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Oxford
1 Oxford® Policy Update Bulletin: February 2020
February 2020
policy update bulletin Medical & Administrative Policy Updates
In This Issue
Clinical Policy Updates Page
NEW
• Adakveo® (Crizanlizumab-Tmca) – Effective Mar. 1, 2020 ..................................................................................................................................... 4 • Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing for Infectious Diarrhea – Effective Apr. 1, 2020 ........................................................... 5 • Genitourinary Pathogen Nucleic Acid Detection Panel Testing – Effective May 1, 2020 ............................................................................................... 5 • Givlaari™ (Givosiran) – Effective Mar. 1, 2020 ..................................................................................................................................................... 5 • Inhaled Nitric Oxide for Infants – Effective Apr. 1, 2020 ........................................................................................................................................ 7 • Percutaneous Patent Foramen Ovale (PFO) Closure – Effective May 1, 2020............................................................................................................. 7
REVISED
• Cardiac Event Monitoring – Effective Feb. 1, 2020 ................................................................................................................................................ 7 • Cardiology Procedures Requiring Precertification for eviCore healthcare Arrangement – Effective Feb. 1, 2020 ............................................................. 8 • Drug Coverage Criteria – New and Therapeutic Equivalent Medications – Effective Mar. 1, 2020 ................................................................................. 8 • Drug Coverage Guidelines – Effective Feb. 1, 2020 ............................................................................................................................................... 9
o Avsola (Infliximab-Axxq) .............................................................................................................................................................................. 9 o Inflectra (Infliximab) ................................................................................................................................................................................... 9 o Ixifi (Infliximab-Qbtx) .................................................................................................................................................................................. 9 o Levemir (Insulin Detemir) ............................................................................................................................................................................ 9 o Remicade (Infliximab) ................................................................................................................................................................................. 9 o Renflexis (Infliximab) .................................................................................................................................................................................. 9 o Stelara (Ustekinumab): Intravenous Infusion ................................................................................................................................................. 9
• Drug Coverage Guidelines – Effective Mar. 1, 2020 ................................................................................................... Error! Bookmark not defined. o Absorica (Isotretinoin) ............................................................................................................................................................................... 10 o Absorica LD (Isotretinoin) .......................................................................................................................................................................... 10 o Adakveo (Crizanlizumab-Tmca) .................................................................................................................................................................. 10 o Addyi (Flibanserin) .................................................................................................................................................................................... 10 o Anastrozole (Generic) ................................................................................................................................................................................ 10 o Arimidex (Brand Only) (Anastrozole) ........................................................................................................................................................... 10 o Arymo ER (Morphine Sulfate) ..................................................................................................................................................................... 10 o Budesonide/Formoterol (Symbicort Authorized Generic) ................................................................................................................................ 10
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2 Oxford® Policy Update Bulletin: February 2020
o Consensi (Amlodipine and Celecoxib) .......................................................................................................................................................... 11 o Dapsone (Aczone) ..................................................................................................................................................................................... 11 o Divigel 1.25g (Estradiol Gel) ....................................................................................................................................................................... 11 o Embeda (Morphine Sulphate and Naltrexone Hcl) .......................................................................................................................................... 11 o Evista (Raloxifene) (Brand Only) ................................................................................................................................................................. 11 o Exemestane (Generic) ............................................................................................................................................................................... 11 o Genotropin (Somatropin) ........................................................................................................................................................................... 11 o Genotropin Miniquick (Somatropin) ............................................................................................................................................................. 11 o Givlaari (Givosiran) ................................................................................................................................................................................... 12 o Humatrope (Somatropin) ........................................................................................................................................................................... 12 o Ibsrela (Tenapanor) .................................................................................................................................................................................. 12 o Increlex (Mecasermin) ............................................................................................................................................................................... 12 o Jatenzo (Testosterone Undecanoate) ........................................................................................................................................................... 12 o Kanjinti (Trastuzumab-Anns) ...................................................................................................................................................................... 12 o Letrozole (Generic) ................................................................................................................................................................................... 12 o Lorbrena (Lorlatinib) ................................................................................................................................................................................. 12 o Norditropin (Somatropin) ........................................................................................................................................................................... 13 o Norditropin AQ (Somatropin) ...................................................................................................................................................................... 13 o Norditropin Flexpro (Somatropin) ................................................................................................................................................................ 13 o Norditropin Nordiflex (Somatropin).............................................................................................................................................................. 13 o Nourianz (Istradefylline) ............................................................................................................................................................................ 13 o Nuspin (Somatropin) ................................................................................................................................................................................. 13 o Omnitrope (Somatropin) ............................................................................................................................................................................ 13 o Oxbryta (Voxelotor) .................................................................................................................................................................................. 13 o Praluent (Alirocumab) ................................................................................................................................................................................ 13 o Raloxifene (Generic) .................................................................................................................................................................................. 