostic Ophthalmology Procedures Subject to MPPR Policy Lists and therefore, will be excluded from ranking.

Nonphysician Health Care

Professionals Billing Evaluation and Management Codes

Mar. 1, 2020

Attachments • Revised list of nonphysician

health care professionals not allowed to report evaluation and management (E/M) services: o Added:

▪ Case Management

▪ Certified Diabetic

Educator ▪ Psychology, Clinical

(Doctor of Psychology) ▪ Social Worker

(Registered Social Worker)

▪ Social Worker (Licensed

Clinical/Medical) ▪ Social Worker (Marriage

The Current Procedural Terminology (CPT®) book has specific guidelines that give the following instruction: "Select the name of the procedure or service

that accurately identifies the service performed." The National Correct Coding Initiative Policy Manual gives the following instruction: "Procedures should be reported with the most comprehensive CPT code that describes the services performed."

CPT guidance instructs that E/M (CPT codes 99091, 99201-99499) should only be reported by Physicians or other qualified health care professionals. In accordance with CMS guidelines, the only qualified health care professionals that may report E/M services are nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse midwives (CNM) and physician assistants (PA), none of which are considered nonphysician health care professionals for purposes of this policy.

Oxford will not reimburse E/M services (CPT codes 99091, 99201-99499)


Oxford



REVISED

Nonphysician

Health Care Professionals Billing Evaluation and Management

Codes (continued)

Mar. 1, 2020 & Family)

▪ Substance Abuse Services (Alcohol & Drug)

▪ Surgical Technician

▪ Visiting Nurse ▪ Waiver Nursing

o Removed:

▪ Psychoanalyst

when reported by nonphysician health care professionals reporting under

their own individual or group tax identification number (TIN). For purposes of this policy, the specialties that are considered nonphysician health care professionals are listed in the Attachments section of the policy.

There is a wide variety of CPT and Healthcare Common Procedure Coding System (HCPCS) codes that specifically and accurately identify and describe the services and procedures performed by nonphysician health care

professionals.

Procedure and Place of Service

Mar. 1, 2020 Applicable Codes • Revised list of HCPCS codes

allowed for place of service 58: o Added G2067, G2068,

G2069, G2070, G2071,

G2072, G2073, G2074, G2075, G2076, G2077, G2078, G2079, and G2080

o Removed G2086, G2087, and G2088

Oxford will reimburse CPT and HCPCS codes when reported with an appropriate Place of Service (POS).

Oxford aligns with The Centers for Medicare & Medicaid Services (CMS) POS Code set, which are two-digit codes submitted on the CMS 1500 Health Insurance Claim Form or its electronic equivalent to indicate the setting in

which a service was provided. The website containing the POS Code set can be accessed via this link: CMS Place of Service Code Set.

Many CPT and HCPCS codes include a Place of Service in their description or coding guidelines include the place(s) of service where the code may be performed. For example, CPT code 94002 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted

or controlled breathing; hospital inpatient/observation, initial day) would not be appropriate for reporting in an office or home POS because its code description identifies hospital inpatient or observation.

Oxford has established a list of CPT and HCPCS codes along with their appropriate places of service. Refer to the list located in the Applicable Codes section.

Oxford will not reimburse CPT and HCPCS codes assigned the Non-Facility

Indicator “NA” when reported without an appropriate POS.

According to the CMS National Physician Fee Schedule Relative Value File, the Non-Facility Indicator identified as “NA” indicates that “this procedure is rarely or never performed in the non-facility setting.” The website containing the National Physician Fee Schedule Relative Value File can be accessed via this link: CMS National Physician Fee Schedule. Relative Value File.

http://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html


Oxford



REVISED

Supply Policy

Feb. 1, 2020

Notice of Revision: The following

summary of changes has been modified. Revisions to the previous policy update announcement are outlined in red below. Please take

note of the additional updates to be applied on Feb. 1, 2020.

Reimbursement Guidelines • Updated language to clarify

place of service (POS) codes: o 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 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) • Replaced language indicating

“Oxford will not separately reimburse the HCPCS supply

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. 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 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


Oxford



REVISED

Supply Policy

(continued)

Feb. 1, 2020

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 array, epidural) because the electrodes are considered included in the

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

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. 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


Oxford



REVISED

Supply Policy

(continued)

Feb. 1, 2020 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 Codes; added HCPCS code A4226*

o Supply Facility J-Code Denial Codes; added HCPCS codes

J0179*, J0642, J9199*, and J9309*

o Supply DME Codes in a

Facility Setting; added HCPCS codes A4226*, B4187*, E0787*, E2398*, K1001*, K1002*, K1003*,

K1004*, K1005*, L2006*, L8033*, L8680, and P9099*

(*annual code edit)

Facility Setting). 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.

General Information

Oxford


Policy Update Classifications

New

New clinical coverage criteria and/or documentation review

requirements have been adopted for a health service (e.g., test, drug,

device or procedure)

Updated

An existing policy has been reviewed and changes have not been made

to the clinical coverage criteria or documentation review requirements;

however, items such as the clinical evidence, FDA information, and/or

list(s) of applicable codes may have been updated

Revised

An existing policy has been reviewed and revisions have been made to

the clinical coverage criteria and/or documentation review requirements

Replaced

An existing policy has been replaced with a new or different policy

Retired

The health service(s) addressed in the policy are no longer being

managed or are considered to be proven/medically necessary and are

therefore not excluded as unproven/not medically necessary services,

unless coverage guidelines or criteria are otherwise documented in

another policy

The inclusion of a health service (e.g., test, drug, device or procedure)

in this bulletin indicates only that UnitedHealthcare is adopting a new

policy and/or updated, revised, replaced or retired an existing policy;

it does not imply that Oxford® provides coverage for the health service.

Note that most benefit plan documents exclude from benefit coverage

health services identified as investigational or unproven/not medically

necessary. Physicians and other health care professionals may not seek

or collect payment from a member for services not covered by the

applicable benefit plan unless first obtaining the member’s written

consent, acknowledging that the service is not covered by the benefit

plan and that they will be billed directly for the service.

Note: The absence of a policy does not automatically indicate or imply

coverage. As always, coverage for a health service must be determined

in accordance with the member’s benefit plan and any applicable

federal or state regulatory requirements. Additionally, Oxford® reserves

the right to review the clinical evidence supporting the safety and

effectiveness of a medical technology prior to rendering a coverage

determination.

Oxford® respects the expertise of the physicians, health care

professionals, and their staff who participate in our network. Our goal is

to support you and your patients in making the most informed

decisions regarding the choice of quality and cost-effective care, and to

support practice staff with a simple and predictable administrative

experience. The Policy Update Bulletin was developed to share

important information regarding Oxford® Medical and Administrative

Policy updates. When information in this bulletin conflicts with

applicable state and/or federal law, Oxford® follows such applicable

federal and/or state law.

Tips for using the Policy Update Bulletin

• From the table of contents, click the policy title to be directed to the

corresponding policy update summary.

• From the policy updates table, click the policy title to view a

complete copy of a new, updated, or revised policy.

A complete library of Oxford Medical and Administrative Policies is available at OxfordHealth.com > Providers > Tools & Resources > Medical

Information > Medical and Administrative Policies or at UHCprovider.com > Policies and Protocols > Commercial Policies > UnitedHealthcare

Oxford Clinical, Administrative and Reimbursement Policies. Refer to the back of the member's health care ID card for the applicable website.

https://www.oxhp.com/secure/policy/medical_administrative_policy_index.html

https://www.oxhp.com/secure/policy/medical_administrative_policy_index.html

https://www.uhcprovider.com/

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