oxford health plansedits; added l8679 onfi (clobazam) feb. 1, 2014 • updated description of...

Policy Update Bulletin

A monthly notice of recently approved and/or revised clinical, administrative and reimbursement policies is provided below for your review. By clicking on a policy title in the following table, you may view the new or updated policy version, in its entirety, along with an overview or summary of changes. The appearance of an item or procedure in this bulletin indicates only that Oxford® has recently adopted or reviseda clinical, administrative or reimbursement policy; it doesnot imply that Oxford® provides coverage for the items orprocedures listed. 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.

Medical and Administrative Policy Classifications

• New: New clinical coverage criteria and/or documentation review requirements have been adopted for a service, procedure, test, drug 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

January 2014

Take Note Page Annual CPT® and HCPCS Code Updates................................................................................................. 4

Clinical Policy Updates New: Enzyme Replacement Therapy for Gaucher Disease - Effective Feb. 1, 2014......................................... 7 Updated: Drug Coverage Guidelines - Effective Feb. 1, 2014.................................................................................. 7 Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation - Effective Feb. 1, 2014..... 7 Elidel® (pimecrolimus) and Protopicl® (tacrolimus) - Effective Feb. 1, 2014........................................ 8 Fulyzaq (Crofelemer) - Effective Feb. 1, 2014.......................................................................................... 8 Gattex (Teduglutide [Rdna Origin]), for Injection, for Subcutaneous Use - Effective Feb. 1, 2014........ 8 Occipital Neuralgia and Cervicogenic Cluster and Migraine Headaches - Effective Feb. 1, 2014........... 8 Onfi (Clobazam) - Effective Feb. 1, 2014................................................................................................. 8 Vagus Nerve Stimulation - Effective Feb. 1, 2014.................................................................................... 8 Revised: Abnormal Uterine Bleeding and Uterine Fibroids - Effective Feb. 1, 2014.............................................. 8 Agents for Migraine - Triptans - Effective Feb. 1, 2014........................................................................... 9 Biologics in the Treatment of Skin, Joint and Gastrointestinal Conditions - Triptans - Effective Feb. 1,

2014........................................................................................................................................................... 9 Blepharoplasty, Blepharoptosis and Brow Ptosis Repair - Triptans - Effective Feb. 1, 2014................... 9 Botulinum Toxins A and B - Effective Feb. 1, 2014................................................................................. 10 Campath (Alemtuzumab) - Effective Feb. 1, 2014.................................................................................... 10 Cardiology Procedures for CareCore National Arrangement - Effective Apr. 1, 2014............................. 10

(continued on next page)

Policy Update Bulletin | January 2014 For more information, visit oxfordhealth.com

January 2014

Clinical Policy Updates (continued) Page Revised: Cardiology Procedures Requiring Precertification - Effective Apr. 1, 2014............................................. 10 Clotting Factors and Coagulant Blood Products - Effective Feb. 1, 2014................................................. 10 Compounds and Bulk Powders - Effective Feb. 1, 2014........................................................................... 10 Contraceptives - Effective Feb. 1, 2014.................................................................................................... 11 Deep Brain Stimulation - Effective Feb. 1, 2014...................................................................................... 11 Drug Coverage Criteria - New and Therapeutic Equivalent Medications - Effective Feb. 1, 2014.......... 11 Forteo (Teriparatide) - Effective Feb. 1, 2014........................................................................................... 11 Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable - Effective

Feb. 1, 2014............................................................................................................................................... 11 Hip Resurfacing Arthroplasty - Effective Feb. 1, 2014............................................................................. 12 Home Health Care - Effective Feb. 1, 2014.............................................................................................. 12 Icatibant (Firazyr) and C1 Esterase Inhibitors Human (Berinert) - Effective Feb. 1, 2014...................... 12 Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors - Effective Feb. 1, 2014. 12 Infertility Procedures Requiring Notification and/or Precertification - Effective Feb. 1, 2014................ 12 Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines - Effective

Feb. 1, 2014............................................................................................................................................... 13 Oral Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines - Effective Feb. 1,

2014........................................................................................................................................................... 13 Radiopharmaceuticals and Contrast Media- Effective Feb. 1, 2014......................................................... 13 Sandostatin LAR Depot (Octreotide Acetate) - Effective Feb. 1, 2014.................................................... 13 Sandostatin Subcutaneous Formulation (Octreotide Acetate) - Effective Feb. 1, 2014............................ 13 Selzentry (Maraviroc) - Effective Feb. 1, 2014......................................................................................... 14 Signifor (Pasireotide Diaspartate) - Effective Feb. 1, 2014....................................................................... 14 Stelara (Ustekinumab)- Effective Feb. 1, 2014......................................................................................... 14 Stribild™ (Elvitegravir/ Cobicistat/ Emtricitabine/ Tenofovir Disoproxil Fumarate) - Effective Feb. 1,

2014........................................................................................................................................................... 14 Topical Retinoids (Pharmaceutical Treatment of Acne) - Effective Feb. 1, 2014.................................... 14 Transcranial Magnetic Stimulation - Effective Feb. 1, 2014..................................................................... 15 Transportation Services - Effective Feb. 1, 2014...................................................................................... 15 Treatment of Infertility - Effective Feb. 1, 2014....................................................................................... 17 Treatment of Infertility for Connecticut Groups - Effective Feb. 1, 2014................................................. 17 Treatment of Infertility for New Jersey Large Groups - Effective Feb. 1, 2014....................................... 17 Treatment of Infertility for New Jersey Small Groups - Effective Feb. 1, 2014....................................... 17 Treatment of Infertility for New York Large and Small Group - Effective Feb. 1, 2014......................... 17 Truvada (Emtricitabine/Tenofovir Disoproxil Fumarate) - Effective Feb. 1, 2014.................................. 17

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Policy Update Bulletin | January 2014 For more information, visit oxfordhealth.com

January 2014

Administrative Policy Updates Page New: Requests for In-Network Exceptions - Effective Feb. 1, 2014.................................................................. 18 Revised: Autism - Effective Feb. 1, 2014................................................................................................................. 18 Precertification Exemptions for Outpatient Services - Effective Apr. 1, 2014......................................... 18 Preexisting Condition - Effective Feb. 1, 2014......................................................................................... 18 Protocol for Providing Advance Notice to Commercial Customers when Involving Non-Participating

Providers in Customers’ Care - Effective Apr. 1, 2014............................................................................. 18

