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Provider Press

PHARMACY UPDATEBlue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) will be expanding prior authorization (PA) of pharmaceuticals under its pharmacy and medical benefits. Policies that apply to drugs under the medical benefit will continue to be published as they are today. Upcoming pharmacy program descriptions will be available in one convenient location within the provider section of the Blue Cross website 45 days prior to their active implementation dates.

New PA’s will be available for initial viewing online at providers.bluecrossmn.com:

• UnderTools&ResourcesselectMedicalPolicy,thenacknowledgetheAcceptance statement

• SelectViewAllActivePolicies

• SelectUpcomingPharmacyUtilizationManagement(UM)Programs

Provider Press

Provider Press is a quarterly newsletter available online at providers.bluecrossmn.com. Issues are published inMarch,June,September and December.

Inside preview

Pharmacy Update / 1 FYI / 1-3 Coding Corner / 4-5 Quality Improvement / 5 Medical and Behavioral Health Policy Update / 6-21

March 2014 / Vol. 18, No. 1

Provider information

FYIREALLY SIMPLE SYNDICATIONNotallproviderpublicationsaremailedouttoproviders.ThemajorityofourinformationalQuickPointsandthequarterlyProviderPressarepostedtoourwebsiteforproviderstoview.Providersfrequentlyaskushowtheycanbeadvisedwhennewpublications are added to the website at providers.bluecrossmn.com.

ProviderscansignuptogetRSS(reallysimplesyndication)feedsofourlatestnewsreleases and updates to provider-related forms and publications. A sample of the feeds that can be requested includes:

• Bulletins • Forms:adminupdatesandcontracting • Forms:credentialing • Forms:pre-certificationandpre-authorization • Manuals • ProviderPress • QuickPoints

Go to providers.bluecrossmn.comandenter“RSS”inthesearchwindowtolearnmoreaboutRSS.QuestionsaboutRSSfeedsspecifictoyourinternalsystemsshouldbedirectedtoyourITsupportarea.

http://providers.bluecrossmn.com





March 2014 / 2

Provider Demographic Change Form

TheProviderDemographicChange form needs to be completed when your address,phonenumber,hospital affiliation or office hours change. Go to providers.bluecrossmn.com and enter “provider demographicchangeform”in the search window to obtain the form. Completed forms can be:

Emailed to: [email protected]

Faxed to (651) 662-6684

Mailed to: Blue Cross and Blue Shield of Minnesota PDO,R316 P.O. Box 64560 St.Paul,MN55164-0560

FYI

PUBLICATIONS AVAILABLE ONLINE ThefollowingisalistofQuickPointsandBulletinspublishedfromDecember2013to February 2014 that are available online at providers.bluecrossmn.com. As a reminder,Bulletinsaremailedtoallparticipatingprovidersaffectedbytheinformation.QuickPointsareavailableonlyonourwebsiteunlessnotedotherwiseinthebottomleft corner of the publication.

QUICK POINTS TITLEQP27-13 RegionsHospitalscheduledtobecomenonparticipatingeffectiveJanuary1,2014

QP28-13 Chiropracticnetworkstructurechanges

QP1-14 BlueCrossreachesagreementwithRegionsHospital

QP2-14 QualityImprovementProjectforSecureBlueSM (HMO SNP) Subscribers: DecreasingHighRiskMedicationUse

QP3-14 2014 Hospice Pharmacy Education

QP4-14 SplitFillProgramforSelected,OrallyAdministeredOncologyMedications

QP5-14 Clarification to independent clinical lab claim submission through BlueCard

QP6-14 TransportationchangesbacktoBlueRideforMHCPsubscribers

QP7-14 Pre-CertificationandPre-AuthorizationRequestFormUpdates

BULLETINS TITLEP1-14 January2014HCPCScodeupdates

P2-14 Update to Attachment B: Definitions of outpatient health services categories

P3-14 Clarificationtopost-operativepainblockrecoveryrequestandeditremovalnotification

FYIHELPFUL PHONE NUMBERSBLUELINE (voice response unit) (651) 662-5200 or 1-800-262-0820

BlueCard® member benefits or eligibility 1-800-676-BLUE (2583)

FEP® (voice response unit) (651) 662-5044 or 1-800-859-2128

Availity 1-800-282-4548

Provider services (651) 662-5200 or 1-800-262-0820

Please verify these numbers are correctly programmed into your office phones.

providers.bluecrossmn.com



March 2014 / 3

FYI

PROVIDER MANUAL UPDATES ThefollowingisalistofBlueCrossandBlueShieldofMinnesotaprovidermanualsthathavebeenupdatedfromDecember2013toFebruary2014.Asareminder,provider manuals are available online at providers.bluecrossmn.com.Toviewthemanuals,select“Forms&publications,”then“manuals.”Updatestothemanualsaredocumentedinthe“Summaryofchanges”sectionoftheonlinemanuals.

MANUAL NAME

CHAPTER NUMBER AND TITLE

CHANGE

Provider Policy and Procedure Manual

Chapter4,CareManagement

Content change to Pre-Certification/Pre-Authorization


Chapter11,CodingPoliciesandGuidelines,BehavioralHealth

Thefollowingtopicshadchanges:

•EligibleGroupsforARMHS

•IntensiveResidentialTreatmentServices(IRTS)forMedicaidGovernmentProgramsonly

•AdultNon-ResidentialCrisisServices(MHCPmembers only)

•PsychiatricConsultationtoPrimaryCarePractitioners

•ExtendedCareandHalfwayHouseRoomandBoard (Medicaid Government Programs only)

•Children’ResidentialMentalHealth(MedicaidGovernment Programs only)


Chapter11,CodingPoliciesandGuidelines,DurableMedical Equipment


•HearingAids

•CodingModifiers

Thefollowingnewtopicswereadded:

