november 2015 policy update bulletin - oxhp · sonohysterogram or saline infusion ultrasound the...

UnitedHealthcare respects the expertise of the physicians, health care professionals, and their staff who participate in our network. Our goal is to

support you and your patients in making the most informed decisions regarding the choice of quality and cost-effective care, and to support practice

staff with a simple and predictable administrative experience. The Policy Update Bulletin was developed to share important information regarding

Oxford® Medical and Administrative Policy updates.*

*Where information in this bulletin conflicts with applicable state and/or federal law, Oxford® follows such applicable federal and/or state law

November 2015

policy update bulletin Medical & Administrative Policy Updates

Oxford

Oxford

2 Oxford® Policy Update Bulletin: November 2015

Oxford® Medical and Administrative Policy Updates

Overview

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.

Policy Update Classifications

New

New clinical coverage criteria and/or documentation review requirements

have been adopted for a service, procedure, test, or device

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 procedural codes and/or services previously outlined in the policy are

no longer being managed or are considered to be proven/medically

necessary and are therefore not excluded as unproven/not medically

necessary services, unless coverage guidelines or criteria are otherwise

documented in another policy

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

coverage. As always, coverage for a service or procedure must be

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

applicable federal or state regulatory requirements. Additionally,

UnitedHealthcare reserves the right to review the clinical evidence

supporting the safety and effectiveness of a medical technology prior to

rendering a coverage determination.

This bulletin provides complete details on Oxford® Medical and

Administrative Policy updates. The appearance of a service or

procedure in this bulletin indicates only that Oxford® has recently

adopted a new policy and/or updated, revised, replaced or

retired an existing policy; it does not imply that Oxford® provides

coverage for the service or procedure. In the event of an

inconsistency or conflict between the information provided in this

bulletin and the posted policy, the provisions of the posted policy

will prevail. Note that most benefit plan documents exclude from

benefit coverage health services identified as investigational or

unproven/not medically necessary. Physicians and other health

care professionals may not seek or collect payment from a

member for services not covered by the applicable benefit plan

unless first obtaining the member’s written consent,

acknowledging that the service is not covered by the benefit plan

and that they will be billed directly for the service.

A complete library of Oxford® Medical and Administrative

Policies is available at OxfordHealth.com > Providers >

Tools & Resources > Medical Information > Medical and

Administrative Policies.


Oxford


In This Issue

Clinical Policy Updates Page

NEW

Infertility Diagnosis and Treatment - Effective Dec. 1, 2015 ................................................................................................................................... 7

UPDATED

Cosmetic and Reconstructive Procedures - Effective Dec. 1, 2015 ........................................................................................................................... 9 Deep Brain Stimulation - Effective Dec. 1, 2015 ................................................................................................................................................. 10 Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation - Effective Dec. 1, 2015 ........................................................................... 12 Implanted Electrical Stimulator for Spinal Cord - Effective Dec. 1, 2015 ................................................................................................................ 14 Lyme Disease - Effective Nov. 1, 2015 .............................................................................................................................................................. 14 Maximum Dosage Policy - Effective Nov. 1, 2015 ................................................................................................................................................ 15 Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) - Effective Nov. 1, 2015 ....................................................................... 18 Neurophysiologic Testing - Effective Dec. 1, 2015 ............................................................................................................................................... 19 Obstructive Sleep Apnea Treatment - Effective Dec. 1, 2015 ................................................................................................................................ 22 Sensory Integration Therapy and Auditory Integration Training - Effective Nov. 1, 2015 .......................................................................................... 25 Vagus Nerve Stimulation - Effective Dec. 1, 2015 ............................................................................................................................................... 25 Visual Information Processing Evaluation and Orthoptic and Vision Therapy - Effective Nov. 1, 2015 ......................................................................... 27 Warming Therapy and Ultrasound Therapy for Wounds - Effective Nov. 1, 2015 ..................................................................................................... 28

REVISED

Autologous Chondrocyte Transplantation in the Knee - Effective Dec. 1, 2015 ........................................................................................................ 29 Diabetic Insulins - Effective Dec. 1, 2015 ........................................................................................................................................................... 30 Discogenic Pain Treatment - Effective Dec. 1, 2015 ............................................................................................................................................ 32 Drug Coverage Criteria - New and Therapeutic Equivalent Medications - Effective Dec. 1, 2015 ................................................................................ 33 Drug Coverage Guidelines - Effective Nov. 1, 2015 ............................................................................................................................................. 34

o Abilify (Aripiprazole) .................................................................................................................................................................................. 33 o Aplenzin (Bupropion) ................................................................................................................................................................................. 33 o Celexa (Citalopram) (Brand Only) ............................................................................................................................................................... 34 o Cymbalta (Duloxetine) (Brand Only) ............................................................................................................................................................ 34 o Effexor XR (Venlafaxine) (Brand Only) ......................................................................................................................................................... 34 o Forfivo XL (Bupropion HCL) ........................................................................................................................................................................ 34 o Lexapro (Escitalopram) (Brand Only) .......................................................................................................................................................... 34 o Pexeva (Paroxetine Mesylate) ..................................................................................................................................................................... 34 o Prozac (Fluoxetine) (Brand Only) ................................................................................................................................................................ 34 o Wellbutrin SR (Brand Only) (Bupropion) ...................................................................................................................................................... 34 o Wellbutrin XL (Bupropion Extended Release) ................................................................................................................................................ 34


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In This Issue

o Zoloft (Sertraline)(Brand Only) ................................................................................................................................................................... 34 Drug Coverage Guidelines - Effective Dec. 1, 2015 ............................................................................................................................................. 34

o Addyi (Flibanserin) .................................................................................................................................................................................... 34 o Afrezza (Insulin, Human) ........................................................................................................................................................................... 34 o Antagon (Ganirelix) ................................................................................................................................................................................... 35 o Berinert (C1 Esterase Inhibitor Human) ....................................................................................................................................................... 35 o Cetrotide (Cetrorelix Acetate) ..................................................................................................................................................................... 35 o Cetuximab (Erbitux) .................................................................................................................................................................................. 35 o Chorionic Gonadatropin ............................................................................................................................................................................. 35 o Cresemba (Isavuconazonium Sulfate) .......................................................................................................................................................... 36 o Crinone (Progesterone Gel) ........................................................................................................................................................................ 36 o Crinone 8% (Progesterone) ........................................................................................................................................................................ 36 o Daraprim (Pyrimethamine) ......................................................................................................................................................................... 36 o Darbepoetin Alfa (Aranesp) ........................................................................................................................................................................ 36 o Durlaza (Aspirin) ....................................................................................................................................................................................... 36 o Endometrin (Progesterone) ........................................................................................................................................................................ 37 o Entresto (Valsartan-Sacubitril) .................................................................................................................................................................... 37 o Envarsus XR (Tacrolimus) .......................................................................................................................................................................... 37 o Fertinex (Urofollitropin) ............................................................................................................................................................................. 37 o First Progesterone (Progestin) .................................................................................................................................................................... 37 o Fortamet (Metformin Extended-Release) ...................................................................................................................................................... 38 o Glumetza (Metformin Extended-Release) ..................................................................................................................................................... 38 o HCG (Chorionic Gonadotropin) .................................................................................................................................................................... 39 o Humegon (Menotropins) ............................................................................................................................................................................ 39 o Insulins (Novolin 70/30, Novolog Pens and Vials, Novolog Mix 70/30 Pens and Vials, Apidra, Apidra Solostar, Novolin N, Novolin R) ....................... 40 o Keveyis (Dichlorphenamide) ....................................................................................................................................................................... 40 o Leuprolide Acetate (Subcutaneous) (Eligard), 1mg/0.2ml ............................................................................................................................... 40 o Lupron, Lupron-3, Lupron-4, Lupron Depot, Lupron Implant (Leuprolide Acetate) ............................................................................................. 40 o Menopur (Menotropins) .............................................................................................................................................................................. 40 o Metrodin (Urofollitropin)............................................................................................................................................................................. 40 o Novarel (Chorionic Gonadotropin) ............................................................................................................................................................... 41 o Ovidrel (Chorionic Gonadotropin) ................................................................................................................................................................ 41 o Oxaydo (Oxycodone HCL) .......................................................................................................................................................................... 41 o Pergonal (Menotropins) .............................................................................................................................................................................. 41 o Pregnyl (Chorionic Gonadotropin)................................................................................................................................................................ 42 o Prochieve (Progesterone Gel) ..................................................................................................................................................................... 42 o Profasi (Chorionic Gonadotropin) ................................................................................................................................................................. 42 o Puregon (Follitropin Beta) .......................................................................................................................................................................... 43 o Repronex (Menotropins) ............................................................................................................................................................................ 43 o Tolak 4% Cream (Fluorouracil) ................................................................................................................................................................... 43


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In This Issue

o Zohydro ER (Hydrocodone Bitartrate Extended Release) ................................................................................................................................ 43 Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines - Effective Feb. 1, 2016 ................................................................. 44 Osteochondral Grafting of Knee - Effective Dec. 1, 2015 ...................................................................................................................................... 48 Select Brand Medications - Effective Nov. 1, 2015 .............................................................................................................................................. 51 Standing Systems and Gait Trainers - Effective Dec. 1, 2015 ............................................................................................................................... 51

RETIRED/REPLACED

Diagnostic (Basic) Procedures for Infertility - Effective Dec. 1, 2015 ..................................................................................................................... 55 Entresto (Valsartan-Sacubitril) - Effective Nov. 1, 2015 ....................................................................................................................................... 55 Infertility Procedures Requiring Notification and/or Precertification - Effective Dec. 1, 2015 ..................................................................................... 55 Treatment of Infertility - Effective Dec. 1, 2015 .................................................................................................................................................. 55 Treatment of Infertility for Connecticut Groups - Effective Dec. 1, 2015 ................................................................................................................ 55 Treatment of Infertility for New Jersey Large Groups - Effective Dec. 1, 2015 ........................................................................................................ 55 Treatment of Infertility for New Jersey Small Groups and New Jersey Individual Plans - Effective Dec. 1, 2015 .......................................................... 56 Treatment of Infertility for New York Large and Small Groups - Effective Dec. 1, 2015 ............................................................................................ 56

Administrative Policy Updates

UPDATED

Speech Therapy and Early Intervention Programs/Birth to Three - Effective Nov. 1, 2015 ........................................................................................ 57

REVISED

Par Gastroenterologists Using Non-Par Anesthesiologists in Office Settings - Effective Dec. 1, 2015 .......................................................................... 57

Reimbursement Policy Updates

UPDATED

Assistant Surgeon - Effective Nov. 1, 2015 ........................................................................................................................................................ 60 B Bundle Codes - Effective Dec. 1, 2015 .................................................................................................................. Error! Bookmark not defined. Bilateral Procedures - Effective Dec. 1, 2015 ...................................................................................................................................................... 63 Co-Surgeons; Team Surgeon - Effective Dec. 1, 2015 ......................................................................................................................................... 66 Discontinued Procedures - Effective Dec. 1, 2015 ............................................................................................................................................... 68 Durable Medical Equipment, Orthotics and Prosthetics Multiple Frequency - Effective Dec. 1, 2015 ........................................................................... 69 Increased Procedural Services - Effective Dec. 1, 2015........................................................................................................................................ 73 Injection and Infusion Services - Effective Dec. 1, 2015 ...................................................................................................................................... 74 Microsurgery - Effective Dec. 1, 2015 ................................................................................................................................................................ 76 Modifier Reference - Effective Dec. 1, 2015 ........................................................................................................................................................ 77


Oxford


In This Issue

One or More Sessions - Effective Dec. 1, 2015 ................................................................................................................................................... 77 Preventive Medicine and Screening - Effective Dec. 1, 2015 ................................................................................................................................. 79 Prolonged Services - Effective Dec. 1, 2015 ....................................................................................................................................................... 79 Reduced Services - Effective Dec. 1, 2015 ......................................................................................................................................................... 80 Robotic-Assisted Surgery - Effective Dec. 1, 2015............................................................................................................................................... 81 Same Day/Same Service - Effective Dec. 1, 2015 ............................................................................................................................................... 81 Split Surgical Package - Effective Dec. 1, 2015 ................................................................................................................................................... 85 Standby Services - Effective Dec. 1, 2015 ......................................................................................................................................................... 85 Supply Policy - Effective Dec. 1, 2015 ............................................................................................................................................................... 86 T Status Codes - Effective Dec. 1, 2015 ............................................................................................................................................................. 89 Telemedicine - Effective Dec. 1, 2015 ............................................................................................................................................................... 89 Urgent Care - Effective Dec. 1, 2015 ....................................................................................................................... Error! Bookmark not defined.

REVISED

Maximum Frequency Per Day - Effective Dec. 1, 2015 ......................................................................................................................................... 91 Moderate Sedation - Effective Dec. 1, 2015 ....................................................................................................................................................... 96


Oxford

Clinical Policy Updates

NEW

Policy Title Effective Date Coverage Rationale

Infertility Diagnosis and Treatment

Dec. 1, 2015

Diagnostic Procedures

Females The following tests or procedures are proven and medically necessary for diagnosing infertility in female patients: Antral follicle count

Clomiphene citrate challenge test The following hormone level tests:

o Antimüllerian hormone (AMH) o Estradiol o Follicle-stimulating hormone (FSH) o Luteinizing hormone (LH) o Progesterone o Prolactin

o Thyroid-stimulating hormone (TSH) Hysterosalpingogram (HSG) Diagnostic hysteroscopy Diagnostic laparoscopy with or without chromotubation

Pelvic ultrasound (transabdominal or transvaginal) Sonohysterogram or saline infusion ultrasound

The following tests are unproven and not medically necessary for diagnosing infertility in female patients: Inhibin B Uterine/endometrial receptivity testing (e.g., E-tegrity® and Endometrial Function Test® (EFT®)) There is insufficient evidence to permit conclusions regarding the use of these tests. More studies are needed to support improved outcomes (i.e., increased successful pregnancies with delivery of liveborn children) with use of

these diagnostic tests.

Males The following tests or procedures are proven and medically necessary for diagnosing infertility in male patients: Antisperm antibodies

The following genetic screening tests: o Cystic fibrosis gene mutations o Karyotyping for chromosomal abnormalities o Y-chromosome microdeletions testing

The following hormone level tests:


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NEW


Infertility Diagnosis and Treatment (continued)

Dec. 1, 2015

o LH o FSH o prolactin o testosterone (total and free)

Leukocyte count in semen

Post-ejaculatory urinalysis

Scrotal, testicular or transrectal ultrasound Semen analysis Testicular biopsy Vasography The following tests are unproven and not medically necessary for diagnosing infertility in male patients:

Computer-assisted sperm analysis (CASA) Hyaluronan binding assay (HBA) Postcoital cervical mucus penetration test Reactive oxygen species (ROS) test Sperm acrosome reaction test Sperm DNA integrity/fragmentation tests (e.g. sperm chromatin structure assay (SCSA), single-cell gel

electrophoresis assay (Comet), deoxynucleotidyl transferase-mediated dUTP nick end labeling assay (TUNEL),

sperm chromatin dispersion (SCD) or Sperm DNA Decondensation™ Test (SDD)) Sperm penetration assays There is insufficient evidence to permit conclusions regarding the use of these tests. More studies are needed to support improved outcomes (i.e., increased successful pregnancies with delivery of liveborn children) with use of these diagnostic tests.

Therapeutic Procedures

For medical necessity reviews, refer to the Optum Infertility Clinical Performance Guideline.

The following procedures are unproven and not medically necessary for treating infertility: Co-culture of embryos EmbryoGlue® In vitro maturation (IVM) of oocytes

Studies describe different techniques of co-culture of embryos, but no standardized method of co-culturing has been defined. The use of co-cultures may improve blastocyst development but may not result in an improved pregnancy or delivery rate.


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NEW


Infertility Diagnosis and Treatment (continued)

Dec. 1, 2015 There is inadequate published scientific data to permit conclusions regarding the use of EmbryoGlue. Although preliminary results with IVM are promising, studies to date show that implantation and pregnancy rates are significantly lower than those achieved with standard IVF. Further evidence from well-designed trials is needed to determine the long-term safety and efficacy of the procedure.

Cryopreservation Cryopreservation of sperm, semen or embryos is proven and medically necessary for individuals who are undergoing treatment with assisted reproductive technologies or are planning to undergo therapies that threaten their reproductive health, such as cancer chemotherapy.

Cryopreservation of mature oocytes (eggs) is proven and medically necessary for women, under the age of 42, who are undergoing treatment with assisted reproductive technologies or are planning to undergo therapies that threaten their reproductive health, such as cancer chemotherapy. Cryopreservation of immature oocytes (eggs) is unproven and not medically necessary. Further evidence from well-designed trials is needed to determine the long-term safety and efficacy of

cryopreserving immature oocytes for future in vitro maturation.

Cryopreservation of ovarian or testicular tissue is unproven and not medically necessary. Ovarian tissue banking remains a promising clinical technique because it avoids ovarian stimulation and provides the opportunity for preserving gonadal function in prepubertal, as well as adult patients. However, this procedure has produced very few live births.

Testicular tissue or testis xenografting are in the early phases of experimentation and have not yet been successfully tested in humans.

UPDATED

Policy Title Effective Date Summary of Changes Coverage Rationale

Cosmetic and Reconstructive

Procedures

Dec. 1, 2015

Updated list of applicable CPT codes; removed 40500 and 69320

Indications for Coverage Criteria for a procedure to be considered as reconstructive and

medically necessary: 1. There is documentation that the physical abnormality and/or physiological

abnormality is causing a functional impairment that requires correction. 2. The proposed treatment is of proven efficacy; and is deemed likely to

significantly improve or restore the patient’s physiological function.


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UPDATED


Cosmetic and Reconstructive Procedures (continued)

Dec. 1, 2015 Coverage Limitations and Exclusions Some states require benefit coverage for services that Oxford considers cosmetic procedures, such as repair of external congenital anomalies in the absence of a functional impairment. Please refer to enrollee’s plan specific documents.

1. Cosmetic surgery, plastic or reconstructive surgery which is performed

primarily to improve the appearance of any portion of the body including but not limited to: surgery for sagging of extra skin; any augmentation or reduction procedure (e.g., mammoplasty); liposuction; keloids; rhinoplasty and associated surgery. Complications of such surgeries are covered only if they are medically necessary and are otherwise covered. Remedial work is not covered. This also applies to services or supplies

deemed cosmetic even if changing or improving an individual's appearance is justified by the individual's mental health needs.

2. Cosmetic surgery does not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or diseases of the involved part, and reconstructive surgery because of

congenital disease or anomaly of a Covered Dependent child which has resulted in a functional defect.

Deep Brain Stimulation

Dec. 1, 2015

Updated list of applicable HCPCS codes; removed L8681 and L8689

Deep brain stimulation is considered to be proven and medically necessary for treating the following: Idiopathic Parkinson's disease when used according to U.S. Food and Drug

Administration (FDA) indications. Essential tremor when used according to U.S. Food and Drug

Administration (FDA) indications.

Primary dystonia* (occurs apart from any other identifiable illness), including generalized and/or segmental dystonia, hemidystonia and cervical dystonia (torticollis) when used according to U.S. Food and Drug Administration (FDA) indications.

