Medical Prior Authorization List Notice of Change

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Dulcie Long
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1 Medical Prior Authorization List Notice of Change For prescription drug requirements, see plan formularies. See separate list for AdventHealth & Rosen Employees. This is a listing of the changes that have occurred to the Medical Prior Authorization List effective February 1, For a complete list of services and procedures that require prior authorization, please refer to the Medical Prior Authorization List (Auth List). Click here to view the Medical Prior Authorization List. General Information Florida Hospital Care Advantage ( Health Plans ) administer these requirements. Benefits are determined by the plan. Items listed may have limited coverage or not be covered at all. Referrals are not required for in-network specialist care. Refer to the current Provider Directory or visit our website at myfhca.org for a list of network providers. Authorization is not a guarantee of payment. Coverage is subject to member eligibility, as well as applicable benefit and provider contract provisions on the date of service. Contract limitations may apply and supersede any authorization provided. If waiting for a decision in the standard timeframe could seriously harm the member s life, health or ability to regain maximum function, an expedited process is available. To request authorization from the Health Plan, submit the appropriate medical or pharmacy (drug) Authorization Request form or request authorization online. Include applicable codes, patient identification and clinical information to support the request. IMPORTANT CONTACTS FOR AUTHORIZATIONS SUBMITTED TO THE HEALTH PLAN You can submit requests electronically using your secure account at: myfhca.org/myportal You can fax authorization requests to: (toll-free) Please include applicable codes and clinical information to support the request. For questions, call Customer Service toll-free at Monday through Friday from 8 a.m. to 6 p.m.

2 SERVICE AND PROCEDURES NOW REQUIRING PRIOR AUHORIZATION CODE CODE DESCRIPTION 0080U Oncology (lung), mass spectrometric analysis of galectin-3-binding protein and scavenger receptor cysteine-rich type 1 protein M130, with five clinical risk factors (age, smoking status, nodule diameter, nodule-spiculation status and nodule location), utilizing plasma, algorithm reported as a categorical probability of malignancy 0081U Oncology (uveal melanoma), mrna, gene-expression profiling by real-time RT-PCR of 15 genes (12 content and 3 housekeeping genes), utilizing fine needle aspirate or formalin-fixed paraffin-embedded tissue, algorithm reported as risk of metastasis 0082U Drug test(s), definitive, 90 or more drugs or substances, definitive chromatography with mass spectrometry, and presumptive, any number of drug classes, by instrument chemistry analyzer (utilizing immunoassay), urine, report of presence or absence of each drug, drug metabolite or substance with description and severity of significant interactions per date of service 0083U Oncology, response to chemotherapy drugs using motility contrast tomography, fresh or frozen tissue, reported as likelihood of sensitivity or resistance to drugs or drug combinations Allograft, includes templating, cutting, placement and internal fixation, when performed; osteoarticular, including articular surface and contiguous bone (List separately in addition to code for primary procedure) Allograft, includes templating, cutting, placement and internal fixation, when performed; hemicortical intercalary, partial (ie, hemicylindrical) (List separately in addition to code for primary procedure) Allograft, includes templating, cutting, placement and internal fixation, when performed; intercalary, complete (ie, cylindrical) (List separately in addition to code for primary procedure) Replacement, aortic valve; by translocation of autologous pulmonary valve and transventricular aortic annulus enlargement of the left ventricular outflow tract with valved conduit replacement of pulmonary valve (Ross-Konno procedure) Aortic hemiarch graft including isolation and control of the arch vessels, beveled open distal aortic anastomosis extending under one or more of the arch vessels, and total circulatory arrest or isolated cerebral perfusion (List separately in addition to code for primary procedure) Orthopantogram (e.g. panoramic x ray) BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; evaluation to detect abnormal AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; characterization of alleles (eg, expanded size and methylation status) Page 2 of 6

3 81173 AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; known familial variant ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; full gene sequence ATN1 (atrophin 1) (eg, dentatorubral-pallidoluysian atrophy) gene analysis, evaluation to detect abnormal ATXN1 (ataxin 1) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal ATXN2 (ataxin 2) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal ATXN3 (ataxin 3) (eg, spinocerebellar ataxia, Machado-Joseph disease) gene analysis, evaluation to detect abnormal ATXN7 (ataxin 7) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal ATXN8OS (ATXN8 opposite strand [non-protein coding]) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal ATXN10 (ataxin 10) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; evaluation to detect abnormal CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; full gene sequence CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; known familial variant CNBP (CCHC-type zinc finger nucleic acid binding protein) (eg, myotonic dystrophy type 2) gene analysis, evaluation to detect abnormal CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; evaluation to detect abnormal CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; full gene sequence CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant(s) AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; characterization of alleles (eg, expanded size or methylation status) BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, C481S, C481R, C481F) DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis, full gene sequence EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, diffuse large B-cell lymphoma) gene analysis, common variant(s) (eg, codon 646) HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles HTT (huntingtin) (eg, Huntington disease) gene analysis; characterization of alleles (eg, expanded size) Page 3 of 6