•CPAPandBi-PapBillingforPublicPrograms

•MedicareGuidelinesforDMEinaSNForNF


Chapter11,CodingPoliciesandGuidelines,HomeHealth,HomeInfusion,Hospice


•ElderlyWaiverProgram

•ReferralsandPriorAuthorization

•RAPClaimSubmission

•HospiceBillingforMedicareProducts


Chapter11,CodingPoliciesandGuidelines,MedicalServices

ContentchangetoEarWaxRemoval


Chapter11,CodingPoliciesandGuidelines,PublicPrograms


•NewbornCircumcision

•PCABilling

•Chiropractic,Physical,OccupationalandSpeechTherapyAuthorization

•MHCPchangesinPre-Authorization

•SpecialTransportation

2014 HOLIDAY SCHEDULEProvider services will be closed on the following days in 2014:

Monday,May26

Friday,July4

Monday,September1

Thursday,November27

Friday,November28

Thursday,December25

Friday,December26

Withtheexceptionofthedatesstatedabove,representatives answering the provider services numbers are available to assist you 8 a.m. to 5 p.m. MondaythroughThursday,and 9 a.m. to 5 p.m. on Friday.

March 2014 / 4

CODING CORNER

SIGN HERE PLEASE

It’sbeensaidbefore,butworthrepeating.Thedocumentationforaserviceorvisitispart of the patient’s permanent legal record. Signatures are an important element of documentation. Blue Cross requires that medical record entries for services provided/orderedbeauthenticatedbytheauthor.Theacceptedmethodisahandwrittenorelectronicsignature.Stampsignaturesarenotacceptable.Patientidentification,dateofservice,andprovideroftheserviceshouldbeclearlyidentifiedonthesubmitteddocumentation.

Medical records sent without signatures are not acceptable. Providers should verify that all signatures are being printed on their medical records when sending copies from electronic medical record systems or vendors.

CODE EDITS UPDATE REMINDER Blue Cross’ coding edits are not updated and loaded at the same time as the coding changesareavailable.Whilewearereviewingpotentialeditsatthistime,untilimplemented,codingeditswillnotbeappliedtothenew2014codes.Thisdoesnotmeanthatthecodesareinvalid.AllnewHCPCS/CPTcodeseffectiveJanuary1,2014,have been loaded to our claims system.

Oncethenewandrevisededitsareimplemented,allclaimssubmittedaftertheimplementationdateoftheupdate,regardlessofservicedate,willbeprocessedaccording to that updated version or instituted edit.

E/M BASED ON TIME CPTindicatesthatwhencounselingand/orcoordinationofcaredominatesmorethan50percentoftheface-to-facephysiciantimethentimeshallbeconsideredthekeyorcontrollingfactorforaparticularlevelofE/M.CPTalsostipulatesthattheextentofcounseling and/or coordination of care must be documented in the medical record.

Whiletheactualtimeofadditionalcounselingand/orcoordinationmustbepartofthemedicalrecord,thedetails–the extent-the“who”,“what”and“why”ofthat counseling and/or coordination must also be part of the medical record for consideration.

FUN WITH ICD-10 So how do you code for the headaches from ICD-10 code training?

• G44.209Tension-typeheadache,unspecified,notintractable;and

• Z56.6Otherphysicalandmentalstrainrelatedtowork

Don’t forget to code what caused that headache.

March 2014 / 5

QUALITY IMPROVEMENT

PCC QUALITY OF CARE COMPLAINT REPORTProviders are required to complete the Blue Plus Quality of Care Complaint report forallwrittenandverbalcomplaintsfromBluePlus,PrepaidMinnesotaAssistanceProgramandMinnesotaCaresubscribersonaquarterlybasis,perMinnesotaDepartment of Health regulations. Complaints logged at the provider offices are to be investigated and resolved by the provider’s office whenever possible.

ThesecomplaintsarereportedtoBluePlusinJanuary,April,JulyandOctoberfortheprecedingthreemonths.ThePrimaryCareClinic(PCC)mustsubmitaquarterlyreport even if the facility does not receive any complaints for the quarter. Your contract outlines the procedures required for your Quality of Care (QOC) PCC complaint reporting adherence agreement.

Complaints should no longer be directed to the attention of a single designated person. Sending your PCC QOC complaint report form to any source not listed below may delay the processing of your PCC QOC complaint report.

ToaccessthePCCBluePlusQualityofCareComplaintReportForm,gotoproviders.bluecrossmn.comandselect“Forms&publications,”then“forms-clinicaloperations.”

Submit quarterly PCC QOC reports using one of these methods:

Email: [email protected]

Secure fax line: (651) 662-4004

Mail: Blue Plus Attn: Quality Health Management Dept. R472 P.O. Box 64179 St.Paul,MN55164-0179

PROVIDER POLICY AND PROCEDURE MANUAL UPDATES ThemanualhasorisbeingupdatedwithcodingchangesthatwereeffectiveJanuary1,2014,sobesuretocheckouttheupdatestothevariouscodingsectionsof Chapter 11. Access the manual through the Blue Cross website at providers.bluecrossmn.com.ManualsarefoundundertheForms&publicationssection.

CODING CORNER

March 2014 / 6

MEDICAL AND BEHAVIORAL HEALTH POLICY UPDATE

Medical and behavioral health policies are available for your use and review on the Blue Cross and Blue Shield of Minnesota website at providers.bluecrossmn.com.Fromthissite,therearetwowaystoaccessmedicalpolicyinformation depending on the patient’s Blue Plan membership.

For out-of-area Blue Plan patients:

Select“MedicalPolicyPreCert/PreAuthRouter”andclickGo.Youwillbetakentothepagewhereyouselecteithermedical policy or pre-certification/prior authorization and enter the patient’s three-letter alpha prefix as found on their memberidentificationcard,andclickGo.Onceyouaccepttherequirements,youwillberoutedtothepatient’shomeplanwhere you can access medical policy or pre-certification/pre-authorization information.