13 o Saizen (Somatropin) ................................................................................................................................................................................. 13 o Secuado (Asenapine) ................................................................................................................................................................................. 13 o Serostim (Somatropin) .............................................................................................................................................................................. 14 o Simvastatin Oral Suspension (Flolipid Authorized Generic) ............................................................................................................................. 14 o Soltamox (Tamoxifen Citrate) ..................................................................................................................................................................... 14 o Sucraid (Sacrosidase) ................................................................................................................................................................................ 14 o Takhzyro (Lanadelumab-Flyo) .................................................................................................................................................................... 14 o Talicia (Omeprazole Magnesium, Amoxicillin and Rifabutin) ............................................................................................................................ 14 o Talzenna (Talazoparib) .............................................................................................................................................................................. 14 o Tamoxifen 20mg (Generic) ......................................................................................................................................................................... 14 o Tetrabenazine (Generic) ............................................................................................................................................................................ 14 o Trulance (Plecanatide) ............................................................................................................................................................................... 14 o Valtoco (Diazepam) ................................................................................................................................................................................... 15 o Vosevi (Sofosbuvir/Velpatasvir/Voxilaprevir) ................................................................................................................................................ 15 o Wakix (Pitolisant) ...................................................................................................................................................................................... 15 o Xenazine (Tetrabenazine) (Brand) ............................................................................................................................................................... 15 o Yupelri (Revefenacin) ................................................................................................................................................................................ 15 o Zelnorm (Tegaserod Maleate) ..................................................................................................................................................................... 15
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3 Oxford® Policy Update Bulletin: February 2020
o Ziextenzo (Pegfilgrastim-Bmez) .................................................................................................................................................................. 15 o Zirabev (Bevacizumab-Bvzr) ...................................................................................................................................................................... 15 o Zomacton (Somatropin) ............................................................................................................................................................................. 16 o Zorbtive (Somatropin) ............................................................................................................................................................................... 16
• Infliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®) – Effective Feb. 1, 2020 ................................................................................................ 16 • Infliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®) – Effective May 1, 2020 ................................................................................................ 19 • Outpatient Surgical Procedures - Site of Service – Effective Apr. 6, 2020 ............................................................................................................... 19 • Provider Administered Drugs – Site of Care – Effective Apr. 1, 2020 ..................................................................................................................... 21 • Rituximab (Rituxan®, Ruxience™ & Truxima®) – Effective Feb. 1, 2020 .................................................................................................................. 23 • White Blood Cell Colony Stimulating Factors – Effective Mar. 1, 2020 .................................................................................................................... 27 • White Blood Cell Colony Stimulating Factors – Effective May 1, 2020 .................................................................................................................... 29
Administrative Policy Updates
RETIRED
• Hospice Care – Effective Feb. 1, 2020 ............................................................................................................................................................... 30
Reimbursement Policy Updates
UPDATED
• Co-Surgeon/Team Surgeon – Effective Jan. 21, 2020 .......................................................................................................................................... 31 • Co-Surgeon/Team Surgeon (CES) – Effective Jan. 21, 2020 ................................................................................................................................. 31
REVISED
• Drug Testing – Effective Mar. 1, 2020 ............................................................................................................................................................... 31 • Maximum Frequency Per Day – Effective Feb. 1, 2020 ........................................................................................................................................ 33 • Maximum Frequency Per Day (CES) – Effective Feb. 1, 2020 ............................................................................................................................... 35 • Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular and Ophthalmology Procedures – Effective Feb. 1, 2020 .......................... 38 • Nonphysician Health Care Professionals Billing Evaluation and Management Codes – Effective Mar. 1, 2020 ............................................................... 41 • Procedure and Place of Service – Effective Mar. 1, 2020 ...................................................................................................................................... 42 • Supply Policy – Effective Feb. 1, 2020 ............................................................................................................................................................... 43
Clinical Policy Updates
Oxford
4 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Coverage Rationale
NEW
Adakveo®
(Crizanlizumab-Tmca)
Mar. 1, 2020
Adakveo (crizanlizumab-tmca) has been added to the Review at Launch program. Some members may
not be eligible for coverage of this medication at this time. Refer to the policy titled Review at Launch for New to Market Medications for additional details. Adakveo is proven and/or medically necessary to reduce the frequency of vasoocclusive crises in
patients with sickle cell disease who meet ALL of the following criteria:
Initial Therapy
• Patient is 16 years of age or older; and • Diagnosis of a sickle cell disease, including, but not limited to, homozygous hemoglobin S [HbSS], sickle
hemoglobin C disease [HbSC], sickle beta0 thalassemia, and sickle beta+ thalassemia; and • Patient has previously experienced 2 or more sickle cell-related vasoocclusive crises within the previous 12
months; and • One of the following:
o Patient is currently receiving hydroxyurea therapy o Patient has a history of treatment failure, intolerance, or contraindication to hydroxyurea therapy and
• Patient is not receiving concomitant chronic, prophylactic blood transfusion therapy; and • Patient is not receiving concomitant Oxbryta (voxelotor) therapy; and • Adakveo is prescribed by, or in consultation with, a hematologist, or other specialist with expertise in the
diagnosis and management of sickle cell disease; and • Adakveo initial dosing is in accordance with the United States Food and Drug Administration approved labeling:
5 mg/kg by intravenous infusion on week 0, week 2, and every 4 weeks thereafter; and
• Initial authorization will be for no more than 6 months. Continuation Therapy
• Diagnosis of a sickle cell disease, including, but not limited to, homozygous hemoglobin S [HbSS], sickle hemoglobin C disease [HbSC], sickle beta0 thalassemia, and sickle beta+ thalassemia; and
• Patient has experienced a reduction in sickle cell-related vasoocclusive crises and/or a decrease in severity of sickle cell-related vasoocclusive crises from pretreatment baseline while on Adakveo; and
• Patient is not receiving concomitant chronic, prophylactic blood transfusion therapy; and • Patient is not receiving concomitant Oxbryta (voxelotor) therapy; and
• Adakveo is prescribed by, or in consultation with, a hematologist, or other specialist with expertise in the diagnosis and management of sickle cell disease; and
• Adakveo maintenance dosing is in accordance with the United States Food and Drug Administration approved labeling: 5 mg/kg by intravenous infusion every 4 weeks; and
• Reauthorization will be for no more than 12 months.