*Primary dystonia may include genetic torsion dystonia, acquired torsion dystonia (not due to drugs), spasmodic torticollis, fragments of torsion

dystonia, and unspecified torticollis. Deep brain stimulation is unproven and not medically necessary for treating secondary Parkinsonism (result of head trauma, metabolic conditions, toxicity, drugs or other medical disorders. Well-designed studies demonstrating the efficacy of deep brain stimulation


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UPDATED


Deep Brain Stimulation (continued)

Dec. 1, 2015 for treating secondary Parkinsonism are not available. Clinical trials are needed to demonstrate the benefit of deep brain stimulation for this patient population. Deep brain stimulation is unproven and not medically necessary for

treating secondary dystonia (occurs with illness, after trauma or

following exposure to certain medications or toxins). There is inadequate evidence of the safety and efficacy of deep brain stimulation for treating secondary dystonia. Questions remain with regard to patient selection criteria and long-term benefits and safety compared with standard treatments. Formal comparisons, with large randomized controlled or comparative trials of pallidotomy, thalamotomy, and deep brain

stimulation, are required before conclusions can be drawn regarding the use of deep brain stimulation for patients with secondary dystonia. Deep brain stimulation is unproven and not medically necessary for treating conditions other than those listed as medically necessary. This includes but is not limited to the following diagnoses:

Depression

Obsessive-compulsive disorder (OCD) Epilepsy Tourette syndrome Cluster headache Impulsive or violent behavior Chronic pain

Trigeminal neuralgia Movement disorders caused by multiple sclerosis (MS) Some studies have examined the use of deep brain stimulation for treating

major depression, obsessive-compulsive disorder (OCD), epilepsy, Tourette syndrome, cluster headache, impulsive or violent behavior, stroke pain, chronic pain, phantom limb pain, trigeminal neuralgia and movement

disorders of multiple sclerosis (MS). However, because of limited studies, small sample sizes, weak study designs and heterogenous patient characteristics, there is insufficient data to conclude that deep brain stimulation is safe and/or effective for treating these indications.


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UPDATED


Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation

Dec. 1, 2015

Updated list of applicable HCPCS codes; removed L8681 and L8689

Functional electrical stimulation (FES), a form of neuromuscular electrical stimulation is proven and medically necessary for rehabilitation in persons with paralyzed lower limbs due to spinal cord injury (SCI) with ALL of the following characteristics: Intact lower motor units (L1 and below) (both muscle and peripheral

nerves);

Muscle and joint stability for weight bearing at upper and lower extremities that can demonstrate balance and control to maintain an upright support posture independently;

Demonstrate brisk muscle contraction to NMES and have sensory perception of electrical stimulation sufficient for muscle contraction;

Possess high motivation, commitment and cognitive ability to use such

devices for walking; Able to transfer independently and can demonstrate independent standing

tolerance for at least 3 minutes; Demonstrate hand and finger function to manipulate controls; Post recovery from spinal cord injury and restorative surgery of at least 6

months;

No hip and knee degenerative disease and no history of long bone fracture

secondary to osteoporosis. Functional electrical stimulation is unproven and not medically necessary for the treatment of disuse muscle atrophy in persons with spinal cord injury (who do not meet the requirements above) or multiple sclerosis.

Further studies are needed to confirm that functional electrical stimulation promotes bone remineralization and prevents or reverses muscle atrophy. Only a few studies have looked at FES as a modality of treatment of multiple

sclerosis, and the results are limited and conflicting regarding whether FES improves treatment outcomes in multiple sclerosis when offered in addition to other rehabilitative treatment modalities.

Functional electrical stimulation is unproven and not medically necessary for the treatment of gait disorders (e.g., foot drop) of central neurologic origin including but not limited to stroke or multiple sclerosis. There is insufficient evidence in the peer reviewed literature that use of


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UPDATED



(continued)

Dec. 1, 2015

functional electrical stimulation will improve health outcomes in patients with gait disorders. Published studies have included small heterogeneous patient populations, short-term follow-ups, and various treatment protocols, outcome measure, and FES devices. Only a few studies have looked at FES as a modality of treatment of multiple sclerosis, and the results are limited

and conflicting regarding whether FES improves treatment outcomes in

multiple sclerosis when offered in addition to other rehabilitative treatment modalities. Neuromuscular electrical stimulation (NMES) is proven and medically necessary for: a. Treatment of disuse muscle atrophy if:

o The nerve supply to the muscle is intact; and o The disuse muscle atrophy is not of neurological origin but originates

from conditions such as casting, splinting or contractures; or b. Treatment to improve wrist and finger function and prevent or correct

shoulder subluxation in persons with partial paralysis following stroke.

Neuromuscular electrical stimulation (NMES) is unproven and not

medically necessary for the treatment of neurologic, orthopedic (e.g., scoliosis) or other abnormalities including pain not listed as proven and medically necessary. Additionally, there is insufficient evidence for NMES for all other indications.

There is insufficient evidence in the peer reviewed literature that use of electrical stimulation will improve health outcomes for the treatment of neurologic or orthopedic conditions other than those identified above as proven. Randomized, controlled trials are necessary to assess the durability

of this procedure in comparison to other types of treatment. Interferential therapy (IFT) is unproven and not medically necessary

for the treatment of musculoskeletal disorders or injuries, or stimulating healing of nonsurgical soft tissue injuries. Interferential therapy is unproven and not medically necessary to facilitate the healing of bone fractures. There is insufficient evidence from the available studies to conclude that interferential therapy promotes healing of bone fractures. None of the double-blind, randomized, placebo-controlled studies reported a positive


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UPDATED



(continued)

Dec. 1, 2015 treatment effect of interferential therapy for bone fractures. Pulsed electrical stimulation (PES) is unproven and not medically necessary for the treatment of osteoarthritis. There is insufficient evidence to conclude that PES provides health benefits to

patients with osteoarthritis. Randomized, controlled trials are necessary to

assess the durability of this procedure in comparison to other types of treatment. Peripheral subcutaneous field stimulation (PSFS) or peripheral nerve field stimulation (PNFS) is unproven and not medically necessary for the treatment of pain.

Evidence for the effectiveness of PSFS or PNFS based on controlled studies is lacking. Randomized controlled trials are needed to evaluate the efficacy of this treatment.

Implanted Electrical

Stimulator for Spinal Cord

Dec. 1, 2015 Reorganized policy content Updated list of applicable

CPT/HCPCS codes; removed L8681 and L8689

For information regarding medical necessity review, when applicable, see MCG™ Care Guidelines, 19th edition, 2015, MCG: Implanted Electrical

Stimulator, Spinal Cord. ACG: A-0243 (AC).

Lyme Disease

Nov. 1, 2015

Updated supporting information to reflect the most current clinical evidence and references; no change to coverage rationale or

list of applicable codes

The use of parenteral antibiotics, such as ceftriaxone, cefotaxime or penicillin G, for a period up to 4 weeks is proven and medically necessary for treating Lyme disease.

The use of parenteral antibiotics beyond 4 weeks is not medically necessary and unproven for treating Lyme disease. Available evidence suggests that prolonged use of parenteral antibiotics does not improve treatment outcomes and is associated with an increased incidence of adverse events.

Additional Information

Patients with objective signs of relapse, after receiving recommended antibiotic therapy, may need a second course of treatment. Experts recommend waiting several months before initiating retreatment because of the anticipated slow resolution of inflammation after treatment. Retreatment with parenteral antibiotics is not recommended except in patients with late neurologic disease. Multiple, repeated courses of antimicrobials for the same

episode of Lyme disease are not recommended (Wormser et al., 2006;


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UPDATED


Lyme Disease (continued)

Nov. 1, 2015 reviewed and deemed current as of 10/2011). If patients have no resolution of arthritis after completion of a course of antibiotics, and if polymerase chain reaction (PCR) results for a sample of synovial fluid or tissue are negative for B. burgdorferi nucleic acids,

symptomatic treatment is recommended. Symptomatic therapy might

consist of nonsteroidal anti-inflammatory agents (NSAIDS), intra-articular injections of corticosteroids or disease-modifying antirheumatic drugs (DMARDs), such as hydroxychloroquine (Wormser et al., 2006 deemed current 2011). Exception for Connecticut Commercial Members: Precertification is not

required for the use of parenteral antibiotics, regardless of treatment length/timeframe, when referred or recommended by a board certified rheumatologist, infectious disease specialist and/or neurologist. (CT Ins. Code 38A-518H and 38A-492H)

Maximum Dosage

Policy

Nov. 1, 2015

Updated coverage rationale:

o Clarified J Code Based Maximum Dosage Information; added “Zoledronic Acid” (with corresponding dosing information) to list of applicable brand name medications

This policy provides information about the maximum dosage per

administration for certain specialty pharmacy medications administered by a medical professional. Note: This policy does not apply to services provided in the home setting. Drug Products: Bevacizumab (Avastin®)

Infliximab (Remicade®) Pegfilgrastim (Neulasta®) Rituximab (Rituxan®) Trastuzumab (Herceptin®) Zoledronic acid (zoledronic acid, Reclast® and Zometa®)

Most medications have a maximum dosage based upon body surface

area or patient weight or a set maximal dosage independent of patient body size, and are proven when used according to labeled indications or when otherwise supported by published clinical evidence. The medications included in this policy when given beyond maximum dosages based upon body surface area or patient weight or a set maximal dosage independent of patient body size are not

supported by package labeling or published clinical evidence and are


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UPDATED


Maximum Dosage Policy (continued)

Nov. 1, 2015

not medically necessary. J Code Based Maximum Dosage Information:

Medication Name Maximum Dosage Per

Administration

J

Code

Maximum

Allowed Brand Generic

Avastin bevacizumab 15 mg/kg J9035

179 HCPCS units (10 mg per

unit)

Herceptin trastuzumab 8 mg/kg J9355 95 HCPCS units (10 mg per unit)

Neulasta pegfilgrastim 6 mg total dose J2505 1 HCPCS unit (6 mg per unit)

Reclast

zoledronic acid

5 mg total dose

J3489 5 HCPCS units (1 mg per unit)

Zoledronic Acid

5 mg total dose

Zometa 4 mg total dose

Zoledronic Acid

4 mg total dose

Remicade infliximab 10 mg/kg J1745

119 HCPCS units (10 mg per unit)

Rituxan rituximab 1,225 mg total

dose J9310

13 HCPCS units

(100 mg per unit)

Maximum Allowed Quantities for National Drug Code (NDC) Billing: This information only applies to select providers billing medical claims by National Drug Code (NDC). The allowed quantities in this section are

calculated based upon both the maximum dosage information supplied within this policy as well as the process by which NDC claims are billed. This list may not be inclusive of all available NDC’s for each drug product and is subject to change.


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UPDATED



Nov. 1, 2015

Medication Name How Supplied

National Drug Code

Maximum Allowed Brand Generic

Avastin Bevacizumab 100 mg/4mL solution in

vials

50242-0060-01 72 mL

Avastin Bevacizumab 400 mg/16 mL solution

in vials 50242-0061-01 72 mL

Herceptin trastuzumab

440 mg

powder for reconstitution

50242-0056-56 3 vials

Herceptin trastuzumab 440 mg


50242-0134-68 3 vials

Neulasta pegfilgrastim 6 mg/0.6 mL

prefilled syringe

54868-5229-00 0.6 mL

Neulasta pegfilgrastim 6 mg/0.6 mL

prefilled

syringe

55513-0190-01 0.6 mL

Neulasta pegfilgrastim

6 mg/0.6 mL prefilled

syringe with on-body

Injector

55513-0190-01 0.6 mL

Reclast zoledronic

acid

5 mg/100 mL solution in

vials 00078-0435-61 100 mL

Reclast zoledronic

acid

5 mg/100 mL

solution in vials

35356-0351-01 100 mL

Remicade infliximab 100 mg


57894-0030-01 12 vials

Rituxan rituximab 100 mg/10 mL solution

in vials 50242-0051-21 130 mL


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UPDATED



Nov. 1, 2015 Rituxan rituximab

500 mg/50 mL solution

in vials 50242-0053-06 130 mL

zoledronic

acid

zoledronic

acid


vials

25021-0830-82 42023-0163-01 43598-0331-11

23155-0186-31 55111-0688-52

100 mL

zoledronic acid

zoledronic acid


vials

00143-9642-01

47335-0035-40 25021-0801-66 42023-0151-01 43598-0330-11 53150-0871-01 23155-0170-31

55111-0685-07 60505-6110-00

45963-0440-55

5 mL

zoledronic acid

zoledronic acid

4 mg/5 ml lyophilisate for solution

for injection in vials

47335-0962-41 5 mL

zoledronic acid

zoledronic acid


vials 25021-0826-82 100 mL

Zometa zoledronic

acid


vials 00078-0387-25 5 mL

Zometa zoledronic

acid


vials

00078-0590-61 100 mL

Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD)

Nov. 1, 2015

Updated supporting information to reflect the most current clinical evidence, FDA information and references; no change to coverage rationale or list of applicable codes

Due to insufficient evidence to support medical efficacy, endoscopic therapies for the treatment of gastroesophageal reflux disease (GERD) will not be reimbursed by Oxford. Endoscopic therapies are unproven and not medically necessary for

the treatment of gastroesophageal reflux disease (GERD).


Oxford


UPDATED


Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD)

(continued)

Nov. 1, 2015

Examples include, but are not limited to: 1. Radiofrequency energy

o Stretta System

2. Endoscopic plication suturing o Bard EndoCinch Endoscopic Suturing System

o Endoscopic Suturing Device (ESD) o Surgical Endoscopic Plication System (EPS) o EsophyX™ System with SerosaFuse™ Fastener (transoral incisionless

fundoplication procedure) 3. Injection or implantation techniques

o Gatekeeper Reflux Repair System o Plexiglas (polymethylmethacrylate [PMMA]) procedure o Durasphere

The safety and efficacy of endoscopic therapies for the treatment of GERD have not been established in the published medical literature. Current studies are generally of small to moderate size, lack adequate control or

comparison groups, and provide only short-term follow-up. Further well-designed clinical trials with long-term follow up are required to establish that endoscopic therapies benefit health outcomes in patients with GERD by eliminating symptoms, preventing recurrence of symptoms or progression of disease, healing esophagitis, and reducing the need for pharmacologic therapy.

The LINX™ Reflux Management System is unproven and not medically necessary for the treatment of GERD. The safety and efficacy of this system has not been established in the peer-reviewed medical literature. Available studies are hampered by a number of limitations, including small study size, lack of statistical power, lack of controls or

comparators, and lack of long-term follow-up.

Note: Refer to policy: Bariatric Surgery for information regarding transoral endoscopic surgery (such as transoral gastroplasty [TOGA®], StomaphyX, and Restorative Obesity Surgery, Endoluminal [ROSE] procedure) for the treatment of obesity.

Neurophysiologic

Testing

Dec. 1, 2015

Updated coverage rationale:

o Reorganized coverage criteria for nerve conduction studies;

Electromyography (EMG)

Surface electromyography (SEMG) is unproven and not medically necessary. There is limited and insufficient evidence to support the use of


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UPDATED


Neurophysiologic Testing (continued)

Dec. 1, 2015

added language to clarify both of the noted criterion must be met

o Added language to clarify policy does not address intraoperative

neurophysiologic testing

Updated supporting information to reflect the most current clinical evidence, FDA information and references

SEMG. Studies varied considerably in SEMG instrumentation, SEMG protocol, and diagnostic algorithm. Depending on the study's SEMG approach, diagnostic performance ranged from poor to fair. Further research is needed to standardize SEMG approaches and diagnostic algorithms, increase diagnostic performance, and to assess the role of SEMG in clinical practice.

Macroelectromyography (macro-EMG) testing is unproven and not medically necessary. There is limited and insufficient evidence to support the use of macro-EMG. Additional studies are needed to establish how this test improves diagnostic capabilities and physician decision-making. Nerve Conduction Studies

Nerve conduction studies with or without late responses (e.g., F-wave and H-reflex tests) are proven and medically necessary when BOTH of the following criteria are met: One of the following disorders is known or suspected: o Peripheral nerve entrapment syndromes o Generalized neuropathies

o Hereditary, metabolic, or degenerative polyneuropathy

o Plexopathy (acquired disorder in tissue along nerves that causes motor and sensory dysfunction)

o Neuromuscular junction disorders o Myopathies o Motor neuron disease o Spine disorder with nerve root impingement symptoms

o Cervical, thoracic, and/or lumbosacral radiculopathy o Guidance for botulinum toxin injection for spasmodic dysphonia or

segmental dystonia when it is difficult to isolate affected muscles o Traumatic nerve lesions

and Nerve conduction studies are performed in conjunction with needle

electromyography EXCEPT for any of the following situations:

o Patients treated with anticoagulants; or o Patients with lymphedema; or o Patients being evaluated for carpal tunnel syndrome

The American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) states that it is in the best interest of patients, in the majority of situations, for the needle EMG and the NCS examination to be conducted and


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UPDATED



Dec. 1, 2015

interpreted on-site in real time. According to the AANEM, the use of the term “real time” with regard to nerve conduction studies indicates that information from the history and physical examinations are integrated, the specific and tailored electrodiagnostic (EDX) study is performed, and the analysis of the waveforms are all done at the same time and while the patient is present in

the EDX laboratory (AANEM, Proper Performance and Interpretation of

Electrodiagnostic Studies, 2014). Nerve conduction studies are considered unproven and not medically necessary for all conditions other than those listed above as medically necessary. There is limited and insufficient evidence to conclude that nerve conduction studies are beneficial for health outcomes in patients

with disorders other than those listed above as medically necessary. Non-invasive automatic or portable nerve conduction monitoring systems that test only distal motor latencies and conduction velocities are considered unproven and not medically necessary for the purpose of electrodiagnostic testing.

Studies of these devices are primarily small case series comparing portable

with conventional nerve conduction studies in the same patient. Studies that did use controls did not always report the patients' conditions. Large, robust randomized, controlled studies are needed to prove the safety and efficacy of this technology. Physiologic Recording of Tremor

Physiologic recording of tremor using accelerometers and is unproven and not medically necessary. There is insufficient evidence and too few studies to conclude that these devices improve therapeutic responses for the purpose of decreasing tremor

in patients with tremor. Well-designed controlled studies are needed to determine the usefulness of these devices.

Quantitative Sensory Testing Quantitative sensory testing, including monofilament testing, pressure-specified sensory testing, computer assisted sensory examinations, and current perception threshold (CPT) testing for the diagnosis and evaluation of nervous system disorders is unproven and not medically necessary.


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UPDATED



Dec. 1, 2015 Definitive conclusions for current perception threshold (CPT) testing cannot be drawn due to evidence that is inconsistent. Furthermore, in the absence of other testing, CPT tests do not include sensory nerve conduction amplitudes or other critical data to reach conclusions on diagnoses. Further research is needed to validate the clinical utility of pressure-specified sensory

testing.

This policy does not address intraoperative neurophysiologic testing.

Obstructive Sleep Apnea Treatment

Dec. 1, 2015

Updated list of applicable HCPCS codes; removed L8681

Removed lists of applicable ICD-9

& ICD-10 diagnosis codes

Nonsurgical Treatment

Removable oral appliances are proven and medically necessary for treating obstructive sleep apnea (OSA) as documented by polysomnography. Refer to policy titled Attended Polysomnography for Evaluation of Sleep Disorders for further information. For information regarding medical necessity review, when applicable, see MCG™ Care Guidelines, 19th edition, 2015, Oral Appliances (Mandibular

Advancement Devices), A-0341 (ACG).

Removable oral appliances are unproven and not medically necessary for treating central sleep apnea. This type of sleep apnea is caused by impaired neurological function, and these devices are designed to manage physical obstructions.