For local Blue Cross and Blue Shield of Minnesota plan patients:

Select“Medicalpolicy”(undertheTools&Resources),readandaccepttheBlueCrossMedicalPolicyStatement,andthenselect“ViewAllActivePolicies.”YouhavenownavigatedtotheBlueCrossandBlueShieldofMinnesotaMedicalandBehavioralHealthPolicyManual,wherethereareseveralselectionstoassistwithyourinquiry.

The“What’sNew”sectionidentifiesourlatestneworrevisedpoliciesapprovedbyBlueCross’MedicalandBehavioralHealth Policy Committee at least 50daysago.Thesepoliciesarenoweffective,andprovidersshouldbeginfollowingthesepoliciesimmediately.Thesepoliciesalsoappearinthe“ActivePolicy”sectionoftheMedicalandBehavioralHealthPolicy Manual.

The“UpcomingPolicies”sectionlistsneworrevisedpoliciesapprovedbytheBlueCrossMedicalandBehavioralHealthPolicy Committee and are effective 50daysfromthedatetheywerepostedtothe“UpcomingPolicies”sectionoftheMedical and Behavioral Health Policy Manual.

The“ActivePolicy”sectioncontainstheentirelistofpolicieseffectiveatthetimeofyourinquiry.Pleasenote,DHSPrograms(CoverageGuidelinesforDHSPrograms-MHCPManual)andMedicareContractors(PartA–NationalGovernmentServices[NGS],PartB–NationalGovernmentServices[NGS],HomeHealthandHospice–NationalGovernmentServices[NGS],DurableMedicalEquipmentMedicareAdministrativeContractor–NationalGovernmentServices[NGS],andTheCentersforMedicareandMedicaidServices–CMS)haveseparatesections.

The“Pre-Certification/Pre-Authorization”sectionidentifiesvariousservices,procedures,prescriptiondrugs,andmedicaldevicesthatrequirepre-certification/pre-authorization.ThefollowingPre-Certification/Pre-AuthorizationListsareprovidedforreview:Commercial(includingBlueLinkTPA),MNGovernmentPrograms,andBlueEssentials(HMO-POS).Theselistsarenotexclusivetomedicalpolicyservicesonly;theyencompassotherservicesthataresubjectto pre-certification/pre-authorization requirements.

Ifyouhaveadditionalquestionsregardingmedicalorbehavioralhealthpolicyissues,callproviderservicesat (651) 662-5200 or 1-800-262-0820 for assistance.

March 2014 / 7


MEDICAL AND BEHAVIORAL HEALTH POLICY ACTIVITY

Policies Effective: 01/20/14 Notification Posted: 11/27/13

Policies developedIntravenous Human Epidermal Growth Factor Receptor 2 (HER2) Targeted Agents

•Pre-Certification/Pre-Authorization: No.

•Breast Cancer

A.Trastuzumab(Herceptin),ado-trastuzumabemtansine(Kadcyla),andpertuzumab(Perjeta)maybeconsidered MEDICALLYNECESSARYfortreatmentofpatientswithbreastcanceronlywhentumoroverexpressionofHER2has been confirmed by testing in accordance with current ASCO/CAP or NCCN guidelines.

B. Trastuzumab(Herceptin),ado-trastuzumabemtansine(Kadcyla),andpertuzumab(Perjeta)areconsidered INVESTIGATIVEfortreatmentofbreastcancerforwhichtumoroverexpressionofHER2hasnotbeenconfirmed.

•Gastric,Esophageal,andGastroesophagealJunctionAdenocarcinoma

A. Trastuzumab(Herceptin)maybeconsideredMEDICALLYNECESSARYfortreatmentofpatientswhentumor overexpressionofHER2hasbeenconfirmedbytestinginaccordancewithcurrentASCO/CAPorNCCNguidelinesin the following instances:

1.Metastaticgastricorgastroesophagealjunctionadenocarcinoma;

OR

2.Palliativecareofpatientswithadvancedgastric,esophagealorgastroesophagealjunctionadenocarcinomawitha Karnofskyperformancescoreof60%orgreater(Unabletowork;abletoliveathomeandcareformostpersonal needs;varyingamountofassistanceneeded,orabletocarryonnormalactivityandtowork;nospecialcare needed)OREasternCooperativeOncologyGroup(ECOG)performancescoreof2orlessincombinationwith systemicchemotherapy.AnECOGscoreof2orlessindicatesthatthepatientisambulatorymorethat50%of wakinghoursandcapableofself-care.

B. Trastuzumab(Herceptin)isconsideredINVESTIGATIVEfortreatmentofadvancedormetastaticgastric,esophagealor gastroesophagealjunctionadenocarcinomaforwhichtumoroverexpressionofHER2hasnotbeenconfirmed.

C. Ado-trastuzumabemtansine(Kadcyla)andpertuzumab(Perjeta)areconsideredINVESTIGATIVEfortreatmentof gastric,esophageal,orgastroesophagealjunctionadenocarcinoma.

•Other Cancers

Trastuzumab(Herceptin),ado-trastuzumabemtansine(Kadcyla),andpertuzumab(Perjeta)areconsideredINVESTIGATIVE fortreatmentofallothercancersincludingbutnotlimitedtocolorectal,endometrial,esophageal(exceptasstatedin IIAabove),gastric(exceptasstatedinIIAabove),headandneck,non-smallcelllung,osteosarcoma,ovarian, pancreatic,peritoneal,prostate,salivarygland,andurothelial.

•AssessmentofHER2expression

AssessmentofHER2expressionintumortissuethatisnotinaccordancewithcurrentASCO/CAPorNCCNguidelines, includingbutnotlimitedtobyquantitativetotalHER2expressionorHER2homodimermeasurement,isconsidered INVESTIGATIVE.