Clinical Policy Updates
Oxford
5 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Coverage Rationale
NEW
Adakveo®
(Crizanlizumab-Tmca) (continued)
Mar. 1, 2020 Adakveo is not proven or medically necessary for the treatment of:
• Pediatric patients less than 16 years of age with sickle cell disease • Myelofibrosis
Gastrointestinal
Pathogen Nucleic Acid Detection
Panel Testing for Infectious Diarrhea
Apr. 1, 2020 The following are proven and medically necessary:
• Multiplex polymerase chain reaction (PCR) panel testing of gastrointestinal pathogens of up to 5 targets when performed as part of an evaluation that includes blood cultures for an individual with any of the following:
o Diarrhea for more than 7 days with fever and suspected bacteremia; or o Suspected enteric fever (i.e., typhoid or paratyphoid) in an individual with a history of recent travel to an
endemic region (e.g., south-central Asia, Southeast Asia, and southern Africa) or who has consumed foods prepared by people with recent endemic exposure
• Multiplex PCR panel testing of gastrointestinal pathogens of up to 11 targets for the evaluation of persistent diarrhea in an individual with any of the following: o Diarrhea for more than 7 days with fever and suspected bacteremia, and the individual is at risk for
Clostridium difficile (C. difficile) colitis; or o Acquired Immune Deficiency Syndrome (AIDS); or o On immunosuppressive medications following an organ transplant; or
o Other condition causing immunosuppression and other stool diagnostic studies have failed to yield a pathogenic organism
Due to insufficient evidence of efficacy, multiplex PCR panel testing of gastrointestinal pathogens is
unproven and not medically necessary for evaluating all other indications not listed above as proven and medically necessary.
Genitourinary Pathogen Nucleic Acid Detection Panel Testing
May 1, 2020 The following are proven and medically necessary to evaluate symptomatic women for Vaginitis: • Direct and amplified DNA probe testing for Trichomoniasis vaginalis • Direct probe testing for Candida sp
Due to insufficient evidence of efficacy, the following are unproven and not medically necessary:
• Amplified DNA probe testing for vulvovaginitis due to Candida sp • Direct and amplified DNA probe testing for bacterial Vaginosis (i.e., Gardnerella vaginalis) • Multiplex polymerase chain reaction (PCR) panel testing of genitourinary pathogens, including but not limited to
pathogens commonly associated with Vaginitis
Note: This policy does not apply to tests for gonorrhea and chlamydia.
Givlaari™ (Givosiran)
Mar. 1, 2020
Givlaari (givosiran) has been added to the Review at Launch program. Some members may not be eligible for coverage of this medication at this time. Refer to the Clinical Policy titled Review at Launch for New to Market Medications for additional details.
Clinical Policy Updates
Oxford
6 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Coverage Rationale
NEW
Givlaari™
(Givosiran) (continued)
Mar. 1, 2020 Givlaari is proven and/or medically necessary for the treatment of acute hepatic porphyrias:
Initial Therapy
• Diagnosis of an acute hepatic porphyria (AHP) [i.e., acute intermittent porphyria, hereditary coproporphyria, variegate porphyria, ALA dehydratase deficient porphyria]; and
• One of the following: o Patient has active disease as defined in the clinical trial by having at least 2 documented porphyria attacks
within the past 6 months; or o Patient is currently receiving treatment with prophylactic hemin to prevent porphyria attacks and
• Provider attestation that the patient’s baseline (before givosiran is initiated) hemin administration requirements (prophylactic or treatment) and rate and/or number of porphyria attacks has been documented; and
• Patient has not had a liver transplant; and • Patient will not receive concomitant prophylactic hemin treatment while on Givlaari; and • Prescribed by, or in consultation with, a hematologist, or a specialist with expertise in the diagnosis and
management of AHPs; and • Givlaari dosing is in accordance with the United States Food and Drug Administration approved labeling: up to a
maximum of 2.5 mg/kg (body weight) subcutaneously once monthly; and • Initial authorization will be for no more than 6 months. Continuation Therapy
• Patient has previously received Givlaari for the treatment of AHP; and • Documentation that the patient has experienced a positive clinical response while on Givlaari by demonstrating
all of the following from pre-treatment baseline: o Reduction in hemin administration requirements (if previously required, including prophylactic and/or
treatment doses)
o Reduction in the rate and/or number of porphyria attacks o Improvement of signs and symptoms of AHPs (e.g., pain, neurological, gastrointestinal, renal, quality of life,
etc.) and
• Patient has not had a liver transplant; and • Patient will not receive concomitant prophylactic hemin treatment while on Givlaari; and
• Prescribed by, or in consultation with, a hematologist, or a specialist with expertise in the diagnosis and management of AHPs; and
• Givlaari dosing is in accordance with the United States Food and Drug Administration approved labeling: up to a maximum of 2.5 mg/kg (body weight) subcutaneously once monthly; and
• Reauthorization will be for no more than 12 months.