Nasal dilator devices are unproven and not medically necessary for treating obstructive sleep apnea (OSA). There is insufficient clinical evidence supporting the safety and efficacy of nasal dilators for treating OSA. Results from available studies indicate that therapeutic response is variable among the participants. Further research from larger, well-designed studies is needed to evaluate the effectiveness of

the device compared with established treatments for OSA, to determine its long-term effectiveness and to determine which patients would benefit from this therapy. Surgical Treatment

The following surgical procedures are proven and medically necessary for treating obstructive sleep apnea as documented by polysomnography. Refer to policy titled Attended Polysomnography for Evaluation of Sleep Disorders for further information. Also see the Definitions


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UPDATED


Obstructive Sleep Apnea Treatment (continued)

Dec. 1, 2015

section below for information on the definitions and severity of OSA. Uvulopalatopharyngoplasty (UPPP)

For information regarding medical necessity review, when applicable, see MCG™ Care Guidelines, 18th edition, 2014, Uvulopalatopharyngoplasty

(UPPP), A-0245 (ACG).

Maxillomandibular advancement surgery (MMA) For information regarding medical necessity review, when applicable, see

MCG™ Care Guidelines, 18th edition, 2014, Maxillomandibular Osteotomy and Advancement, A-0248 (ACG).

Multilevel procedures whether done in a single surgery or phased multiple surgeries. There are a variety of procedure combinations, including mandibular osteotomy and genioglossal advancement with hyoid myotomy (GAHM). For information regarding medical necessity review, when applicable, see MCG™ Care Guidelines, 18th edition, 2014, Mandibular Osteotomy, A-0247 (ACG).

Radiofrequency ablation of the soft palate and/or tongue base is proven and medically necessary for treating mild to moderate obstructive sleep apnea as documented by polysomnography. Refer to policy Attended Polysomnography for Evaluation of Sleep Disorders for further information. In addition to the criteria listed above, radiofrequency ablation of the soft palate and/or tongue base is medically necessary for

patients who fail to improve with or cannot tolerate an adequate trial of continuous positive airway pressure (CPAP) or another device, including bi-level positive airway pressure (BiPAP), auto-titrating positive airway pressure (APAP) and/or oral appliances.

The following surgical procedures are unproven and not medically necessary for treating obstructive sleep apnea:

Laser-assisted uvulopalatoplasty (LAUP) Palatal implants Lingual suspension - also referred to as tongue stabilization, tongue stitch

or tongue fixation Transoral robotic surgery (TORS) Implantable hypoglossal nerve stimulation

There is insufficient evidence to conclude that laser-assisted


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UPDATED


Obstructive Sleep Apnea Treatment (continued)

Dec. 1, 2015

uvulopalatoplasty (LAUP) results in improved apnea-hypopnea index (AHI) or secondary outcomes. Some studies saw a worsening of symptoms as well as increased complications. Results of studies provide preliminary but inconsistent evidence that palatal

implants benefit patients with mild to moderate OSA. However, the

magnitude of the benefits has been small; the largest randomized controlled trial (RCT) found that average OSA worsened in spite of treatment; and the available studies involved ≤ 1 year of patient monitoring after treatment. Additional studies are needed to determine the role of palatal implants in the management of OSA.

There is insufficient evidence to support the safety, efficacy and long-term outcomes of lingual suspension in the treatment of OSA. The published peer-reviewed medical literature includes a few small, uncontrolled studies with short-term follow-up. Large, controlled studies, with long-term follow-up, comparing lingual suspension to established procedures are necessary.

There is insufficient evidence to support the safety, efficacy and long-term

outcomes of transoral robotic surgery (TORS) in the treatment of OSA. Large, controlled studies, with long-term follow-up, comparing TORS to established procedures are necessary. There is insufficient evidence to support the safety, efficacy and long-term outcomes of hypoglossal nerve stimulation in the treatment of OSA. The

optimal patient selection criteria for the use of hypoglossal nerve stimulation have not been defined. Randomized controlled trials or comparative effectiveness trials with long-term follow-up, comparing hypoglossal nerve stimulation to established procedures are necessary to evaluate the

effectiveness of this technology. Follow-up polysomnography should be performed following surgery to

evaluate response to treatment (Kushida et al., 2006; Ferguson et al., 2006). Refer to policy Attended Polysomnography for Evaluation of Sleep Disorders for further information.


Oxford


UPDATED


Sensory Integration Therapy and Auditory Integration

Training

Nov. 1, 2015

Routine review; no change to non-coverage rationale or list of applicable codes

Sensory integration therapy is unproven and not medically necessary for the treatment of any condition including the following: Learning disabilities Developmental delay Sensory integration disorder

Autism spectrum disorder

Cerebrovascular accident Speech disturbances Lack of coordination Abnormality of gait

The available studies of sensory integration therapy are weak and inconclusive and derived primarily from poorly controlled trials with methodological flaws. These trials fail to demonstrate that sensory integration therapy provides long-term improvement in neurological

development and behavioral development. There is no reliable data from well-designed clinical studies that indicate that sensory integration therapy improves clinical outcomes in patient with cerebrovascular accidents, speech

disturbances, gait abnormalities, or other medical conditions. Further and better designed clinical trials of sensory integration therapy are necessary in order to establish their clinical usefulness.

Auditory integration training (AIT) is unproven and not medically necessary. There is insufficient reliable data indicating that AIT devices significantly improve behavior, language, listening ability, or learning ability. AIT is based on the unproven theory that some disorders are caused by hearing or listening deficiencies. It is unknown if the sound levels used for AIT are harmful to hearing.

Vagus Nerve Stimulation

Dec. 1, 2015

Updated list of applicable HCPCS codes; removed L8681

Vagus nerve stimulation (VNS) is proven and medically necessary for treating epilepsy in patients with all of the following: Medically refractory epileptic seizures and the patient is not a surgical

candidate or has failed surgical intervention No history of left or bilateral cervical vagotomy

The U.S. Food and Drug Administration (FDA) identifies a history of left or bilateral cervical vagotomy as a contraindication to vagus nerve stimulation.


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UPDATED


Vagus Nerve Stimulation (continued)

Dec. 1, 2015

It is an expectation that the physician have experience and expertise in the use of vagus nerve stimulation. Vagus nerve stimulation is unproven and not medically necessary for treating all other indications, including the following:

Alzheimer's disease

Anxiety disorder Autism spectrum disorder Back and neck pain Bipolar disorder Bulimia Cerebral palsy

Chronic pain syndrome Cluster headaches Depression Fibromyalgia Heart failure Migraines

Morbid obesity

Narcolepsy Obsessive-compulsive disorder Paralysis agitans Sleep disorders Tourette's syndrome

Available studies on the use of vagus nerve stimulation for treating severe, major depression or bipolar disorder refractory to medical therapy contain methodological flaws such as lack of control group, small sample size, potential bias, lack of randomization and blinding and lack of statistical

power analysis. There is a substantial placebo effect associated with depression treatments and the lack of data from prospective randomized controlled or comparative clinical studies considerably limits the conclusions

that can be drawn from the available evidence. Furthermore, preliminary analysis of a randomized controlled trial did not find a statistically significant difference between sham and active VNS. Definitive patient selection criteria for vagus nerve stimulation (VNS) in patients with treatment-resistant depression have not yet been established, and significant predictors of response have also not been identified.


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UPDATED


Vagus Nerve Stimulation (continued)

Dec. 1, 2015 Early research has examined the use of vagus nerve stimulation for additional indications. However, because of limited studies, small sample sizes and weak study designs, there is insufficient data to conclude that

vagus nerve stimulation is safe and/or effective for treating these indications.

Visual Information

Processing

Evaluation and Orthoptic and Vision Therapy

Nov. 1, 2015

Updated supporting information to

reflect the most current clinical

evidence and FDA information; no change to coverage rationale or list of applicable codes

Occlusion therapy is proven and medically necessary for the

treatment for amblyopia (lazy eye).

Prism adaptation therapy is proven and medically necessary for the treatment of esotropia (a form of strabismus when the eye deviates inward). Orthoptic or vision therapy is proven and medically necessary for the treatment of convergence insufficiency (ability of eyes to fix on the

same point). Orthoptic or vision therapy is unproven and not medically necessary for the treatment of the following:

Exotropia (eye deviates outward) without convergence insufficiency Nystagmus (involuntary movement of the eyeballs) Convergence excess (esotropia is greater for near vision than for far

vision) Divergence insufficiency Divergence excess Stroke or traumatic brain injury with visuospatial deficit, hemispatial

neglect, or visual loss

The available data supporting the use of vision therapy for these indications is weak and inconclusive, and derived primarily from uncontrolled or poorly controlled studies with significant methodological flaws.

The use of visual information processing evaluations to diagnose reading or learning disabilities is unproven and not medically necessary. There is inadequate clinical evidence to support the use of visual information

processing evaluations for diagnosing reading or learning-related disabilities. Additional well-designed studies with larger sample sizes are needed to establish the diagnostic utility of this procedure. Orthoptic or vision therapy including colored lenses, filters, and


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UPDATED


Visual Information Processing Evaluation and Orthoptic and Vision Therapy

(continued)

Nov. 1, 2015

overlays is unproven and not medically necessary for the treatment of dyslexia and other learning and reading disabilities. There is a lack of robust data available on the efficacy of orthoptic therapy for treating dyslexia and other reading and learning disabilities. Several small randomized controlled trials of vision therapy have been published, but these

studies were flawed by design limitations (including small sample size and

poorly defined patient selection criteria). The American Academy of Pediatrics has published a statement that concludes that vision therapy is ineffective for the treatment of learning and reading problems. Visual perceptual therapy is unproven and not medically necessary for any type of learning disability or language disorder, including

developmental delay. The available data supporting the use of visual perceptual therapy to treat learning or developmental disabilities is weak and inconclusive, and derived primarily from uncontrolled or poorly controlled studies with significant methodological flaws.

Vision restoration therapy is unproven and not medically necessary

as a treatment for visual field deficits following stroke or neurotrauma. There is inadequate evidence of efficacy for this treatment. The number of participants in the few available published studies is small and follow-up time is short.

Warming Therapy and Ultrasound Therapy for Wounds

Nov. 1, 2015

Routine review; no change to coverage rationale or lists of applicable codes

Warming therapy or noncontact normothermic wound therapy is unproven and not medically for the treatment of wounds. The safety and efficacy of warming therapy or noncontact normothermic wound therapy for the treatment of chronic wounds has not been established in the published medical literature. Limitations of the existing studies include

small samples, a lack of controls and/or randomization, short follow-up times, differences in standard therapy received by the treatment and control

groups, and a paucity of statistical analyses of the results. These limitations create difficulties in drawing definitive conclusions about the relative efficacy and/or safety of this therapy for healing chronic wounds. Well-designed trials evaluating the efficacy and safety of warming therapy are needed to demonstrate that warming therapy is beneficial for health outcomes in patients with chronic wounds.


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UPDATED


Warming Therapy and Ultrasound Therapy for Wounds (continued)

Nov. 1, 2015 Low frequency ultrasound is not medically necessary and unproven for the treatment of wounds. Evidence for the use of low frequency ultrasound to treat wounds is limited and consists of studies that lack adequate sample sizes and proper control groups. Additional research with larger trials is needed to demonstrate that

low frequency ultrasound is beneficial for health outcomes in patients with

wounds.

REVISED


Autologous Chondrocyte

Transplantation in the Knee

Dec. 1, 2015

Revised coverage rationale: o Updated list of unproven/not

medically necessary indications: Removed/replaced:

- Treatment of cartilage damage associated with

generalized osteoarthritis - Pre-existing conditions,

including meniscus tears, joint instability, or malalignment, unless these conditions are assessed and treated prior to or concurrent with autologous

chondrocyte implantation Added:

- Osteoarthritis

- Patients with unstable knee

- Total meniscectomy

- Inflammatory diseases of the joint

Updated supporting information to reflect the most current description of services, clinical evidence, FDA information, and

Autologous chondrocyte transplantation (ACT) is proven and medically necessary in Members with a single symptomatic full-

thickness articular cartilage defect when ALL of the following are present: Adult younger than age 55, Defect is greater than 2 squared cm, Defect is caused by acute or repetitive trauma,

Defect is in the articular cartilage of the femoral condyle (medial, lateral, or trochlea),

Member has had an inadequate response to a prior arthroscopic or other surgical repair procedure (e.g., debridement, microfracture, drilling/abrasion arthroplasty, or osteochondral allograft/autograft), and

Member has failed to respond to conservative treatment such as physical therapy, braces, and/or nonsteroidal anti-inflammatory drugs (NSAIDs).

Autologous Chondrocyte Transplantation is considered unproven and

not medically necessary for the following indications: Patients who have cartilage defects in locations other than the femoral

condyle of the knee,

Patients whose growth plates have not closed, Patients who have partial-thickness defects, Patients with history of multiple defects,

Patients with history of defects of the patella, Patients who have osteochondritis dissecans, Patients who have had previous history of cancer in the bones, cartilage,

fat or muscle of the treated limb, Osteoarthritis, Patients with unstable knee,


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REVISED


Autologous Chondrocyte Transplantation in the Knee (continued)

Dec. 1, 2015 references Total meniscectomy, Inflammatory diseases of the joint There is insufficient evidence to conclude that ACT is beneficial for health outcomes in patients with osteochondritis dissecans, osteoarthritis, or for

cartilage defects.

Diabetic Insulins

Dec. 1, 2015

Reorganized and revised coverage rationale to indicate coverage will be approved based on the following criteria (authorization will be issued for 12 months):

o Novolin 70/30 Diagnosis of Diabetes

Mellitus; and Patient has a history of a

three month trial* resulting in a therapeutic failure,

contraindication, or intolerance to the following (list reason for therapeutic failure, contraindication, or intolerance) to Humulin or Humulin 70/30 or any of its inactive ingredients

*Only a 30-day trial will be required for Connecticut (CT) plan members

o Novolog pens and vials, Apidra and Apidra Solostar

Diagnosis of Diabetes Mellitus; and

Patient has a history of a three month trial* resulting in a therapeutic failure, contraindication, or intolerance to the following (list reason for therapeutic

failure, contraindication, or

Novolin 70/30 will be approved based on both of the following criteria: Diagnosis of Diabetes Mellitus; and Patient has a history of a three month trial* resulting in a therapeutic

failure, contraindication, or intolerance to the following (list reason for therapeutic failure, contraindication, or intolerance) to Humulin or Humulin

70/30 or any of its inactive ingredients

Novolog pens and vials, Apidra, and Apidra Solostar will be approved based on the both of following criteria: Diagnosis of Diabetes Mellitus; and Patient has a history of a three month trial* resulting in a therapeutic

failure, contraindication, or intolerance to the following (list reason for therapeutic failure, contraindication, or intolerance) to Humalog or any of its inactive ingredients

Novolin N will be approved based on both of the following criteria: Diagnosis of Diabetes Mellitus; and Patient has a history of a three month trial* resulting in a therapeutic

failure, contraindication, or intolerance to the following (list reason for therapeutic failure, contraindication, or intolerance) to Humulin N or any of its inactive ingredients

Novolin R will be approved based on both of the following criteria:

Diagnosis of Diabetes Mellitus; and Patient has a history of a three month trial* resulting in a therapeutic

failure, contraindication, or intolerance to the following (list reason for therapeutic failure, contraindication, or intolerance) to Humulin R or any of its inactive ingredients

Novolog Mix 70/30 pens and vials will be approved based on both the following criteria:

Diagnosis of Diabetes Mellitus; and


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REVISED


Diabetic Insulins (continued)

Dec. 1, 2015

intolerance) to Humalog or any of its inactive ingredients *Only a 30-day trial will be required for CT plan

members

o Novolin N Diagnosis of Diabetes


three month trial* resulting in a therapeutic failure,

contraindication, or intolerance to the following (list reason for therapeutic failure, contraindication, or intolerance) to Humulin N or any of its inactive

ingredients

*Only a 30-day trial will be required for CT plan members

o Novolin R Diagnosis of Diabetes

Mellitus; and

Patient has a history of a three month trial* resulting in a therapeutic failure, contraindication, or

intolerance to the following (list reason for therapeutic failure, contraindication, or

intolerance) to Humulin R or any of its inactive ingredients *Only a 30-day trial will be required for CT plan members

o Novolog Mix 70/30 pens

Patient has a history of a three month trial* resulting in a therapeutic failure, contraindication, or intolerance to the following (list reason for therapeutic failure, contraindication, or intolerance) to Humalog 72/25 or any of its inactive ingredients

Authorization will be issued for 12 months.

* For Connecticut business, only a 30 day trial will be required.


Oxford


REVISED


Diabetic Insulins (continued)

Dec. 1, 2015

and vials Diagnosis of Diabetes


three month trial* resulting

in a therapeutic failure,

contraindication, or intolerance to the following (list reason for therapeutic failure, contraindication, or intolerance) to Humalog 72/25 or any of its inactive

ingredients *Only a 30-day trial will be required for CT plan members

Updated benefit considerations; added language to indicate supply

limits may be in place

Discogenic Pain Treatment

Dec. 1, 2015

Updated/reorganized coverage rationale: o Replaced reference to “thermal

intradiscal annuloplasty procedures” with “thermal

intradiscal procedures (TIPs)” o Added “percutaneous

intradiscal annuloplasty” to list of examples of unproven/not medically necessary thermal

intradiscal procedures (TIPs)

Thermal intradiscal procedures (TIPs) are unproven and not medically necessary for the treatment of discogenic pain. TIPs include the following procedures: Intradiscal electrothermal therapy (IDET) Intradiscal biacuplasty (IDB)

Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) Percutaneous intradiscal annuloplasty Percutaneous discectomy procedures are unproven and not medically necessary for the treatment of discogenic pain. Percutaneous

discectomy procedures include the following procedures: Nucleoplasty [percutaneous disc decompression) decompression (PDD) or

percutaneous plasma discectomy] Discectomy [laser disc decompression (PLDD); laser-assisted disc

decompression (LADD); or percutaneous endoscopic discectomy, with or without laser (PELD)]

Yeung Endoscopic Spinal Surgery (YESS) [arthroscopic microdiskectomy or percutaneous endoscopic diskectomy (PELD)]


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REVISED


Discogenic Pain Treatment (continued)

Dec. 1, 2015 Overall, the evidence regarding the efficacy of TIPs and percutaneous discectomy procedures for the treatment of low back pain is insufficient to demonstrate beneficial health outcomes. Available clinical studies are weakened by the lack of randomization, lack of comparator groups, and lack of long-term follow-up. Well-designed studies with larger patient populations

are needed to evaluate the relative safety and effectiveness of these

procedures. Annulus fibrosis repair following spinal surgery is unproven and not medically necessary. Evidence is limited to a single narrative review. Further studies are needed to establish whether annulus fibrosis repair is beneficial for health outcomes in patients with low back pain following spinal

surgery.

Drug Coverage Criteria - New and Therapeutic Equivalent

Medications

Dec. 1, 2015 Revised list of medications requiring precertification through the pharmacy benefit manager (PBM):

o Added Durlaza, Envarsus XR, Keveyis, Oxaydo and Tolak 4% cream

o Removed Afrezza, buprenorphine/naloxone (generic Suboxone), Cresemba and Zohydro ER (Abuse-

Deterrent) o Updated formulary alternative

for Absorica

Refer to the policy for complete details on Drug Coverage Criteria - New and Therapeutic Equivalent Medications.