March 2014 / 8

MEDICAL AND BEHAVIORAL HEALTH POLICY UPDATE Policies revisedAutologous Chondrocyte Implantation of Focal Articular Cartilage Lesions


•Autologous chondrocyte implantation (ACI)

A. ACImaybeconsideredMEDICALLYNECESSARYforthetreatmentofdisablingfull-thicknessarticularcartilage defectsofthekneecausedbyacuteorrepetitivetrauma,inpatientswhohavehadaninadequateresponsetoaprior surgicalprocedure(e.g.,debridement,subchondraldrilling,abrasionarthroscopy,microfracture),whenallofthe following criteria are met:

1.PatientisanadultORaskeletallymatureadolescentwithdocumentedclosureofgrowthplates(e.g.,15yearsor older);

2.Totalareaofthecartilagelesion(i.e.lengthxwidth,incentimetersorcm)isgreaterthan1.5cm2(centimeters squared);

3.Focal,full-thickness(OuterbridgegradeIIIorIV)unipolarlesionsontheweightbearingsurfaceofthefemoral condylesortrochlea;

4. Documented minimal to absent degenerative changes in the surrounding articular cartilage (Outerbridge Grade II orless),andnormal-appearinghyalinecartilage;surroundingtheborderofthedefect;

5.Presenceofpersistentsymptoms(e.g.,pain,swellingandcatching/locking)thatsignificantlylimitactivitiesofdaily living;

6.Presenceofstableligaments(ifligamentsareunstable,documentationshouldbeprovidedastohowthis conditionwillbeaddressed);

7.Nomalalignmentpresent(ifmalalignmentispresent,documentationshouldindicateplannedconcurrent correction of alignment).

B. ACIfortreatmentofallotherarticularcartilagedefectsoftheknee(i.e.,defectsthatdonotmeetthecriteriaoutlined underI.A.)areconsideredINVESTIGATIVE,duetoalackofevidencedemonstratinganimpactonimprovedhealth outcomes.

C. ACIforallotherindicationsisconsideredINVESTIGATIVEduetoalackofevidencedemonstratinganimpacton improvedhealthoutcomes.Thoseinvestigativeindicationsinclude,butnotlimitedto:

1.Lesionsinjointsotherthantheknee(e.g.,talus);

2. Lesions of the patella or tibia.

D. Matrix-inducedautologouschondrocyteimplantationisconsideredINVESTIGATIVEforallindicationsduetoalackof evidence demonstrating an impact on improved health outcomes.

Osteochondral Allografts and Autografts in the Treatment of Focal Articular Cartilage Lesions


March 2014 / 9

•Osteochondral Allograft

A. OsteochondralallografttransplantationmaybeconsideredMEDICALLYNECESSARYforthetreatmentof symptomaticfull-thicknessarticularcartilagedefectsofthekneecausedbyacuteorrepetitivetrauma,inpatients whohavehadaninadequateresponsetoapriorsurgicalprocedure(e.g.,debridement,subchondraldrilling,abrasion arthroscopy,microfracture),whenallthefollowingcriteriaaremet:


2.Totalareaofthecartilagelesion(i.e.lengthxwidth,incentimetersorcm)isgreaterthan1.5cm2(centimeters squared);

3.Focalfull-thickness(OuterbridgegradeIIIorIV)cartilagelesionsontheweight-bearingsurfaceofthefemoral condyles(medialorlateral)ortrochlea;

4. Documented minimal to absent degenerative changes in the surrounding articular cartilage (Outerbridge grade II or less)andnormal-appearinghyalinecartilagesurroundingtheborderofthedefect;




B. Osteochondralallografttransplantationfortreatmentofallotherarticularcartilagedefectsoftheknee(i.e.,defects thatdonotmeetthecriteriaoutlinedunderI.A.)isconsideredINVESTIGATIVE,duetoalackofevidence demonstrating an impact on improved health outcomes.

C. OsteochondralallografttransplantationforallotherindicationsandinallotherjointsisconsideredINVESTIGATIVE duetoalackofevidencedemonstratinganimpactonimprovedhealthoutcomes.Thoseinvestigativeindications include,butnotlimitedto:



D. AllograftmincedcartilageproceduresareconsideredINVESTIGATIVEforallindicationsandinalljoints,duetoalack of evidence demonstrating an impact on improved health outcomes.

•Osteochondral Autografts

A. Osteochondralautografttransplantation(OATSorautologousmosaicplasty),usingoneormorecoresof osteochondraltissuemaybeconsideredMEDICALLYNECESSARYforthetreatmentofsymptomaticfull-thickness cartilagedefectsofthekneecausedbyacuteorrepetitivetrauma,inpatientswhohavehadaninadequateresponse toapriorsurgicalprocedure(e.g.,debridement,subchondraldrilling,abrasionarthroscopy,microfracture),whenall the following criteria are met:


March 2014 / 10


2.Totalareaofthecartilagelesion(i.e.lengthxwidth,incentimetersorcm)is≥ 1.0 cm2 (centimeters squared) and ≤2.0cm2;

3.Focalfull-thickness(OuterbridgegradeIIIorIV)cartilagelesionsontheweight-bearingsurfaceofthefemoral condyles(medialorlateral)ortrochlea;

4. Documented minimal to absent degenerative changes in the surrounding articular cartilage (Outerbridge grade II or less)andnormal-appearinghyalinecartilagesurroundingtheborderofthedefect;




B. Osteochondralautografttransplantationfortreatmentofallotherarticularcartilagedefectsoftheknee(i.e.,defects thatdonotmeetthecriteriaoutlinedunderII.A.)isconsideredINVESTIGATIVE,duetoalackofevidence demonstrating an impact on improved health outcomes.

C. OsteochondralautografttransplantationforallotherindicationsandinallotherjointsisconsideredINVESTIGATIVE duetoalackofevidencedemonstratinganimpactonimprovedhealthoutcomes.Thoseinvestigativeindications include,butnotlimitedto:



D. AutograftmincedcartilageproceduresareconsideredINVESTIGATIVEforallindicationsandinalljoints,duetoalack of evidence demonstrating an impact on improved health outcomes.

