* PLACE OF SERVICE REQUIREMENTS FOR ADDITIONAL HIGHMARK WV MEDICAL POLICIES ANNOUNCED IN THE FEBRUARY 2011 ISSUE OF PROVIDER NEWS *

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1 * PLACE OF SERVICE REQUIREMENTS FOR ADDITIONAL HIGHMARK WV MEDICAL POLICIES ANNOUNCED IN THE FEBRUARY ISSUE OF PROVIDER NEWS * Read this bulletin on-line via NaviNet MARCH 25, HWVPROV--004 TO: FROM: (1) CHIEF FINANCIAL OFFICER (2) DIRECTOR/MANAGER OF PATIENT ACCOUNTS (3) BILLING OFFICE STAFF HIGHMARK WEST VIRGINIA PROVIDER RELATIONS SUBJECT: PLACE OF SERVICE REQUIREMENTS FOR ADDITIONAL HIGHMARK WV MEDICAL POLICIES ANNOUNCED IN THE FEBRUARY ISSUE OF Provider News REFERENCE: BULLETIN HWV-PROV--003, DATED JANUARY 20, BULLETIN HWV-PROV--004, DATED FEBRUARY 15, ======================================================================= PURPOSE This bulletin identifies several additional Highmark Blue Cross Blue Shield West Virginia (Highmark WV) Medical Policies that will have place of service requirements on and after June 13,. It also provides a table of corrections being made in Medical Policy information (including, in some cases, the required place of service and/or the effective date) previously announced in earlier issues of the Provider News and the corresponding facility bulletin. BACKGROUND/OVERVIEW New Place of Service Requirements Highmark WV is now assigning place of service requirements to selected medical policies. As announced in the February Issue of Provider News, seven additional Highmark WV Medical Policies will include place of service requirements effective June 13,. Those policy numbers are listed in the table below, along with their respective policy topics, required place of service and effective date.

2 Policy # Policy Topic Place of Service Effective Date G-24* Obesity June 13, S-93 Percutaneous (Transluminal) Inpatient June 13, Balloon Valvuloplasty S-109 Transcatheter Arterial Inpatient June 13, Chemoembolization S-122 Heart Transplantation Inpatient June 13, S-125 Heart/Lung Transplantation Inpatient June 13, S-155 Gastric Electrical Stimulation, Inpatient June 13, Gastric Pacing S-170* Infrared Coagulation of Hemorrhoids June 13, For more information about those policies annotated with an asterisk (*), please see the Additional Guidelines section below. *Additional Guidelines Highmark WV will consider each person s unique clinical circumstances with respect to requests for coverage of inpatient services typically performed in an outpatient setting. In addition to the policies listed above, some of those circumstances are provided in the examples below: Medical Policy G-24, Obesity, Effective June 13, The adjustable gastric lapband procedure is typically an outpatient procedure that is only eligible for coverage as an inpatient procedure in special circumstances, including but not limited to, patients with: Significant cardiac co-morbidity Myocardial infarction Coronary artery disease Congestive heart failure Previous coronary artery bypass graft or stent Significant valvular disease Previous valve repair or replacement Abnormal stress test Significant arrhythmia requiring postoperative monitoring Any patient taking digoxin or Plavix Significant pulmonary co-morbidity Deep vein thrombosis (DVT) or pulmonary embolism (PE) Emphysema Chronic obstructive pulmonary disease (COPD) Severe restrictive defect Significant dyspnea on exertion

3 Poorly controlled asthma Poorly controlled diabetes Anticoagulant therapy Known coagulopathy Diabetic patients with body mass index (BMI) >60 Medical Policy S-170, Infrared Coagulation of Hemorrhoids, Effective June 13, Infrared coagulation of hemorrhoids is typically an outpatient procedure that is only eligible for coverage as an inpatient procedure in special circumstances including, but not limited to, patients with active bleeding, hematocrit less than 25 percent, platelets less than 60,000, or International Normalized Ratio (INR) greater than 2. Corrections in Place of Service Information Published in Previous Facility Bulletins and Previous Issues of Provider News The February Issue of Provider News also notifies professional providers of changes Highmark WV is making in place of service information communicated in previous issues of that publication. Since this same information was communicated to facility providers via a corresponding facility bulletin, the table below identifies the affected policies by number and topic, the current Place of Service requirement, the effective date and the number of the facility bulletin in which the original (now corrected) information was published. Policy # Policy Topic Place of Service Effective Date Provider News in Which Information was Originally Published S-40* Implantable Infusion Pump FORMERLY Inpatient NOW June 13, S-75* S-77* Guidelines only) Extracorporeal Photopheresis May 23, Endometrial Ablation February See Additional Guidelines, omitted from December 2010 Provider News

