Prior Authorization Review Panel MCO Policy Submission

Transcription

1 Prior Authorization Review Panel MCO Policy Submission A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review. Plan: Aetna Better Health Submission Date: 10/01/2018 Policy Number: 0173 Policy Name: Prothrombin Time (INR) Home Testing Devices Effective Date: Revision Date: Type of Submission Check all that apply: New Policy* Revised Policy Annual Review No Revisions *All revisions to the policy must be highlighted using track changes throughout the document. Please provide any clarifying information for the policy below: CPB 0173 Prothrombin Time (INR) Home Testing Devices Policy is new to Aetna Better Health of Pennsylvania. Name of Authorized Individual (Please type or print): Signature of Authorized Individual: Dr. Bernard Lewin, M.D. New 10/01/2018

2 Prothrombin Time (INR) Home Testing Devices - Medical Clinical Policy Bulletins Aetna Page 1 of 16 --> ( Prothrombin Time (INR) Home Testing Devices Number: 0173 *Please see amendment for Pennsylvania Medicaid at the end of this CPB. Policy Aetna considers prothrombin time home testing units/home INR testing (e.g., the Coag-Sense Self-Test PT/INR Monitoring System, the CoaguChek XS Plus System, and the INRatio 2 PT/INR Monitoring System) medically necessary durable medical equipment for persons who require chronic oral anticoagulation with warfarin for a mechanical heart valve, ventricular assist device, chronic atrial fibrillation, deep venous thrombosis, pulmonary embolism, venous embolism and thrombosis of deep vessels of lower extremity, or hypercoagulable states (e.g., antithrombin III deficiency, Factor V Leiden, protein C deficiency, and protein S deficiency, etc) when all of the following criteria are met: 1. The expected need for home INR testing is 6 or more months; and 2. The person must have been anticoagulated for at least 3 months prior to use of the home INR devices; and Policy His tory Last Review 07/28/2018 Effective: 09/22/1997 Next Review: 02/14/2019 Review History Definitions A dditiona l In form at ion Clinical Policy Bulletin Notes 3. Self-testing with the device should not occur more frequently than once a week.

3 Prothrombin Time (INR) Home Testing Devices - Medical Clinical Policy Bulletins Aetna Page 2 of 16 Aetna considers prothrombin time home testing units experimental and investigational for all other indications (e.g., arterial embolism to the eye, atrial flutter, and Kawasaki disease) because its effectiveness for indications other than the ones listed above has not been established. Aetna considers additional hardware/software systems needed for down-loading data from prothrombin time home testing units to computers for the management of anticoagulation as not medically necessary convenience items. Background This policy is consistent with the conclusions of an assessment from the Centers for Medicare & Medicaid Services (CMS, 2008). Prothrombin time home testing systems are portable, batteryoperated instruments for the quantitative determination of prothrombin time from finger-stick whole blood. The monitoring device measures the time it takes an individual s blood to clot. A drop of blood is obtained by a finger-stick using a lancet. The drop of blood is placed on a test strip and analyzed by the device. The device displays both the PT and calculated international normalized ratio (INR). If the results are out of normal range, the individual usually is advised to retest to confirm and if the results remain abnormal, they contact their physician as soon as possible. These devices store of the most recent test results, which are date and time stamped, enabling the health care provider to review the results and monitor trends in the individual s oral anticoagulant therapy control. The goal of home PT monitoring is to help the individual maintain an INR in the desired therapeutic range. International Normalized Ratio (INR) is a system established by the World

4 Prothrombin Time (INR) Home Testing Devices - Medical Clinical Policy Bulletins Aetna Page 3 of 16 Health Organization (WHO) and the International Committee on Thrombosis and Hemostasis for reporting the results of blood coagulation (clotting) tests. The INR is the ratio of the individual's prothrombin time compared to the mean prothrombin time for a group of normal individuals. The prothrombin time is the amount of time needed for a small amount of blood to clot. Examples of US Food and Drug Administration (FDA) approved devices for home self-monitoring PT/INR include, but may not be limited to: Alere INRatio 2 PT/INR Monitoring System; CoagCare System; CoaguChek XS System; INRatio Prothrombin Time Monitoring System; INRatio 2 Prothrombin Time Monitoring System; and ProTime Microcoagulation System. These portable testing devices are available by prescription for home use under a physician s supervision. The physician who prescribes a home PT monitor is responsible for the training and ongoing management of individuals who use these devices. Alternatives to home PT monitoring include visits to a laboratory facility or health care provider s office for drawing and testing of a venous blood sample. Physician consultation is advised to make an informed decision based on an individual s health needs. Home INR monitors are designed to aid in the management of high-risk patients taking oral anticoagulants. They require considerable patient training and compliance to be useful. Self-testing and/or self-management by the patient using home international normalization ratio (INR) monitors represent another model of care with the potential for improved outcomes as well as greater convenience. Selftesting may provide a convenient opportunity for increased frequency of testing when deemed necessary. The use of the same instrument may increase the degree of consistency in instrumentation, and self-testing provides the potential for greater knowledge and awareness of therapy which may lead

