New Medicare Advantage HMO and PPO policy notifications posted October 1, 2014

Transcription

1 New Medicare Advantage HMO and PPO policy notifications posted October 1, 2014 Below is a listing of the policy notifications available on our website for Medicare Advantage HMO and PPO policies that go into effect January 1, To view all notifications and policy changes, visit and select Accept and Go to Medical Policy Online. Then select the Medicare Advantage link under Policy Notifications. The below policies are listed numerically within the following categories: Administrative Medicine Anesthesia Drugs and Biologics Case Management Radiology Clinical Logic Rehabilitation Services Dental Surgery Durable Medical Equipment (DME) Miscellaneous Pathology and Laboratory Administrative MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA Obsolete or Unreliable Diagnostic Tests and Medical Services Continuous Glucose Monitors Preventive Care Services Routine Costs of Clinical Trials and Coverage of Investigational Devices A and B Experimental/Investigational Services Infusion Therapy Services as Performed by Home Infusion Providers Reporting and Documentation Requirements for Anesthesia Services PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services Modifier 62: Two Surgeons Cast and Splint Applications and Associated Supplies Provided in the Office Setting Physician Standby Services Modifier 66: Surgical Team Modifiers for Assistant-at-Surgery Services: 80, 81, 82, and AS Add-on Codes Medical Team Conferences Prolonged Face-to-Face Physician Services Radiologic Guidance of a Procedure STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point-of-Service (POS) Products MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA Intravenous (IV) Administration of Fluids as a Treatment of a Medical Condition or for the Preparation of Pharmaceuticals, Biologics, and other Substances Inpatient Hospital Readmission Reporting Requirements for Drugs and Biologicals Reporting of Healthcare Common Procedure Coding System (HCPCS) C Series Codes Always Bundled Procedure Codes Diagnostic Radiology Services Included in Capitation Outpatient Short-Term Rehabilitation Services Included in Capitation Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/ OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products X-rays Associated with Fractures in the Office Setting Direct Access Obstetrics/Gynecology (OB/GYN) Services Paid Above Capitation for Health Maintenance Organization (HMO) Primary Care Physicians Photography Used for Documentation/Record- Keeping Purposes Home Visits by a Physician Remote Patient Management: Telemedicine and Telehealth 1

2 Administrative (continued) MA MA MA MA MA MA MA MA Anesthesia MA MA MA MA MA Anesthesia Services for a Cancelled or Discontinued Procedure Preoperative Consultations Performed by Providers in Anesthesia Specialties Organ and Tissue Recovery from a Cadaveric Donor and Associated Services Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services Case Management MA MA MA Clinical Logic MA MA MA MA Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus Marijuana for Medical Use Never Events and Preventable Adverse Events Facility Reporting of Observation Services National Correct Coding Initiative (NCCI) Code Pair Edits Humanitarian Use Devices (HUDs) Diagnosis Criteria for Reimbursement of Emergency Room Services Reimbursement for Certified Registered Nurse Practitioners (CRNP) Hospice Care Private Duty Nursing Home Health Care Services Modifier 76: Repeat Procedure by Same Physician Modifier 50: Bilateral Procedure Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service Modifier 51: Multiple Procedures MA MA MA MA MA MA MA MA MA MA MA MA MA Dental MA MA DME MA MA MA MA MA MA MA Modifier 59: Distinct Procedural Service Modifiers LT/RT: Left Side/Right Side Procedures Modifier 77: Repeat Procedure by Another Physician Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician Following the Initial Procedure for a Related Procedure During the Postoperative Period Modifier 24: Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period Modifier 57: Decision for Surgery Modifiers 26 (Professional Component) and TC (Technical Component) Modifier 79: Unrelated Procedure or Service by the Same Physician During the Postoperative Period Modifier 51 Exempt Modifier 52 Reduced Services Electrocardiogram (ECG/EKG) Reported with Single Photon Emission Computed Tomography (SPECT) for Myocardial Perfusion Imaging (MPI) Insertion or Application of Urinary Catheters and the Associated Supplies Provided in the Office Setting Modifiers for Shared or Split Surgical Services (Modifiers 54, 55, 56) Dental Extractions Prior to Cardiac Surgery, Radiation Therapy, or Transplant Surgery Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth High-Frequency Chest Wall Oscillation Devices Hospital Beds and Accessories Speech and Non-Speech Generating Devices Pneumatic Compression Therapy Devices for Lymphedema and Chronic Venous Insufficiency Automatic External Defibrillators Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies Nebulizers 2