Clinical Policy Updates
Oxford
7 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Coverage Rationale
NEW
Inhaled Nitric
Oxide for Infants
Apr. 1, 2020 Inhaled nitric oxide (iNO) is proven and medically necessary for treating term or near-term infants (at
least 34 weeks gestation at birth) with hypoxic respiratory failure or echocardiographic evidence of persistent pulmonary hypertension of the newborn (PPHN) and ALL of the following: • Absence of congenital diaphragmatic hernia (CDH) • Failure of conventional treatments (e.g., mechanical ventilation)
Note: In the postoperative management of pulmonary hypertension associated with heart or lung surgery in infants, iNO is a clinically accepted option and will be covered as bridge therapy during the acute recovery phase.
Due to insufficient evidence of efficacy, iNO is unproven and not medically necessary for treating ALL other newborns including but not limited to: • Newborns with CDH • Preterm newborns who are less than 34 weeks gestation at birth
Percutaneous
Patent Foramen Ovale (PFO) Closure
May 1, 2020 Note: This policy does not apply to individuals <18 years of age.
Percutaneous patent foramen ovale closure for the prevention of recurrent ischemic stroke is proven and medically necessary when used according to U.S. Food and Drug Administration (FDA) labeled
indications, contraindications, warnings and precautions and ALL of the following criteria are met: • History of cryptogenic stroke confirmed by imaging; and • A cardiologist and a neurologist agree that the stroke is likely embolic in nature; and • Other causes of ischemic stroke have been ruled out including, but not limited to, carotid disease,
hypercoagulable states or atrial fibrillation; and • Individual is 18–60 years of age. Due to insufficient evidence of efficacy, percutaneous patent foramen ovale closure is unproven and not medically necessary for all other stroke or related neurological indications including, but not limited to, primary prevention of stroke, transient ischemic attacks, and migraine prevention.
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Cardiac Event Monitoring
Feb. 1, 2020
Conditions of Coverage • Updated list of CPT codes that
do not require referral or precertification in the office or
outpatient setting; added 93268, 93270, 93271, and 93272
• Updated list of CPT/HCPCS codes that require precertification with
Cardiac event monitoring is proven and medically necessary for evaluating suspected cardiac arrhythmias as outlined below. • Ambulatory Event Monitoring
o Holter monitor
o Event monitor o Patch-type monitor
• Outpatient Cardiac Telemetry for any of the following indications: o Suspected cardiac arrhythmia and non-diagnostic Ambulatory Event
Clinical Policy Updates
Oxford
8 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Cardiac Event
Monitoring (continued)
Feb. 1, 2020 review by a Medical Director
when performed in an inpatient, outpatient, or participating provider office setting to reflect annual code edits:
o Added G2066 o Removed 93299
Monitoring after a minimum of 3 weeks
o Cryptogenic stroke with suspected occult atrial fibrillation as the cause of the stroke
o Monitoring arrhythmia status following an ablation procedure • Implantable Loop Recorder in certain circumstances. For medical
necessity clinical coverage criteria, see MCG™ Care Guidelines, 23rd edition, 2019, Loop Recorder (Cardiac Event Monitor), Implantable, A-0122 (AC).
Cardiology Procedures Requiring Precertification for eviCore healthcare Arrangement
Feb. 1, 2020 Applicable Codes • Revised list of CPT codes
requiring precertification; added
0501T, 0502T, 0503T, and 0504T (effective for claims with dates of service on or after Jan. 1, 2019)
Supporting Information
• Updated Description of Services section to reflect the most current information
Refer to the policy for complete details on Cardiology Procedures Requiring Precertification for eviCore healthcare Arrangement.