Bone Morphogenetic Protein (BMP)


•Useofrecombinanthumanbonemorphogeneticprotein-2(rhBMP-2),maybeconsideredMEDICALLYNECESSARYfor the following indications:

A. Asanadjuncttoananteriorlumbarinterbodyfusionprocedurewhenuseofanautograftisunfeasible(e.g.,needfor agreaterquantityofautograftthanisavailable);OR

B. Forinstrumentedposterolateralintertransversespinalfusionwhenuseofanautograftisunfeasible(e.g.,needfora greaterquantityofautograftthanisavailable);OR

C. Asanadjuncttotreatmentofopenfractureofthetibialshaft,whenuseofanautograftisunfeasible(e.g.,needfora greater quantity of autograft than is available).


March 2014 / 11

•Useofrecombinanthumanbonemorphogeneticprotein-7(rhBMP-7)maybeconsideredMEDICALLYNECESSARYfor the following indications:

A. Inrecalcitrantlongbonenon-unionswhereuseofanautograftisunfeasible(e.g.,needforagreaterquantityof autograftthanisavailable)andalternativetreatmentshavefailed;OR

B. For revision posterolateral intertransverse spinal fusion procedures in compromised patients when use of an autograftisunfeasible(e.g.,needforagreaterquantityofautograftthanisavailable).

•Use of recombinant human bone morphogenetic protein-2 (rhBMP-2) or recombinant human bone morphogenetic protein-7(rhBMP-7)isconsideredINVESTIGATIVEforallotherindications,includingbutnotlimitedto:

A. Asanadjuncttothoracicandcervicalfusionprocedures;

B. Asinitialtreatmentorrevisionofposterolateralspinalfusion,exceptasindicatedabove;

C. Asmanagementofearlystagesofosteonecrosisofthevascularheadorfemoralshaft;

D. Asanadjuncttodistractionosteogenesis(Iliazarovprocedure)

E. Craniofacialapplicationsincluding,butnotlimitedto,periodontaldefectregeneration,cleftpalaterepair,cranial defectrepair,sinusaugmentation,andlocalizedalveolarridgeaugmentationsfordefectsassociatedwithextraction sockets.

Treatment of Urinary Dysfunction

•Pre-Certification/Pre-Authorization:Yes,ONLYforPercutaneousTibialNerveStimulation(PTNS).

•BotulinumToxinTherapy

BotulinumtoxinmaybeconsideredMEDICALLYNECESSARYforincontinenceduetodetrusoroveractivity, incontinenceofneurogenicorigin(e.g.,spinalcordinjury,multiplesclerosis),oroveractivebladderinadultswhohave had an inadequate response to or are intolerant of an anticholinergic medication.

•Magnetic Stimulation

Useofmagneticstimulationofthepelvicfloormuscles[ExtracorporealMagneticInnervation(ExMI™),NeoControl® PelvicFloorSystem]astreatmentforurinaryincontinenceisconsideredINVESTIGATIVEduetolackofclinicalevidence indicating its impact on improved health outcomes.

•Pelvic Floor Electrical Stimulation

Useofpelvicfloorelectricalstimulation(i.e.,pelvicTENS)maybeconsideredMEDICALLYNECESSARYastreatment for stress and/or urge incontinence in patients who have undergone a documented trial of pelvic muscle exercises for a period of at least six (6) months with no significant improvement in incontinence.

•PercutaneousTibialNerveStimulation(PTNS)

A. PercutaneoustibialnervestimulationmaybeconsideredMEDICALLYNECESSARYfortreatmentofurinary dysfunction(i.e.,incontinence,urgencyfrequency,andnon-obstructiveurinaryretention)inpatientswhomeetallthe following criteria:


March 2014 / 12

1.Absenceofneurologicdiseaseassociatedwithdetrusorhyperreflexia;AND

2.Absenceofoutletobstruction;AND

3.Symptomshaveresultedinsignificantdisability(e.g.,thefrequencyand/orseverityofleakagesarelimitingthe patient’sabilitytoworkorparticipateinactivitiesoutsidethehome);AND

4. Conservative forms of treatment have been tried for at least one year and have failed.

B. TheuseofpercutaneoustibialnervestimulationforanyotherindicationisconsideredINVESTIGATIVE.

•PeriurethralBulkingAgents

A. UseofthefollowingperiurethralbulkingagentsmaybeconsideredMEDICALLYNECESSARYtotreatstressurinary incontinence:

1.Collagenimplants(e.g.,ContigenBardcollagenimplants);

2.Carbon-coatedspheres(e.g.,Durasphere);

3.Calciumhydroxylapatite(e.g.,Coaptite®);

4.Polydimethylsiloxane(e.g.,Macroplastique®);

B. Useoftheseperiurethralbulkingagentsastreatmentforanyothertypeofurinaryincontinenceisconsidered INVESTIGATIVE.

C. Useofautologouscellulartherapy(e.g.,myoblasts,fibroblasts,muscle-derivedstemcells,oradipose-derivedstem cells),autologousfat,andautologousearchondrocytesisconsideredINVESTIGATIVE.

D. UseofanyotherperiurethralbulkingagentsforurinaryincontinenceisconsideredINVESTIGATIVE.

•Personal Use Ultrasound Devices

A. Useofaportablepersonaluseultrasounddevicetonon-invasivelymeasurebladdervolume(e.g.,BladderManager®) maybeconsideredMEDICALLYNECESSARYonlyforspinalcord-injurypatientswithautonomicdysreflexia.

B. AllotherusesareconsideredINVESTIGATIVE.

•TransurethralRadiofrequencyMicro-Remodeling

Useoftransurethralradiofrequencymicro-remodeling(e.g.,Renessa)fortreatmentofstressurinaryincontinenceis consideredINVESTIGATIVEduetoalackofpublishedevidencesupportingitsimpactonimprovedhealthoutcomes.

