January 29, Dear Provider:

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1 January 29, 2019 Dear Provider: This notice is to provide details of changes effective April 1, 2019 such as: Updates to Provider Audit, Sampling & Extrapolation & Re-Audit Process Policy Medical Policies: new, revised, archived, and updated Changes in for certain services Provider Audit, Sampling & Extrapolation & Re-Audit Process Policy We have updated our policy for Provider Audit, Sampling & Extrapolation & Re-Audit Process Policy (formerly called Facility/Provider Audit, Sampling and Extrapolation Policy) transformed it to a payment policy, and posted to the secure provider website at bcbsvt.com under the BCBSVT policies link under the Payment Policies. Medical Policies: new, revised, archived, and updated We have reviewed, updated, and created new medical policies. The chart below provides a highlevel overview of the changes that will be effective April 1, We post the updated medical policies at least 30 days prior to their effective dates on our website at We encourage you to review the medical policies in their entirety. Some of the changes may affect eligible services, non-covered services, services that are not medically necessary, prior approval or investigational services. The changes to these policies may also affect financial responsibilities for members and/or providers. Ambulatory Cardiac Event Monitors and Mobile Cardiac Outpatient Telemetry (formerly Ambulatory Event Monitors and Mobile Cardia Outpatient Telemetry) Applied Behavioral Analysis (ABA) High-Level Overview Change in name for this policy Clarified medical necessity and investigational criteria Updated code, removed deleted codes replaced with new codes Updated Attachment III descriptors and codes Revised language under Applied Behavior Analysis for treatment of ASD section

2 Autologous Chondrocyte Transplantation or Implantation Breast Surgery Cochlear Implants Cognitive Rehabilitation Cranial Wigs Drug Wastage Electrical Bone Growth Stimulation of the Appendicular Skeleton Electrical Stimulation of the Spine as an adjunct to Spinal Fusion Procedures Fecal Analysis in Diagnosis of Intestinal Disorders Fecal Calprotectin Testing Glucose Monitoring (CGMS) in Interstitial Fluid (continuous or intermittent) Homocysteine Testing Insulin Pumps (external) Laser Treatment of Port Wine Stains High-Level Overview Matrix induced ACI removed as investigational from policy statement HCPCS codes C1789, Q4122 require prior approval New medical policy CPT requires prior approval Added language for artificial pancreas device Added language for artificial pancreas Pulse Dye Lasers (PDL) moved to the preferred initial treatment. Other laser treatments with more side effects reserved for treatment failure with PDL Light Therapy for Psoriasis Policy updates; see policy for specifics Light Therapy for Vitiligo Light box therapy wording updated to align with members certificates of coverage References updated Lumbar Spinal Fusion Added CPT Revised descriptor for CPT MRI (whole body) Medical Food for Inherited Metabolic Disease Nonpharmacologic Treatment of Rosacea Nutrient/Nutritional Panel Testing & Intracellular Micronutrient Analysis New medical policy CPT is investigational References updated Updated ICD-10-CM table Updated ICD-10-CM table

3 Oral Appliances for Obstructive Sleep Apnea Pediatric Neurodevelopmental and Autism Spectrum Disorder (ASD) Screening Prostatic Urethral Lift Sacroiliac Joint Pain (diagnosis and treatment) Sleep Disorders Diagnosis and Treatment Temporomandible Joint Dysfunction (TMJ) Total Parenteral Nutrition (TPN) in the Home Setting Transcranial Magnetic Stimulation as a Treatment for Depression (TMS) Transcutaneous Electrical Nerve Stimulation (TENS) Varicose Veins/Venous Insufficiency (Treatment) Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus and Colon High-Level Overview Oral appliance statements clarified Mild and severe sleep apnea definitions clarified Language revisions with regard to oral appliances Updated codes removed deleted, replaced with new codes Added CPT 96111, 96112, they do not require prior approval UNLESS (1) the number of screening tests performed prior to the age of three exceeds five or (2) when screening members over the age of three Updated policy criteria Clarified criteria and age range, especially around definition of obstructive uropathy Eliminated PSA for sub groups who would not otherwise require PSA, such as elderly patients with BPH and LUTS and known cancer patients Policy statements remain unchanged ICD-10-CM coding table updated in the medical necessity and home sleep study sections Updated CPAP to add auto-adjusting positive airway devices to be included in policy as CPAP/APAP Added policy guide clarifications Clarified benefit exceptions Added to investigational services Added language related to lost/stolen TMJ appliances Updated codes removed deleted codes, replaced with new codes Replaced ICD-9-CM table with a ICD-10-CM table No policy changes No policy changes; added language related to lost/stolen TENS. Policy clarified as to the definition of CEAP Category 1 veins. No policy changes

4 Changes in for certain services Starting with dates of service April 1, 2019 or after, there will be a change in for the following services. Code Processing through March 31, 2019 Change for April 1, T Investigational Requires prior approval through AIM Specialty 0504T Health for BCBSVT members For New England Health Plan/Access Blue New England members, prior approval needs to be obtained through BCBSVT Requires prior approval Prior approval not required, eligible, subject to medical necessity Investigational Investigational Single unit designation Multiple unit designation & Investigational Non-covered Investigational Informational, no reimbursement Requires prior approval Prior approval not required, eligible, subject to medical necessity A9541 Investigational for all diagnosis Investigational when billed with a diagnosis from the code ranges of R92.2 through R92.8 or Z12.31 through Z J1930 J2353 & J2354 J2502 J7192 & J7199 J7318 These HCPCS codes are a catch all for several drugs. We have been allowing regardless of NDC reported on the claim submission All other diagnosis are eligible, subject to medical necessity. Medical review will occur. The NDC submitted on claim will be used to determine the eligibility of the drug.

5 Code Processing through March 31, 2019 Change for April 1, 2019 J J7329 Q4154 Investigational Note: BCBSVT members excludes members of the Federal Employee Program, and BlueCard (including New England Health Plan and Access Blue New England). The changes reflected above may change impact fee/allowances. The fee/allowances for the above codes may be obtained by contacting your provider relations consultant. Thank you for your time. If you have any questions regarding this notice, please feel free to contact your provider relations consultant at (888) option 1 or at providerrelations@bcbsvt.com. Business hours are Monday through Friday from 8 a.m. to 4:30 p.m., except holidays. Sincerely, Teresa F. Voci Director, Quality and Provider Relations