REVISED

Policy Title Effective Date Drug/Medication Status Summary of Changes

Drug Coverage

Guidelines

Nov. 1, 2015

Abilify (aripiprazole) Updated Updated reference links to related policies/guidelines:

o Removed/replaced Abilify o Added Select Brand Medications

Aplenzin (bupropion) Updated Updated reference links to related policies/guidelines: o Removed/replaced Aplenzin o Added Select Brand Medications


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REVISED


Drug Coverage Guidelines (continued)

Nov. 1, 2015

Celexa (citalopram) (brand only)

Updated Updated reference links to related policies/guidelines: o Removed/replaced Celexa o Added Select Brand Medications

Cymbalta (duloxetine)

(brand only)

Updated Updated reference links to related policies/guidelines:

o Removed/replaced Cymbalta o Added Select Brand Medications

Effexor XR (venlafaxine) (brand only)

Updated Updated reference links to related policies/guidelines: o Removed/replaced Effexor XR o Added Select Brand Medications

Forfivo XL (bupropion HCL)

Updated Updated reference links to related policies/guidelines: o Removed/replaced Forfivo o Added Select Brand Medications

Lexapro (escitalopram) (brand only)

Updated Updated reference links to related policies/guidelines: o Removed/replaced Lexapro

o Added Select Brand Medications

Pexeva (paroxetine mesylate)

Updated Updated reference links to related policies/guidelines: o Removed/replaced Pexeva


Prozac (fluoxetine)

(brand only)

Updated Updated reference links to related policies/guidelines:

o Removed/replaced Prozac o Added Select Brand Medications

Wellbutrin SR (brand only) (bupropion)

Updated Updated reference links to related policies/guidelines: o Removed/replaced Wellbutrin SR o Added Select Brand Medications

Wellbutrin XL (bupropion extended release)

Updated Updated reference links to related policies/guidelines: o Removed/replaced Wellbutrin XL o Added Select Brand Medications

Zoloft (sertraline) (brand only)

Updated Updated reference links to related policies/guidelines: o Removed/replaced Zoloft


Drug Coverage Guidelines

Dec. 1, 2015

Reformatted and retitled “related policy” table header and corresponding reference links; added sub-headers noting applicable coverage criteria/guideline type

Revised coverage guidelines for the following medications/drugs: Addyi (Flibanserin) New Added coverage guidelines (precertification requirements apply); refer to

Prior Authorization/Notification Guidelines: Addyi for complete details on applicable coverage criteria

Afrezza (Insulin, Human)

Revised

Revised prior authorization/medical necessity guidelines (refer to Prior Authorization/Medical Necessity Guidelines: Afrezza for complete details


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REVISED



Dec. 1, 2015

Afrezza (Insulin, Human) (continued)

Revised on applicable coverage criteria): o Removed criterion requiring history of intolerance or therapeutic failure

to treatment with Humalog (vials and pens), Humulin R Removed reference link to policy/guideline titled Drug Coverage Criteria -

New and Therapeutic Equivalent Medications

Antagon (Ganirelix)

Revised

Revised coverage guidelines (precertification requirements apply); refer to

Precertification Guidelines: Infertility Diagnosis and Treatment for complete details on applicable coverage criteria

Revised reference links to applicable policies/guidelines: o Added Precertification Guidelines: Infertility Diagnosis and Treatment o Removed:

Treatment of Infertility Treatment of Infertility for NJ Small Group Plans Treatment of Infertility for NJ Large Groups Treatment of Infertility for New York Large and Small Group Treatment of Infertility for Connecticut Groups Infertility Procedures Requiring Notification and/or Precertification

Berinert (C1 Esterase Inhibitor Human)

Updated Updated list of applicable HCPCS codes; replaced “J3490” with “J0597”

Cetrotide (Cetrorelix Acetate)

Revised

Revised coverage guidelines (precertification requirements apply); refer to Precertification Guidelines: Infertility Diagnosis and Treatment for complete details on applicable coverage criteria


Treatment of Infertility Treatment of Infertility for NJ Small Group Plans Treatment of Infertility for NJ Large Groups Treatment of Infertility for New York Large and Small Group

Treatment of Infertility for Connecticut Groups Infertility Procedures Requiring Notification and/or Precertification

Cetuximab (Erbitux) Revised Revised precertification routing information to indicate no precertification requirements apply

Chorionic Gonadatropin Revised Revised coverage guidelines (precertification requirements apply); refer to Precertification Guidelines: Infertility Diagnosis and Treatment for complete details on applicable coverage criteria

Revised reference links to applicable policies/guidelines: o Added Precertification Guidelines: Infertility Diagnosis and Treatment

https://www.oxhp.com/secure/policy/treatment_of_infertility.pdf

https://www.oxhp.com/secure/policy/treatment_of_infertility_for_new_jersey_small_group.pdf

https://www.oxhp.com/secure/policy/treatment_of_infertility_for_new_jersey_large_group.pdf


https://www.oxhp.com/secure/policy/treatment_of_infertilit_for_new_york_large_and_small_groups.pdf


https://www.oxhp.com/secure/policy/treatment_of_infertility_for_connecticut_groups.pdf

https://www.oxhp.com/secure/policy/infertility_procedures_requiring_notification_and_precertification.pdf










Oxford


REVISED



Dec. 1, 2015

Cresemba (Isavuconazonium Sulfate)

Revised Revised coverage guidelines to indicate precertification is no longer required

Removed reference link to policy/guideline titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Crinone (Progesterone Gel)

Revised

Revised coverage guidelines (precertification requirements apply); refer to Precertification Guidelines: Infertility Diagnosis and Treatment for

complete details on applicable coverage criteria Revised reference links to applicable policies/guidelines: o Added Precertification Guidelines: Infertility Diagnosis and Treatment o Removed:

Treatment of Infertility

Treatment of Infertility for NJ Small Group Plans Treatment of Infertility for NJ Large Groups Treatment of Infertility for New York Large and Small Group Treatment of Infertility for Connecticut Groups Infertility Procedures Requiring Notification and/or Precertification

Crinone 8%

(Progesterone)

Revised






Daraprim

(Pyrimethamine)

New Added coverage guidelines (precertification requirements apply); refer to

Prior Authorization/ Medical Necessity Guidelines: Daraprim for complete details on applicable coverage criteria

Darbepoetin Alfa (Aranesp)

Revised Revised precertification routing information to indicate precertification is required through Oxford’s Medical Management Department

Durlaza (Aspirin) New Added coverage guidelines (precertification requirements apply); refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details on applicable coverage criteria


















Oxford


REVISED



Dec. 1, 2015

Endometrin (Progesterone)

Revised



o Removed:


Entresto (Valsartan – Sacubitril)

New Added coverage guidelines (precertification requirements apply); refer to the following policies for complete details on applicable coverage criteria: o Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and

Therapeutic Equivalent Medications o Prior Authorization/ Notification Guidelines: Entestro (valsartan-

sacubitril)

Envarsus XR (Tacrolimus)

New Added coverage guidelines (precertification requirements apply); refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details on applicable coverage criteria

Fertinex (Urofollitropin) Revised Revised coverage guidelines (precertification requirements apply); refer to Precertification Guidelines: Infertility Diagnosis and Treatment for complete details on applicable coverage criteria




First Progesterone (Progestin)

Revised


Revised reference links to applicable policies/guidelines:


















Oxford


REVISED



Dec. 1, 2015

First Progesterone (Progestin) (continued)

Revised o Added Precertification Guidelines: Infertility Diagnosis and Treatment o Removed:

Treatment of Infertility Treatment of Infertility for NJ Small Group Plans Treatment of Infertility for NJ Large Groups

Treatment of Infertility for New York Large and Small Group


Fortamet (Metformin Extended-Release)

Revised

Revised prior authorization/medical necessity guidelines (refer to Prior Authorization/Medical Necessity Guidelines: Fortamet (metformin extended-release) for complete details on applicable coverage criteria):

o Revised coverage criteria: Added new/additional criterion requiring:

- History of greater than or equal to 12 week trial* of metformin extended-release (generic Fortamet) (*For Connecticut plan members, only a 30 day trial will be required)

- One of the following: Submission of medical records (e.g. chart notes, laboratory

values) documenting an inadequate response to metformin extended-release (generic Fortamet) as evidenced by the following: Hemoglobin A1c level is above patients goal; or

Submission of medical records (e.g. chart notes, laboratory values) documenting an intolerance to metformin extended-

release (generic Fortamet) which is unable to be resolved with attempts to minimize the adverse effects where appropriate (e.g. dose reduction)

- Submission of article(s) published in the peer-reviewed medical literature showing that the requested drug is likely to be more

efficacious to this patient than metformin extended-release (generic Glucophage XR)

Changed authorization approval timeframe from “5 years” to “12 months”

Glumetza (Metformin Extended-Release)

Revised

Revised prior authorization/medical necessity guidelines (refer to Prior Authorization/ Medical Necessity Guidelines: Glumetza (metformin extended-release) for complete details on applicable coverage criteria):

o Revised coverage criteria: Added new/additional criterion requiring:

- History of greater than or equal to 12 week trial* of metformin










Oxford


REVISED



Dec. 1, 2015

Glumetza (Metformin Extended-Release) (continued)

Revised

extended-release (generic Fortamet) (*For Connecticut plan members, only a 30 day trial will be required)

- One of the following: Submission of medical records (e.g. chart notes, laboratory

values) documenting an inadequate response to metformin

extended-release (generic Fortamet) as evidenced by the following: Hemoglobin A1c level is above patients goal; or

Submission of medical records (e.g. chart notes, laboratory values) documenting an intolerance to metformin extended-release (generic Fortamet) which is unable to be resolved with attempts to minimize the adverse effects where appropriate

(e.g. dose reduction) - Submission of article(s) published in the peer-reviewed medical

literature showing that the requested drug is likely to be more efficacious to this patient than metformin extended-release (generic Glucophage XR)

Changed authorization approval timeframe from “5 years” to “12

months”

HCG (Chorionic Gonadotropin)

Revised



o Removed: Treatment of Infertility Treatment of Infertility for NJ Small Group Plans Treatment of Infertility for NJ Large Groups Treatment of Infertility for New York Large and Small Group


Humegon (Menotropins)

Revised



o Removed: Treatment of Infertility Treatment of Infertility for NJ Small Group Plans












Oxford


REVISED



Dec. 1, 2015

Humegon (Menotropins) (continued)

Revised Treatment of Infertility for NJ Large Groups Treatment of Infertility for New York Large and Small Group Treatment of Infertility for Connecticut Groups Infertility Procedures Requiring Notification and/or Precertification

Insulins (Novolin 70/30, Novolog Pens and Vials,

Novolog Mix 70/30 Pens and Vials, Apidra, Apidra Solostar, Novolin N, Novolin R)

Revised Revised step therapy guidelines (refer to Step Therapy Guidelines: Insulin for complete details on applicable coverage criteria):

o Revised coverage criteria for Novolog pens and vials: Updated criterion requiring history of intolerance or therapeutic

failure to treatment; removed “Humalog 75/25” as trial option o Added language to indicate authorization approval will be issued for 12

months

Keveyis (Dichlorphenamide)

New Added coverage guidelines (precertification requirements apply); refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details on applicable coverage criteria

Leuprolide Acetate (Subcutaneous)

(Eligard), 1mg/0.2ml

Revised Removed reference link to policy/guideline titled Infertility Procedures Requiring Notification and Precertification

Lupron, Lupron-3, Lupron-4, Lupron Depot, Lupron Implant

(Leuprolide Acetate)

Revised Removed reference link to policy/guideline titled Infertility Procedures Requiring Notification and Precertification

Menopur (Menotropins) Updated Revised reference links to applicable policies/guidelines; removed: o Treatment of Infertility o Treatment of Infertility for NJ Small Group Plans o Treatment of Infertility for NJ Large Groups

o Treatment of Infertility for New York Large and Small Group o Treatment of Infertility for Connecticut Groups o Infertility Procedures Requiring Notification and/or Precertification

Metrodin (Urofollitropin)

Revised






















Oxford


REVISED



Dec. 1, 2015

Metrodin (Urofollitropin) (continued)

Revised Treatment of Infertility for New York Large and Small Group Treatment of Infertility for Connecticut Groups Infertility Procedures Requiring Notification and/or Precertification

Novarel (Chorionic

Gonadotropin)

Revised Revised coverage guidelines (precertification requirements apply); refer to



Treatment of Infertility Treatment of Infertility for NJ Small Group Plans

Treatment of Infertility for NJ Large Groups Treatment of Infertility for New York Large and Small Group Treatment of Infertility for Connecticut Groups Infertility Procedures Requiring Notification and/or Precertification

Ovidrel (Chorionic

Gonadotropin)

Revised


Precertification Guidelines: Infertility Diagnosis and Treatment for

complete details on applicable coverage criteria Revised reference links to applicable policies/guidelines: o Added Precertification Guidelines: Infertility Diagnosis and Treatment o Removed:

Treatment of Infertility Treatment of Infertility for NJ Small Group Plans

Treatment of Infertility for NJ Large Groups Treatment of Infertility for New York Large and Small Group Treatment of Infertility for Connecticut Groups Infertility Procedures Requiring Notification and/or Precertification

Oxaydo (Oxycodone HCL)

New Added coverage guidelines (precertification requirements apply); refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and

Therapeutic Equivalent Medications for complete details on applicable coverage criteria

Pergonal (Menotropins)

Revised


























Oxford


REVISED



Dec. 1, 2015

Pergonal (Menotropins) (continued)

Revised


Pregnyl (Chorionic

Gonadotropin)

Revised Revised coverage guidelines (precertification requirements apply); refer to




Prochieve (Progesterone Gel)

Revised




Profasi (Chorionic Gonadotropin)

Revised



Treatment of Infertility Treatment of Infertility for NJ Small Group Plans Treatment of Infertility for NJ Large Groups Treatment of Infertility for New York Large and Small Group






























Oxford


REVISED



Dec. 1, 2015 Profasi (Chorionic Gonadotropin) (continued)

Revised Treatment of Infertility for Connecticut Groups Infertility Procedures Requiring Notification and/or Precertification

Puregon (Follitropin

Beta)

Revised Revised reference links to applicable policies/guidelines:

o Added Precertification Guidelines: Infertility Diagnosis and Treatment o Removed Follicle Stimulating Hormones (FSH) used in the Treatment of

Infertility

Repronex (Menotropins) Revised Revised coverage guidelines (precertification requirements apply); refer to Precertification Guidelines: Infertility Diagnosis and Treatment for complete details on applicable coverage criteria



Treatment of Infertility for New York Large and Small Group


Tolak 4% Cream (Fluorouracil)

New Added coverage guidelines (precertification requirements apply); refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details

Zohydro ER (Hydrocodone Bitartrate Extended Release)

Revised Revised prior authorization/medical necessity guidelines (refer to Prior Authorization/ Medical Necessity Guidelines: Zohydro ER for complete details on applicable coverage criteria): o Revised coverage criteria; removed criterion requiring history of

intolerance or therapeutic failure to treatment with fentanyl

transdermal patch (generic Duragesic), morphine sulfate extended-release (generic MS Contin), Nucynta ER, Opana ER, Zohydro ER

Removed reference link to policy/guideline titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications












Oxford


REVISED


Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines

Feb. 1, 2016*

*Notice of Revision and Implementation Delay: The changes noted below will not be effective on Dec. 1, 2015 as previously announced.

Implementation of the revised policy

has been postponed until Feb. 1, 2016. Revisions to the original policy update announcement are outlined in red below. Please take note of the amended guidelines to be applied beginning Feb. 1, 2016.

Added conditions of coverage/

authorization requirements to indicate precertification is required for injectable chemotherapy drugs through CareCore National (CCN)

eviCore Healthcare

o Precertification is required for services covered under the Member's General Benefits package when performed in the office of a participating provider For Commercial plans,

precertification is not required, but is encouraged for out-of-network services performed in the office that

are covered under the Member's General Benefits package

If precertification is not obtained, Oxford may review for medical necessity after the service is rendered

o Precertification is required for injectable chemotherapy drugs administrated by a participating

Oxford has engaged eviCore Healthcare to perform precertification* reviews for injectable chemotherapy drugs administrated by participating providers in an office, outpatient or home setting to treat a cancer diagnosis. Oxford continues to be responsible for claims payment decisions and for appeals.

Note: Precertification is not required for injectable chemotherapy drugs

administrated by a non-participating provider in an office or outpatient setting however precertification will be provided upon request. All precertification requests for injectable chemotherapy drugs are handled by eviCore Healthcare. To obtain precertification for injectable chemotherapy medications providers must contact CCN. Providers are

encouraged to obtain precertification on line by logging in to OxfordHealth.com and selecting the link to the eviCore Healthcare authorization web site. Providers may also obtain precertification by calling 1-877-773-2882. eviCore Healthcare uses the National Comprehensive Cancer Network’s

(NCCN) guidelines in their decision making process. These guidelines

provide independent recommendations for evidence-based cancer treatment. The guidelines are continually updated to be consistent with the current treatment options. Providers and patients may access and view the NCCN guidelines at NCCN.org. Oxford recognizes indications and uses of oncology medications listed in the

NCCN Drugs and Biologics Compendium with Categories of Evidence and Consensus of 1, 2A, and 2B as proven and medically necessary and Categories of Evidence and Consensus of 3 as unproven and not medically necessary.

*The term “Precertification” is also referred to as “Prior Authorization”. You may notice both terms are used, both are the same.

Additional Information

The NCCN Clinical Practice Guidelines in Oncology™ (NCCN Guidelines®) are a comprehensive set of guidelines documenting sequential management decisions and interventions that apply to malignancies which affect about

97% of all patients with cancer. They also address supportive care issues.


Oxford


REVISED



(continued)

Feb. 1, 2016*

provider in an office, outpatient or home setting Precertification is not required

for injectable chemotherapy drugs administrated by a

non-participating provider in

an office and outpatient setting however precertification will be provided upon request

Updated benefit considerations: o Removed language indicating

this policy does not apply to Members younger than 19 years of age

o Added language pertaining to precertification guidelines for NJ Small, NJ Individual, NJ School

Board and NJ Municipality

products Revised coverage rationale: o Added language to indicate:

Oxford has engaged CareCore National (CCN) eviCore Healthcare to perform

precertification reviews for injectable chemotherapy drugs administrated in an outpatient setting to treat a

cancer diagnosis; Oxford continues to be responsible for claims payment decisions

and for appeals All precertification requests

for injectable chemotherapy drugs are handled by CCN eviCore Healthcare - To obtain precertification

for injectable

The guidelines are developed and updated by 47 individual panels, composed of more than 950 clinicians and oncology researchers from the 25 NCCN member institutions and their affiliates. NCCN Categories of Evidence and Consensus

Category 1: The recommendation is based on high-level evidence (i.e., high-powered randomized clinical trials or meta-analyses), and the panel has reached uniform consensus that the recommendation is indicated. In this context, uniform means near unanimous positive support with some possible neutral positions.

Category 2A: The recommendation is based on lower level evidence, but

despite the absence of higher level studies, there is uniform consensus that the recommendation is appropriate. Lower level evidence is interpreted broadly, and runs the gamut from phase II to large cohort studies to case series to individual practitioner experience. Importantly, in many instances, the retrospective studies are derived from clinical

experience of treating large numbers of patients at a member institution, so panel members have first-hand knowledge of the data. Inevitably, some recommendations must address clinical situations for which limited or no data exist. In these instances the congruence of experience-based opinions provides an informed if not confirmed direction for optimizing patient care. These recommendations carry the implicit recognition that

they may be superseded as higher level evidence becomes available or as outcomes-based information becomes more prevalent.

Category 2B: The recommendation is based on lower level evidence, and there is nonuniform consensus that the recommendation should be made. In these instances, because the evidence is not conclusive, institutions

take different approaches to the management of a particular clinical

scenario. This nonuniform consensus does not represent a major disagreement rather it recognizes that given imperfect information, institutions may adopt different approaches. A Category 2B designation should signal to the user that more than one approach can be inferred from the existing data.