5 Prothrombin Time (INR) Home Testing Devices - Medical Clinical Policy Bulletins Aetna Page 4 of 16 to improved compliance. There is, however, insufficient evidence comparing the effectiveness of patient selftesting and self-management using a home INR monitor to care provided by an anticoagulation management service. Ansell et al (2001) explained: "Although a growing number of studies indicate the superiority of patient PST [patient selftesting] or PSM [patient self-management of dose adjustments] over UC [usual care, i.e., patients managed by their usual physicians], there is little evidence comparing them to care provided by an AMS [anticoagulation management service (i.e., anticoagulation clinic)]. PST and PSM require special patient training to implement, and therapy should be managed by a knowledgeable provider. A definitive recommendation cannot yet be made as to the overall value of PST or PSM." In a randomized controlled trial, Gardiner and colleagues (2005) ascertained if patients can achieve accurate INR values through patient self testing (PST) by means of the CoaguChek S (Roche Diagnostics, Lewes, UK). The main outcome measurements were comparability of INR values obtained by PST and the hospital laboratory, patient acceptability as assessed by a questionnaire and anticoagulant control. A total of 84 subjects (53 men, 31 women; median age of 59 years), receiving long-term oral anticoagulation (warfarin), were recruited. Subjects were randomized to weekly self-testing or continuing 4-weekly hospital laboratory monitoring of INR. Comparison of INRs (n = 234) showed no significant differences between the CoaguChek (median INR 3.02) and laboratory testing (median INR 3.07). There was excellent correlation between the 2 methods (r = 0.95), with 85 % of CoaguChek results within 0.5 INR units of the laboratory method. On 4 occasions, differences of greater than 1 unit INR were obtained, but in each case the patient's anticoagulation was unstable (INR greater than 4.5 by both methods) and the differences in INR would not have altered patient management. The results showed that 87 % of patients found self-testing straightforward, 87 % were

6 Prothrombin Time (INR) Home Testing Devices - Medical Clinical Policy Bulletins Aetna Page 5 of 16 confident in the result they obtained and 77 % preferred selftesting. These investigators concluded that PST is a reliable alternative to hospital clinic attendance and is acceptable to the majority of suitably trained patients. In 2002, CMS issued a national coverage determination for the use of home prothrombin time INR monitoring for anticoagulation management for patients with mechanical heart valves on warfarin. More recently, a CMS Decision Memorandum (2008) concluded that there is sufficient evidence of the effectiveness of home prothrombin time (INR) monitoring for patients with a mechanical heart valve, chronic atrial fibrillation, or deep venous thrombosis. The monitor and the home testing must be prescribed by a treating physician and the following requirements must be met: Self-testing with the device should not occur more frequently than once a week; and The patient continues to correctly use the device in the context of the management of the anticoagualtion therapy following initiation of home monitoring; and The patient must have been anticoagulated for at least 3 months prior to use of the home INR devices; and The patient must undergo an educational program on anticoagulation management and demonstrated the correct use of the device prior to its use in the home. Matchar and colleagues (2010) examined the effect of home testing of INR on clinical events in patients with atrial fibrillation or mechanical heart valves. These investigators randomly assigned 2,922 patients who were taking warfarin because of mechanical heart valves or atrial fibrillation and who were competent in the use of point-of-care INR devices to either weekly self-testing at home or monthly high-quality testing in a clinic. The primary end point was the time to a first major event (stroke, major bleeding episode, or death). Patients were followed for 2.0 to 4.75 years, for a total of 8,730 patient-