•TransvaginalRadiofrequencyBladderNeckSuspension

•Useoftransvaginalradiofrequencybladdernecksuspensionfortreatmentofstressurinaryincontinenceisconsidered INVESTIGATIVEduetoalackofpublishedevidencesupportingitsimpactonimprovedhealthoutcomes.

Policies inactivated

T-Wave Alternans Uterine Activity Monitoring (Home Ambulatory)


March 2014 / 13

MEDICAL AND BEHAVIORAL HEALTH POLICY UPDATE Policies Effective: 03/17/14 Notification Posted: 01/23/14

Policies developed None

Policies revisedSpinal Fusion: Cervical

•Pre-Certification/Pre-Authorization: Yes.

•CervicalspinalfusionmaybeconsideredMEDICALLYNECESSARYforANYofthefollowingindications:

A. Acutetraumaticspinalinjuryresultingincervicalspinalinstability;OR

B. Osteomyelitisresultinginvertebralbodydestruction;OR

C. Primaryormetastaticbonetumorresultinginfractureinstabilityorspinalcordcompression;OR

D. Cervicalnerverootcompressionverifiedbydiagnosticimaging(i.e.,MRIorCTmyelogram)andresultinginsevere pain(e.g.,painnecessitatinghospitaladmissionforpaincontrol)ORprofoundweaknessoftheextremities(e.g., profounddeltoidbiceps,triceps,orhandweakness;OR

E. Nontraumatic atlantoaxial (C1-C2) subluxation related to ONE of the following conditions:

1.CongenitalabnormalityoftheC1-C2vertebrae;OR

2.Osodontoideum;OR

3.Rheumatoidarthritis

OR

F. Symptomaticpseudarthrosis;OR

G. SpondyloticradiculopathywhenBOTHofthefollowingcriteriaaremet:

1.Persistentorprogressiveradicularpainorweaknesssecondarytonerverootcompressiondespiteeight(8)weeks of conservative therapy with at least two (2) of the following:

a. Activepainmanagementprogramorprotocol,underthedirectionofaphysician,withpharmacotherapythat addressesneuropathicpainandotherpainsources(e.g.,aprescriptionoralanalgesic [preferablyanti-inflammatory],musclerelaxantortricyclicanti-depressantmedication)OR

b. Medicalmanagementwithoralsteroidsandepiduralsteroidinjections;OR

c. Physical therapy

AND

2.Diagnosticimaging(i.e.,MRIorCTmyelogram)demonstratescervicalnerverootcompression

March 2014 / 14

OR

H. SpondyloticmyelopathywhenBOTHofthefollowingcriteriaaremet:

1.Clinicalsignsand/orsymptomsofmyelopathy,asdemonstratedbyatleastONEofthefollowing:

a. Upper/lowerextremityweakness,numbness,orpain;OR

b. Bladderorbowelincontinence;OR

c. Increasedtoneorspasticity;OR

d. GaitabnormalitiesconsistentwithcervicalmyelopathyOR

e. Overactiveoroverresponsivereflexes;OR

f. Hoffman’ssign;OR

g. PositiveBabinskisign;OR

h. Hand incoordination or clumsiness

AND

2.Diagnosticimaging(i.e.,MRIorCTmyelogram)demonstratesspinalcordcompression;

OR

I. Degenerativespinalsegmentadjacenttoapriordecompressionorfusionprocedure*whenatleastONEofthe following criteria are met:

1.Symptomsofradiculopathy(asdescribedunderGabove)associatedwiththeadjacentlevelofthecervicalspine ANDconservativenonsurgicaltreatment(asdescribedunderGabove)hasfailed;OR

2.Symptomsofmyelopathy(asdescribedunderHabove)associatedwiththeadjacentlevelofthecervicalspine

*NOTE:Anyrequestthatwouldresultinmorethantwo(2)cervicalfusionsinaperson’slifetimerequiresMedical Director review.

OR

J. Othercausesofnontraumaticinstabilityorcervicalspondylosis,whendocumentationdemonstratesALLofthe following:

1.Moderatetosevereneckpaindespiteeight(8)weeksofconservativetherapywithatleasttwo(2)ofthe following:

a. Activepainmanagementprogramorprotocol,underthedirectionofaphysician,withpharmacotherapy thataddressesneuropathicpainandotherpainsources(e.g.,aprescriptionoralanalgesic[preferablyanti- inflammatory],musclerelaxantortricyclicanti-depressantmedication);OR

b. Medicalmanagementwithoralsteroidsandepiduralsteroidinjections;OR

c. Physical therapy

AND


March 2014 / 15

2.Clinicallysignificantfunctionlimitationresultinginimpaired,age-appropriateactivitiesofdailylivinganddiminished qualityoflife;AND

3. Diagnostic imaging by x-ray demonstrates ONE of the following:

a. Instability by flexion and extension x-rays

-Sagittalplanetranslation>3mm;OR

-Sagittalplanetranslation>20%ofvertebralbodywidth

OR

b. Relativesagittalplaneangulation>11degrees.

Genetic Testing and Counseling for Heritable Disorders


•TestingForCarrierStatus

A. CarriertestinginaparentorprospectiveparentmaybeconsideredMEDICALLYNECESSARYwhentheparentor prospectiveparentisathighriskofbeingacarrierofaspecificgeneticdisorderbaseduponfamilyhistoryasdefined by meeting one or more of the following conditions in section I.A and all of the criteria in section IB:

1.AnaffectedchildisidentifiedwithanautosomalrecessiveorX-linkeddisorderandgenetictestingisperformedto guidesubsequentreproductivedecisions;

OR

2. One or both parents or prospective parents have a first or a second degree relative who is affected by a specific geneticdisorder,orthefirstdegreerelativehasanaffectedchildwithanautosomalrecessiveorX-linkeddisorder andgenetictestingisperformedtoguidesubsequentreproductivedecisionsortoguidemedicalmanagement;

OR

3.Oneparentorprospectiveparentisknowntobeacarrierofaclinicallysignificantautosomalrecessivecondition;

OR

4.Theparentsorprospectiveparentsaremembersofaracialorethnicgroupwithahighriskofaspecificgenetic disorder with an autosomal recessive pattern of inheritance.

