Review Services Update September 2015

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1 Review Services Update September 2015 Unless otherwise indicated, prior authorization guidelines are applicable to members with active Group Health coverage. Prior Authorization Updates Procedure Notifications Providers must submit a Procedure Notification prior to performing procedures. All procedures performed at a facility require notification. Procedures performed in the office require a procedure notification if the service requires medical necessity review. If authorization is not obtained, the claim will be denied. To reduce claim denials for no authorization, please submit a Procedure Notification prior to the date of service. Medical records may be faxed to to determine medical necessity if applicable. Please allow time for review if indicated. If the services change during the procedure, please contact Review Services to change the procedure code within 14 days and prior to submitting the claim. A Procedure Notification may be requested online by using the Referral Request or Procedure Notification functions on MyGroupHealth for Providers at provider.ghc.org. Transition of Care Policy The Continuing Care with Terminated Practitioners and Continuing Care with Providers outside of the Members Group Health Plan Network for the new enrollee s policy will be merged into one document to address continued coverage with a non-network provider. Medical records may be faxed to to determine medical necessity if applicable. ICD-10 Starting in September, Group Health will begin accepting requests for authorization with ICD-10 codes for services that will take place October 1, 2015 and beyond.

2 The My Group Health for Providers Referral Request site will give providers the option of choosing ICD-9 or ICD-10 as their diagnosis code. Choose the radio button to identify which code you plan to enter in your request. Group Health will honor current authorizations with ICD-9 codes even if the date of service is after October 1, There is no requirement that providers send a new authorization request with an ICD-10 code. However, you will be required to bill with ICD-10 coding after October 1, 2015.

3 Medical Necessity Review Criteria To view the Group Health clinical criteria, visit MyGroupHealth for Providers at provider.ghc.org and select Referrals & Clinical Review, then Clinical Review Criteria. You will notice that a number of the Group Health clinical criteria are being transitioned to the MCG manuals (formerly Milliman Care Guidelines). The MCG manuals are proprietary and cannot be published and/or distributed. However, on an individual member basis, Group Health can share a copy of the specific criteria document used to make a utilization management decision. If one of your patients is being reviewed using these criteria, you may request a copy of the criteria by calling the Group Health Clinical Review Services toll-free at Criteria with changes The following were approved to adopt the MCG without modifications: Diabetes Mellitus HNF4A, GCK, HNF1A, PDX1, HNF1B, NEURO1, KLF11, CEL, PAX4, INS, BLK, ABCC8, EIF2AK3, FOXP3, KCNJ11, AND PTF1A. Polycystic Kidney Disease PKD1, PKD2, and PKHD1 Genes. The following were approved to adopt the MCG with modifications: Lower Limb Prosthesis: First indication from Group Health criteria added to MCG criteria. HCPC codes have been included to indicate specific limbs in the body. Genetic Screening and Testing: CFTR Gene & Mutation Panel added the clinical indication, Adult with concerning history for possible cystic fibrosis. Oncotype Dx: Adopted MCG for Colon & Prostate. Retained GHC edits for Breast. The following changes were made to Group Health criteria: Insulin Pumps: Group Health is adopting criteria to mirror indications for C-peptide testing as listed in the Medicare guidelines. The new testing requirement language for fasting C-peptide is applicable to both adult and pediatric members.

4 The following changes were made to Group Health criteria: Blepharoplasty: Clarified use of MRD1 for ptosis. Review not required for dermatochalasis (pre-authorization may still be required). Dermatology Services: Excimer Laser therapy is only covered for treatment of vitiligo on the face, neck, and hands. There must be documentation of the failure of medical management with topical therapy. o Bioengineered Skin Substitutes: Added the following products to the exclusion list Architect Biomatrix Biodesign (Surgisis) AFP Anal Fistula Plug Biodesign (Surgisis) Hiatal Hernia Matrix Biodesign (Surgisis) Inguinal Hernia Matrix Biodesign (Surgisis) RVP Recto-Vaginal Fistula Plug Clarix Regenerative Matrix Duraguard Excellagen Integra Flowable Wound Matrix Neox Wound Matrix Repriza SteriShield Vascu-Guard Bariatric Surgery: Revised to highlight treatment for bariatric complications and repeat bariatric surgical procedure criteria. Lymphedema Therapy: Revised to mirror Medicare guidelines. Capsule Endoscopy: Modifications were made to include esophageal varices and to allow approval for NSAIDS if ASA is used for anticoagulation. Monitored Anesthesia Care: The 70 year old age limit has been removed. Definition of pediatric group as 16 years and younger. Clarification of high dose and unstable has been added. Language as documented by anesthesia has been added. Transcatheter Aortic Valve Replacement: Changed ejection fraction from >15% to >20%. Low dose CT Cancer Screening: Age limits were changed to align with Medicare. Array-Based Comparative Genomic Hybridization (acgh): A determination was made to follow Group Health criteria of insufficient evidence.

5 Fecal DNA Testing: A determination was made to follow Group Health criteria of insufficient evidence. 2. New technology reviewed and determined Not to have Evidence of Efficacy or Utility The following new technology did not pass the Medical Technology Assessment Committee (MTAC) criteria and will not be covered based on lack of evidence of efficacy or utility for Group Health members. SoundBite Hearing Device Sensory Integration Therapy LINK Reflux Management System Per Oral Endoscopic Myotomy (POEM) Exoskeleton Sterotactic Radiosurgery (gamma knife) for multiple brain metastese (5 or more lesions) Negative Wound Pressure Therapy, non-powered (PICO or SNAP) Galectin-3 Blood Assay Test Insulin Pump for Type 2 Diabetes Digital Breast Tomosynthesis Ova1 for Assessment of Ovarian Cancer DecisioDx Melanoma SERI Surgical Scaffold for Breast Reconstruction Radiofrequency Ablation with Vertebral Augmentation for Painful Spinal Metastases 3. New technology reviewed and approved for coverage if criteria are met CYP2D6 Gene Testing for Tamoxifen Metabolism: Adopted criteria for new Eliglustat drug. 4. Pharmacy and Therapeutics criteria additions The information below addresses office-administered drugs only. Outpatient drug changes are communicated using another vehicle. Criteria will be updated on MyGroupHealth for Providers at provider.ghc.org under Prior-Authorization for Office-Administered Injectable Drugs. Pembrolizumab: will not be covered based on lack of evidence of efficacy or utility for Group Health members. Interferon beta-1a (Avonex): A trial and failure of preferred therapies.

6 Nivolumab (Opdivo) and Pembroluzumab (Keytruda): will not be covered based on lack of evidence of efficacy or utility for Group Health members. Ramucirumab (Cyramza): will not be covered based on lack of evidence of efficacy or utility for Group Health members. Pertuzumab: criteria has been updated to allow coverage for nonadjuvant use in combination with trastuzumab and a traxane in patients with confirmed HER2+, locally advanced, inflammatory, or early stage (either greater than 2cm in diameter or node positive) breast cancer. Some criteria are applicable for both Medicare and non-medicare plans, while some apply to just one or the other. Medicare-only criteria sets are being added regularly and are always available at the Centers for Medicare & Medicaid Services website. Please be sure to check your patient s coverage and verify if medical necessity criteria apply. Questions and requests for more information regarding Group Health s Review Services Updates may be directed to your Provider Services consultant.

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