Category 3: The recommendation has engendered a major disagreement among the panel members. Several circumstances can cause major disagreements. For example, if substantial data exists about two


Oxford


REVISED



(continued)

Feb. 1, 2016*

chemotherapy medications providers must contact CareCore National (CCN) eviCore Healthcare

- Providers are encouraged

to obtain precertification

on line by logging in to OxfordHealth.com and selecting the link to the CCN eviCore Healthcare authorization web site

- Providers may also obtain

precertification by calling 866-889-8054 1-877-773-2882

CCN eviCore Healthcare uses the National Comprehensive Cancer Network’s (NCCN)

guidelines in their decision

making process - These guidelines provide

independent recommendations for evidence-based cancer treatment

- The guidelines are continually updated to be consistent with the current treatment options

- Providers and patients may access and view the NCCN guidelines at

NCCN.org “Precertification” is also

referred to as “Prior Authorization”; these terms are used interchangeably

o Removed language indicating: Oxford will cover all

interventions but they have never been directly compared in a randomized trial, adherents to one set of data may not accept the interpretation of the other side's results. Another situation resulting in a Category 3 designation is when experts disagree about how trial data can be generalized. A Category 3 designation alerts users to a major

interpretation issue in the data and directs them to the manuscript for an

explanation of the controversy. If the drug regimen being requested does not have a NCCN 1, 2a, or 2b NCCN Guideline recommendation, refer to the following Oxford policies:

Clinical Trials Experimental/Investigational Treatment Experimental/Investigational Treatment for NJ Plans

Facilities, physicians and other health care professionals are encouraged to utilize the most appropriate ICD-10-CM diagnosis codes in accordance with applicable code set guidelines.


Oxford


REVISED



(continued)

Feb. 1, 2016*

chemotherapy agents for individuals under the age of 19 years for oncology indications; the majority of pediatric patients receive

treatments on national

pediatric protocols that are quite similar in concept to the NCCN patient care guidelines

While precertification is not required for injectable chemotherapy drugs, Oxford

will provide a pre-service clinical review and coverage determination upon request

In the absence of precertification for injectable chemotherapy drugs, Oxford

will perform a post-service

retrospective review upon claim submission; medical necessity is determined via the guidelines described in this policy, and may be reviewed in conjunction with

one or more of the following Oxford policies

Chemotherapy drugs used in the treatment of diagnoses

listed on the Exceptions to Cancer Diagnosis Codes List are not subject to clinical

review and will be reimbursed in accordance with a Member's health benefits plan

Added content/language pertaining to Applicable Codes: o Added list of HCPCS codes

included in the eviCore


Oxford


REVISED



(continued)

Feb. 1, 2016*

Healthcare arrangement (requiring precertification effective 02/01/2016)

o Added notation to refer to the following policies for details on

applicable coverage guidelines

for injectable chemotherapy drugs utilized for non-oncology indications: J9010: Alemtuzumab J9217: Lupron-Depot/Lupron-

Depot (Leuprolide Acetate)

J9310: Rituxan (Rituximab) Added a “description of services”

addressed in the policy

Osteochondral Grafting of Knee

Dec. 1, 2015

Revised coverage rationale: o Updated/reorganized coverage

criteria for osteochondral autograft transplantation for treatment of cartilage defect of the knee Modified list of

proven/medically necessary indications:

- Added: Symptomatic focal full-

thickness articular cartilage defect

- Removed:

Absence of inflammatory joint

disease or steroid-induced cartilage or bone disease

- Replaced: “Adult who has

achieved mature

skeletal growth” with

Osteochondral autograft transplantation is proven and medically necessary for treatment of a cartilage defect of the knee when all of

the following are present: Adult who has achieved mature skeletal growth with documented closure

of growth plates Symptomatic focal full-thickness articular cartilage defect Considered unsuitable candidate for total knee replacement Presence of debilitating symptoms that significantly limit ambulation Normal alignment or correctable varus or valgus deformities

Minimal to absent degenerative changes in surrounding articular cartilage (Outerbridge Grade II or less)

Failed conventional medical treatment (including physical therapy and/or bracing techniques) and/or prior surgical treatment

Willingness to comply with extensive period of rehabilitation following

surgery

Osteochondral autograft transplantation for all other joints, and any indications other than those listed above, is considered unproven and not medically necessary. The peer-reviewed scientific literature regarding the treatment of osteochondral defects in joints other than the knee is limited. Additional studies are needed to establish the appropriateness of the treatment of

these osteochondral defects.


Oxford


REVISED


Osteochondral Grafting of Knee (continued)

Dec. 1, 2015

“adult who has achieved mature skeletal growth with documented closure of growth plates”

Added language to indicate:

- Osteochondral autograft transplantation for all other joints and any indications other than those listed is considered unproven and not

medically necessary - The peer-reviewed

scientific literature regarding the treatment of osteochondral defects in joints other than the knee

is limited; additional

studies are needed to establish the appropriateness of the treatment of these osteochondral defects

o Updated/reorganized coverage

criteria for allograft transplantation using human cadaver tissue for treatment of cartilage defect of the

knee Modified list of

proven/medically necessary

indications: - Added:

Symptomatic focal full-thickness articular cartilage defect

- Removed: Absence of

Osteochondral allograft transplantation using human cadaver tissue is proven and medically necessary for the treatment of a cartilage defect of the knee when all of the following are present: Adult who has achieved mature skeletal growth with documented closure

of growth plates

Symptomatic focal full-thickness articular cartilage defect

Considered unsuitable candidate for total knee replacement Presence of debilitating symptoms that significantly limit ambulation Normal alignment or correctable varus or valgus deformities Minimal to absent degenerative changes in surrounding articular cartilage

(Outerbridge Grade II or less) Failed conventional medical treatment (including physical therapy and/or

bracing techniques) and/or prior surgical treatment Willingness to comply with extensive period of rehabilitation following

surgery Osteochondral allograft transplantation for all other joints, and any indications other than those listed above, is considered unproven

and not medically necessary.

The peer-reviewed scientific literature regarding the treatment of osteochondral defects in joints other than the knee is limited. Additional studies are needed to establish the appropriateness of the treatment of these osteochondral defects. Minced articular cartilage repair (allograft or autograft) is unproven

and not medically necessary for the treatment of osteochondral defects of the knee. Randomized trials that compare the outcomes of minced articular cartilage repair with standard methods have not been published. Clinical studies are needed to establish the safety and outcome

benefit of this technique over standard methods of cartilage repair.


Oxford


REVISED


Osteochondral Grafting of Knee (continued)

Dec. 1, 2015

inflammatory joint disease

- Replaced: “Adult who has

achieved mature

skeletal growth” with

“adult who has achieved mature skeletal growth with documented closure of growth plates”

Added language to indicate:

- Osteochondral allograft transplantation for all other joints and any indications other than those listed is considered unproven and not

medically necessary

- The peer-reviewed scientific literature regarding the treatment of osteochondral defects in joints other than the knee is limited; additional

studies are needed to establish the appropriateness of the treatment of these

osteochondral defects Removed “Additional Products”

information listing specific orthotic

device names and manufacturers Updated supporting information to

reflect the most current description of services, clinical evidence, FDA information, and references


Oxford


REVISED


Select Brand Medications

Nov. 1, 2015

Changed policy title; previously titled Brand Antidepressants

Revised coverage rationale: o Replaced references to “brand

antidepressants” with “brand

medications”

o Added Abilify (aripiprazole) to list of approved brand medications (when criteria is met)

This policy applies to the following brand medications: Abilify (aripiprazole) Aplenzin (bupropion extended-release) Celexa (citalopram) Cymbalta (duloxetine)

Effexor XR (venlafaxine extended-release)

Forfivo XL (bupropion extended-release) Lexapro (escitalopram) Pexeva (paroxetine) Prozac (fluoxetine) Wellbutrin SR (bupropion sustained-release) Wellbutrin XL (bupropion extended-release)

Zoloft (sertraline) The brand medications Abilify, Aplenzin, Celexa, Cymbalta, Effexor XR, Forfivo XL, Lexapro, Pexeva, Prozac, Wellbutrin SR, Wellbutrin XL, or Zoloft will be approved based on one of the following criteria:

1. Both of the following: a. History of greater than or equal to 4 week trial of the therapeutically

equivalent generic (Document date and duration of trial. For Wellbutrin XL, trial must be in 2014 or later); and

b. Submission of medical records documenting the inadequate response to the therapeutically equivalent generic

or 2. Both of the following:

a. Documented history of intolerance to the therapeutically equivalent generic which is unable to be resolved with attempts to minimize the adverse effects where appropriate (e.g. take with food to minimize nausea, take prior to bedtime to manage fatigue, take in the morning

to manage insomnia, eat high-fiber diet with plenty of water to

minimize constipation, etc.); and b. Submission of medical records documenting the adverse effect of the

therapeutically equivalent generic

Authorization will be issued for 60 months.

Standing Systems and Gait Trainers

Dec. 1, 2015

Changed policy title; previously titled Standing Systems

Revised coverage rationale:

Stationary, mobile and active standing systems are proven and medically necessary for the treatment of individuals who are non-ambulatory and who meet the following criteria:


Oxford


REVISED


Standing Systems and Gait Trainers (continued)

Dec. 1, 2015

o Changed coverage status for stationary, mobile, and active standing systems from “unproven and not medically necessary for the treatment of

individuals with neuromuscular

disorders” to “proven and medically necessary for the treatment of individuals who are non-ambulatory and meet the following criteria”: The individual using

equipment has the capacity for at least partial independence in one or more of the following activities of daily living in his/her home: - Eating

- Personal hygiene

- Toileting - Dressing - Transfer

or There is a goal of prevention

of one or more of the

following medical complications: - Decubitus ulcer: Where

there is a need for off-

loading of a decubitus ulcer which cannot be accomplished by other

means - Osteoporosis: Where

improvement or stabilization of bone density cannot be achieved with other treatment or activities

1. Standing Systems

A. The individual using equipment has the capacity for at least partial independence in one or more of the following activities of daily living in his/her home: Eating

Personal hygiene Toileting

Dressing Transfer

or B. There is a goal of prevention of one or more of the following medical

complications: Decubitus ulcer: where there is a need for off-loading of a decubitus

ulcer which cannot be accomplished by other means. Osteoporosis: where improvement or stabilization of bone density

cannot be achieved with other treatment or activities Contracture development: High potential for progressive contracture

formation including but not limited to post-operative release of contractures.

Compromised bowel/bladder function: where there has been

demonstration there is incomplete emptying of bladder or constipation refractory to other medical treatment.

Pulmonary complications: where there has been demonstration of recurrent infections and poor clearance of pulmonary secretions despite the use of other medical treatment.

Hip dislocation: where hip subluxation/dislocation is worsening and alternate treatments have not been successful.

and C. The patient is unable to accomplish the above with his/her current

medical device/equipment or alternate medical treatment; and D. The individual has been evaluated with a trial using the standing

device and has shown compliance, tolerance and demonstrated potential for clinical benefit, as determined by an independent

reviewer. Powered standing systems or electric lift mechanisms are unproven and not medically necessary because they are a convenience feature and are not primarily medical in nature.


Oxford


REVISED



Dec. 1, 2015

- Contracture development: High potential for progressive contracture formation including but not limited to post-

operative release of

contractures - Compromised

bowel/bladder function: Where there has been demonstration there is incomplete emptying of

bladder or constipation refractory to other medical treatment

- Pulmonary complications: Where there has been demonstration of recurrent

infections and poor

clearance of pulmonary secretions despite the use of other medical treatment

- Hip dislocation: Where hip subluxation/dislocation is worsening and alternate

treatments have not been successful

and The patient is unable to

accomplish the above with his/her current medical device/equipment or

alternate medical treatment and The individual has been

evaluated with a trial using the standing device and has shown compliance, tolerance and demonstrated potential

2. Gait Trainers

Gait Trainers are proven and medically necessary for the treatment of non-ambulatory individuals who meet the following criteria:

A. The individual has the potential for ambulation; or

B. The individual is able to ambulate and uses the gait trainer as a walker where documentation shows other usual walkers have not been effective.

3. Accessories for Standing Systems and Gait Trainers

Accessories for Standing Systems and Gait Trainers are unproven and not medically necessary because they are convenience

feature and are not primarily medical in nature.


Oxford


REVISED



Dec. 1, 2015

for clinical benefit, as determined by an independent reviewer.

o Added coverage guidelines for powered standing

systems/electric lift

mechanisms, gait trainers, and accessories for standing systems and gait trainers to indicate: Powered standing systems or

electric lift mechanisms are unproven and not medically

necessary because they are a convenience feature and are not primarily medical in nature

Gait trainers are proven and medically necessary for the

treatment of non-ambulatory

individuals who meet the following criteria: - The individual has the

potential for ambulation; or

- The individual is able to

ambulate and uses the gait trainer as a walker where documentation shows other usual walkers

have not been effective Accessories for standing

systems and gait trainers are

unproven and not medically necessary because they are convenience feature and are not primarily medical in nature

Updated list of applicable HCPCS codes; added E8000, E8001 and


Oxford


REVISED



Dec. 1, 2015

E8002 Removed “Additional Products”

information listing specific standing system device names and manufacturers

Updated supporting information

to reflect the most current clinical evidence, FDA information and references

RETIRED/REPLACED

Policy Title Effective Date Summary of Changes

Diagnostic (Basic) Procedures for Infertility

Dec. 1, 2015 Policy replaced; refer to policy titled Infertility Diagnosis and Treatment for applicable coverage guidelines

Entresto (Valsartan-

Sacubitril)

Nov. 1, 2015 Policy replaced; refer to policy titled Entresto for applicable coverage guidelines

Infertility Procedures Requiring Notification and/or Precertification




Treatment of Infertility for

Connecticut Groups


Treatment of Infertility for New Jersey Large Groups



Oxford


RETIRED/REPLACED

Policy Title Effective Date Summary of Changes

Treatment of Infertility for New Jersey Small Groups and New Jersey Individual

Plans


Treatment of Infertility for New York Large and Small Groups



Oxford


UPDATED

Policy Title Effective Date Summary of Changes Administrative Guidelines

Speech Therapy and Early Intervention Programs/Birth to Three

Nov. 1, 2015 Updated coverage rationale: o Modified language pertaining to

subrogation for New York (NY) plan members; removed language indicating written

claims for early intervention

program services must be submitted within 150 days from the date of service

Refer to the policy for complete details on the coverage guidelines for Speech Therapy and Early Intervention Programs/Birth to Three.

REVISED


Par Gastroenterologists

Using Non-Par Anesthesiologists in Office Settings

Dec. 1, 2015

Revised procedures and responsibilities; added language to

indicate any payment previously made for gastroenterology services will be subject to

recovery if provider does not comply with noted administrative requirements

The following procedures and responsibilities apply in non-emergent situations when the services are provided by a participating

gastroenterologist in New York: 1. Services performed in an office setting by a participating

gastroenterologist with anesthesia, must be performed in conjunction with an anesthesiologist who is participating with the Oxford network; or

2. If the participating gastroenterologists intends to utilize an

anesthesiologist that does not participate in the Oxford network, the provider must discuss referral options with the member prior (no more than 90 days before the scheduled date of the procedure) to making referrals to, or scheduling services on their behalf with, a non-participating anesthesiologist. Following the discussion, the member must indicate their choice to use a participating or non-participating anesthesiologist by

marking the appropriate box on the Non-Participating Provider Consent Form. The member must then sign and date the form.

3. Non-Participating Provider Consent Forms must be kept on file by a

participating gastroenterologist. A separate Non-Participating Provider Consent Form is required for every service when the participating gastroenterologist wants to refer to or involve a non-participating

anesthesiologist in a member’s care. The Non-Participating Provider Consent Form will only be valid for 90 days from the date of member signature.


Oxford


REVISED


Par Gastroenterologists Using Non-Par Anesthesiologists in Office Settings

(continued)

Dec. 1, 2015

Oxford may request a copy of the completed Non-Participating Provider Consent Form from the participating gastroenterologist (who is required to keep the form on file) in order to conduct standard business. When requested, the participating gastroenterologist must provide a copy of the Non-Participating Provider Consent Form within 15 days of the request. If

a copy of the completed Non-Participating Provider Consent Form is not

received within 15 days of the request, the participating gastroenterologist’s claim will be denied administratively for failure to comply with the protocol. In these instances, the participating provider is prohibited from balance billing the member.

4. Participating gastroenterologists must coordinate the office based

procedure on behalf of the member according to the arrangements agreed upon between the participating gastroenterologist and the member within the Non-Participating Provider Consent Form including but not limited to supplying a participating anesthesiologist, In-Network Exceptions and/or claims appeals.

5. If requesting an In-Network Exception to have a non-participating

anesthesiologist covered as if they were participating with the Oxford network, the participating gastroenterologist must make the exception request. The exception request will not be accepted from the non-participating anesthesiologist. o The participating gastroenterologist must make the In-Network

Exception request no less than 14 days in advance of the scheduled

procedure in order to avoid delays in care and alleviate potential complications with the patient’s required preparations for the procedure.

o If the participating gastroenterologist requests an In-Network Exception

less than 14 days in advance of the scheduled procedure, the In-Network Exception request will be processed per Oxford’s standard guidelines, however the participating gastroenterologist will receive an

administrative denial for their claim for failure to follow protocol. o The participating gastroenterologist may be asked to provide

information regarding their New York State Office Based Surgery Accreditation status, which they should have available when making the In-Network Exception request.

6. When a participating gastroenterologist performs non-emergent services in


Oxford


REVISED


Par Gastroenterologists Using Non-Par Anesthesiologists in Office Settings

(continued)

Dec. 1, 2015 the office setting using a participating anesthesiologist, there will be no additional requirements to fulfill. A Non-Participating Provider Consent Form is not required.

Non-compliance with this policy:

Providers are required to keep a signed copy of the Non-Participating

Provider Consent Form on file. Oxford may request a copy of the signed Non-Participating Provider Consent Form at any time, including when responding to a member appeal. Providers are not required to submit this form with their initial claim. If the participating gastroenterologist cannot provide the signed Non-

Participating Provider Consent Form, within 15 days of the request, as proof that they discussed the member’s options for selecting a participating or non-participating anesthesiologist in advance of the service, Oxford will administratively deny the participating gastroenterologist claim. Any payment previously made for the gastroenterology service will be subject to recovery. The participating gastroenterologist cannot balance bill the

member for claims denied for administrative reasons.


Oxford

Reimbursement Policy Updates \

UPDATED

Policy Title Effective Date Summary of Changes Reimbursement Guidelines

Assistant Surgeon

Nov. 1, 2015

Updated policy application language to clarify this policy applies to all network and non-network physicians and other qualified health care professionals,

including, but not limited to, non-

network authorized and percent of charge contract physicians and other qualified health care professionals

Multiple Procedures If an Assistant Surgeon submits multiple procedure codes, multiple procedure reductions will apply. Refer to Multiple Procedure Policy. Cesarean Section

Only a non-global cesarean section delivery code (without antepartum or

postpartum components) is a reimbursable service when submitted with an appropriate Assistant Surgeon modifier. Global cesarean section Current Procedural Terminology (CPT) codes 59510, 59515, 59618, and 59622 submitted by an Assistant Surgeon will be

reimbursed using the non-global cesarean section codes 59514 and 59620 as follows: 59510 reimbursed using 59514 59515 reimbursed using 59514 59618 reimbursed using 59620 59622 reimbursed using 59620

Assistant Surgeon Eligible List The Assistant Surgeon Eligible List is developed based on the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule Relative Value File (NPFS) status indicators. All codes in the NPFS with the following status code indicator "2" for "Assistant Surgeons" are considered by Oxford to be reimbursable for

Assistant Surgeon services, as indicated by an Assistant Surgeon modifier (80, 81, 82, or AS).