B. IfoneormoreofthecriteriainSectionA(above)aremet,parentsorprospectiveparentsmustmeetALLofthe following criteria:

1.Foreachdisorder,aspecificcausativemutation,orsetofmutations,hasbeenestablishedinthepopulation beingtested;

AND

2. A clinical association between the mutation detected and the severity of the disorder has been validated in the peer-reviewedmedicalliterature;AND


March 2014 / 16

3.Thetestwillidentifyorruleoutheritabilityoftheconditionandwillprovideinformationthatestablished biochemicalorothertestingcannotprovide;AND

4.Genetictestingisperformedtofacilitatedecisionssurroundingreproduction;

AND

5.Testingisaccompaniedbygeneticcounseling.

C. GenetictestingforcarrierstatusisconsideredINVESTIGATIVEwhenthecriteriaabovearenotmet.Thereisalack of clinical evidence demonstrating its impact on improved health outcomes.

D. ExpandedcarrierscreeningpanelsareconsideredINVESTIGATIVE.Theseincludebutarenotlimitedtothe following:

• 23andMe

• Counsyl™

• GoodStartSelect™

• Inherigen™

• InherigenPlus™

• Inheritest™

• NateraOne™

•PresymptomaticGeneticTestingToPredictRiskofaDisorder

A. PresymptomaticgenetictestingmaybeconsideredMEDICALLYNECESSARYinindividualswithareasonable expectation that the condition exists or may arise based on family history and a pedigree analysis and who have no signs or symptoms of a genetic disorder when ALL of the following criteria are met:

1.Aspecificcausativemutation,orsetofmutations,hasbeenestablishedforthedisorderbeingevaluated;

AND

2. A clinical association between the mutation detected and the severity of the disorder has been validated in the peer-reviewedmedicalliterature;

AND

3.Theresultsofthegenetictestwillimpactdiseaseprevention,surveillance,ormedicalmanagementofthe individual;

AND


B. PresymptomaticgenetictestingtopredictriskofadisorderisconsideredINVESTIGATIVEwhenthecriteriaabove arenotmet.Thereisalackofclinicalevidencedemonstratingitsimpactonimprovedhealthoutcomes.Examplesof these tests include but are not limited to the following:


March 2014 / 17

• 23andMe

• deCODET2™

• deCODEAF™

• deCODEMI™

• deCODEGlaucoma™

C. GenetictestingofchildrentopredictadultonsetofdiseaseisconsideredNOTMEDICALLYNECESSARYunless test results will guide current decisions concerning prevention and this benefit would be lost by waiting until the child has reached adulthood.

•DiagnosticTesting

A.GenetictestingmaybeconsideredMEDICALLYNECESSARYtodiagnoseageneticdisorderinindividualswithsigns or symptoms who meet ALL of the following criteria:

1.Thetestusedhasbeenestablishedinthepeer-reviewedmedicalliteraturetoreliablydetectaspecificcausative mutationorsetofmutationsorachromosomevariantassociatedwithaspecificdisease;

AND

2.Abiochemicalorothertestisidentifiedbuttheresultsareindeterminate,orthegeneticdisordercannot be identified through biochemical or other testing (e.g. serum cholesterol testing for familial hypercholesterolemia orultrasoundscreeningforaorticdiseaseinMarfansyndrome);

AND

3.Theresultsofthegenetictestwillimpactthemedicalmanagementoftheindividual;

AND


B. GenetictestingfordiagnosticpurposesinindividualsnotmeetingtheabovecriteriaisconsideredINVESTIGATIVE. Thereisalackofclinicalevidencedemonstratingitsimpactonimprovedhealthoutcomes.

C. Genetic testing of an individual’s entire genome or exome for any indication in the absence of genetic counseling withpedigreeanalysisasdefinedinthispolicyisconsideredINVESTIGATIVE.Thereisalackofclinicalevidencethat this type of testing improves health outcomes.

Knee Arthroplasty (Knee Replacement)

•Pre-Certification/Pre-Authorization:Yes,ONLYwhenBOTHofthefollowingcriteriaaremet:

1. TheproviderperformingthekneearthroplastyislocatedinMinnesotaoraborderingcounty;AND

2. Thememberislessthan60yearsofageOR80yearsofageorolder.

Thispolicydoesnotapplytothefollowinglinesofbusiness:

1. FederalEmployeePlan(FEP);OR


March 2014 / 18

2. GovernmentProgramsproducts;OR

3. Medicare Primary products.

•Totalkneearthroplasty(alsoknownastotalkneereplacement)forthetreatmentofadvancedkneejointdiseasemaybe consideredMEDICALLYNECESSARYforEITHERofthefollowingindications:

A. Imagingand/orarthroscopicevidenceofcompletecartilagedestruction(i.e.,modifiedOuterbridgegradeIVor Kellgren-Lawrencegrade4)ANDbothofthefollowing:

1.Moderatetoseverepersistentkneepain;AND

2.Clinicallysignificantfunctionallimitationresultinginimpaired,age-appropriateactivitiesofdailylivingand diminished quality of life.