7 Prothrombin Time (INR) Home Testing Devices - Medical Clinical Policy Bulletins Aetna Page 6 of 16 years of follow-up. The time to the first primary event was not significantly longer in the self-testing group than in the clinictesting group (hazard ratio, 0.88; 95 % confidence interval [CI]: 0.75 to 1.04; p = 0.14). The 2 groups had similar rates of clinical outcomes except that the self-testing group reported more minor bleeding episodes. Over the entire follow-up period, the self-testing group had a small but significant improvement in the percentage of time during which the INR was within the target range (absolute difference between groups, 3.8 percentage points; p < 0.001). At 2 years of follow-up, the self-testing group also had a small but significant improvement in patient satisfaction with anti-coagulation therapy (p = 0.002) and quality of life (p < 0.001). The authors concluded that as compared with monthly high-quality clinic testing, weekly self-testing did not delay the time to a first stroke, major bleeding episode, or death to the extent suggested by prior studies. These results do not support the superiority of self-testing over clinic testing in reducing the risk of stroke, major bleeding episode, and death among patients taking warfarin therapy. Bonaros et al (2004) stated that ventricular assist device (VAD) implantation is associated with impaired primary hemostasis and thromboembolic complications. Recently, a new generation of implantable continuous flow axial pumps was introduced into clinical application. To study the potential thrombogenic properties of this type of pump, these researchers applied extensive platelet monitoring. In their institution, 13 patients received the MicroMed DeBakey VAD as a bridge to transplantation. Routine coagulation tests (platelet count, activated partial thromboplastin time, prothrombin time, anti-thrombin III activity) and platelet function tests (whole blood aggregometry, thrombelastography, flow cytometry) were performed. No clinically relevant thromboembolic events were detected. No correlation was found between global function tests, platelet aggregation, and thrombelastography. No correlation was detected between platelet activation and hemolysis

8 Prothrombin Time (INR) Home Testing Devices - Medical Clinical Policy Bulletins Aetna Page 7 of 16 parameters. Platelet aggregation and coagulation index were significantly suppressed early after operation. A subsequent phase of hyper-aggregability, starting around day 6, suggested the initiation of anti-aggregation therapy. Platelet activation markers were up-regulated in the post-operative period but were returned to pre-operative levels after initiation of aspirin. In contrast to routine coagulation monitoring, platelet function tests reflect in detail the coagulation status of blood pump recipients and the efficiency of anti-aggregation therapy. Aspirin and dipyridamole therapy in addition to oral anticoagulation using phenprocoumon may contribute to platelet function and clot mechanics restoration and is, therefore, recommended for patients after VAD implantation. Joshi and colleagues (2007) noted that prothrombin time, expressed as INR and activated partial thromboplastin time (aptt), are standard methods of monitoring coumadin and heparin administration. Prothrombin activation fragment (F1.2) is an index of in vivo thrombin generation. These investigators hypothesized that F1.2 would provide a better surrogate of thromboembolism risk than standard coagulation assays during VAD support. In this study, INR, PTT and F1.2 were analyzed in 31 patients after implantation of a left-sided VAD daily during hospitalization and weekly after discharge. Thromboembolic events (TE) were defined by evidence of neurological injury revealed by plasma levels of S-100beta. The relationships between F1.2, INR for patients on coumadin and aptt for patients on heparin were evaluated from 1,250 observations of blood samples. S-100beta was positively correlated with F1.2, but not with INR and aptt. Correlation between S-100beta and F1.2 is significantly higher than with the other 2 markers (p < ). Higher values of aptt and INR were not associated with TE. Compared to conventional coagulation assays, the F1.2 level provides a single endpoint that is a more accurate predictor of TE after VAD implantation. The authors stated that further trials that incorporate the F1.2

9 Prothrombin Time (INR) Home Testing Devices - Medical Clinical Policy Bulletins Aetna Page 8 of 16 marker into anti-coagulation algorithms may help reduce adverse events in this high-risk population. CPT Codes / HCPCS Codes / ICD-10 Codes Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+": Code Code Description CPT codes covered if selection criteria are met: Patient/caregiver training for initiation of home international normalized ratio (INR) monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient's/caregiver's ability to perform testing and report results Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab international normalized ratio (INR) test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed HCPCS codes covered if selection criteria are met:

10 Prothrombin Time (INR) Home Testing Devices - Medical Clinical Policy Bulletins Aetna Page 9 of 16 Code Code Description G0248 Demonstration, prior to initial use, of home INR monitoring for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient ability to perform testing prior to its use G0249 G0250 Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes provision of materials for use in the home and reporting of test results to physician; not occurring more frequently than once a week Physician review, interpretation and patient management of home INR testing for a patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes face-to-face verification by the physician that the patient uses the device in the context of the management of the anticoagulation therapy following initiation of the home INR monitoring; not occurring more frequently than once a week ICD-10 codes covered if selection criteria are met: D D68.62 Thrombophilia (Antithrombin III deficiency, Factor V leiden, Protein C deficiency, Protein S deficiency)