CMS Definition of Assistant Surgeon Indicator "2":

2 = Payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid.

Oxford applies the payment indicators for HCPCS codes G0412-G0415 when adjudicating CPT codes 27215-27218 for the purpose of this policy.

Important Note: Review by an Oxford Medical Director is required for the services of an assistant surgeon in any procedure not listed on the Assistant Surgeon Eligible List. If an assistant surgeon is not warranted

for that procedure, the charges of the assistant surgeon are denied as not


Oxford


UPDATED


Assistant Surgeon (continued)

Nov. 1, 2015

medically necessary. Participating surgeons are required to use participating assistant surgeons if available. Failure to use participating assistant surgeons may be considered an administrative violation potentially warranting

administrative disciplinary action.

Physicians (MD/DO) Oxford's standard reimbursement for Assistant Surgeon services on the Assistant Surgeon Eligible List which are provided by a physician is 16% of the Allowable Amount for eligible surgical procedures. This percentage is based on CMS.

Exception: For New Jersey individual and small group plans, standard reimbursement is based on the 80th percentile of Prevailing Healthcare Charges System (PHCS).

Assistant Surgeons who are Physicians should submit the identical procedure

code(s) as the primary surgeon with one of the following modifiers to

represent their service(s):

Modifier Description

80 Assistant Surgeon

81 Minimum Assistant Surgeon

82 Assistant Surgeon (when qualified resident surgeon

not available)

Health Care Professionals Oxford's standard reimbursement for Assistant Surgeon services on the

Assistant Surgeon Eligible List which are provided by a Health Care

Professional is 14% of the Allowable Amount for the surgical procedures. This percentage is based on CMS.

Exception: For New Jersey individual and small group plans, standard reimbursement is based on the 80th percentile of Prevailing Healthcare Charges System (PHCS).

Assistant surgeons who are Health Care Professionals should submit the


Oxford


UPDATED


Assistant Surgeon (continued)

Nov. 1, 2015 identical procedure code(s) as the primary surgeon with the following modifier to represent their service(s):


AS PA (physician assistant), nurse practitioner, or clinical nurse specialist services for assistant at surgery

Health care professionals acting as Assistant Surgeons should report their services under a surgeon's provider number. Oxford will not reimburse independently submitted services by non-contracted, health care practitioner (other than a Physician or Health Care Professional) who is seeking reimbursement for services using an Assistant Surgeon modifier unless a state mandate exists that requires reimbursement,

in which case they will be reimbursed pursuant to this policy. For information about the health care-related mandates and laws in your state, contact the appropriate federal or state legislative office.

B Bundle Codes

Dec. 1, 2015

Updated reimbursement guidelines; added language to

clarify this policy applies to: o Services reported using the UB-

04 claim form, the 1500 Health Insurance Claim Form (a/k/a CMS-1500), or their electronic equivalents or their successor forms

o All network and non-network providers, including hospitals, ambulatory surgical centers,

physicians and other qualified health care professionals including, but not limited to,

non-network authorized and percent of charge contract physicians and other qualified health care professionals

All codes published on the NPFS Relative Value File are assigned a status code. The status code indicates whether the code is separately payable if the service

is covered. Per the public use file that accompanies the NPFS Relative Value File, the following is stated for the status code B: "Payment for covered services is always bundled into payment for other services not specified. If RVUs are shown, they are not used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. (An example is a telephone call from a hospital nurse regarding care of a patient)."

Consistent with CMS, Oxford will not separately reimburse for specific Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding

System (HCPCS) codes assigned a status code “B” on the NPFS Relative Value File indicating a bundled procedure. B Bundle Codes are not reimbursable services regardless of whether they are billed alone or in

conjunction with other services. The codes which Oxford has included in this policy (for which separate reimbursement is not made) can be found in the attachment section.


Oxford


UPDATED


Bilateral Procedures

Dec. 1, 2015

Updated reimbursement guidelines; added language to clarify this policy applies to: o Services reported using the UB-

04 claim form, the 1500 Health

Insurance Claim Form (a/k/a

CMS-1500), or their electronic equivalents or their successor forms


physicians and other qualified health care professionals including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified

health care professionals

Bilateral Eligible List The Oxford Bilateral Eligible Procedures Policy List is developed based on the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS) Relative Value File status indicators.

All codes in the NPFS with the "bilateral" status indicators "1" or "3" are

considered by Oxford to be eligible for bilateral services as indicated by the bilateral modifier 50. When a bilateral eligible code with a bilateral indicator of "1" is reported with modifier 50 and is subject to reductions under the Multiple Procedures policy, the code will be eligible for reimbursement at 150% of the allowable amount

not to exceed billed charges for a single procedure code, with one side reimbursed at 100% and the other side reimbursed at 50%. When other reducible procedure codes are reported on the same date of service, an additional multiple procedure reduction may or may not be applied to the line paid at 100% depending on whether another procedure code is ranked as primary or not.

When a bilateral eligible code with a bilateral indicator of "3" is reported with modifier 50 and is not subject to reductions under the Multiple Procedure Policy, the code will be eligible for reimbursement at 100% of the allowable amount for each side for a sum of 200% of the allowable amount not to exceed billed charges.

For a list of procedure codes that are subject to multiple procedure reductions, see Oxford's Multiple Procedures policy. Bilateral Eligible Procedures List CMS Files for Download

Multiple Procedure Reduction Eligible Bilateral Procedures on the Oxford Bilateral Eligible Procedures Policy

List may be subject to multiple procedure reductions as defined in Oxford's Multiple Procedures. In order to fully understand Oxford's reimbursement rules for eligible Bilateral Procedures, refer to the Multiple Procedures in conjunction with this policy. Bilateral Modifier (50) Modifier 50 identifies the same procedures that are performed as a bilateral


Oxford


UPDATED


Bilateral Procedures (continued)

Dec. 1, 2015

service. The procedure should be billed on one line with modifier 50 and one unit with the full charge for both procedures. A procedure code submitted with modifier 50 is a reimbursable service as set forth in this policy only when it is listed on the Oxford Bilateral Eligible Procedures List.

When a CPT or HCPCS code is reported with modifier 50 and the code is not

listed on the Bilateral Eligible Procedures Policy List, the code will not be reimbursed. CPT or HCPCS codes with 'bilateral' or 'unilateral or bilateral' written in the description are not on Oxford's Bilateral Eligible Procedures Policy List and will not be reimbursed with modifier 50.

There are rare instances in which a bilateral service may be performed on multiple sites and not just bilaterally. In those instances, use modifier 59 Distinct Procedural Service or XS Separate Structure to report the additional units beyond the bilateral services performed indicating that the services were performed on a different site or organ system. Medical record

documentation must support the use of modifier 59 or XS.

Procedure Codes with the Term "Bilateral" in the Description When CPT or HCPCS codes with "bilateral" or "unilateral or bilateral" written in the description are reported, special consideration will be given when reported with modifiers LT or RT.

When a CPT or HCPCS procedure code exists for both a unilateral and a Bilateral Procedure, select the code that best represents the procedure. For example: 40842 Vestibuloplasty; posterior, unilateral and 40843 Vestibuloplasty; posterior, bilateral.

Codes with "Bilateral" in the Description List

Consistent with CPT guidelines, if a unilateral procedure has not been defined by CPT or HCPCS and only a bilateral description of a procedure exists, report the code with "bilateral" in the description with modifier 52 (reduced services) when the procedure is performed unilaterally. For more information on reimbursement for reduced services, see Oxford's Reduced Services policy.


Oxford


UPDATED



Dec. 1, 2015

For Oxford purposes, when both modifiers LT and RT are reported separately for codes with "bilateral" in the description, only one charge will be eligible for reimbursement up to the respective Maximum Frequency per Day (MFD) value as the procedure is inherently bilateral. For additional information, refer to the Questions and Answers section, Q3A3. For more information on

maximum frequency per day values, see Oxford's Maximum Frequency Per

Day policy. When a procedure with "unilateral or bilateral" written in the description is performed unilaterally, then the CPT or HCPCS procedure code need not be reported with modifier 52 since the procedure description already indicates that the service can be performed either unilaterally or bilaterally. For

example: 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure). Codes with "Unilateral or Bilateral" in the Description List The use of modifiers LT or RT will be recognized as informational only when

the procedure with "unilateral or bilateral" in description is performed on only

one side. Consistent with CMS guidelines, when both modifiers LT and RT are reported separately on the same day by the same individual physician, hospital, ambulatory surgical center or other health care professional, only one charge will be eligible for reimbursement up to the maximum frequency per day limit.

For maximum frequency per day limits, see Oxford's Maximum Frequency Per Day policy. Modifier Definitions

Modifier Modifier Description

50

Bilateral Procedure Unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate five digit code.

59 Distinct Procedural Service Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from


Oxford


UPDATED



Dec. 1, 2015 other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must

support a different session, different procedure or surgery, different size or organ system, separate incision or excision,

separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive

modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service performed on the same date, see modifier 25.

XS

Separate Structure

A service that is distinct because it was performed on a separate organ/structure.

LT Left Side

RT Right Side

Co-Surgeons; Team Surgeon

Dec. 1, 2015


04 claim form, the 1500 Health Insurance Claim Form (a/k/a

CMS-1500), or their electronic

equivalents or their successor forms


physicians and other qualified health care professionals including, but not limited to, non-network authorized and percent of charge contract

Co-Surgeon Services Modifier 62 identifies a Co-Surgeon involved in the care of a patient at surgery. Each Co-Surgeon should submit the same Current Procedural Terminology (CPT) code with modifier 62. For services included on the Co-Surgeon Eligible List, Oxford will reimburse

Co-Surgeon services at 63% of the Allowable Amount to each surgeon

subject to additional multiple procedure reductions if applicable (see Multiple Procedure Reduction section). The Allowable Amount is determined independently for each surgeon and is calculated from the Allowable Amount that would be given to that surgeon performing the surgery without a Co-surgeon. The reimbursable percentage amount (63%) of allowable is based

on the rate adopted by the Centers for Medicare and Medicaid Services (CMS), which allows 62.5% of allowable to each Co-Surgeon. Exception: For New Jersey individual and small group plans, standard reimbursement is based on the 80th percentile of Prevailing Healthcare


Oxford


UPDATED


Co-Surgeons; Team Surgeon (continued)

Dec. 1, 2015

physicians and other qualified health care professionals

Charges System (PHCS). Team Surgeon Services Modifier 66 identifies Team Surgeons involved in the care of a patient during surgery. Each Team Surgeon should submit the same CPT code with modifier

66.

Each Team Surgeon is required to submit written medical documentation describing the specific surgeon's involvement in the total procedure. For services included on the Team Surgeon Eligible List, Oxford will review each submission with its appropriate medical documentation and will make reimbursement decisions on a case-by-case basis.

Co-Surgeon and Team Surgeon Eligible Lists The Co-Surgeon and Team Surgeon Eligible List are developed based on the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS) Relative Value File status indicators.

All codes in the NPFS with status code indicators "1" or "2" for "Co-Surgeons"

are considered by Oxford to be eligible for Co-Surgeon services as indicated by the co-surgeon modifier 62. Oxford applies the payment indicators for HCPCS codes G0412-G0415 when adjudicating CPT codes 27215-27218 for the purposes of this policy.

All codes in the NPFS with the status code indicators "1" or "2" for "Team Surgeons" are considered by Oxford to be eligible for Team Surgeon services as indicated by the team surgeon modifier 66.

CMS Files for Download Multiple Procedure Reductions

Multiple procedure reductions apply to Co-Surgeon and Team Surgeon claim submissions when one or more physicians are billing multiple CPT codes that are eligible for reductions. Refer to Oxford Multiple Procedures for application of multiple procedure reductions. Assistant Surgeon and Co-Surgeon Services During the Same Encounter


Oxford


UPDATED


Co-Surgeons; Team Surgeon (continued)

Dec. 1, 2015 Oxford follows CMS guidelines and does not reimburse for Assistant Surgeon services, as indicated by modifiers 80, 81, 82, or AS, for procedures where reimbursement has been provided for eligible Co-Surgeon services, using the same surgical procedure code, during the same encounter.

If a Co-Surgeon acts as an Assistant Surgeon in the performance of

additional procedure(s) during the same surgical session, the procedures are reimbursable services (if eligible per the Assistant Surgeon Eligible List) when indicated by separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. Simultaneous Bilateral Services

Simultaneous bilateral services are those procedures in which each surgeon performs the same procedure on opposite sides. Each surgeon should report the simultaneous bilateral procedures with modifiers 50 and 62. Assistant Surgeon services will not be reimbursed services in addition to the simultaneous bilateral submission as described in the Assistant Surgeon and Co-Surgeon Services During Same Encounter section in this policy.

Discontinued Procedures

Dec. 1, 2015




o All network and non-network providers, including hospitals,

ambulatory surgical centers, physicians and other qualified

health care professionals including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals

Under certain circumstances such as a serious risk to the patient's well-being, a surgical or diagnostic procedure is terminated at the physician, hospital, ambulatory surgical center or other health care professional's direction. Under these circumstances the procedure provided should be identified by its usual procedure code and the addition of Modifier 53 (Discontinued Procedure) signifying that the procedure was started but discontinued. This

provides a means of reporting the Discontinued Procedure leaving the identification of the basic service intact. According to the Centers for Medicare & Medicaid Services (CMS) and CPT coding guidelines, modifier 53 should be used with surgical codes or medical

diagnostic codes. Modifier 53 should not be used with: Evaluation and management (E/M) services

Elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite

When a laparoscopic or endoscopic procedure is converted to an open procedure or when a procedure is changed or converted to a more extensive procedure.

Oxford’s standard for reimbursement of Discontinued Procedures with


Oxford


UPDATED


Discontinued Procedures (continued)

Dec. 1, 2015 modifier 53 is 25% of the Allowable Amount for the primary unmodified procedure. Multiple procedure reductions will still apply. For procedures that are partially reduced or eliminated at the physician's direction, see Reduced Services (Modifier 52) policy.

Durable Medical Equipment, Orthotics and Prosthetics Multiple Frequency

Dec. 1, 2015





physicians and other qualified health care professionals including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals

Rental and Purchase Modifiers Some DME items are eligible for rental as well as for purchase. The codes representing these items are listed in Items Eligible for Rental or Purchase in the Attachments section below and must be reported with the appropriate rental or purchase modifier in order to be considered for reimbursement.

Some DME items are eligible for rental only. The codes representing these items are listed in Items Eligible for Rental Only in the Attachments section below and must be reported with the appropriate rental modifier in order to be considered for reimbursement.

Rental guidelines are explained further in the sections titled Monthly Rental and Daily Rental. Rental Modifiers The following modifiers indicate that an item has been rented: RR - Rental KH - Initial Claim, purchase or first month rental

KI - Second or third monthly rental KJ - Capped rental months four to fourteen KR - Partial month Purchase Modifiers

The following modifiers indicate that an item has been purchased: NU - New Equipment (use the NR modifier when DME which was new at

the time of rental is subsequently purchased) UE - Used Equipment NR - New when rented KM - Replacement of facial prosthesis including new impression/moulage KN - Replacement of facial prosthesis using previous master model

Monthly Rental


Oxford


UPDATED



(continued)

Dec. 1, 2015

Monthly rental of DME, Orthotics, or Prosthetics identified by the applicable code with a rental modifier RR and/or modifiers KH, KI, KJ, KR appended will be reimbursed once per Calendar month to the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional. A Calendar Month is the period of duration from a day of one month to the

corresponding day of the next month (please see Definitions) and is

determined based on the “From” date reported on the claim. If a code is submitted with modifier RR and/or modifiers KH, KI, KJ, KR with units greater than 1, or multiple times during the same Calendar Month, Oxford will only reimburse one monthly rate per Calendar Month to the Same Specialty Physician Hospital, Ambulatory Surgical Center or Other Health

Care Professional except where noted below. Modifiers RT and LT An additional rental rate will be allowed in the same Calendar Month for

codes with a rental modifier when both modifiers RT and LT are submitted for the same HCPCS code on separate lines. Modifiers RT and LT may be

used to report an item for the right or left side of the body. Use of these

modifiers may convey that multiples of that item are being utilized. Backup Ventilator: One additional rental rate will be allowed in the same

Calendar Month for a backup ventilator reported with a rental modifier plus modifier TW (backup equipment), appended to HCPCS codes E0450, E0460, E0461, E0463 or E0464.

Codes with Extension/Flexion, Supination/Pronation, or Each in the Description Up to two rental rates will be allowed in the same Calendar Month for codes with "extension/flexion," "supination/pronation" or "each" in the description.

These codes describe services where multiple devices may be reported. If these codes are reported with modifiers RT and LT and multiple units, Oxford will consider for separate reimbursement up to two units for each side for a

total of up to four rental rates in the same Calendar Month.

For additional information, refer to the Questions and Answers section, Q&A, and the Attachments section of this policy. Reporting Monthly Rental Monthly rental of DME, Orthotics, or Prosthetics should be reported on a 1500


Oxford


UPDATED



(continued)

Dec. 1, 2015

Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form according to the National Uniform Billing Committee (NUBC) and the National Uniform Claim Committee (NUCC) guidelines. The appropriate HCPCS code and rental modifier are submitted with one unit

for each Calendar Month time span. The rental initiation date is entered in the

"From" field, and the end date in the "To" field. In the following example, the rental for HCPCS code E1130 (Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests), is initiated on 1/10/2013, and the item is rented for 3 months, ending on 4/9/2013. The claim should be submitted as follows:

Code Modifier Units From Date To Date

E1130 RR 1 1/10/2013 2/9/2013

E1130 RR 1 2/10/2013 3/9/2013

E1130 RR 1 3/10/2013 4/9/2013

E1130-RR reported with 3 units, a From Date of 1/10/2013 and a To Date of 4/9/2013 on one line will result in reimbursement of only 1 unit. Daily Rental

Oxford will allow a daily rental for the following items to the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional. HCPCS codes E0935 (Continuous passive motion exercise device for use on knee only), and E0936 (Continuous passive motion exercise device for use other than knee) are reimbursed on a daily basis consistent with CMS

guidelines. The following HCPCS codes are also reimbursed on a daily basis: E0193 - Powered air flotation bed (low air loss therapy) E0194 - Air fluidized bed E0277 - Powered pressure-reducing air mattress

E0304 - Hospital bed, heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress

E0371 - Nonpowered advanced pressure reducing overlay for mattress,


Oxford


UPDATED



(continued)

Dec. 1, 2015

standard mattress length and width E0372 - Powered air overlay for mattress, standard mattress length and

width E0373 - Nonpowered advanced pressure reducing mattress E1639 - Scale, each

E2402 - Negative pressure wound therapy electrical pump, stationary or

portable Maintenance and Service Fees Oxford allows for reimbursement of maintenance and service once every six months to the Same Specialty Physician Hospital, Ambulatory Surgical Center or Other Health Care Professional. The appropriate HCPCS code appended

with modifier MS (maintenance/service fee) is required to identify such services. The Maintenance and Service modifier (MS), must be reported on a separate line in order to be considered for separate reimbursement from the rental or purchase of the equipment. Maintenance and Service agreements include the following:

Regular routine maintenance and performance checks as required to

maintain the warranty or performance standards Re-education Compliance with alerts and recalls necessary supplies in accordance with the applicable agreement Back-up equipment Emergency availability and replacement equipment when out-of-service for

repair For the purposes of this policy, maintenance and servicing does not apply

to Orthotics or Prosthetics.

