Medical Policy Update Summer 2017 Highlights of recent medical policy revisions as well as any new medical policies approved by Prevea360 Health Plan s Medical Policy Committee are shown below. The Medical Policy Committee meetings take place monthly. We appreciate contributions by specialists during the technology assessment of medical procedures and treatments. To view all Prevea360 Health Plan medical policies, go to our Medical Management page. This page is updated as the medical policies become effective. If you have questions regarding any medical policy or would like copies of a complete medical policy, please contact our Customer Care Center at 877.230.7555. All other Prevea360 Health Plan clinical guidelines used by the Quality and Care Management Division, such as MCG (formerly known as Milliman Care Guidelines) and the American Society of Addiction Medicine are accessible to the provider upon request. To request clinical guidelines, contact the Customer Care Center at 877.230.7555. Coverage of any medical intervention discussed in a Prevea360 Health Plan medical policy is subject to the limitations and exclusions outlined in the Member Certificate. A verbal request for a referral does not guarantee authorization of the referral or the services. After a written referral request has been reviewed in the Quality and Care Management Division, a printed notification is sent to the requesting provider and member. Note that prior authorization through the Prevea360 Health Plan Quality and Care Management Division may be required for some treatments or procedures.
For imaging prior authorizations, please contact National Imaging Associates (NIA). Providers can contact NIA by phone at 866.307.9729 Monday-Friday from 7:00 a.m. to 7:00 p.m. CST, or by email at RadMDSupport@MagellanHealth.com. Details about the radiology prior authorization program can be found here. Medical Policy Update Summer 2017 New Medical Policies Collagenase Injection for Dupuytren s Contracture MP9489 Effective September 1, 2017, Prevea360 Health Plan will cover Collagenase Injections for Dupuytren s Contracture. Prior authorization is required and a maximum of three injections per cord is medically necessary as an alternative to surgical treatment when the medical policy criteria are met. Electric Tumor Treatment Fields (Optune ) MP9474 Effective March 1, 2017, Prevea360 Health Plan will cover electric tumor treatment fields (ETTF) for the treatment of glioblastoma. Prior authorization is required and this limited to Oncology specialists. Treatment is considered medically necessary for adults 18 years of age and older when criteria is met. Pressure Reducing Support Surfaces MP9472 Effective May 1, 2017, Prevea360 Health Plan will require prior authorization for pressure reducing support surfaces when the cost is greater than $500. The clinical criteria for Group 1 to 3 support surfaces can be found in the policy. (Group 1) Mattress or overlay > $500. (Group 2) Power pressure reducing mattress, non-powered advanced pressure reducing mattresses, and overlays for these devices. (Group 3) Air-fluidized beds. MRI TRUS Fusion-Guided Prostate Biopsy MP9492 Effective September 1. 2017, Prevea360 Health Plan will cover MRI TRUS Fusion- Guided Prostate Biopsy with prior authorization. The procedure is medically appropriate for patients with one or more negative TRUS biopsies and the patient is considered high risk due to either a persistently elevated prostate specific antigen (PSA) or a rising PSA. Medical Policy Changes Sex Transformation Surgery MP9469 Surgical procedures, with an associated diagnosis of gender dysphoria, not indicated in the medical policy are required to be reviewed by a medical director. 2
Technology Assessments FilmArray Blood Culture Identification (BCID) A panel for rapid identification of pathogens has been determined to be medically necessary. Non-covered Services and Procedures MP9415 The following services and/or procedures were reviewed by Prevea360 Health Plan and have been determined to be non-covered: Eustachian tube balloon dilation systems, genomic testing to assess prostate cancer risk/aggressiveness, molecular breast imaging scintigraphy and devices for the treatment of stuttering. Measurement of Serum Levels and Antibodies to REMICADE (infliximab) and HUMIRA (adalimumab) MP9464 The requirement to use a specific lab (PROMETHEUS ) was removed. Codes that require prior authorization are 80299, 82397, and 84999. Genetic Testing MP9012 Prevea360 Health Plan genetic testing medical policies were updated and will become effective July 1, 2017. Specific genetic tests require pre and post-genetic counseling. Self-funded (ASO) plans do not require genetic counseling. If a CPT code or genetic test is not referenced in a policy, prior authorization is required. MP9012 is the general genetic testing policy with links to sixteen new genetic testing policies. The information provided is not intended to be all-inclusive. Hereditary Cardiac Disease and Arrhythmias MP9472 Genetic testing is considered experimental and investigational for short QT syndrome, atrial fibrillation and broad multi-condition panel testing. General population testing for hereditary conditions is not medically necessary. Thrombophilia MP9473 Factor V Leiden thrombophilia (F5 gene) and prothrombin thrombophilia (F2) gene testing criteria. MTHFR gene testing is considered experimental and investigational. Reproductive Carrier Screening and Prenatal Care MP9477 Examples of when prior authorization is not required for screening include: Ashkenazi Jewish carrier, spinal muscular atrophy, cystic fibrosis carrier, recurrent pregnancy loss, genetic prenatal cell-free DNA, and invasive prenatal testing of a fetus. BRCA1 and BRCA2 Genes MP9478 Multigene panel testing for hereditary cancer susceptibility syndromes, which may or may not accompany BRCA testing, is considered experimental and investigational. 3
Pharmacogenetics MP9479 Multigene pharmacogenetics genotyping assays which do not meet medical policy criteria are considered experimental and investigational. Peutz-Jeghers Syndrome (PJS) MP9480 STK11 gene testing, which requires prior authorization, is medically necessary for diagnostic confirmation of Peutz-Jeghers syndrome or for screening an at-risk individual. Hearing Loss and Usher Syndrome MP9481 Diagnostic confirmation of Usher syndrome Type 1, 2 or 3 or for the screening an at-risk individual, requires prior authorization. Multigene testing is medically necessary for congenital and nonsyndromic hearing loss. Polyposis MP9482 Genetic testing criteria for familial adenomatous polyposis, MYH-associated polyposis, and juvenile polyposis syndrome requires prior authorization. Multiple Endocrine Neoplasia MP9483 Type 1 (MEN 1) and Type 2 (MEN2) RET gene testing requires prior authorization. Diffuse Gastric Cancer MP9484 CDH1 gene testing requires prior authorization. Li-Fraumeni Syndrome (LFS) MP9485 TP53 gene testing requires prior authorization. Somatic Tumor Markers MP9486 The medical policy includes reference to National Comprehensive Cancer Network (NCCN Guidelines ) category 1, 2A or 2B recommendations. Prior authorization is not required. Lynch Syndrome MP9487 EPCAM, MLH1, MSH2, MSH6, and PMS2 gene testing requires prior authorization. Cowden Syndrome MP9488 PTEN gene testing requires prior authorization and is considered medically necessary in individuals with a suspected or known clinical diagnosis of Cowden syndrome, Bannayan-Riley-Ruvalcaba syndrome or a known family history of PTEN mutation. Huntington Disease MP9490 HTT gene confirmatory and diagnostic testing requires prior authorization. 4
Chromosomal Microarray Analysis (CMA) MP9491 CMA does not require prior authorization and is medically necessary for any of the following: non-syndromic autism spectrum disorder, non-syndromic global developmental delay or intellectual disability, and multiple congenital anomalies not specific to a well-delineated genetic syndrome. Prior authorization is not required. 5