Reimbursement Policy Updates Revised: Assistant Surgeon Policy - Effective Jan. 1, 2014..................................................................................... 19 B Bundle Code Policy - Effective Jan. 1, 2014......................................................................................... 19 Bilateral Procedures - Effective Jan. 1, 2014............................................................................................. 19 Co-Surgeons; Team Surgeon Policy - Effective Jan. 1, 2014................................................................... 19 Global Days Policy - Effective Jan. 1, 2014.............................................................................................. 19 Inpatient Consultations - Effective Feb. 1, 2014....................................................................................... 19 Maximum Frequency Per Day - Effective Jan. 21, 2014........................................................................... 20 Maximum Frequency Per Day - Effective Feb. 1, 2014............................................................................ 22 Moderate Sedation Policy - Effective Jan. 1, 2014.................................................................................... 22 Multiple Procedures Policy - Effective Jan. 1, 2014................................................................................. 22 Prolonged Services Policy- Effective Feb. 1, 2014................................................................................... 22 Telemedicine Policy - Effective Jan. 1, 2014............................................................................................ 23

Take Note

Policy Update Bulletin | January 2014 For more information, visit oxfordhealth.com 4

Annual CPT® and HCPCS Code Updates

Effective Jan. 1, 2014, all applicable policies have been modified to reflect the 2014 Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) code additions, revisions, and deletions. Refer to the following sources for information on the 2014 code changes:

• American Medical Association. Current Procedural Terminology: CPT® 2014 • Centers for Medicare & Medicaid Services. Healthcare Common Procedure Coding System:

HCPCS Level II

Title Policy Type Summary of Changes Abnormal Uterine Bleeding and Uterine Fibroids

Clinical Policy • Added 0336T • Removed 37210

Apheresis Clinical Policy • Added 0342T

Biologics in the Treatment of Skin, Joint and Gastrointestinal Conditions

Clinical Policy • Added J0717 and J1602 • Removed J0718

Botulinum Toxins A and B Clinical Policy • Removed 64613 and 64614

Breast Reconstruction Post Mastectomy

Clinical Policy • Removed 19102 and 19103 • Revised description for 15777

Cardiovascular Disease Risk Tests Clinical Policy • Added 0337T

Chromosome Microarray Testing Clinical Policy • Revised description for 81228 and S3870

Contraceptives Clinical Policy • Added J7301 • Removed Q0090

Dental and Oral Surgical Procedures Clinical Policy • Revised description for 21015 and 21016

Dialysis Services Clinical Policy • Revised description for 90947

DME, Orthotics, Ostomy Supplies, Medical Supplies, and Repairs/ Replacements

Administrative Policy

• Added A4555, A7047, E0766, E1352, L0455, L0457, L0467, L0469, L0641, L0642, L0643, L0648, L0649, L0650, L0651, L1812, L1833, L1848, L3678, L3809, L3916, L3918, L3924, L3930, L4361, L4387, L4397, L5969 and T4544

• Removed L0430 • Revised description for A5081, A9272, E0601,

E2301, L0120, L0160, L0172, L0174, L0450, L0454, L0456, L0460, L0468, L0621, L0623, L0625, L0626, L0627, L0628, L0630, L0631, L0633, L0637, L0639, L0980, L0982, L0984, L1600, L1610, L1620, L1810, L1830, L1832, L1836, L1843, L1845, L1847, L1850, L1902, L1904, L1906, L1907, L3100, L3170, L3650, L3660, L3670, L3675, L3677, L3710, L3762, L3807, L3908, L3912, L3915, L3917, L3923, L3925, L3927, L3929, L4350, L4360, L4370, L4386, L4396, L4398 and T4543

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page?

Take Note


Title Policy Type Summary of Changes Drug Coverage Guidelines Clinical Policy • Added J0717, J1442, J1446, J1602, and J3489

• Removed J0718, J1440, J1441, J3487, J3488 and J9002

Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)

Clinical Policy • Revised description for 43257

Gene Expression Tests Clinical Policy • Added 81504

Glaucoma Surgical Treatments Clinical Policy • Added 66183 • Removed 0192T

High Frequency Chest Wall Compression Devices

Clinical Policy • Added 94669

Immune Globulin (IVIG and SCIG)

Clinical Policy • Added J1556

Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors

Clinical Policy • Added 37204

In-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy


Macular Degeneration and Ocular Tumor Treatment

Clinical Policy • Removed 0124T and 0186T

Maximum Dosage Policy Reimbursement Policy

• Added J3489 • Removed J3487 and J3488

Noninvasive Prenatal Diagnosis of Fetal Aneuploidy Using Cell-Free Fetal Nucleic Acids in Maternal Blood

Clinical Policy • Added 81507 • Removed 0005M

Omnibus Codes Clinical Policy • Added 0335T, 0338T, 0339T, 0340T, 0341T, 0346T and Q202

• Removed 0186T and Q2027 • Revised description for CPT codes 43206 and

43252

Oxford's Outpatient Imaging Self-Referral Policy

Clinical Policy • Removed 75960

Physical, Occupational (ACN Group OptumHealth Arrangement) and Speech Therapy including Cognitive/ Neuropsychological Rehabilitation for New Jersey Small Group and New Jersey Individual


Precertification Exemptions for Outpatient Services

Administrative Policy

• Added 19081, 19082, 19083, 19084, 19085 and 19086

• Removed 19102, 19103, 19295 and 92506

Preventive Care Clinical Policy • Added 90673 and J7301 • Removed Q0090 and Q2033

Take Note


Title Policy Type Summary of Changes Preventive Medicine and Screening Policy

Clinical Policy • Added G0463

Procedures for Ablation of Varicose Veins


Radiation Therapy Procedures Requiring Precertification

Clinical Policy • Added 77293 • Removed 37204 • Revised description for 77295 and C9726

Radiology Procedures Requiring Precertification


Transcatheter Heart Valve Procedures

Clinical Policy • Added 33366, 0343T, 0344T and 0345T • Removed 0318T

Vaccines Clinical Policy • Added 90673 • Removed Q2033

Warming Therapy and Ultrasound Therapy for Wounds

Clinical Policy • Added 97610 • Removed 0183T

Clinical Policy Updates


NEW Title Effective Date Coverage Rationale Enzyme Replacement Therapy for Gaucher Disease

Feb. 1, 2014

• This policy refers to the following drug products, all of which are enzyme replacement therapies used in the treatment of Gaucher disease: o Imiglucerase (Cerezyme®) o Taliglucerase (Elelyso™) o Velaglucerase (VPRIV®)*

• Imiglucerase, taliglucerase and velaglucerase* are medically necessary for the treatment of Type 1 Gaucher disease when all of the following criteria are met:1-6,10-14 o Diagnosis of Type 1 Gaucher disease; and o Symptomatic disease (e.g., moderate to severe anemia,

thrombocytopenia, bone disease, hepatomegaly, splenomegaly); and

o Dose does not exceed 60 units/kg every 2 weeks • There may be other conditions that qualify as serious, rare

diseases for which the use of ERT may be appropriate. Please refer to: Acquired Rare Disease Drug Therapy Exception Process for additional information.