HCPCS Codes A9900, A9901 and L9900 Delivery, set-up and supplies are included in the payment rates associated with a DME, Orthotic, or Prosthetic item. They are not reimbursable services

when submitted alone or with another service. Therefore, Oxford will not separately reimburse the following codes: A9900 - Miscellaneous DME supply, accessory, and/or service component

of another HCPCS code A9901 - DME delivery, set up, and/or dispensing service component of

another HCPCS code


Oxford


UPDATED



(continued)

Dec. 1, 2015 L9900 - Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS "L" code

Increased Procedural Services

Dec. 1, 2015





ambulatory surgical centers, physicians and other qualified


Oxford's standard for additional reimbursement of Modifier 22 (increased procedural services) and/or Modifier 63 (procedures performed on infants less than 4 kg) is 20% of the Allowable Amount for the unmodified procedure, not to exceed the billed charges. Claims submitted with these modifiers must include medical record documentation which supports the use of the modifiers and which will be reviewed by Oxford in accordance with this

policy. Note: When both modifier 22 and modifier 63 are appended to the same CPT code, reimbursement will be a total of an additional 20% of the Allowable Amount of the unmodified procedure, not to exceed the billed charges,

provided the documentation supports use of either Modifier 22 or Modifier 63.

Refer to the Obstetrical Policy for information on the use of Modifier 22 with obstetrical services. Modifier 22 - Increased Procedural Services In order to be considered for additional reimbursement when reporting Modifier 22, thorough medical records or reports and a separate document containing a concise statement about how the service differed from the usual

service or procedure is required. The documents must indicate the substantial additional work performed and the reason for the additional work which may include, but not be limited to, increased intensity or time, technical difficulty

of procedure that is not described by a more comprehensive procedure code, severity of the patient’s condition, or increased physical and mental effort required.

Additional reimbursement will only be considered for services appended with Modifier 22 that are assigned a global period of 0, 10, 42 or 90 days. Modifier 22 should not be appended to an evaluation and management service. Refer to the “Global Days Policy” for a listing of those codes with a global day period.


Oxford


UPDATED


Increased Procedural Services (continued)

Dec. 1, 2015 Modifier 63 - Procedure Performed on Infants less than 4 kg In order to be considered for additional reimbursement when reporting Modifier 63, thorough medical record(s) or report(s) that support the use of the modifier is required. The document(s) must indicate the substantial additional work performed and the reason for the additional work which may

include, but not be limited to, increased intensity or time, technical difficulty

of procedure that is not described by a more comprehensive procedure code, severity of the patient’s condition, or increased physical and mental effort required. Unless otherwise designated, this modifier may only be appended to procedures/services listed in the 20005-69990 code series. Modifier 63

should not be appended to any CPT code listed in the Evaluation and Management Services, Anesthesia, Radiology, Pathology/Laboratory, or Medicine sections.

Injection and Infusion Services

Dec. 1, 2015




o All network and non-network providers, including hospitals, ambulatory surgical centers, physicians and other qualified health care professionals

including, but not limited to, non-network authorized and

percent of charge contract physicians and other qualified health care professionals

Injections (96372-96379) and Evaluation and Management Services by Place of Service

Facility, Emergency Room, and Ambulatory Surgical Center Services Per CPT and the CMS National Correct Coding Initiative (NCCI) Policy Manual, CPT codes 96372-96379 are not intended to be reported by the physician in the facility setting. Thus, when an E/M service and a therapeutic and diagnostic injection service are submitted with CMS Place of Service (POS)

codes 21, 22, 23, 24, 26, 51, 52, and 61 for the same patient by the Same Individual Physician or Other Health Care Professional on the same date of service, only the E/M service will be reimbursed and the therapeutic and diagnostic Injection(s) are not separately reimbursed, regardless of whether a modifier is reported with the injection(s). Non-Facility Injection Services

E/M services provided in a non-facility setting are considered an inherent component for providing an injection service. CPT indicates these services typically require direct supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff. When a diagnostic and therapeutic Injection procedure is performed in a POS other than 21, 22, 23, 24, 26, 51, 52, and 61 and an E/M service is provided on the same date of service, by the Same Individual

Physician or Other Health Care Professional only the appropriate therapeutic and diagnostic injection(s) will be reimbursed and the EM service is not


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UPDATED


Injection and Infusion Services (continued)

Dec. 1, 2015

separately reimbursed. If a significant, separately identifiable EM service is performed unrelated to the physician work (injection preparation and disposal, patient assessment, provision of consent, safety oversight, supervision of staff, etc.) required for

the injection service, modifier 25 may be reported for the E/M service in

addition to 96372-96379. If the E/M service does not meet the requirement for a significant separately identifiable service, then modifier 25 would not be reported and a separate E/M service would not be reimbursed. Exceptions CPT 99211: E/M service code 99211 will not be reimbursed when submitted

with a diagnostic or therapeutic Injection code, with or without modifier 25. This very low service level code does not meet the requirement for "significant" as defined by CPT, and therefore should not be submitted in addition to the procedure code for the injection. CPT 99381-99429: The Preventive Medicine codes (99381-99429) do not

need modifier 25 to indicate a significant, separately identifiable service when

reported in addition to the diagnostic and therapeutic injection service. The Preventive Medicine codes include routine services such as the ordering of immunizations or diagnostic procedures. The performance of these services is to be reported in addition to the Preventive Medicine E/M code. Therefore, diagnostic and therapeutic Injections can be reported at the same time as a Preventive Medicine code without appending modifier 25.

CMS POS Database

E&M Codes for Injection Codes 96372-96379 Injection and Infusion Services (96360-96549) and HCPCS Supplies

Consistent with CPT guidelines, HCPCS codes identified by code description as standard tubing, syringes, and supplies are considered included when reported with Injection and Infusion services, CPT codes 96360-96549, and will not be separately reimbursed.

Injection and Infusion Inclusive Supplies

Note: Additional editing may be applicable to CPT codes 96360-96549 under the T Status Codes Policy.


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UPDATED


Injection and Infusion Services (continued)

Dec. 1, 2015 Drug Codes Oxford reimbursement policy is aligned with CMS and will separately reimburse for the HCPCS drug code when submitted with Injection or Infusion codes (CPT 96360-96549) by the Same Individual Physician or Other Health Care Professional on the same date of service under the guidelines of this

policy.

Microsurgery

Dec. 1, 2015



Insurance Claim Form (a/k/a CMS-1500), or their electronic equivalents or their successor forms


ambulatory surgical centers, physicians and other qualified health care professionals including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified


CPT Code 64727 Consistent with the CPT book coding guidelines for CPT code 64727, Oxford will only reimburse CPT code 64727 when submitted with internal neurolysis codes on the list of Services Allowed with CPT 64627.

The Centers for Medicare and Medicaid Services (CMS) Medicare Claims Processing Manual and the Correct Coding Initiative (CCI) state that CPT code 69990 is not to be reported in addition to CPT code 64727. CPT Code 69990 CMS reimbursement guidelines differ from the CPT book coding guidelines.

Oxford follows CMS reimbursement guidelines for reimbursement of 69990 with certain nervous system surgeries. Oxford will reimburse CPT code 69990 when billed in conjunction with services described in the List of Services Allowed with CPT 69990. The codes listed in this policy are for reference purposes only. Listing of a

service or device code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the Member’s plan of benefits or Certificate of Coverage. This list of codes may not be all inclusive.

Applicable CPT Codes

CPT® Code Description

64727 Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty includes external neurolysis)

69990 Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary

procedure)


Oxford


UPDATED


Modifier Reference Dec. 1, 2015 Updated reimbursement guidelines; added language to clarify this policy applies to: o Services reported using the UB-


Insurance Claim Form (a/k/a





Refer to the policy for complete details on applicable reimbursement guidelines.

One or More Sessions

Dec. 1, 2015




o All network and non-network

providers, including hospitals, ambulatory surgical centers,



Oxford will reimburse a CPT or HCPCS code only once during the Defined Treatment or Monitoring Period. The Defined Treatment Period mirrors the National Physician Fee Schedule (NPFS) global fee period. The Monitoring Period is in accordance with the

code description and/or coding guidelines. National Physician Fee Schedule Multiple submissions of the same CPT or HCPCS code by the Same Physician,

Hospital, Ambulatory Surgical Center or Other Health Care Professional for the same patient during the Defined Treatment Period or Monitoring Period

will be denied as part of the global service unless an appropriate modifier is reported. Refer to the Modifiers and Attachments sections of this policy. Services addressed in the One or More Sessions Policy may also be subject to global surgical package guidelines. Please refer to the Global Days policy for additional information.


Oxford


UPDATED


One or More Sessions (continued)

Dec. 1, 2015 Modifiers Modifiers offer the physician, hospital, ambulatory surgical center or healthcare professional a way to identify that a service or procedure has been altered in some way. Under appropriate circumstances, modifiers should be used to identify unusual circumstances, staged or related procedures, distinct

procedural services or separate anatomical location(s).

Oxford recognizes the following designated modifiers, when appropriately reported, under this reimbursement policy:


LT Left side (used to identify procedures performed on the left side of the body)

RT Right side (used to identify procedures performed on the left side

of the body)

50 Bilateral procedure

52 Reduced services

53 Discontinued procedure

54 Surgical care only

55 Postoperative management only

56 Preoperative management only

79

Unrelated Procedure or Service by the Same Physician or Other

Qualified Health Care Professional During the Postoperative Period

Preventive Medicine and Screening

Dec. 1, 2015

Updated reimbursement guidelines: o Added language to clarify this

policy applies to: Services reported using the

UB-04 claim form, the 1500 Health Insurance Claim Form (a/k/a CMS-1500), or

Refer to the policy for complete details on the reimbursement guidelines for Preventive Medicine and Screening.


Oxford


UPDATED


Preventive Medicine and Screening (continued)

Dec. 1, 2015 their electronic equivalents or their successor forms

All network and non-network providers, including hospitals, ambulatory

surgical centers, physicians

and other qualified health care professionals including, but not limited to, non-network authorized and percent of charge contract physicians and other

qualified health care professionals

o Reorganized/reformatted list of Codes Included in Preventive Medicine Services; split CPT and HCPCS code listings into

separate tables

Prolonged Services

Dec. 1, 2015





providers, including hospitals, ambulatory surgical centers,



Oxford reimburses Prolonged Services with Direct Patient Contact when reported with E/M codes in which time is a factor in determining level of service in accordance with CPT guidelines. Physicians, hospitals, ambulatory surgical centers or other health care professionals should report only Prolonged Services with Direct Patient Contact beyond the typical duration of

the service on a given date, even if the time spent by the physician or other care professional is not continuous. Providers should not include the time devoted to performing separately reportable services when determining the amount of prolonged services time. For example, the time devoted to performing cardiopulmonary resuscitation (CPT code 92950) should not be

included in prolonged services time. A prolonged service of less than 30 minutes total duration on a given date is not separately reported because the

work involved is included in the total work of the evaluation and management codes.

Report CPT code 99354 (office or outpatient place of service codes) for the

first hour of prolonged services. This code should be used only once per date, and prolonged services must exceed 30 minutes in order to report this service.

Report CPT code 99355 (office or outpatient place of service codes) for


Oxford


UPDATED


Prolonged Services (continued)

Dec. 1, 2015 each additional 30 minutes beyond the first 60 minutes of prolonged services. Additional services must exceed 15 minutes in order to report this service.

Report CPT code 99356 (inpatient place of service code) for the first hour of prolonged services. This code should be used only once per date, and

prolonged services must exceed 30 minutes in order to report this service.

Report CPT code 99357 (inpatient place of service code) for each additional 30 minutes beyond the first 60 minutes of prolonged services. Additional services must exceed 15 minutes in order to report this service.

According to CPT, prolonged service codes 99354-99357 are considered add-on codes and should not be reported without the appropriate primary code.

Refer to Oxford’s Add-on Policy for details. Prolonged services for labor and delivery are not separately reimbursable services as described in American College of Obstetricians and Gynecologists (ACOG) coding guidelines, prolonged services are not reported for services that do not have a time component such as labor and delivery management.

Refer to the Obstetrical Policy for more information.

In accordance with The Centers for Medicare Services (CMS).Prolonged Services without Direct Patient Contact (CPT codes 99358-99359) will not be separately reimbursed.

Reduced Services

Dec. 1, 2015

Updated reimbursement

guidelines; added language to clarify this policy applies to: o Services reported using the UB-


CMS-1500), or their electronic equivalents or their successor

forms o All network and non-network

providers, including hospitals, ambulatory surgical centers, physicians and other qualified health care professionals

including, but not limited to,

There are no industry standards for reimbursement of claims billed with

modifier 52 from the Centers for Medicare and Medicaid Services (CMS) or other professional organizations. Oxford's standard for reimbursement of modifier 52 is 50% of the Allowable Amount for the unmodified procedure. This modifier is not used to report the elective cancellation of a procedure

before anesthesia induction, intravenous (IV) conscious sedation, and/or surgical preparation in the operating suite.

Modifier 52 should not be used with an evaluation and management (E/M) service.


Oxford


UPDATED


Reduced Services (continued)

Dec. 1, 2015 non-network authorized and percent of charge contract physicians and other qualified health care professionals

Robotic-Assisted

Surgery

Dec. 1, 2015



04 claim form, the 1500 Health Insurance Claim Form (a/k/a CMS-1500), or their electronic


o All network and non-network providers, including hospitals, ambulatory surgical centers, physicians and other qualified


According to the Centers for Medicare and Medicaid Services (CMS), medical

and surgical procedures should be reported with the Current Procedural Terminology (CPT®)/Health Care Common Procedure Coding System (HCPCS) codes that most comprehensively describe the services performed. Oxford considers code S2900, (Surgical techniques requiring use of robotic surgical system [list separately in addition to code for primary procedure]) to

be a technique integral to the primary surgical procedure and not a separately reimbursed service. When a surgical procedure is performed using code S2900, reimbursement will be considered included as part of the primary surgical procedure. Use of Modifier 22 (increased procedural services) appended to the primary

surgical procedure is not appropriate if used exclusively for the purpose of reporting the use of robotic assistance. Modifier 22 may only be used when substantial additional work is performed, (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, and physical and mental effort required) that is unrelated to robotic assistance. Documentation must demonstrate the reason for the substantial additional work performed during the surgical procedure. See the Oxford Increased

Procedural Services Reimbursement Policy for additional information on modifier 22.

Same Day/Same Service

Dec. 1, 2015





providers, including hospitals,

The Medicare Claims Processing Manual states: "Physicians in the same group practice who are in the same specialty must

bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same

day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.


Oxford


UPDATED


Same Day/Same Service (continued)

Dec. 1, 2015

ambulatory surgical centers, physicians and other qualified health care professionals including, but not limited to, non-network authorized and

percent of charge contract


Contractors pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not. The inpatient hospital visit descriptors contain the phrase “per day” which means that the code and the payment established for the code represent all services provided on that date. The physician should select a code that

reflects all services provided during the date of the service.

In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, contractors do not pay physician B for the second visit. The hospital visit descriptors include the phrase “per day” meaning care for the day.

If the physicians are each responsible for a different aspect of the patient’s care, pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses.” The National Correct Coding Initiative Policy Manual states:

"Procedures should be reported with the most comprehensive CPT code that

describes the services performed. Physicians must not unbundle the services described by a HCPCS/CPT code. A physician should not report multiple HCPCS/CPT codes when a single comprehensive HCPCS/CPT code describes these services."

Consistent with Medicare, Oxford's Same Day/Same Service policy recognizes physicians or other health care professionals of the same group and specialty as the same physician, physician subspecialty is not considered. According to correct coding methodology, physicians are to select the code that accurately

identifies the service(s) performed. Multiple E/M services, when reported on the same date for the same patient by the same specialty physician, will be subject to edits used by and sourced to third party authorities. As stated

above, physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. Edit Sources Oxford sources its Same Day Same Service edits to methodologies used and recognized by third party authorities. Those methodologies can be definitive or interpretive. A definitive source is one that is based on very specific


Oxford


UPDATED



Dec. 1, 2015

instructions from the given source. An interpreted source is one that is based on an interpretation of instructions from the identified source. Please see the edit types section below for further explanations of these sources. The sources used to determine if a Same Day Same Service edit is appropriate are as follows:

Current Procedural Terminology book (CPT®) from the American Medical

Association (AMA); CMS National Correct Coding Initiative (CCI) edits; CMS Policy; and Physician specialty societies (e.g., American Academy of Orthopaedic

Surgeons (AAOS), American College of Obstetricians and Gynecologists (ACOG), American College of Cardiology, and Society of Cardiovascular

Interventional Radiology. Edit Types The following are edit types that may be applied in the Same Day Same Service Policy. CCI Definitive: An edit sourced to specific billing guidelines from the

General Correct Coding Policies contained in the National Correct Coding

Policy Manual published by CMS. For example, the Evaluation and Management Services section (chapter xi) specifically states "A physician should not report an 'initial' per diem E&M service with the same type of 'subsequent' per diem service on the same date of service." Oxford will not separately reimburse for an initial and a subsequent per diem service on the same date, such as 99223 and 99232.

CMS Definitive: An edit sourced to a specific billing guideline from CMS. For example, the Medicare Claims Processing Manual states "If the same physician who admitted a patient to observation status also admits the patient to inpatient status from observation before the end of the date on

which the patient was admitted to observation, pay only an initial hospital visit for the evaluation and management services provided on that date." Oxford will not separately reimburse for an initial observation care service

on the same date as an initial hospital care service, such as 99218 and 99222.

CPT Definitive: An edit sourced to specific CPT® book direction related to the reporting of exact codes or modifiers. For example, the CPT coding book states "Do not report 94002-94004 in conjunction with Evaluation and Management services 99201-99499." Oxford will not separately reimburse for any service in the range 94002-94004 when reported with


Oxford


UPDATED



Dec. 1, 2015

any service in the range of 99201-99499. CCI Interpretive: CMS does not always create a comprehensive set of

edits between similar codes because of its target population and certain code sets that it does not recognize. Oxford, however, may include edits which have been created between similar codes based on an interpretation

or extrapolation of the existing CCI edits. Examples of these codes include

newborn services, preventive medicine services and other CPT and HCPCS codes for which CMS has indicated the code is invalid for Medicare.

CMS Interpretive: The CMS National Correct Coding Initiative Policy Manual cites certain specialty specific services which primarily involve evaluation and management services. When these specialty specific codes are reported, a separate evaluation and management service from the

range of CPT codes 99201-99499 should not be reported on the same date of service. Examples of these codes include general and special ophthalmologic services and general and special diagnostic and therapeutic psychiatric services.

CPT Interpretive: Based on Current Procedural Terminology (CPT) code definition, when a service is a component that is necessary to complete the

primary service, it is by definition included in the reimbursement of that

primary service. Examples of this would be codes that include words or phrases that indicate they include other services. For instance certain evaluation and management codes have descriptions that state "...admission and discharge on the same date..." By definition an initial observation care service or an initial hospital care service would be a component necessary to complete the primary service.

Significant, Separately Identifiable Evaluation and Management Service According to the CPT® book "It may be necessary to indicate that on the day

a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and

postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service)..." Oxford will allow modifier 25 to indicate a significant and separately identifiable E/M service when a second physician in the same group and


Oxford


UPDATED



Dec. 1, 2015 specialty provides a separate E/M service on the same day for an unrelated problem. However, there are instances when modifier 25 would not be appropriate to report, including but not limited to, reporting two E/M services where one is a "per day" code or reporting separate services when a more comprehensive code exists that describes the services.