Drug Coverage
Criteria – New and Therapeutic Equivalent Medications
Mar. 1, 2020 Coverage Rationale
• Revised list of medications requiring precertification through the pharmacy benefit manager (PBM): o Added Absorica LD,
Budesonide/Formoterol (Symbicort authorized
generic), Consensi, Dapsone
7.5% Gel (Aczone 7.5% authorized generic), Divigel 1.25g, Jatenzo, Oxbryta, Secuado, Simvastatin Oral Suspension (Flolipid
authorized generic), Talicia, and Valtoco
o Removed Zelnorm
Refer to the policy for complete details on Drug Coverage Criteria – New and
Therapeutic Equivalent Medications.
Clinical Policy Updates
Oxford
9 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage Guidelines
Feb. 1, 2020
Avsola (Infliximab-Axxq)
New • Added coverage guidelines to indicate coverage is provided under the medical benefit o Precertification is not required however it is strongly recommended o While no penalty will be imposed for failure to request a pre-service
review, if one is not requested, a medical necessity review will be
conducted post-service to determine coverage o It is the referring physician’s responsibility to provide medical
documentation to demonstrate clinical necessity for the medication o Beginning May 1, 2020, precertification will be required
• Added precertification guidelines; refer to the following policies for complete details: o Precertification Guidelines: Infliximab (Avsola™, Remicade®,
Inflectra™, Renflexis™) o Precertification Guidelines: Review at Launch for New to Market
Medications
Inflectra (Infliximab) Revised • Revised notation pertaining to precertification requirements to indicate precertification is required in all sites of service; additional
precertification may be required for the site of care of the injection • Updated reference link to reflect title change for Precertification
Guidelines: Infliximab (Avsola™, Remicade®, Inflectra™, Renflexis™)
Ixifi (Infliximab-Qbtx) Updated • Updated reference link to reflect title change for Precertification Guidelines: Infliximab (Avsola™, Remicade®, Inflectra™, Renflexis™)
Levemir (Insulin Detemir)
Revised • Revised coverage guidelines to indicate precertification is not required • Removed prior authorization/notification guidelines and corresponding
reference link to the policy titled to Prior Authorization/Notification
Guidelines: Levemir
Remicade (Infliximab) Revised • Revised notation pertaining to precertification requirements to indicate precertification is required in all sites of service; additional
precertification may be required for the site of care of the injection • Updated reference link to reflect title change for Precertification
Guidelines: Infliximab (Avsola™, Remicade®, Inflectra™, Renflexis™)
Renflexis (Infliximab) Updated • Updated reference link to reflect title change for Precertification Guidelines: Infliximab (Avsola™, Remicade®, Inflectra™, Renflexis™)
Stelara (Ustekinumab): Intravenous Infusion
Revised • Added notation to indicate precertification is required in all sites of
service; additional precertification may be required for the site of care of
the injection
Clinical Policy Updates
Oxford
10 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines
Mar. 1, 2020 Absorica (Isotretinoin) Updated • Updated prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: Absorica for complete details
Absorica LD (Isotretinoin)
New • Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)
• Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent
Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details
Adakveo (Crizanlizumab-Tmca)
New • Added language to indicate coverage is provided under the medical benefit o Precertification is not required however it is strongly recommended o While no penalty will be imposed for failure to request a pre-service
review, if one is not requested, a medical necessity review will be conducted post-service to determine coverage
o It is the referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the medication
o Beginning Jul. 1, 2020, precertification will be required
• Added precertification guidelines; refer to the following policies for complete details: o Precertification Guidelines: Adakveo® (Crizanlizumab-Tmca) o Precertification Guidelines: Review at Launch for New to Market
Medications
Addyi (Flibanserin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Addyi for complete details
Anastrozole (Generic) New • Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)
• Added prior authorization/regulatory guidelines; refer to Prior
Authorization/Regulatory Guidelines: Anastrozole for complete details
Arimidex (Brand Only)
(Anastrozole)
Updated • Updated list of applicable HCPCS codes; replaced J8499 with S0170
Arymo ER (Morphine Sulfate)
Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Arymo ER for complete
details
Budesonide/Formoterol (Symbicort Authorized Generic)
New
• Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)
• Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent
Clinical Policy Updates
Oxford
11 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Mar. 1, 2020 Budesonide/Formoterol
(Symbicort Authorized Generic) (continued)
New Medications for complete details
Consensi (Amlodipine
and Celecoxib)
New • Added language to indicate precertification is required through the
Pharmacy Benefit Manager (PBM) • Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent
Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details
Dapsone (Aczone) New • Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)
• Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent
Medications for complete details
Divigel 1.25g (Estradiol Gel)
New • Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)
• Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details
Embeda (Morphine Sulphate and Naltrexone Hcl)
Removed • Removed coverage guidelines
Evista (Raloxifene) (Brand Only)
Revised • Removed prior authorization/regulatory guidelines and corresponding reference link to the policy titled Prior Authorization/Regulatory Guidelines: Evista
Exemestane (Generic) New • Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)
• Added prior authorization/regulatory guidelines; refer to Prior Authorization/Regulatory Guidelines: Exemestane for complete details
Genotropin (Somatropin)
Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Genotropin (Somatropin) for
complete details
Genotropin Miniquick (Somatropin)
Revised • Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Genotropin MiniQuick for complete details
Clinical Policy Updates
Oxford
12 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Mar. 1, 2020 Givlaari (Givosiran) New • Added language to indicate coverage is provided under the medical
benefit o Precertification is not required however it is strongly recommended o While no penalty will be imposed for failure to request a pre-service
review, if one is not requested, a medical necessity review will be
conducted post-service to determine coverage o It is the referring physician’s responsibility to provide medical
documentation to demonstrate clinical necessity for the medication
o Beginning Jul. 1, 2020, precertification will be required • Added precertification guidelines; refer to the following policies for
complete details: o Precertification Guidelines: Givlaari™ (Givosiran) o Precertification Guidelines: Review at Launch for New to Market
Medications
Humatrope (Somatropin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Humatrope (Somatropin) for complete details