4 S-81 Congenital Cleft Palate Repair Place of Service requirement removed N/A S-106* Treatment of Urinary Incontinence/Periurethral Bulking Agents February S-114* S-129* Uterine Artery Embolization for Uterine Fibroids Mastectomy and Reconstructive Surgery May 23, FORMERLY Inpatient NOW Inpatient or June 13, See Additional Guidelines, omitted from December 2010 PRN S-130* (revised Additional Guidelines only) Cryosurgery of the Liver February S-143* Additional Guidelines only) S-181* Donor Leukocyte Infusion for Hematologic Malignancies that Relapse after Allogeneic Stem Cell Transplant Coronary Revascularization FORMERLY Inpatient NOW Inpatient or February February *New Additional Guidelines Medical Policy S-40, Implantable Infusion Pump, Effective June 13, The implantation of an infusion pump is typically an outpatient procedure that is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the need to titrate medication to achieve control of symptomatology and the need for ongoing monitoring for

5 potential complications related to the specific medication being administered. Medical Policy S-75, Extracorporeal Photopheresis, Effective May 23, [Omitted from December 2010 PRN] Extracorporeal photopheresis is typically an outpatient procedure that is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, current therapeutic anticoagulant therapy or for patients experiencing symptoms of acute rejection of the transplanted organ. Medical Policy S-77, Endometrial Ablation, Effective February Endometrial ablation is typically an outpatient procedure that is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, current therapeutic anticoagulant therapy or a hematocrit less than 25 percent, hemoglobin less than 8.3 g/dl. Medical Policy S-106, Treatment of Urinary Incontinence/Periurethral Bulking Agents, Effective February Treatment of urinary incontinence with periurethral bulking agents is typically an outpatient procedure. Medical Policy S-114, Uterine Artery Embolization for Uterine Fibroids, Effective May 23, [Omitted from December 2010 PRN] Uterine artery embolization for uterine fibroids is typically an outpatient procedure that is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, current therapeutic anticoagulant therapy or a hematocrit less than 25 percent, hemoglobin less than 8.3 g/dl. Medical Policy S-129, Mastectomy and Reconstructive Surgery, Effective June 13, When performed for non-cancer diagnoses or independent of the mastectomy or the breast reconstruction flap, nipple/areola reconstruction, nipple tattooing, preparation of moulage for custom breast implants, augmentation mammoplasty, reduction mammoplasty and mastopexy are typically outpatient procedures that are only eligible for coverage as inpatient procedures in special circumstances, including, but not limited to, current therapeutic anticoagulation therapy or when performed in conjunction with a service typically performed in the inpatient setting. Medical Policy S-130, Cryosurgery of the Liver, Effective February Cryosurgery of the liver is typically an eligible outpatient procedure which may be eligible for coverage when performed in an inpatient setting only when special conditions exist, including, but not limited to, patients with intractable pain or jaundice with International Normalized Ratio (INR) greater than 2. Medical Policy S-143, Donor Leukocyte Infusion for Hematologic Malignancies that Relapse after Allogeneic Stem Cell Transplant, Effective February Donor leukocyte infusion for hematologic malignancies that relapse after allogeneic stem cell transplant is typically an outpatient procedure that is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, chemotherapy-related complications such as T greater than 100.4, hematocrit less than 18 percent, hemoglobin less than

6 6.0 g/dl. Medical Policy S-181, Coronary Revascularization, Effective February Percutaneous coronary revascularization is typically an outpatient procedure that is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, unstable angina; and, under special conditions, including but not limited to current therapeutic anticoagulation therapy, severe pulmonary co-morbidity, insulin-dependent diabetes with unstable blood sugar. IMPACT/ACTION Facilities are encouraged to determine whether and to what extent the information in this bulletin affects their business. Providers should be especially careful in analyzing the information supplied in the section of the bulletin identified as Corrections in Place of Service Information in Previously Published Facility Bulletins and Previous Issues of Provider News. Providers are reminded that inpatient services require authorization and that requesting authorizations is a provider-driven requirement. TIME FRAME The place of service requirements identified in this bulletin apply on and after the respective effective dates of the corresponding Highmark WV Medical Policies. ASSISTANCE This Bulletin Questions regarding this bulletin may be directed to your assigned External Provider Relations representative. Inquiries About Eligibility, Benefits, Claim Status or Authorizations For inquiries about eligibility, benefits, claim status or authorizations, Highmark WV encourages providers to use the electronic resources available to them NaviNet and the applicable HIPAA transactions prior to placing a telephone call to the Customer Service Center. Highmark Blue Cross Blue Shield West Virginia is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. The Blue Cross and Blue Shield symbols are registered marks of the Blue Cross and Blue Shield Association. NaviNet is a registered trademark of NaviNet, Inc. NaviNet, Inc., is an independent company that provides a secure, Web-based portal between providers and health care insurance plans.