Split Surgical Package

Dec. 1, 2015





physicians and other qualified health care professionals including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals

Consistent with the Centers for Medicare and Medicaid Services (CMS), Oxford considers the surgical care rendered by the Same Group Physician and/or Other Health Care Professional to include pre-operative management. Accordingly, in Split Surgical Package situations, the pre-operative and surgical care portions of the Surgical Package are combined by Oxford in the reimbursement of surgical codes appended with modifier 54. Preoperative

care is not reimbursed separately. Postoperative care management may be reimbursed separately when a physician or other health care professional who is not within the Same Group Practice as the operating physician provides the postoperative care as denoted by submission of the surgical code appended with modifier 55.

Split surgical package situations will be reimbursed not to exceed 100% of the total global surgical allowable amount, and are reimbursable at the percentages indicated:

Modifier Modifier Description Percentage

54 Surgical Care Only (includes preoperative and surgical care management)

80%

55 Postoperative Management only 20%

56 Preoperative Management only 0%

TOTAL 100%

Standby Services

Dec. 1, 2015





Centers for Medicare and Medicaid Services

The Centers for Medicare and Medicaid Services (CMS) does not reimburse for physician standby services. These services are considered by CMS to be included in the payment to a facility as part of providing quality care and are

not separately reimbursable. Standby Services In accordance with CMS, Oxford does not reimburse physician or other qualified health care professional standby services submitted with CPT code 99360. If a specific service is directly rendered to the patient by the standby


Oxford


UPDATED


Standby Services (continued)

Dec. 1, 2015 providers, including hospitals, ambulatory surgical centers, physicians and other qualified health care professionals including, but not limited to,

non-network authorized and

percent of charge contract physicians and other qualified health care professionals

physician or other qualified health care professional (i.e., tissue examination of frozen section biopsy), the service or procedure would be reported under the appropriate CPT code (i.e., 88331). Mandated Hospital On Call Service

Oxford does not reimburse for hospital mandated on call services billed under

CPT codes 99026 and 99027 because they do not involve direct patient contact. The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is

determined by the Member’s plan of benefits or Certificate of Coverage. This list of codes may not be all inclusive. Non Reimbursable CPT Codes:


99026 Hospital mandated on call service; in-hospital, each hour

99027 Hospital mandated on call service; out-of-hospital, each hour

99360

Physician standby service, requiring prolonged physician

attendance, each 30 minutes (e.g., operative standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG)

CPT® is a registered trademark of the American Medical Association.

Supply Policy

Dec. 1, 2015





Supply Reimbursement for a Physician, Hospital, Ambulatory Surgical Center or Other Qualified Health Care Professional Pursuant to Centers for Medicare and Medicaid Services (CMS) policy, certain HCPCS supply codes are not separately reimbursable as the cost of supplies

is incorporated into the Practice Expense Relative Value Unit (RVU) for the Evaluation and Management (E/M) service or procedure code. Consistent with CMS, 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 by a physician, hospital, ambulatory surgical center, or other qualified health care professional.

The Oxford Supply Policy Codes List (see the Attachment section below) contains the codes that are not separately reimbursable under this policy. It


Oxford


UPDATED


Supply Policy (continued)

Dec. 1, 2015

health care professionals including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified


is developed based on the CMS National Physician Fee Schedule (NPFS) Relative Value File and consists of codes that based on their descriptions, CMS considers part of the practice expense and not separately reimbursable. Supplies, Purchased Durable Medical Equipment (DME), Orthotics,

Prosthetics, Biologicals and Drugs submitted with a J Code Reported

with a Facility Place of Service 21, 22, 23, 24 CMS follows a Prospective Payment System (PPS) where Medicare payment is based on a predetermined, fixed amount payable to a facility for inpatient or outpatient hospital services. In addition, CMS reimburses ambulatory surgery centers under an Ambulatory Payment Classification (APC) payment methodology. With these fixed rates all costs associated with drugs and

supplies are also deemed included in the global payment to the facility and 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, purchased DME, orthotics, prosthetics, biological,

and drugs reported with a HCPCS J code when submitted on a CMS-1500 claim form by any physician or other qualified healthcare professional in the following facility POS 21, 22, 23, and 24.

The purchase of certain DME, orthotics, and prosthetics will not be separately reimbursed when reported by a physician or other qualified health care professional on a CMS-1500 claim form in POS 21, 22, 23 or 24 and the

services are reported with no modifier or with one of the following purchase modifiers: NU New Equipment (use the NR modifier when DME which was new at the

time of rental is subsequently purchased). UE Used Equipment

NR New when rented KM Replacement of facial prosthesis including new impression/moulage

KN Replacement of facial prosthesis using previous master model

Please refer to the attachments below for a list of those codes/services that

are not separately reimbursable in POS 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


Oxford


UPDATED



Dec. 1, 2015

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 the facility and not reimbursed separately when reported by a physician or other qualified health care professional on a CMS-1500 claim form with one of the

following facility POS:

POS 31: Skilled Nursing Facility POS 32: Nursing Facility

Please refer to the attachments below for a list of codes/services that are not separately reimbursable in POS 31 and 32. 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, hospitals, ambulatory surgical centers 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, hospitals, ambulatory surgical centers 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 or other qualified health care professional 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 not reported with at least one of these CPT codes, HCPCS codes A4648 and A4650 are not separately reimbursable. 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, hospital, ambulatory surgical center or other qualified health care


Oxford


UPDATED



Dec. 1, 2015 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.

T Status Codes

Dec. 1, 2015


guidelines; added language to


04 claim form, the 1500 Health Insurance Claim Form (a/k/a CMS-1500), or their electronic equivalents or their successor

forms o All network and non-network

providers, including hospitals, ambulatory surgical centers, physicians and other qualified health care professionals

including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals

Per the public use file that accompanies the NPFS Relative Value File, the

following is stated for status indicator "T":

"There are RVUs and payment amounts for these services, but they are only

paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made."

Consistent with CMS, Oxford considers Current Procedural Terminology (CPT®) and Healthcare Common Procedural Coding System (HCPCS) codes with a status indicator of T bundled into any other service provided, on the same date by the Same Individual Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, for which payment is made. No

modifier overrides will exempt T status codes from bundling into the services for which payment is made.

In the case of two T status codes being billed together with no other service, on the same date of service by the Same Individual Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, Oxford will bundle the code with the lower relative value unit (RVU) into the code with the higher RVU.

Telemedicine

Dec. 1, 2015






Refer to the policy for complete details on the reimbursement guidelines for

Telemedicine.


Oxford


UPDATED


Telemedicine (continued)

Dec. 1, 2015 health care professionals including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified


Urgent Care

Dec. 1, 2015





ambulatory surgical centers, physicians and other qualified health care professionals including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified


The American Medical Association Current Procedural Terminology (CPT®) Professional Edition gives the following instruction for code selection: “Select the name of the procedure or service that accurately identifies the service performed.”

According to Centers for Medicare and Medicaid Services (CMS), Place of Service (POS) Codes Database: “Place of service codes and descriptions should be used on professional claims to specify the entity where service(s) were rendered.” Consistent with CPT® and CMS, physicians and other healthcare professionals

should report the evaluation and management, and/or procedure code(s) that specifically describe the service(s) performed. Additionally a place of service code should be utilized to report where service(s) were rendered. Oxford will not reimburse S9088 (Services provided in an urgent care center (list in addition to code for service). S9088 is informational as it pertains to the place of service not the specific service provided.

The Current Procedural Terminology (CPT®) codes and Healthcare Common Procedure Coding System (HCPCS) codes listed in this policy are for reference purposes only. Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service.

Coverage is determined by the member specific benefit document and applicable laws that may require coverage for a specific service. The inclusion

of a code does not imply any right to reimbursement or guarantee claims payment. Other policies and coverage determination guidelines may apply. This list of codes may not be all inclusive.

HCPCS Code Description

S9088 Services provided in an urgent care center (List in addition to code for service)


Oxford


REVISED

Policy Title

Effective

Date Summary of Changes Reimbursement Guidelines

Maximum Frequency Per Day

Dec. 1, 2015

Revised reimbursement guidelines: o Added language to clarify this

policy applies to: Services reported using the

UB-04 claim form, the 1500 Health Insurance Claim Form (a/k/a CMS-1500), or their electronic equivalents or their successor forms

All network and non-network providers, including hospitals,

ambulatory surgical centers, physicians and other qualified health care professionals

including, but not limited to, non-network authorized and percent of charge contract


o Updated Maximum Frequency Per Day Code List (attachment file detailing the maximum frequency per day value assignments for CPT and HCPCS

codes); removed 97010, 97012, 97014, 97016, 97018, 97022,

97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97532, 97533, 97535, 97537,

97542, 97545, 97546, 97750, 97760, 97761, 97762 and G0283

o Updated list of Codes Restricting

MFD Determination: Part I The following criteria are first used to determine the MFD values for codes to

which these criteria are applicable:

The service is classified as bilateral (CMS Indicators 1 or 3) on the Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule (NPFS) or the term 'bilateral' is included in the code descriptor. For the

majority of these codes, the MFD value is 1. There are some codes that describe more than one anatomical site or vertebral level that can be treated bilaterally where the MFD value may be more than 1.

Where the CPT or HCPCS code description/verbiage references reporting the code once per day, the MFD value is 1.

The service is anatomically or clinically limited with regard to the number of times it may be performed, in which case the MFD value is established

at that value.

The CPT or HCPCS code description/verbiage indicates the number of times the service can be performed, in which case the MFD value is set at that value.

CMS Durable Medical Equipment Medicare Administrative Contractor (DMEMAC) Local Coverage Determination (LCD) assigns an MFD value in which case the MFD value is set at that value.

Where the criteria above have not defined an MFD value, the CMS Medically Unlikely Edits (MUE) value, where available, will be utilized to establish an MFD value.

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.

Where no other definitive value has been established based on the criteria above, unlisted CPT and HCPCS codes will have an MFD value of 999 which indicates they are exempt from the MFD policy.

Where no other definitive value has been established based on the criteria above, new CPT codes released by the American Medical Association and new HCPCS codes released by CMS since the last MFD value update (not covered by any of the above criteria), will have an MFD value of 100.

MFD Determination: Part II


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Maximum Frequency Per Day (continued)

Dec. 1, 2015

Modifiers LT and RT (attachment file detailing codes that allow up to the MFD limit that have “bilateral” or “unilateral or

bilateral” in the description or

where the concept of laterality does not apply); removed 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97110, 97112,

97113, 97116, 97124, 97140, 97150, 97530, 97532, 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97760, 97761, 97762 and G0283

When none of the criteria listed in Part I apply to a code, data analysis is conducted to establish MFD values according to common billing patterns. When a code has 50 or more claim occurrences in a data set, the MFD

values are determined through claim data analysis and are set at the

100th percentile (i.e. the highest number of units billed for that CPT or

HCPCS code in the data set). If the 100th percentile exceeds the 98th percentile by a factor of four, the MFD will be set at the 98th percentile.

When a code has less than 50 claim occurrences in a data set, the MFD values will be set at the default of 100 until the next annual analysis.

In any case where, in Oxford's judgment, the 98th percentile does not account for the clinical circumstances of the services billed, the MFD for a

code may be increased so as to capture only obvious billing submission and data entry errors.

The "MFD per Day Policy List" list below contains the most current MFD values.

Maximum Frequency Per Day List Reimbursement The MFD values apply whether a physician, hospital, ambulatory surgical

center, or other health care professional submits one CPT or HCPCS code with multiple units on a single claim line or multiple claim lines with one or more unit(s) on each line. It is common coding practice for some CPT and HCPCS codes to be submitted with multiple units. However, when reporting the same CPT or HCPCS code on multiple and/or separate claim lines, the claim line may be classified as a duplicate service and/or may be subject to additional Oxford reimbursement policies.

Services provided are reimbursable services up to and including the MFD value for an individual CPT or HCPCS code. In some instances, a modifier may be necessary for correct coding and corresponding reimbursement purposes.

Bilateral payment via the use of modifiers LT or RT is inappropriate for procedures, services, and supplies where the concept of laterality does not apply. Oxford will pay up to the maximum frequency per day value for codes with "bilateral" or "unilateral or bilateral" in description or for codes where


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the concept of laterality does not apply, whether submitted with or without modifiers LT and/or RT by the same individual physician, hospital, ambulatory surgical center, or other healthcare professional on the same date of service for the same member. Use of modifiers LT and/or RT on the

codes identified in the "Codes Restricting Modifiers LT and RT" list will be

considered informational only.

Codes Restricting Modifiers LT and RT

There may be situations where a physician, hospital, ambulatory surgical center, or other healthcare professional reports units accurately and those units exceed the established MFD value. In such cases, Oxford will consider additional reimbursement if reported with an appropriate modifier such as modifier 59, 76, 91, XE, XS or XU. Medical records are not required to be

submitted with the claim when modifiers 59, 76, 91, XE, XS or XU are appropriately reported. Documentation within the medical record should reflect the number of units being reported and should support the use of the

modifier. Modifiers

Modifier Modifier Description

59

Distinct Procedural Service Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from

other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must

support a different session, different procedure or surgery, different size or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in

extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used. Note: Modifier 59


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should not be appended to an E/M service. To report a separate and distinct E/M service performed on the same date, see modifier 25.

76

Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional

It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service.

Note: This modifier should not be appended to an E/M service. To report a separate and distinct E/M service performed on the same date, see modifier 25. It is also inappropriate to use modifier 76 to indicate repeat laboratory services. Modifiers 59 or 91 should be used to indicate repeat or distinct laboratory services, as appropriate according to the AMA and CMS.

Separate consideration for reimbursement will not be given to

laboratory codes reported with modifier 76.

91

Repeat Clinical Diagnostic Laboratory Test In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances,

the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91. Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (eg, glucose

tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.

XE Separate Encounter A service that is distinct because it occurred during a separate

encounter.

XS Separate Structure A service that is distinct because it was performed on a separate organ/structure.


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XU Unusual Non-Overlapping Service The use of a service that is distinct because it does not overlap usual components of the main service.

Anatomic Modifiers

Modifier


E1 Upper left eyelid

E2 Lower left eyelid

E3 Upper right eyelid

E4 Lower right eyelid

F1 Left hand, second digit

F2 Left hand, third digit

F3 Left hand, fourth digit

F4 Left hand, fifth digit

F5 Right hand, thumb

F6 Right hand, second digit

F7 Right hand, third digit

F8 Right hand, fourth digit

F9 Right hand, fifth digit

FA Left hand, thumb

LC Left circumflex coronary artery

LD Left anterior descending coronary artery

LM Left main coronary artery

LT Left side

RC Right coronary artery

RI Ramus intermedius coronary artery

RT Right side

T1 Left foot, second digit

T2 Left foot, third digit

T3 Left foot, fourth digit

T4 Left foot, fifth digit

T5 Right foot, great toe

T6 Right foot, second digit

T7 Right foot, third digit


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Dec. 1, 2015 T8 Right foot, fourth digit

T9 Right foot, fifth digit

TA Left foot, great toe

Moderate Sedation

Dec. 1, 2015

Revised reimbursement guidelines:

o Added language to clarify this policy applies to: Services reported using the

UB-04 claim form, the 1500 Health Insurance Claim Form (a/k/a CMS-1500), or their

electronic equivalents or their successor forms

All network and non-network providers, including hospitals, ambulatory surgical centers, physicians and other qualified


o Updated list of Procedures that

include Moderate Sedation Codes 99143-99145 list (attachment file detailing procedures that do not allow separate reimbursement for moderate

sedation CPT codes 99143-99145); added 0387T and 0388T

Attending Physician (99143-99145)

Oxford will allow separate reimbursement for Moderate Sedation services reported as CPT codes 99143-99145 when provided by the Same Physician, hospital, ambulatory surgical center, or other qualified health care professional reporting the diagnostic or therapeutic procedure except when reported with:

1. Procedures listed in Appendix G of the CPT book 2. Anesthesia procedures (CPT codes 00100-01999) 3. CPT and HCPCS codes that are part of CMS NCCI edits These procedures include Moderate Sedation as an inherent part of providing the service. Refer to the list below for a comprehensive listing of the non-

anesthesia procedures that include Moderate Sedation and for which CPT codes 99143-99145 will not be considered separately. Procedures that include Moderate Sedation codes (99143-99145) Note: Procedure codes that are listed in Appendix G of the CPT book that are also identified on the National Physicians Fee Schedule (NPFS) as Status B

are addressed in the B Bundle Codes Policy. Second Physician (99148-99150) Moderate Sedation services performed by a second physician, hospital, ambulatory surgical center, or other qualified health care professional (who

is not performing the diagnostic or therapeutic procedure that the sedation supports), should be reported as CPT codes 99148-99150. Reimbursement of

CPT codes 99148-99150 based on the place of service is as follows: Non-facility setting According to the AMA “When moderate sedation is performed in the non-facility setting, the efforts of the second physician are not reported with the codes in Appendix G because moderate sedation is included in these codes.

Therefore, it would not be appropriate to separately report for moderate


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Moderate Sedation (continued)

Dec. 1, 2015

sedation.” Based on AMA guidelines, Oxford will reimburse CPT codes 99148-99150 in a non-facility setting except when a procedure code listed in Appendix G of the CPT codebook is also reported on the same date of service by the same physician or other qualified health care professional.

Facility setting Moderate Sedation services reported as CPT codes 99148-99150 that are performed by a second physician, hospital, ambulatory surgical center, or other qualified health care professional in a facility place of service (see listing below) are eligible for reimbursement.

For purposes of this policy a facility place of service would include any of the following locations: 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room-Hospital 24 Ambulatory Surgical Center

26 Military Treatment Facility

31 Skilled Nursing Facility 34 Hospice 41 Ambulance - Land 42 Ambulance - Air or Water 51 Inpatient Psychiatric Facility 52 Psychiatric Facility - Partial Hospitalization

53 Community Mental Health Center 56 Psychiatric Residential Treatment Center 61 Comprehensive Inpatient Rehabilitation Facility

Drug Reimbursement The cost of the drug used in Moderate Sedation, if supplied by the physician in a location other than inpatient/outpatient hospital, emergency room or

ambulatory surgical center, is reimbursable at the appropriate fee schedule or contracted rate. For additional information on drugs supplies in an inpatient/outpatient hospital, emergency room or ambulatory surgical center, refer to the Supply Policy. The Current Procedural Terminology (CPT®) codes and Healthcare Common Procedure Coding System (HCPCS) codes listed in this policy are for


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reference purposes only. Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the member specific benefit document and applicable laws that may require coverage for a specific

service. The inclusion of a code does not imply any right to reimbursement or

guarantee claims payment. Other policies and coverage determination guidelines may apply. This list of codes may not be all inclusive.


99143

Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patients level of consciousness and physiological status;

under 5 years of age, first 30 minutes intra-service time

99144

Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of

the patients level of consciousness and physiological status; age 5 years or older, first 30 minutes intra-service time

99145

Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician performing the diagnostic or therapeutic service

that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of

the patients level of consciousness and physiological status; each additional 15 minutes intra-service time (List separately in addition to code for primary service)

99148

Moderate sedation services (other than those services

described by codes 00100-01999), provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; under 5 years of age, first 30 minutes intra-service time


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99149

Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the health care professional performing the

diagnostic or therapeutic service that the sedation supports; age 5 years or older, first 30 minutes intra-

service time

99150

Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the health care professional performing the

diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intra-service time (List separately in addition to code for primary service)

CPT® is a registered trademark of the American Medical Association.

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