4 81284 FXN (frataxin) (eg, Friedreich ataxia) gene analysis; evaluation to detect abnormal (expanded) alleles FXN (frataxin) (eg, Friedreich ataxia) gene analysis; characterization of alleles (eg, expanded size) FXN (frataxin) (eg, Friedreich ataxia) gene analysis; full gene sequence FXN (frataxin) (eg, Friedreich ataxia) gene analysis; known familial variant(s) MYD88 (myeloid differentiation primary response 88) (eg, Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.leu265pro (L265P) variant NUDT15 (nudix hydrolase 15) (eg, drug metabolism) gene analysis, common variant(s) (eg, *2, *3, *4, *5, *6) PABPN1 (poly[a] binding protein nuclear 1) (eg, oculopharyngeal muscular dystrophy) gene analysis, evaluation to detect abnormal PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, R335W, S707F, L845F) SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; dosage/deletion analysis (eg, carrier testing) includes SMN2 (survival of motor neuron 2, centromeric) analysis, if performed TGFBI (transforming growth factor beta-induced) (eg, corneal dystrophy) gene analysis, common variants (eg, R124H, R124C, R124L, R555W, R555Q) SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; full gene sequence SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; known familial sequence variant(s) PP2R2B (protein phosphatase 2 regulatory subunit Bbeta) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal TBP (TATA box binding protein) (eg, spinocerebellaar ataxia) gene analysis, evaluation to detect abnormal TERT (telomerase reverse transcriptase) (eg, thyroid carcinome, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region) Genetic testing for severe inherited conditions (eg, cystic fibrosis, Ashkenazi Jewishassociated disorders [eg, Bloom syndrome, Canavan disease, Fanconi anemia type C, mucolipidosis type VI, Gaucher disease, Tay-Sachs disease], beta hemoglobinopathies, phenylketonuria, galactosemia), genomic sequence analysis panel, must include sequencing of at least 15 genes (eg, ACADM, ARSA, ASPA, ATP7B, BCKDHA, BCKDHB, BLM, CFTR, DHCR7, FANCC, G6PC, GAA, GALT, GBA, GBE1, HBB, HEXA, IKBKAP, MC0LN1, PAH) Oncology (breast) mrna, gene expression profiling by real-time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy Infectious disease, chronic hepatitis C virus (HCV) infection, six biochemical assays (ALT, A2- macroglobulin, apolipoprotein A-1, total bilirubi, GGT, and haptoglobin) utilizing serum, prognostic algorithm reported as scores for fibrosis and necroinflammatory activity in liver Therapeutic repetitive transcranial magnetic stimulation treatment; planning Therapeutic repetitive transcranial magnetic stimulation treatment; delivery and management, per session Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management Insertion, subcutaneous cardiac rhythm monitor, including programming Page 4 of 6

5 33286 Removal, subcutaneous cardiac rhythm monitor Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed d S1040 Cranial remolding orthotic, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) E0447 Portable oxygen contents, liquid, 1 month's supply = 1 unit, prescribed amount at rest or nighttime exceeds 4 liters per minute (LPM) E0467 Home ventilator, multi-function respiratory device, also performs any or all of the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions Q4183 Surgigraft, per sq cm Q4184 Cellesta, per sq cm Q4185 Cellesta Flowable Amnion (25 mg per cc); per 0.5 cc Q4186 Epifix, per sq cm Q4187 Epicord, per sq cm Q4188 AmnioArmor, per sq cm Q4189 Artacent AC, 1 mg Q4190 Artacent AC, per sq cm Q4191 Restorigin, per sq cm Q4192 Restorigin, 1 cc Q4193 Coll-e-Derm, per sq cm Q4194 Novachor, per sq cm Q4195 PuraPly, per sq cm Q4196 PuraPly AM, per sq cm Q4197 PuraPly XT, per sq cm Q4198 Genesis Amniotic Membrane, per sq cm Q4200 SkinTE, per sq cm Q4201 Matrion, per sq cm Q4202 Keroxx (2.5 g/cc), 1 cc Q4203 Derma-Gide, per sq cm Q4204 L8701 L8702 XWRAP, per sq cm Powered upper extremity range of motion assist device, elbow, wrist, hand with single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease C9751 Bronchoscopy, rigid or flexible, transbronchial ablation of lesion(s) by microwave energy, including fluoroscopic guidance, when performed, with computed tomography acquisition(s) and 3-d rendering, computer-assisted, image-guided navigation, and endobronchial ultrasound (ebus) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]) and all mediastinal and/or hilar lymph node stations or structures and therapeutic intervention(s) Page 5 of 6

6 70355 Orthopantogram (eg, panoramic x-ray) SERVICE AND PROCEDURES NO LONGER REQUIRE PRIOR AUHORIZATION CODE CODE DESCRIPTION Implantation of patient-activated cardiac event recorder C1764 Event recorder, cardiac (implantable) E0616 Implantable cardiac event recorder with memory, activator, and programmer Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa SERVICES AND PROCEDURES WITH PRIOR AUTHORIZATION REQUIREMENT CHANGES CODE CODE DESCRIPTION CHANGE DESCRIPTION 0004U Infectious disease (bacterial), DNA, 27 resistance genes, PCR Code deleted amplification and probe hybridization in microarray format (molecular detection and identification of AmpC, carbapenemase and ESBL coding genes) 0015U Infectious disease (bacterial), DNA, 27 resistance genes, PCR Code deleted amplification and probe hybridization in microarray format (molecular detection and identification of AmpC, carbapenemase and ESBL coding genes) L2820 Addition to lower extremity orthosis, soft interface for molded Code deleted plastic, below knee section BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast Code deleted and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants in BRCA1 (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon del 26kb, exon 22 del 510bp, exon BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; uncommon duplication/deletion variants Code deleted Page 6 of 6

Centers for Medicare and Medicaid Services

Centers for Medicare and Medicaid Services Clinical Laboratory Fee Schedule Annual Laboratory Public Meeting June 25, 2018 Anthony Sireci, MD, Msc Association for Molecular Pathology Outline Germline Procedures