OR

B. Imagingand/orarthroscopicevidenceofcartilagedamage(i.e.,modifiedOuterbridgegradeIIIorKellgren- Lawrence grade 3) when ALL of the following criteria are met:

1.ModeratetoseverepersistentkneepaindespiteuseofBOTHofthefollowing:

a.Medicalmanagementwithnonsteroidalanti-inflammatoryagents(NSAIDS)orotheranalgesicmedications;

AND

b.Physicaltherapy,includingstrengtheningexercises:6weekcourse;

AND


•Unicompartmentalkneearthroplasty(alsoknownaspartialkneereplacement)forthetreatmentofadvancedknee jointdiseaselimitedtoasinglecompartment(i.e.,medial,lateral,orpatellofemoral)maybeconsideredMEDICALLY NECESSARYforEITHERofthefollowingindications:

A. Imagingand/orarthroscopicevidenceofcompletecartilagedestruction(i.e.,modifiedOuterbridgegradeIVor Kellgren-Lawrencegrade4)ANDALLofthefollowing

1.Moderatetoseverepersistentkneepainlocalizedtotheaffectedcompartment(i.e.,medial,lateral,or patellofemoral);AND

2.Clinicallysignificantfunctionallimitationresultinginimpaired,age-appropriateactivitiesofdailylivingand diminishedqualityoflife;AND

3.Involvedkneedemonstratesadequatealignmentandligamentousstability

OR

B. Imagingand/orarthroscopicrevidenceofcartilagedamage(i.e.,modifiedOuterbridgegradeIIIorKellgren-Lawrence grade 3) AND ALL of the following:

1.Moderatetoseverepersistentkneepainlocalizedtotheaffectedcompartment(i.e.,medial,lateral,patellofemoral)


March 2014 / 19


despiteuseofBOTHofthefollowing:

a. Medical management with nonsteroidal anti-inflammatory agents (NSAIDS) or other analgesic medications AND

b. Physicaltherapy,includingstrengtheningexercises:6weekcourse

AND


AND

3.Involvedkneedemonstratesadequatealignmentandligamentousstability.

•RevisionofkneearthroplastymaybeconsideredMEDICALLYNECESSARYforanyofthefollowingindications:

A. Instabilityoftheprostheticcomponentsorasepticloosening;OR

B. Periprostheticfractures;OR

C. Fractureordislocationofthepatella;OR

D. Infection of the implant.

•ThefollowingkneeproceduresareconsideredINVESTIGATIVEduetoalackofevidencedemonstratinganimpacton improved health outcomes:

A. Bicompartmentalkneearthroplastyandbi-unicompartmentalkneearthroplasty;

B. Unicondylar interpositional spacer.

•Documentation:Thefollowingdocumentationmustbesubmittedforinitialkneearthroplasty:

1. Writtenreportdescribingtheextentofcartilagedamageasdeterminedbyarthroscopyand/ordiagnosticimaging, usingtheModifiedOuterbridgeclassificationsystemortheKellgren-Lawrencegradingsystem

2. Clinical notes describing:

a.Levelofkneepain;

b.Functionallimitationsrelatedtokneesymptoms;

c.Medicalmanagementwithnonsteroidalanti-inflammatoryagents(NSAIDS)orotheranalgesics;and

d. Physical therapy.

3. Forunicompartmentalkneearthroplasty:anorthopedicassessmentofkneealignmentandligamentousstability

Gene Expression Testing for Cancers of Unknown Primary

•Pre-Certification/Pre-Authorization: Not applicable.

•GeneexpressiontestingisconsideredINVESTIGATIVEtoevaluatethesiteoforiginofatumorofunknownprimary

March 2014 / 20


ortodistinguishaprimaryfromametastatictumorduetoalackofevidencesupportingitsimpactonimprovedhealth outcomes. Policies inactivated

None

Policies reviewed with no changes in November 2013 – January 2014: Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias

Actigraphy

Anterior Eye Segment Scanning Computerized Imaging

Autism Spectrum Disorders: Assessment

Axial (Percutaneous) Lumbar Interbody Fusion

Bioimpedance Spectroscopy Devices for Detection and Management of Lymphedema

Breast Implant, Removal or Replacement

Communication Assist Devices

CT Colonography (Virtual Colonoscopy)

Electromagnetic Navigation Bronchoscopy

Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Conditions

Functional Neuromuscular Electrical Stimulation Device

Genetic Testing for Familial Alzheimer’s Disease

Growth Hormone Treatment

Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma

Implantation of Intrastromal Corneal Ring Segments

Infliximab

Low-Level Laser Therapy and Deep Tissue Laser Therapy

Lysis of Epidural Adhesions

Neurofeedback/Electroencephalogram (EEG) Biofeedback

Occlusion of Uterine Arteries

Orthognathic Surgery

PathfinderTG® Molecular Testing

Pegloticase (Krystexxa)

Percutaneous Electrical Nerve Stimulation (PENS) or Percutaneous Neuromodulation Therapy (PNT)

Percutaneous Facet Joint Denervation

March 2014 / 21

Medical and Behavioral Health Policy Update

NetworkManagementR317 P.O. Box 64560 St.Paul,MN55164-0560

Provider Press is posted on our website quarterly for business office staff of multi-specialtyclinics,physicians,publichealthagencies,DMEproviders,chiropractors,podiatrists,physicaltherapists,occupationaltherapists,optometristsandbehavioralhealth professionals/providers. Direct inquiries to:

NetworkManagementR317Editor: Holly BatchelderP.O. Box 64560St.Paul,MN55164-0560(651) 662-2014tollfree:1-800-382-2000,ext.22014

Advisors/FaithBauer,CPC,CPC-H,CPC-P;JeannieHarp,CPC;JanineUtecht,CPC,CPC-H,CPC-P,CPMA;andKarenKiemele,MPH

Information in Provider Press is a general outline. Provider and member contracts determine benefits.

CPT-4codesnotedareAMAcopyrighted.

3/14


Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty

Phototherapy for the Treatment of Psoriasis

Psychological and Neuropsychological Testing

Scanning Laser Technologies for Glaucoma Testing and Monitoring

Spinal Cord Stimulation

Subtalar Arthroereisis

Treatment for Temporomandibular Disorder (TMD)

Tumor Markers, Urinary

Thrombopoietin Mimetic Agents for Treatment of Thrombocytopenia

Ultrasound-Guided High-Intensity Focused Ultrasound Ablation for Treatment of Prostate Cancer and Other Tumors

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