*VPRIV is the preferred enzyme replacement therapy.

Additional information to support medical necessity review: • Enzyme replacement therapy with Cerezyme and/or Elelyso is

medically necessary for the treatment of Type 1 Gaucher disease when one of the following criteria is met: o *History of failure of VPRIV due to failure to meet clinical

goals (e.g., persistent anemia, thrombocytopenia, bone disease, hepatomegaly, or splenomegaly) despite VPRIV therapy

o *History of failure of VPRIV due to hypersensitivity to VPRIV therapy

*Does not apply to New Jersey lines of business.

UPDATED Title Effective Date Summary of Changes Drug Coverage Guidelines

Feb. 1, 2014 • Updated list of medications requiring precertification through the pharmacy benefit manager (PBM): o Added Brilinta (ticagrelor), Cinryze [C1 esterase inhibitor

(human)] and Fluticasone (topical) o Updated related policy links for Berinert (C1 esterase

inhibitor human), Fabior (tazarotene) and Firazyr (icatibant)

• Updated list of medications requiring precertification through Oxford’s medical management department: o Added Cerezyme® (imiglucerase), Elelyso (taliglucerase

alfa) and VPRIV (velaglucerase)

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation

Feb. 1, 2014 • Updated list of applicable HCPCS codes to reflect annual code edits; added L8679



UPDATED Title Effective Date Summary of Changes Elidel® (pimecrolimus) and Protopicl® (tacrolimus)

Feb. 1, 2014 • Updated benefit considerations; added language to indicate supply limits may be in place

Fulyzaq (Crofelemer) Feb. 1, 2014 • Updated benefit considerations/background information: o Added language to indicate supply limits may be in place o Removed language indicating the standard dose of Fulyzaq

is 125 mg taken orally twice daily

Gattex (Teduglutide [Rdna Origin]), for Injection, for Subcutaneous Use

Feb. 1, 2014 • Updated benefit considerations/background information: o Added language to indicate supply limits may be in place o Removed language indicating the recommended dose of

Gattex is 0.05 mg/kg body weight administered by subcutaneous injection once daily, alternating sites of administration

Occipital Neuralgia and Cervicogenic Cluster and Migraine Headaches

Feb. 1, 2014 • Updated list of applicable HCPCS codes to reflect annual code edits; added L8679

Onfi (Clobazam) Feb. 1, 2014 • Updated description of services to reflect most current clinical evidence and references

• Revised coverage rationale; removed dosing and availability information

Vagus Nerve Stimulation

Feb. 1, 2014 • Updated list of applicable HCPCS codes to reflect annual code edits (effective 2/1/2014); added L8679

REVISED Title Effective Date Summary of Changes Abnormal Uterine Bleeding and Uterine Fibroids

Feb. 1, 2014 • Updated description of services to reflect most current clinical evidence, FDA information and references

• Revised coverage rationale; removed coverage guidelines/criteria for endometrial ablation

• Updated lists of applicable CPT codes: o Added 37210 (new code effective 01/01/2014) o Removed codes pertaining to endometrial ablation

procedures: 58353, 58356 and 58563 o Removed 37210 (code deletion effective 01/01/2014) o Reformatted/separated lists of codes applicable to uterine

fibroids versus levonorgestrel-releasing intrauterine device • Removed list of applicable ICD-9 and ICD-10 diagnosis codes

(previously included for informational purposes only)



REVISED Title Effective Date Summary of Changes Agents for Migraine - Triptans

Feb. 1, 2014 • Revised coverage rationale; added coverage criteria for Alsuma, Amerge, Axert, Frova, Imitrex, Imitrex Nasal Spray, Imitrex Injection, Maxalt, Maxalt-MLT, Relpax, Sumavel DosePro, Treximet, Zomig, Zomig-ZMT and Zomig Nasal Spray

• Updated benefit considerations: o Revised list of triptan drugs included in the select

designated pharmacy program for NY products/plans: Removed Zomig/Zomig ZMT Added Frova

o Added language to indicate: New York Small Group Members should refer to their

Certificate of Coverage as certain triptan drugs are included in the select designated pharmacy program

New Jersey individual plans and some New Jersey small group plans do not have quantity limit guidelines for prescription drugs. Members of New Jersey small group plans should refer to their Certificate of Coverage for more information

Biologics in the Treatment of Skin, Joint and Gastrointestinal Conditions

Feb. 1, 2014 • Updated description of services to reflect most current clinical evidence and references

• Revised coverage rationale for Certolizumab Pegol (Cimzia) for: o Treatment of rheumatoid arthritis:

Revised coverage criteria Added initial approval timeframe Added reauthorization criteria and reauthorization

approval timeframe o Treatment of Crohn’s Disease:

Revised coverage criteria, reauthorization criteria, and reauthorization approval timeframe

o Treatment of ankylosing spondylitis and psoriatic arthritis: Added coverage criteria, reauthorization criteria, initial

approval timeframes and reauthorization approval timeframes

• Revised coverage rationale for Adalimumab (Humira) for: o Treatment of ankylosing spondylitis and psoriatic arthritis:

Revised step therapy requirements

Blepharoplasty, Blepharoptosis and Brow Ptosis Repair

Feb. 1, 2014

• Revised coverage rationale; added language for Essential Health Benefits for Individual and Small Group to indicate: o For plan years beginning on or after January 1, 2014, the

Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”)

o Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs; however, if such plans choose to provide coverage for benefits which are deemed EHBs (such as maternity benefits), the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans

o The determination of which benefits constitute EHBs is



REVISED Title Effective Date Summary of Changes Blepharoplasty, Blepharoptosis and Brow Ptosis Repair (continued)