11 Prothrombin Time (INR) Home Testing Devices - Medical Clinical Policy Bulletins A... Page 10 of 16 Code Code Description I I26.99 Pulmonary embolism I27.82 Chronic pulmonary embolism I48.0, Atrial fibrillation I48.2, I48.91 I I80.9 Phlebitis and thrombophlebitis of upper and lower extremities and unspecified site I I82.5Z9 Embolism and thrombosis of deep veins of lower extremity I I Acute embolism and thrombosis of deep veins of upper extremity I I Chronic embolism and thrombosis of deep veins of upper extremity T80.0XX+, Pulmonary embolism and infarction T , T81.72x+ T T [I26.90, I26.99 also required] Z95.2 Presence of prosthetic heart valve Z Presence of heart assist device ICD-10 codes not covered for indications listed in the CPB (not all-inclusive): H34.9 Unspecified retinal vascular occlusion [arterial embolism to the eye]

12 Prothrombin Time (INR) Home Testing Devices - Medical Clinical Policy Bulletins A... Page 11 of 16 Code Code Description I48.1 Atrial flutter M30.3 Mucocutaneous lymph node syndrome [Kawasaki disease] The above policy is based on the following references: 1. No authors listed. Home monitoring for warfarin users. Health News. 1999;5(3):5. 2. No authors listed. A new approach to monitoring anticoagulation therapy: Testing prothrombin time at home. Harv Heart Lett. 1999;9(5): Ansell J, Hirsh J, Dalen J, et al. Managing oral anticoagulant therapy. In: Sixth ACCP Conference on Antithrombotic Therapy. Chest. 2001;119:22S-38S. 4. Poller L, Keown M, Chauhan N, et al. European Concerted Action on Anticoagulation--comparison of fresh plasma and whole blood multicentre ISI calibrations of CoaguChek Mini and TAS PT-NC whole blood prothrombin time point-of-care monitors. Thromb Haemost. 2002;87(5): Nowatzke WL, Landt M, Smith C, Wilhite T, et al. Whole blood international normalization ratio measurements in children using near-patient monitors. J Pediatr Hematol Oncol. 2003;25(1): Center for Medicare and Medicaid Services (CMS). Prothrombin time (INR) monitor for home anticoagulation management (#CAG-00087N). National Coverage Analysis (NCA). Baltimore, MD: CMS; September 18, Horstkotte D, Piper C. Improvement of oral anticoagulation therapy by INR self-management. J Heart Valve Dis. 2004;13(3):

13 Prothrombin Time (INR) Home Testing Devices - Medical Clinical Policy Bulletins A... Page 12 of Tripodi A. Prothrombin time international normalized ratio monitoring by self-testing. Curr Opin Hematol. 2004;11(3): Jackson SL, Peterson GM, Vial JH, Jupe DM. Improving the outcomes of anticoagulation: An evaluation of home follow-up of warfarin initiation. J Intern Med. 2004;256(2): Yang DT, Robetorye RS, Rodgers GM. Home prothrombin time monitoring: A literature analysis. Am J Hematol. 2004;77(2): Gardiner C, Williams K, Mackie IJ, et al. Patient selftesting is a reliable and acceptable alternative to laboratory INR monitoring. Br J Haematol. 2005;128 (2): Fitzmaurice DA. Oral anticoagulation control: The European perspective. J Thromb Thrombolysis. 2006;21(1): American Medical Association (AMA). Home anticoagulation monitoring. Report of the Council on Science and Public Health. Chicago, IL: AMA; Brown A, Wells P, Jaffey J, et al. Point-of-care monitoring devices for long-term oral anticoagulation therapy: Clinical and cost effectiveness. Technology Report No. 72. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health (CADTH); February Center for Medicare & Medicaid Services (CMS). Decision memo for prothrombin time (INR) monitor for home anticoagulation management (CAG R). Baltimore, MD: CMS; March 19, Centers for Medicare & Medicaid Services (CMS). National coverage determination (NCD) for home prothrombin time/international normalized ratio (PT/INR) monitoring for anticoagulation management (190.11). Baltimore, MD: CMS; March 19, Bradbury MJ, Taylor G, Short P, Williams MD. A comparative study of anticoagulant control in patients on long-term warfarin using home and hospital