Ibsrela (Tenapanor) New • Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)
• Added prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: Ibsrela for complete details
Increlex (Mecasermin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Increlex (Mecasermin) for complete details
Jatenzo (Testosterone Undecanoate)
Revised • Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent
Medications for complete details
Kanjinti (Trastuzumab-
Anns)
Updated • Updated list of applicable HCPCS codes; replaced J9999 with Q5117
Letrozole (Generic) New • Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)
• Added prior authorization/regulatory guidelines; refer to Prior Authorization/Regulatory Guidelines: Letrozole for complete details
Lorbrena (Lorlatinib) Revised • Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Lorbrena for complete details
Clinical Policy Updates
Oxford
13 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Mar. 1, 2020 Norditropin (Somatropin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: Norditropin (Somatropin) for complete details
Norditropin AQ (Somatropin)
Removed • Removed coverage guidelines
Norditropin Flexpro (Somatropin)
Revised • Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Norditropin FlexPro for
complete details
Norditropin Nordiflex (Somatropin)
Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: NordiFlex (Somatropin) for complete details
Nourianz (Istradefylline) Revised • Added prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: Nourianz for complete details
Nuspin (Somatropin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: NuSpin (Somatropin) for complete details
Omnitrope (Somatropin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Omnitrope (Somatropin) for
complete details
Oxbryta (Voxelotor) New • Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)
• Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details
Praluent (Alirocumab) Updated • Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Praluent (Alirocumab) for complete details
Raloxifene (Generic) Revised • Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Raloxifene for complete details
Saizen (Somatropin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Saizen (Somatropin) for complete details
Secuado (Asenapine)
New
• Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)
• Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent
Clinical Policy Updates
Oxford
14 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Mar. 1, 2020 Secuado (Asenapine)
(continued)
New Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent
Medications for complete details
Serostim (Somatropin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Serostim (Somatropin) for complete details
Simvastatin Oral Suspension (Flolipid
Authorized Generic)
New • Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)
• Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details
Soltamox (Tamoxifen Citrate)
Revised • Removed prior authorization/regulatory guidelines and corresponding reference link to the policy titled Prior Authorization/Regulatory Guidelines: Soltamox
Sucraid (Sacrosidase) Revised • Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Sucraid for complete details
• Removed prior authorization/notification guidelines and corresponding
reference link to the policy titled Prior Authorization/Notification Guidelines: Sucraid
Takhzyro (Lanadelumab-Flyo)
Updated • Updated list of applicable HCPCS code; replaced J3490 with J0593
Talicia (Omeprazole Magnesium, Amoxicillin and Rifabutin)
New • Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)
• Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent
Medications for complete details
Talzenna (Talazoparib) Revised • Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Talzenna for complete details
Tamoxifen 20mg (Generic)
Updated • Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Tamoxifen for complete details
• Updated medication/drug name; added “20mg (Generic)”
Tetrabenazine (Generic) Updated • Updated medication/drug name; previously listed as Xenazine (Tetrabenazine)
Trulance (Plecanatide) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Trulance for complete details
Clinical Policy Updates
Oxford
15 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Mar. 1, 2020 Valtoco (Diazepam) New • Added language to indicate precertification is required through the
Pharmacy Benefit Manager (PBM) • Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent
Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details
Vosevi (Sofosbuvir/ Velpatasvir/Voxilaprevir)
Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Vosevi for complete details
Wakix (Pitolisant) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Wakix for complete details
Xenazine (Tetrabenazine) (Brand)
Revised • Added prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Tetrabenazine for complete details
Yupelri (Revefenacin) Updated • Updated list of applicable HCPCS codes; replaced J3490 with J7677
Zelnorm (Tegaserod Maleate)
Revised • Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Zelnorm for complete details
• Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage
Criteria - New and Therapeutic Equivalent Medications
Ziextenzo (Pegfilgrastim-
Bmez)
Revised • Revised coverage guidelines to indicate:
o Coverage is provided under the PBM benefit when purchased from a pharmacy and self-administered; precertification is required
o Coverage is provided under the medical benefit when administered by a provider: ▪ Precertification is not required however it is strongly
recommended
▪ While no penalty will be imposed for failure to request a pre-service review, if one is not requested, a medical necessity review will be conducted post-service to determine coverage
▪ It is the referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the medication
▪ Beginning May 1, 2020, precertification will be required
• Added eviCore guidelines; refer to eviCore Guidelines: White Blood Cell Colony Stimulating Factors for complete details
Zirabev (Bevacizumab-Bvzr)
Updated • Updated list of applicable HCPCS codes; replaced J9999 with Q5118
Clinical Policy Updates
Oxford
16 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Drug/Medication Status Summary of Changes
REVISED
Drug Coverage
Guidelines (continued)
Mar. 1, 2020 Zomacton (Somatropin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior
Authorization/Medical Necessity Guidelines: Zomacton for complete details
Zorbtive (Somatropin) Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Zorbtive (Somatropin) for
complete details
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Infliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®)
Feb. 1, 2020
Title Change • Previously titled Infliximab
(Remicade®, Inflectra™, Renflexis™)
Conditions of Coverage • Added language to indicate
precertification is not required,
however it is strongly recommended for Avsola
o While no penalty will be imposed for failure to request a pre-service review, if one is not requested, a medical necessity review will be conducted post-service to
determine coverage o It is the referring physician’s
responsibility to provide
medical documentation to demonstrate clinical necessity for the medication
o Beginning May 1, 2020, precertification will be required
Coverage Rationale • Revised list of applicable
infliximab products; added
Refer to the policy for complete details on the coverage guidelines for Infliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®).