3 DME (continued) MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA Negative Pressure Wound Therapy Cervical Traction Devices for In-home Use Ankle-Foot/Knee-Ankle-Foot Orthoses Seat Lift Mechanisms Orthopedic Footwear Knee Braces Ostomy Supplies Home Blood Glucose Monitors and Supplies Home Prothrombin Time Monitoring Home Oxygen Therapy Osteogenic Stimulators (i.e., Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System) Continuous Passive Motion (CPM) Devices for Home Use Therapeutic Shoes Injectable Dermal Fillers Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD) Wheelchair Cushions and Seating Lower Limb Prostheses Pressure Reducing Support Surfaces Manual Wheelchair Bases Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum Heating Pads and Heat Lamps Spinal Orthoses Patient Lifts Power Mobility Devices External Breast Prosthesis Tracheostomy Care Supplies Cold Therapy Devices Commodes Walkers Non-Implantable Pelvic Floor Electrical Stimulator Food and Drug Administration (FDA) Approval of Medical Devices Blood Pressure Devices for Home Use MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA Pulse Oximetry Device in the Home Setting Mechanical Stretching Devices for the Treatment of Joint Stiffness or Contractures Durable Medical Equipment (DME) Compression Garments Wheelchair Options/Accessories Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring in Adults Bladder Stimulators (Pacemakers) Electronic Speech Aids Eye Prosthesis Canes and Crutches Implantable and External Infusion Pumps Urological Supplies Standing Frames Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) and Bi-Level Devices (BiPAP) Upper-Limb Prostheses Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES) Electrical Continence Aid Home Use of Interferential and Sequential Stimulation Devices Repair and Replacement of Durable Medical Equipment (DME) Repair or Replacement of an External Prosthetic Device Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT) Pathology and Laboratory MA MA MA MA MA MA MA Apheresis Therapy In Vitro Allergy Testing In Vivo Allergy Sensitivity Testing Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Treatment Loss-of-Heterozygosity-Based Topographic Genotyping with PathFinderTG Pharmacogenetic Testing to Determine Drug Sensitivity Computer Analysis and Generation of Automated Data in Conjunction with Diagnostic Studies 3