Feb. 1, 2014 made on a state by state basis; as such, when using this guideline, it is important to refer to the enrollee’s specific plan document to determine benefit coverage

• Updated list of applicable CPT codes for strabismus repair; removed 67311, 67312, 67314, 67316, 67318, 67320, 67331, 67332 and 67334

Botulinum Toxins A and B

Feb. 1, 2014 • Revised coverage criteria for Xeomin; removed dosing criteria for treatment of cervical dystonia

Campath (Alemtuzumab)


• Revised coverage rationale; updated medical necessity criteria for relapsing-remitting multiple sclerosis to include criterion for trial and failure of 2 self-administered medications (does not apply to NJ plan members)

Cardiology Procedures for CareCore National Arrangement

Apr. 1, 2014 • Revised list of services requiring precertification through CareCore National; added added echocardiogram and stress echocardiogram

Cardiology Procedures Requiring Precertification

Apr. 1, 2014 • Updated accreditation requirement for Cardiac CT Scan, PET and MRI accreditation requirements; added language to indicate: o Radiology Centers and Hospitals which wish to render

Coronary CT Angiography (CCTA), a Professional Physician Practice Assessment (PPPA) is required; see policy titled Credentialing Guidelines: Participation in the Radiology Network policy for additional information

• Updated list of applicable CPT/HCPCS codes o Added 93303-93304, 93306-93308 (echocardiogram ) and

93350-93351 (stress echocardiogram) to list of codes requiring precertification through CCN

o Added CPT code mapping crosswalk tables for interchange/ substitution of authorized codes: Diagnostic Catheterization Crosswalk Echocardiogram and Stress Echocardiogram

Crosswalk

Clotting Factors and Coagulant Blood Products

Feb. 1, 2014 • Updated description of services to reflect most current clinical evidence and references

• Added coverage guidelines/criteria for NovoSeven® for treatment of Congenital Factor VII Deficiency, Novoeight® for treatment of Hemophilia A, and FEIBA VH® for treatment of Hemophilia A and B

Compounds and Bulk Powders

Feb. 1, 2014

• Revised coverage rationale; added language to indicate topical fluticasone will not be approved unless: o Topical fluticasone is intended to treat a dermatologic

condition; and o Member has a contraindication to all commercially

available topically fluticasone formulations



REVISED Title Effective Date Summary of Changes Contraceptives Feb. 1, 2014 • Revised coverage rationale for members enrolled in new or

renewing groups on or after August 1, 2012: o Replaced header for “Coverage for Oral and Injectable

Contraceptives and Contraceptive Patches and Rings” with “Coverage for Prescription Contraceptives”

o Replaced language indicating “oral and injectable contraceptives as well as contraceptive patches and rings will be covered under the pharmacy benefit without cost-share when the item is purchased from a network pharmacy” with “select prescription contraceptives will be covered under the pharmacy benefit without cost-share when the item is purchased from a network pharmacy”

o Removed examples of contraceptives

Deep Brain Stimulation Feb. 1, 2014 • Updated description of services to reflect most current clinical evidence, FDA information and references

• Updated list of applicable HCPCS codes to reflect annual code edits (effective 2/1/2014); added L8679

Drug Coverage Criteria – New and Therapeutic Equivalent Medications

Feb. 1, 2014

• Revised list of medications requiring precertification through the pharmacy benefit manager (PBM); added Dermasorb AF 3-0.5% kit, Dermasorb XM 39% kit, Noxafil tablets and Sumadan XLT Kit

Forteo (Teriparatide)

Feb. 1, 2014

• Changed policy title; previously titled Teriparatide (Forteo) • Updated description of services to reflect most current clinical

evidence and references • Revised coverage rationale; updated/expanded coverage criteria

to include: o Diagnosis of osteoporosis o History of one of the following resulting from minimal

trauma: Vertebral compression fracture Fracture of the hip Fracture of the distal radius

o History of failure, contraindication, or intolerance to one conventional osteoporosis therapy [e.g., bisphosphonate or selective estrogen receptor modulator (SERM)] (requirement does not apply to NJ plan members)

o Treatment duration not to exceed a total of 24 months during the patient's lifetime

Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable

Feb. 1, 2014

• Reformatted/reorganized and renamed policy; combined content previously outlined in policies titled: o Implantable/Non-Implantable Hearing Devices and Bone-

Anchored Hearing Aids o Hearing Aids

• Added reference links to policies titled Cochlear Implants and Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements

• Revised coverage rationale: o Added language to indicate hearing aids required for the

correction of a hearing impairment (a reduction in the



REVISED Title Effective Date Summary of Changes Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable (continued)

Feb. 1, 2014 ability to perceive sound which may range from slight to complete deafness) are proven and medically necessary

• Reformatted and relocated information pertaining to medical necessity review; incorporated language into applicable coverage rationale statement.

• Added definition of: o hearing aids o conventional hearing aids

• Updated list of applicable CPT codes; added 92590, 92591, 92592, 92593, 92594 and 92595

• Updated list of applicable HCPCS codes; added S0618 • Updated description of services, clinical evidence and FDA

information to reflect most current references

Hip Resurfacing Arthroplasty


• Updated/clarified coverage rationale to indicate patients must meet all of the noted criteria for treatment to be considered medically necessary

• Updated list of applicable CPT codes; added 27125 and 27130

Home Health Care Feb. 1, 2014 • Revised coverage rationale for hemophilia; removed language indicating “these services do not deduct from the home health care benefit”

Icatibant (Firazyr) and C1 Esterase Inhibitors Human (Berinert)

Feb. 1, 2014

• Changed policy titled; previously titled Icatibant (Firazyr) and C1 Esterase Inhibitors Human (Berinert)

• Updated description of services to reflect most current clinical evidence and references

• Revised coverage rationale: o Replaced criterion requiring “Member has a diagnosis of

Type I or Type II hereditary angioedema” with “Member has a diagnosis of hereditary angioedema”

o Changed authorization approval period for Firazyr and Berinert from “12 months” to “60 months”

o Added language to indicate Cinryze (C1 esterase inhibitor human) will be approved based on the following criteria (authorization will be issued for 60 months): Diagnosis of hereditary angioedema (HAE); and One of the following:

- For prophylaxis against HAE attacks; or - For treatment of acute HAE attacks

Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors


• Updated list of applicable CPT codes; removed 37204

Infertility Procedures Requiring Notification and/or Precertification

Feb. 1, 2014 • Updated reference link to Optum Infertility Clinical Guideline (revised effective 2/1/14)