Clinical Policy Updates
Oxford
17 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Infliximab
(Avsola™, Inflectra®, Remicade®, & Renflexis®)
(continued)
Feb. 1, 2020
Avsola™ (infliximab-axxq)
• Added language to indicate: o Avsola (infliximab-axxq) has
been added to the Review at Launch program and some
members may not be eligible for coverage of this medication at this time;
refer to the Medical Benefit Drug Policy titled Review at Launch for New to Market Medications for additional details
Preferred Product: Medical Necessity Plans o Coverage for Avsola™
(infliximab-axxq) will be
provided contingent on the
criteria in this section and the coverage criteria in the Diagnosis-Specific Criteria section [of the policy]
o In order to continue coverage, members already
on Avsola will be required to change therapy to Inflectra or Remicade unless they meet the criteria in [the Preferred Product Criteria]
section [of the policy] o Treatment with Avsola is
medically necessary for the indications specified in the policy when both of the [Preferred Product Criteria listed in the policy] are met
• Replaced Preferred Product criterion requiring:
Clinical Policy Updates
Oxford
18 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Infliximab
(Avsola™, Inflectra®, Remicade®, & Renflexis®)
(continued)
Feb. 1, 2020
o “History of a trial of at least
14 weeks of Remicade and Inflectra resulting in minimal clinical response to therapy and residual disease activity”
with “history of a trial of at least 14 weeks of both Inflectra and Remicade
resulting in minimal clinical response to therapy and residual disease activity”
o “Physician attests that in their clinical opinion, the clinical response would be
expected to be superior with [a non-preferred] infliximab biosimilar product, than
experienced with Remicade or Inflectra” with “physician attests that in their clinical opinion, the clinical response
would be expected to be superior with [a non-preferred] infliximab biosimilar product, than experienced with Inflectra and Remicade”
o “Patient has not developed
neutralizing antibodies to
any infliximab biosimilar product that has led to an attenuation of efficacy of therapy” with “patient has not developed neutralizing
antibodies to any infliximab product that has led to an attenuation of efficacy of therapy”
Clinical Policy Updates
Oxford
19 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Infliximab
(Avsola™, Inflectra®, Remicade®, & Renflexis®)
(continued)
Feb. 1, 2020 Applicable Codes • Added HCPCS codes J3490 and
J3590
Supporting Information • Updated FDA and References
sections to reflect the most current information
Infliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®)
May 1, 2020 Conditions of Coverage • Revised precertification
requirements to indicate precertification with review by a Medical Director or their designee is required for Avsola
Coverage Rationale • Removed reference link to the
Clinical Policy titled Review at
Launch for New to Market
Medications for Avsola (prior authorization requirements apply May 1, 2020)
Refer to the policy for complete details on the coverage guidelines for Infliximab (Avsola™, Inflectra®, Remicade®, & Renflexis®).
Outpatient Surgical Procedures - Site of Service
Apr. 6, 2020
Notice of Revision (Feb. 1, 2020): The following summary of changes has been modified. Revisions to the
previous policy update announcement are outlined in red below. Please take note of the amended guidelines to be applied on Apr. 6, 2020.
Related Policies • Updated list of related policies
Coverage Rationale • Corrected clerical errors in list of
medically necessary indications; replaced:
o “Coronary artery disease ([CAD]/peripheral vascular
UnitedHealthcare® Oxford members may choose to receive surgical procedures in an ambulatory surgical center (ASC) or other locations. We are conducting site of service medical necessity reviews, however, to determine
whether the outpatient hospital department is medically necessary, in accordance with the terms of the member’s benefit plan. If the outpatient hospital department is not considered medically necessary, this location will not be covered under the member’s plan.