4 Pathology and Laboratory (continued) MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA Medicine MA MA MA MA MA MA MA MA Genetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2 (BRCA2) Mutations Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome) Serodiagnosis of Inflammatory Bowel Disease (IBD) and the Prometheus IBD sgi Diagnostic Test Pharmacogenetics and Metabolite Monitoring Using Azathioprine (AZA)/6-Mercaptopurine (6-MP) Therapy AlloMap Molecular Expression Testing for Heart Transplant Rejection Heartsbreath Test for Heart Transplant Rejection Molecular Diagnostics Immune Cell Function Assay Measurement of Serum Antibodies to and Measurement of Serum Levels of Infliximab and Adalimumab Autologous Blood Services (Collection, Storage, Transfusion, and Perioperative Salvage) In Vitro Chemosensitivity and Chemoresistance Assays Biomarkers for Oncology Nerve Fiber Density Testing Circulating Tumor Cell (CTC) Assay Hyperbaric Oxygen Therapy Ultraviolet Light Therapy for the Treatment of Dermatological Conditions Photodynamic Therapy Using Verteporfin (Visudyne ) Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) Ambulatory Blood Pressure Monitoring (ABPM) Platelet-Rich Plasma (PRPs) for Chronic Non-Healing Wounds and Stem-Cell Therapy for Orthopedic Applications Routine Foot Care For Certain Medical Conditions Biofeedback Therapy MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA Topical Oxygenation External Counterpulsation (ECP) Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds Magnetic Pelvic Floor Stimulation (MPFS) Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS) Intravenous Chelation Therapy Hyperthermic Intraperitoneal Chemotherapy (HIPEC) Anorectal Manometry, Electromyography (EMG) of Anorectal or Urethral Sphincters; Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters Reimbursement for the Administration of Immunizations Whole-body Integumentary Photography and Dermatoscopy Partial Coherence Interferometry Wireless Capsule Endoscopy Medical and Surgical Treatment of Temporomandibular Joint Disorder Intrauterine Systems (IUSs) (e.g., Mirena, Skyla ) Refractive Lenses Photodynamic Therapy (PDT) using Porfimer Sodium (Photofrin ) Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies Repetitive Transcranial Magnetic Stimulation (rtms) Cold Laser Therapy Neuropsychological Evaluation/Testing Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI) Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies Complete Decongestive Therapy (CDT) Smell and Taste Dysfunction Testing Measurement of Exhaled Nitric Oxide and Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders Microvolt T-Wave Alternans (MTWA) Corneal Pachymetry Using Ultrasound 4

5 Medicine (continued) MA MA MA MA MA MA MA MA MA MA MA MA Drugs and Biologics MA Vedolizumab (Entyvio ) MA MA MA MA MA MA MA MA MA MA MA MA Pain Management of Peripheral Nerves by Injection Instrument-Based Vision Screening Implantable Cardiac Loop Monitor Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG) Intraoperative Neurophysiological Testing Bioimpedance for the Detection of Lymphedema Allergy Immunotherapy Photodynamic Therapy (PDT) Using Levulan Kerastick (Aminolevulinic Acid HCl [ALA]) or Metvixia (Methyl Aminolevulinate [MAL]) Cardiac Event Detection Monitoring (External Loop Monitoring) Sleep Disorder Testing Oral and Maxillofacial Prosthesis Real-Time, Outpatient Cardiac Telemetry Nesiritide (Natrecor ) for Treatment of Heart Failure Patients Enteral Nutritional Therapy Coagulation Factors for Hemophilia Elosulfase alfa (Vimizim ) Medicare Part B vs. Part D Crossover Drugs Total Parenteral Nutrition (TPN), Intradialytic Nutrition (IDPN) and Intraperitoneal Nutrition (IPN) Immune Globulin: Intravenous (IVIG), Subcutaneous (SCIG) Erythropoiesis Stimulating Agents (ESAs) Off-label Coverage for Prescription Drugs and/or Biologics Radioimmunotherapy with Ibritumomab Tiuxetan (Zevalin ) Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents Intended for Home Use Botulinum Toxin Agents MA Trastuzumab (Herceptin ) MA Infliximab (Remicade ) MA Dofetilide (Tikosyn ) Use in the Inpatient Setting MA Rituximab (Rituxan ) MA Enzyme Replacement for the Treatment of Gaucher's Disease MA Omalizumab (Xolair ) MA MA MA Complex Regional Pain Syndrome (CRPS) Parenteral Treatments Risperidone (Risperdal Consta ) Injection Abatacept (Orencia ) for Injection for Intravenous use MA Natalizumab (Tysabri ) MA Cetuximab (Erbitux ) MA Agalsidase beta (Fabrazyme ) MA Laronidase (Aldurazyme ) MA MA Idursulfase (Elaprase ) Alglucosidase Alfas, rhgaa (Myozyme, Lumizyme ) MA Bortezomib (Velcade ) MA Oxaliplatin (Eloxatin ) MA Plerixafor Injection (Mozobil ) MA Bendamustine Hydrochloride (Treanda ) MA MA Ustekinumab (Stelara ) for Subcutaneous Injection Pralatrexate (Folotyn ) for Injection MA Eculizumab (Soliris ) MA Tocilizumab (Actemra ) for Intravenous Infusion MA Ecallantide (Kalbitor ) MA Pemetrexed (Alimta ) MA MA MA MA MA Ofatumumab (Arzerra ) Paclitaxel Protein-bound Particles for Injectable Suspension (Albumin-bound)/(Abraxane for Injectable Suspension) Alpha 1-Proteinase Inhibitor Therapy (e.g., Prolastin-C, Aralast, Aralast NP, Glassia, Zemaira ) C1 Esterase Inhibitors: Cinryze, Berinert, and Ruconest Denosumab (Prolia, Xgeva ) MA Personalized Vaccines (e.g., Provenge ) MA Cabazitaxel (Jevtana ) MA Romidepsin (Istodax ) MA Eribulin Mesylate (Halaven ) 5