REVISED Title Effective Date Summary of Changes Injectable Chemo-therapy Drugs: Application of NCCN Clinical Practice Guidelines

Feb. 1, 2014

• Revised coverage rationale; added language to indicate/clarify: o Chemotherapy agents will be covered for individuals under

the age of 19 for oncology conditions o Oxford recognizes indications and uses of oncology

medications if the Member is receiving treatment for a non-oncology indication that is recognized in the product labeling, a published compendium (i.e., Micromedex, Clinical Pharmacology), or is demonstrated as medically necessary in the peer reviewed medical literature

• Updated benefit considerations; added language to indicate benefit coverage for an otherwise not medically necessary service for the treatment of serious rare diseases may occur when certain conditions are met

Oral Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines

Feb. 1, 2014 • Revised policy guidelines; added language to indicate Oxford recognizes indications and uses of oncology medications if the Member is receiving treatment for a non-oncology indication that is recognized in the product labeling, a published compendium (i.e., Micromedex, Clinical Pharmacology), or is demonstrated as medically necessary in the peer reviewed medical literature

Radiopharmaceuticals and Contrast Media

Feb. 1, 2014 • Updated list of applicable (non-reimbursable) HCPCS codes; removed A9582

Sandostatin LAR Depot (Octreotide Acetate)


• Revised coverage rationale: o Replaced content/language specific to oncology indications

with reference link to policy titled Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines

o Revised coverage criteria for use of octreotide acetate in the treatment of acromegaly

o Added medical necessity criteria for bleeding esophageal varices

• Updated list of applicable ICD-9 codes: o Added 560.81 and 560.89 o Removed ICD-9 codes 157.4, 164.0, 194.3, 209.00, 209.01,

209.02, 209.03, 209.10, 209.11, 209.12, 209.13, 209.14, 209.15, 209.16, 209.17, 209.20, 209.21, 209.22, 209.23, 209.24, 209.25, 209.26, 209.27, 209.29, 209.30, 209.31, 209.32, 209.33, 209.34, 209.35, 209.36, 209.63, 209.70, 209.71, 209.72, 209.73, 209.74, 209.75, 209.79, 211.7, 212.6, 225.0, 225.2, 225.4, 227.3, 251.1, 251.4, 251.5, 251.8, 258.01, 259.2, 377.51, and V10.91

• Updated list of applicable ICD-10 codes (preview draft effective 10/01/2014)

Sandostatin Subcutaneous Formulation (Octreotide Acetate)

Feb. 1, 2014


• Reformatted and revised coverage rationale for: o Neuroendocrine tumors:



REVISED Title Effective Date Summary of Changes Sandostatin Subcutaneous Formulation (Octreotide Acetate) (continued)

Feb. 1, 2014 Revised coverage criteria for initial authorization to indicate to indicate Sandostatin will be approved based on diagnosis of one of the following: - Lung neuroendocrine tumor - Carcinoid tumor (e.g., Zollinger-Ellison

syndrome) - Neuroendocrine tumors of the pancreas [e.g.,

Islet cell tumors including gastrinomas, glucagonomas, insulinomas and vasoactive intestinal polypeptidomas (VIPomas)]

- Hormone-secreting poorly differentiated (high grade/ large or small cell neuroendocrine tumor

o Chemotherapy and/or radiation-induced diarrhea and HIV/AIDS-related diarrhea: Removed detailed coverage criteria

o All indications: Reformatted/rephrased reauthorization criteria

Selzentry (Maraviroc) Feb. 1, 2014 • Revised coverage rationale: o Changed authorization approval period from “12 months”

to “60 months” o Removed reauthorization criteria

Signifor (Pasireotide Diaspartate)

Feb. 1, 2014 • Revised coverage rationale; changed initial authorization approval period from “6 months” to “3 months”

• Updated benefit considerations/background information: o Added language to indicate supply limits may be in place o Removed language indicating the recommended dosing

range of Signifor is 0.3 to 0.9 mg by subcutaneous injection twice daily; the dose should be titrated based upon response and tolerability

Stelara (Ustekinumab) Feb. 1, 2014 • Updated description of services to reflect most current clinical evidence, FDA information and references

• Reformatted and revised coverage rationale: o Added initial authorization and reauthorization criteria for

treatment of psoriatic arthritis (medically necessary when noted criteria is met; authorization will be issued for 12 months)

• Updated benefit considerations; added language to indicate supply limits may be in place

• Updated list of applicable ICD-9 codes; added 696.0 • Updated list of applicable ICD-10 codes (preview draft

effective 10/01/2014)

Stribild™ (Elvitegravir/ Cobicistat/ Emtricitabine/ Tenofovir Disoproxil Fumarate)

Feb. 1, 2014 • Revised coverage rationale: o Changed authorization approval period from “12 months”

to “60 months” o Removed reauthorization criteria

Topical Retinoids (Pharmaceutical Treatment of Acne)

Feb. 1, 2014 • Revised coverage rationale; added language to indicate authorization will be issued for 12 months.

• Updated background information:



REVISED Title Effective Date Summary of Changes Topical Retinoids (Pharmaceutical Treatment of Acne) (continued)

Feb. 1, 2014 o Added Fabior to list of examples of topical retinoids o Added language to indicate the topical retinoid prescription

will automatically adjudicate without coverage review for Members younger than 30 years of age

Transcranial Magnetic Stimulation


• Updated list of applicable (non-reimbursable) CPT codes; added language to indicate transcranial magnetic stimulation is not medically necessary for all diagnoses (no change to non-coverage rationale)

Transportation Services

Feb. 1, 2014

• Reorganized and revised coverage rationale: o Added language to clarify the term “bed-confined” is not

synonymous with "bed rest" or "non-ambulatory"; bed-confinement, by itself, is neither sufficient nor is it necessary to determine the coverage for transportation benefits. It is simply one element of the patient’s condition that may be taken into account in the Oxford’s determination of whether means of transport other than an ambulance were contraindicated

o Updated medical necessity documentation requirements; added language to indicate: In all cases, the appropriate documentation must be

kept on file and, upon request, presented to Oxford. In addition, the presence (or absence) of a physician’s order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary; transportation service must meet all program coverage criteria in order for payment to be made