14 Prothrombin Time (INR) Home Testing Devices - Medical Clinical Policy Bulletins A... Page 13 of 16 monitoring of the international normalised ratio. Arch Dis Child. 2008;93(4): Ontario Ministry of Health and Long-term Care, Medical Advisory Secretariat (MAS). Point-of-care international normalized ratio (INR) monitoring devices for patients on long-term oral anticoagulation therapy: An evidence-based analysis. Ontario Health Technology Assessment Series. 2009; 9(12): Ryan F, Byrne S, O'Shea S. Randomized controlled trial of supervised patient self-testing of warfarin therapy using an internet-based expert system. J Thromb Haemost. 2009;7(8): Plesch W, van den Besselaar AM. Validation of the international normalized ratio (INR) in a new point-ofcare system designed for home monitoring of oral anticoagulation therapy. Int J Lab Hematol. 2009;31 (1): Greenway A, Ignjatovic V, Summerhayes R, et al. Pointof-care monitoring of oral anticoagulation therapy in children. Comparison of the CoaguChek XS system with venous INR and venous INR using an International Reference Thromboplastin preparation (rtf/95). Thromb Haemost. 2009;102(1): Sobieraj-Teague M, Daniel D, Farrelly B, et al. Accuracy and clinical usefulness of the CoaguChek S and XS Point of Care devices when starting warfarin in a hospital outreach setting. Thromb Res. 2009;123 (6): Ryan F, O'Shea S, Byrne S. The reliability of point-ofcare prothrombin time testing. A comparison of CoaguChek S and XS INR measurements with hospital laboratory monitoring. Int J Lab Hematol. 2010;32(1 Pt 1):e26-e Dolor RJ, Ruybalid RL, Uyeda L, et al; THINRS Site Investigators. An evaluation of patient self-testing competency of prothrombin time for managing anticoagulation: pre-randomization results of VA

15 Prothrombin Time (INR) Home Testing Devices - Medical Clinical Policy Bulletins A... Page 14 of 16 Cooperative Study # The Home INR Study (THINRS). J Thromb Thrombolysis. 2010;30(3): Matchar DB, Jacobson A, Dolor R, et al; THINRS Executive Committee and Site Investigators. Effect of home testing of international normalized ratio on clinical events. N Engl J Med. 2010;363(17): Bonaros N, Mueller MR, Salat A, et al. Extensive coagulation monitoring in patients after implantation of the MicroMed Debakey continuous flow axial pump. ASAIO J. 2004;50(5): Joshi A, Magder LS, Kon Z, et al. Association between prothrombin activation fragment (F1.2), cerebral ischemia (S-100beta) and international normalized ratio (INR) in patients with ventricular assisted devices. Interact Cardiovasc Thorac Surg. 2007;6(3): Bloomfield HE, Krause A, Greer N, et al. Meta-analysis: Effect of patient self-testing and self-management of long-term anticoagulation on major clinical outcomes. Ann Intern Med. 2011;154(7): Nutescu EA, Bathija S, Sharp LK, et al. Anticoagulation patient self-monitoring in the United States: Considerations for clinical practice adoption. Pharmacotherapy. 2011;31(12): Holbrook A, Schulman S, Witt DM, et al.; American College of Chest Physicians. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e152S-84S. 31. National Institute for Health and Care Excellence (NICE). Atrial fibrillation and heart valve disease: Selfmonitoring coagulation status using point-of-care coagulometers (the CoaguChek XS system and the INRatio2 PT/INR monitor). NICE Diagnostics Guidance 14. London, UK: NICE; September 24, 2014.

16 Prothrombin Time (INR) Home Testing Devices - Medical Clinical Policy Bulletins A... Page 15 of DeSantis G, Hogan-Schlientz J, Liska G, et al. STABLE results: Warfarin home monitoring achieves excellent INR control. Am J Manag Care. 2014;20(3): Matchar DB, Love SR, Jacobson AK, et al. The impact of frequency of patient self-testing of prothrombin time on time in target range within VA Cooperative Study #481: The Home INR Study (THINRS), a randomized, controlled trial. J Thromb Thrombolysis. 2015;40(1):17-25.

17 Prothrombin Time (INR) Home Testing Devices - Medical Clinical Policy Bulletins A... Page 16 of 16 Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change. Copyright Aetna Inc.

18 AETNA BETTER HEALTH OF PENNSYLVANIA Amendment to Aetna Clinical Policy Bulletin Number: 0173 Prothrombin Time (INR) Home Testing Devices There are no amendments for Medicaid. New 10/01/2018