6 Drugs and Biologics (continued) MA Belimumab (Benlysta ) MA Ipilimumab (Yervoy ) MA Pegloticase (Krystexxa ) MA Belatacept (Nulojix ) MA Carfilzomib (Kyprolis ) MA Pertuzumab (Perjeta ) MA Omacetaxine Mepesuccinate (Synribo ) MA MA MA MA MA MA Computer Aided Detection (CAD) System for use with Chest Radiographs Positron Emission Mammography (PEM) Digital Breast Tomosynthesis Brachytherapy Radioembolization for Primary and Metastatic Tumors of the Liver Magnetic Resonance Imaging (MRI) for Monitoring the Integrity of Silicone-Gel-Filled Breast Implants in Asymptomatic Individuals MA Octreotide Acetate (Sandostatin LAR Depot) MA Ado-Trastuzumab Emtansine (Kadcyla ) MA Repository Corticotropin (H.P. Acthar Gel Injection) MA Brentuximab Vedotin (Adcetris ) MA MA Radium Ra 223 dichloride (Xofigo ) Injection Golimumab (Simponi Aria ) Intravenous (IV) Injection MA Galsulfase (Naglazyme ) MA Bevacizumab (Avastin ) MA Radiology MA MA MA MA MA MA MA MA MA MA MA MA Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists (e.g., ranibizumab [Lucentis ], pegaptanib sodium [Macugen ], aflibercept [Eylea ]) Intensity Modulated Radiation Therapy (IMRT) High-Technology Radiology Services Echocardiography Contrast Agents High Osmolar Contrast Agents Therapeutic Radiology Port Films Proton Beam Therapy Low Osmolar Contrast Agents Diagnostic and Therapeutic Radiopharmaceutical Agents Magnetic Resonance Imaging (MRI) Contrast Agents Electron Beam Computed Tomography (EBCT) for Screening Evaluations Full-Body Computerized Tomography (CT) Scan Screening Screening for Vertebral Fracture with Dual-Energy X-ray Absorptiometry (DEXA/DXA) Rehabilitation Services MA MA MA MA MA MA Surgery MA MA MA MA MA MA MA MA MA MA MA MA MA Pulmonary Rehabilitation Services Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs Physical Medicine & Rehabilitation Services: Physical Therapy (PT) and Occupational Therapy (OT) Chiropractic Services Day Rehabilitation Speech Therapy Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence Hematopoietic Stem Cell Transplantation Lung Volume Reduction Surgery (LVRS) Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH) Deep Brain Stimulation (DBS) Bronchial Thermoplasty Islet Cell Transplantation Refractive Keratoplasty Abortion Artificial Hearts and Ventricular Assist Devices (VADs) Endovascular Grafts for Abdominal Aortic Aneurysms, Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Nails Wound Care: Bioengineered Skin Substitutes 6