Payment for transportation is based on the level of service actually furnished (provided they were medically necessary), not simply on the vehicle used. Even if a local government requires an ALS response for all calls, payment under the FS is made only for the level of service furnished, and then only when the service is medically necessary

o Updated transportation and vehicle crew requirements; added language to indicate: Basic Life Support vehicles must be staffed by at least

two people, at least one of whom must be certified as an emergency medical technician (EMT) by the State or local authority where the services are being furnished and be legally authorized to operate all lifesaving and life-sustaining equipment on board the vehicle

Advanced Life Support (ALS) vehicles must be staffed by at least two people, at least one of whom must be certified by the State or local authority as an EMT-Intermediate or an EMT-Paramedic

The ambulance must have customary patient care equipment and first aid supplies, including reusable devices and equipment such as backboards, neck



REVISED Title Effective Date Summary of Changes Transportation Services (continued)

Feb. 1, 2014 boards, and inflatable leg and arm splints. These are all considered part of the general transportation service and payment for them is included in the payment rate for the transport

o Added transportation destinations requirements to indicate Member's meeting transportation criteria are covered for medically necessary services to the following destinations: Hospital Critical Access Hospital (CAH) Skilled Nursing Facility Patient’s home Dialysis facility for ESRD patient who requires

dialysis; Physician’s office only as follows:

- The ambulance transport is en route to a covered destination; and

- During the transport, the ambulance stops at a physician's office because of the patient's dire need for professional attention, and immediately thereafter, the ambulance continues to the covered destination

o Updated out of country transportation requirements; added reference to policy titled Members Outside of the United States for additional information on coverage for services received outside of the United States, Mexico, Canada and the U.S. Territories

o Updated air transportation requirements; added language to indicate the following is a list of examples for which air transport could be justified (this list is not inclusive of all situations that justify air transportation, nor is it intended to justify air transportation in all locales in the circumstances listed) Intracranial bleeding - requiring neurosurgical

intervention Cardiogenic shock Burns requiring treatment in a burn center Conditions requiring treatment in a Hyperbaric

Oxygen Unit Multiple severe injuries Life threatening trauma

• Added definition of: o Fixed wing aircraft o Rotary wing aircraft o Repatriation o Rural area

• Updated benefits considerations; added language to indicate transportation of ambulance staff or other personnel when the patient is not onboard the ambulance (e.g., an ambulance transport to pick up a specialty care unit from one hospital to provide services to a patient at another hospital)

• Updated list of applicable HCPCS codes; added A0380, A0390, A0424, A0435 and A0436



REVISED Title Effective Date Summary of Changes Treatment of Infertility Feb. 1, 2014 • Updated reference link to Optum Infertility Clinical Guideline

(revised effective 2/1/14)

Treatment of Infertility for Connecticut Groups


Treatment of Infertility for New Jersey Large Groups


Treatment of Infertility for New Jersey Small Groups


Treatment of Infertility for New York Large and Small Group


Truvada (Emtricitabine/ Tenofovir Disoproxil Fumarate)

Feb. 1, 2014 • Revised coverage rationale for Hepatitis B (off-label): o Changed authorization approval period from “12 months”

to “60 months” o Removed reauthorization criteria and changed o Added language to indicate “supply limits may be in place”

Administrative Policy Updates


NEW Title Effective Date Summary Requests for In-Network Exceptions

Feb. 1, 2014 • This policy provides Oxford's criteria and process for the review of in-network exception requests. These requests may be related to medical services that are considered to be the standard of care, as well as services that are potentially experimental or investigational.

REVISED Title Effective Date Summary of Changes Autism Feb. 1, 2014 • Revised applied behavioral analysis benefit maximum

mandated by the state of New York for plan years beginning on or after 01/01/2014; added language to indicate covered services for applied behavior analysis are limited to a maximum benefit of 680 hours of treatment per Member, per calendar/contract year

Precertification Exemptions for Outpatient Services

Apr. 1, 2014 • Revised coverage rationale; removed echocardiography (CPT codes 93303-93308 and 93320-93325) from list of precertification exemptions

Preexisting Condition Feb. 1, 2014

• Revised applicable lines of business/products; added language to indicate for plan years that begin on or after January 1, 2014: o Individuals of any age cannot be denied coverage, charged

higher premiums, subjected to an extended waiting period or have benefits modified because of a pre-existing condition

o In 2010, this change was implemented for individuals under age 19; beginning in 2014, it is extended to cover all persons covered under an individual or group plan

o The new rules regarding pre-existing condition exclusions do not apply to individual coverage that is a grandfathered plan

• Added language to clarify the noted policy guidelines apply to products/plans that were new or renewed prior to January 1, 2014

Protocol for Providing Advance Notice to Commercial Customers when Involving Non-Participating Providers in Customers’ Care

Apr. 1, 2014 • Added Assistant Surgeons to list of services/provider types included in protocol for providing advance notice to commercial customers when involving non-participating providers in customers’ care

• Updated Member Advance Notice Form (attachment file)

Reimbursement Policy Updates


REVISED Title Effective Date Summary of Changes Assistant Surgeon Policy

Jan. 1, 2014 • Updated Assistant Surgeon Eligible List (attachment file); added 66183

B Bundle Code Policy Jan. 1, 2014 • Updated B Bundle Code List (codes considered bundled into other services): added CPT codes 99446, 99447, 99448 and 99449

Bilateral Procedures Jan. 1, 2014 • Updated Bilateral Procedures Eligible Policy List (attachment file); added the following codes with payment indicator “1”: 19081, 19083, 19085, 19281, 19283, 19285, 19287, 23333, 23334, 23335, 37217, 37236, 37237, 37238, 37239, 52356, 64616, 64617 and 66183

Co-Surgeons; Team Surgeon Policy

Jan. 1, 2014 • Updated Co-Surgeon Eligible List (procedures allowed for co-surgeon reimbursement): o Added 23334, 23335, 33366 and 66183 o Removed 0256T, 0257T, 0258T, 0259T and 32422

• Updated Team Surgeon Eligible List (procedures allowed for surgical team reimbursement): o Added 33366 o Removed 0256T, 0257T, 0258T and 0259T

Global Days Policy Jan. 1, 2014 • Revised lists of applicable procedure codes: o Updated Global Days Assignment List (attachment file);

Added 0335T, 0336T, 0337T, 0338T, 0339T, 0340T, 0341T, 0342T, 0343T, 0344T, 0345T, 0346T, 19081, 19083, 19085, 19281, 19283, 19285, 19287, 23333, 23334, 23335, 33366, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 37217, 37236, 37238, 37241, 37242, 37243, 37244, 43191, 43192, 43193, 43194, 43195, 43196, 43197, 43198, 43211, 43212, 43213, 43214, 43229, 43233, 43253, 43254, 43266, 43270, 43274, 43275, 43276, 43277, 43278, 49405, 49406, 49407, 52356, 64616, 64617, 64642, 64644, 64646, 64647, 66183, 93582, 93583 and 97610

Removed 0242T, 0250T, 0251T, 0252T, 0256T, 0257T, 0258T, 0259T, 29590, 31656, 31715, 32420, 32421, 32422, 37201, 37203, 37209, 43234, 65805, 78072, 88375, 92980, 92982, 92995, 93651, 93652 and D4271

o Updated EM Services Included in the Global Period (attachment file); added G0463

Inpatient Consultations

Feb. 1, 2014

• Revised reimbursement guidelines for: o Follow-up consultation services; added language to

indicate “if subsequent to the completion of a consultation the consultant assumes responsibility for management of a portion or all of the patient’s condition(s), the appropriate Evaluation and Management services codes for the site of service should be reported”

o Initial inpatient telehealth consultation services; added language to indicate the emergency department as a site for



REVISED Title Effective Date Summary of Changes Inpatient Consultations (continued)

Feb. 1, 2014 physician consultations to be delivered via telehealth

Maximum Frequency Per Day

Jan. 21, 2014

• Updated MFD Code Policy List (maximum frequency per day value assignments for CPT and HCPCS codes): o Added 0335T, 0336T, 0337T, 0338T, 0339T, 0340T,

0341T, 0342T, 0343T, 0344T, 0345T, 0346T, 10030, 19081, 19082, 19083, 19084, 19085, 19086, 19281, 19282, 19283, 19284, 19285, 19286, 19287, 19288, 23333, 23334, 23335, 33366, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 37217, 37236, 37237, 37238, 37239, 37241, 37242, 37243, 37244, 43191, 43192, 43193, 43194, 43195, 43196, 43197, 43198, 43211, 43212, 43213, 43214, 43229, 43233, 43253, 43254, 43266, 43270, 43274, 43275, 43276, 43277, 43278, 49405, 49406, 49407, 52356, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647, 66183, 77293, 80155, 80159, 80169, 80171, 80175, 80177, 80180, 80183, 80199, 80203, 81287, 81504, 81507, 87661, 88343, 90673, 92521, 92522, 92523, 92524, 93582, 93583, 94669, 97610, 99446, 99447, 99448, 99449, 99481, 99482, A4555, A7047, A9520, A9575, A9599, D0393, D0394, D0395, D0601, D0602, D0603, D1999, D2921, D2941, D2949, D3355, D3356, D3357, D3427, D3428, D3429, D3431, D3432, D4921, D5863, D5864, D5865, D5866, D5994, D6011, D6013, D6052, D8694, D9985, E0766, E1352, G0461, G0462, G0463, J0151, J0401, J0717, J1442, J1446, J1556, J1602, J3060, J3489, J7301, J7316, J7508, J9047, J9262, J9306, J9354, J9371, J9400, L0455, L0457, L0467, L0469, L0641, L0642, L0643, L0648, L0649, L0650, L0651, L1812, L1833, L1848, L3678, L3809, L3916, L3918, L3924, L3930, L4361, L4387, L4397, L5969, L8679, Q0161, Q2028, Q2052, Q3027, Q3028, Q4137, Q4138, Q4139, Q4140, Q4141, Q4142, Q4143, Q4145, Q4146, Q4147, Q4148, Q4149, S9960, S9961 and T4544

o Revised maximum frequency per day values for 84112 and 88342

o Removed 0030T, 0048T, 0050T, 0173T, 0242T, 0250T, 0251T, 0252T, 0256T, 0257T, 0258T, 0259T, 0276T, 0277T, 0279T, 0280T, 29590, 31656, 31715, 32420, 32421, 32422, 37201, 37203, 37209, 43234, 65805, 71040, 71060, 75650, 75660, 75662, 75665, 75671, 75676, 75680, 75685, 75900, 75961, 78000, 78001, 78003, 78006, 78007, 78010, 78011, 83890, 83891, 83892, 83893, 83894, 83896, 83897, 83898, 83900, 83901, 83902, 83903, 83904, 83905, 83906, 83907, 83908, 83909, 83912, 83913, 83914, 88384, 88385, 88386, 90665, 90701, 90718, 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90857, 90862, 92980, 92981, 92982, 92984, 92995, 92996, 93651, 93652, 95010, 95015, 95075, 95900, 95903, 95904, 95920, 95934, 95936, D0360, D0362, D1203, D1204, D4271, D6254, D6795, D6970, D6972, D6973, D6976, D6977,



REVISED Title Effective Date Summary of Changes Maximum Frequency Per Day (continued)

Jan. 21, 2014

G0290, G0291, G9141, G9142, J1051, J1055, J1056, J1680, J8561, J9001, K0741, K0742, Q2045, Q2046, Q2047, Q2048, S3711, S3713, S3818, S3819, S3820, S3822, S3823, S3828, S3829, S3830, S3831, S3835, S3837, S3843, S3847, S3848, S3851, S3860, S3862, S8049 and S9109

• Updated list of Codes Restricting Modifiers LT and RT (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): o Added 0335T, 0336T, 0337T, 0338T, 0339T, 0340T,

0341T, 0342T, 0343T, 0344T, 0345T, 0346T, 10030, 19082, 19084, 19086, 19282, 19284, 19286, 19288, 33366, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 37241, 37242, 37243, 37244, 43191, 43192, 43193, 43194, 43195, 43196, 43197, 43198, 43211, 43212, 43213, 43214, 43229, 43233, 43253, 43254, 43266, 43270, 43274, 43275, 43276, 43277, 43278, 49405, 49406, 49407, 64642, 64643, 64644, 64645, 64646, 64647, 77293, 80155, 80159, 80169, 80171, 80175, 80177, 80180, 80183, 80199, 80203, 81287, 81504, 81507, 87661, 88343, 90673, 92521, 92522, 92523, 92524, 93582, 93583, 94669, 97610, 99446, 99447, 99448, 99449, 99481, 99482, A4555, A7047, A9520, A9575, A9599, D0393, D0394, D0395, D0601, D0602, D0603, D1999, D2921, D2941, D2949, D3355, D3356, D3357, D3427, D3428, D3429, D3431, D3432, D4921, D5863, D5864, D5865, D5866, D5994, D6011, D6013, D6052, D8694, D9985, E0766, E1352, G0461, G0462, G0463, J0151, J0401, J0717, J1442, J1446, J1556, J1602, J3060, J3489, J7301, J7316, J7508, J9047, J9262, J9306, J9354, J9371, J9400, L0455, L0457, L0467, L0469, L0641, L0642, L0643, L0648, L0649, L0650, L0651, L1812, L1833, L1848, L3678, L3809, L3916, L3918, L3924, L3930, L4361, L4387, L4397, L5969, L8679, Q0161, Q2028, Q2052, Q3027, Q3028, Q4137, Q4138, Q4139, Q4140, Q4141, Q4142, Q4143, Q4145, Q4146, Q4147, Q4148, Q4149, S9960, S9961 and T4544