7 Surgery (continued) MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA Prostate Mapping Biopsy Trigger Point Injections Mohs' Micrographic Surgery (MMS) Vagus Nerve Stimulation (VNS) Non-Surgical Spinal Decompression Therapy Cryosurgery of the Prostate Hyaluronan Acid Therapies for Osteoarthritis of the Knee Percutaneous Vertebroplasty and Percutaneous Vertebral Augmentation Percutaneous Intradiscal Annuloplasty (IDET/PIRFT) Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management Transcatheter Aortic Valve Replacement (TAVR) and Transcatheter Mitral Valve Repair (TMVR) Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS) for the Control of Incontinence Reconstructive Breast Surgery Spinal Cord Stimulation (Dorsal Column Stimulation) Multiple Surgical Reduction Guidelines Solid Organ Transplants Collagen Meniscus Implant Infrared Photocoagulation (IRC) of Hemorrhoids Surgical Treatment of Nails Use of an Operating Microscope During a Surgical Procedure Radiofrequency Micro-remodeling (by transurethral, transvaginal, or paraurethral approach) for Urinary Stress Incontinence Cochlear Implantation Transcatheter Closure of Cardiac Septal Defects Revision of a Previous Cosmetic Procedure Reimbursement for a Presbyopia- or Astigmatism-Correcting Intraocular Lens Artificial Intervertebral Disc Insertion Uterine Artery Embolization Hair Transplants and Cranial Prostheses (Wigs) Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/ Canthopexy MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA Lumbar Interspinous Process Decompression System Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids Treatment of Medical and Surgical Complications Treatment of Obesity and Bariatric Surgery for Treatment of Morbid Obesity Radiofrequency Ablation and Cryosurgical Ablation of Lung Tumors Sterilization Cataract Surgery Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD) Percutaneous Transluminal Angioplasty (PTA) and Extracranial (EC) and Intracranial (IC) Arterial Bypass Surgery Robotic-Assisted Surgery Otoplasty Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee Catheter Ablation of Cardiac Arrhythmias Transcoronary Ablation of Septal Hypertrophy (TASH) Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions Photocoagulation of Macular Drusen Implantable Miniature Telescope (IMT) for the Treatment of End-Stage Age-Related Macular Degeneration (AMD) Endometrial Ablation Ovarian and Internal Iliac Vein Embolization as Treatment for Pelvic Congestion Syndrome Labiaplasty Sentinel Lymph Node Biopsy Reduction Mammoplasty Lipectomy and Liposuction Selective Photothermolysis Using Pulsed-Dye Lasers (PDL) Application and Removal of Tattoos Abdominoplasty and/or Panniculectomy Excision of Redundant Skin Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty Removal of Breast Implants 7

8 Surgery (continued) MA MA MA MA Prophylactic Mastectomy Scar Revision Evaluation and Treatment of Erectile Dysfunction (ED) Mentoplasty or Genioplasty Miscellaneous MA MA MA Alternative Therapies and Complementary Medicine Nonemergency Ambulance Transport Air or Sea Ambulance MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA MA Meniscal Allograft Transplantation Autologous Chondrocyte Implantation (ACI)/ Carticel and Other Cell-based Treatments of Focal Articular Cartilage Lesions Orthognathic Surgery Osteochondral Autograft Transplantation (OAT) Procedure Arthroscopic Electrothermal Joint Repair Osteochondral Allograft Transplantation Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure Hip Resurfacing Surgical Treatment of Femoroacetabular Impingement Manipulation Under Anesthesia Total Ankle Arthroplasty/Replacement Surgical Treatments of Athletic Pubalgia Treatment for Hyperhidrosis (Nonpharmacologic) Lysis of Epidural Adhesions Percutaneous Discectomy Percutaneous Image-Guided Lumbar Decompression (PILD) for Spinal Stenosis Migraine Deactivation Surgery Septoplasty, Rhinoplasty, and Septorhinoplasty Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis Nucleoplasty Denervation of the Spinal Nerves for Chronic Facet Pain Chemical Peels Lacrimal Punctum Plugs Aqueous Shunts, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma 8