o Removed 0030T, 0048T, 0050T, 0173T, 0242T, 0250T, 0251T, 0252T, 0256T, 0257T, 0258T, 0259T, 0276T, 0277T, 0279T, 0280T, 29590, 31656, 32420, 37201, 37203, 37209, 43234, 69210, 71040, 71060, 75650, 75660, 75662, 75665, 75671, 75676, 75680, 75900, 75961, 78000, 78001, 78003, 78006, 78007, 78010, 78011, 83890, 83891, 83892, 83893, 83894, 83896, 83897, 83898, 83900, 83901, 83902, 83903, 83904, 83905, 83906, 83907, 83908, 83909, 83912, 83913, 83914, 88384, 88385, 88386, 90665, 90701, 90718, 90801, 90802, 90804, 90805, 90806, 90807, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90857, 90862, 92980, 92981, 92982, 92984, 92995, 92996, 93651, 93652, 95010, 95015, 95075, 95900, 95903, 95904, 95920, D0360, D0362, D1203, D1204, D4271, D6254, D6795, D6970, D6972, D6973, D6976,



REVISED Title Effective Date Summary of Changes Maximum Frequency Per Day (continued)

Jan. 21, 2014 D6977, G0290, G0291, G9141, G9142, J1051, J1055, J1056, J1680, J8561, J9001, K0741, K0742, S3711, S3713, S3818, S3819, S3820, S3822, S3823, S3828, S3829, S3830, S3831, S3835, S3837, S3843, S3847, S3848, S3851, S3860, S3862, S8049 and S9109

Maximum Frequency Per Day

Feb. 1, 2014 • Updated MFD Code Policy List (maximum frequency per day value assignments for CPT and HCPCS codes); revised maximum frequency per day values for: o CPT codes 15837, 21208, 21209, 23406, 26341, 26498,

31630, 31632, 31633, 35390 and 43227 o HCPCS codes A7502 and A7503

Moderate Sedation Policy

Jan. 1, 2014 • Updated list of Codes that include CPT codes 99143-99145 (attachment file); o Added CPT codes 0335T, 10030, 33282, 33284, 37236,

37237, 37238, 37239, 37241, 37242, 37243, 37244, 43211, 43212, 43213, 43214, 43229, 43233, 43253, 43254, 43266, 43270, 43274, 43275, 43276, 43277, 43278, 49405, 49406, 49407, 93582 and 93583

o Removed CPT codes 0250T, 0251T, 0252T, 0276T, 0277T, 31656, 37203, 43234, 92980, 92981, 92982, 92984, 92995, 92996, 93651 and 93652

Multiple Procedures Policy

Jan. 1, 2014 • Updated Multiple Procedure Reduction Codes List (attachment file): o Added CPT codes 10030, 19081, 19083, 19085, 19281,

19283, 19285, 19287, 23333, 23334, 23335, 33366, 37217, 37236, 37238, 37241, 37242, 37243, 37244, 43191, 43192, 43193, 43194, 43195, 43196, 43197, 43198, 43211, 43212, 43213, 43214, 43229, 43233, 43253, 43254, 43266, 43270, 43274, 43275, 43276, 43277, 43278, 49405, 49406, 49407, 52356, 64616, 64617, 64642, 64644, 64646, 64647, 66183, 93582 and 93583

o Removed CPT codes 29590, 31656, 31715, 32420, 32421, 32422, 37201, 37203, 37209, 43234, 65805, 92980, 92982, 92995, 93651 and 93652

Prolonged Services Policy

Feb. 1, 2014


• Replaced references to “prolonged physician services” or “prolonged physician E&M services” with “prolonged services”

• Revised reimbursement guidelines: o Updated timeframes for identifying the CPT code to report:

Replaced “first 30-60 minutes” with “first hour” Replaced “additional 15-30 minutes” with “additional

30 minutes” o Removed language indicating “in accordance with

guidelines established by such national sources as the AMA and the CMS Correct Coding Initiative (CCI), Oxford will not reimburse prolonged services when they are reported with other services/procedures such as nail trimming, treatment planning, ingestion challenge testing, etc.”



REVISED Title Effective Date Summary of Changes Telemedicine Policy Jan. 1, 2014 • Updated list of applicable CPT codes; added 99446, 99447,

99448 and 99449 • Updated list of Codes Recognized with Modifier GT

(attachment file): o Added 99495 and 99496 o Removed 90801, 90804, 90805, 90806, 90807, 90808,

90809 and 90862

Annual CPTEnzyme ReplacementDrug CoverageGuidelinesElidel®FulyzaqGattexOccipital NeuralgiaOnfi (Clobazam)Vagus NerveAgents for MigraineBiologicsBlepharoplastBotulinum Toxins Aand BCampathCareCore NationalArrangementCardiology ProceduresClotting FactorsContraceptivesDeep Brain StimulationDrug CoverageCriteria – New andForteo (Teriparatide)Hip ResurfacingHome Health CareIcatibantInjectableOralRadiopharmaceuticalsSelzentry (Maraviroc)SigniforTranscranialTransportationServicesTreatment of InfertilityConnecticut GroupsNew Jersey Largefor New Jersey SmallNew York LargeTruvadaRequests for In-Network ExceptionsAutismPrecertificationExemptions forOutpatient ServicesAssistant SurgeonB BundleBilateralCo-Surgeons;Global DaysInpatientMaximum FrequencyMaximum FrequencyModerate SedationMultiple ProceduresTelemedicine

oxford health plansedits; added l8679 onfi (clobazam) feb. 1, 2014 • updated description of...

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