Certain planned surgical procedures performed in a hospital outpatient department are considered medically necessary for an
individual who meets ANY of the following criteria: • Advanced liver disease (MELD Score > 8) • Advance surgical planning determines an individual requires overnight
recovery and care following a surgical procedure • Anticipated need for transfusion • Bleeding disorder requiring replacement factor or blood products or
special infusion products to correct a coagulation defect
Clinical Policy Updates
Oxford
20 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Outpatient Surgical
Procedures - Site of Service (continued)
Apr. 6, 2020
disease [PVD]) (ongoing
cardiac ischemia requiring medical management recently placed [within 1 year] drug eluting stent)”
with “coronary artery disease ([CAD]/peripheral vascular disease [PVD])
(ongoing cardiac ischemia requiring medical management or recently placed [within 1 year] drug eluting stent)”
o “End stage renal disease
([hyperkalemia above reference range] peritoneal or hemodialysis)” with “end
stage renal disease ([hyperkalemia above reference range] receiving peritoneal or hemodialysis)”
Documentation Requirements • Added reference link to the
applicable Clinical Policy for CPT
codes with additional documentation requirements
Applicable Codes • Reformatted content
• Added 1,015 991 CPT/HCPCS
codes (see list for details; revised Feb. 1, 2020)
Definitions • Updated definition of “ASA
Physical Status Classification System Risk Scoring Tool”
• Brittle Diabetes
• Cardiac arrhythmia (symptomatic arrhythmia despite medication) • Chronic obstructive pulmonary disease (COPD) (FEV1 <50%) • Coronary artery disease (CAD)/peripheral vascular disease (PVD)
(ongoing cardiac ischemia requiring medical management or recently
placed [within 1 year] drug eluting stent) • Developmental stage or cognitive status warranting use of a hospital
outpatient department
• End stage renal disease ([hyperkalemia above reference range] receiving peritoneal or hemodialysis)
• History of cerebrovascular accident (CVA) or transient ischemic attack (TIA) (recent event [< 3 months])
• History of myocardial infarction (MI) (recent event [< 3 months]) • Individuals with drug eluting stents (DES) placed within one year or bare
metal stents (BMS) or plain angioplasty within 90 days unless acetylsalicylic acid and antiplatelet drugs will be continued by agreement of surgeon, cardiologist and anesthesia
• Less than 19 years of age • Ongoing evidence of myocardial ischemia • Poorly Controlled asthma (FEV1 < 80% despite medical management) • Pregnancy
• Prolonged surgery (> 3 hours) • Resistant hypertension (Poorly Controlled) • Significant Severe valvular heart disease • Sleep apnea (moderate to severe Obstructive Sleep Apnea (OSA) • Uncompensated chronic heart failure (CHF) (NYHA class III or IV) A planned surgical procedure performed in a hospital outpatient
department is considered medically necessary if there is an inability
to access an ambulatory surgical center for the procedure due to ANY one of the following: • There is no geographically accessible ambulatory surgical center that has
the necessary equipment for the procedure; or • There is no geographically accessible ambulatory surgical center
available at which the individual’s physician has privileges; or • An ASC’s specific guideline regarding the individual’s weight or health
conditions that prevents the use of an ASC
Clinical Policy Updates
Oxford
21 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Outpatient Surgical
Procedures - Site of Service (continued)
Apr. 6, 2020 Planned Surgical Procedures List
Site of service medical necessity reviews will be conducted for surgical procedures on the Applicable Codes List from this policy only when
performed in an outpatient hospital setting.
Provider
Administered Drugs – Site of Care
Apr. 1, 2020
Related Policies
• Added reference link to the Clinical Policy titled Reblozyl®
(Luspatercept-Aamt)
Coverage Rationale • Revised list of specialty
medications requiring healthcare provider administration; added Reblozyl® (luspatercept-aamt)
Definitions • Updated definition of “Site of
Care”
Applicable Codes • Added list of applicable HCPCS
codes: J0129, J0180, J0221,
J0222, J0256, J0257, J0490, J0584, J0638, J1300, J1301, J1303, J1322, J1428, J1458, J1602, J1743, J1745, J1746, J1786, J1931, J2350, J2840, J3060, J3245, J3262, J3380, J3385, J3397, J3590, Q5103,
and Q5104
This policy addresses the criteria for consideration of allowing hospital
outpatient facility specialty medication infusion services. This includes claim submission for hospital based services with the following CMS/AMA Place of Service codes: • 19 Off-Campus - Outpatient Hospital; and
• 22 On-Campus - Outpatient Hospital Alternative sites of care, such as non-hospital outpatient infusion, physician office, ambulatory infusion or home infusion services are well accepted places of service for medication infusion therapy. If an individual does not meet criteria for outpatient hospital facility infusion, alternative sites of care may be used.
Outpatient hospital facility-based intravenous medication infusion is medically necessary for individuals who meet at least ONE of the following criteria (submission of medical records is required): • Documentation that the individual is medically unstable for
administration of the prescribed medication at the alternative sites of care as determined by any of the following:
o The individual’s complex medical status or therapy requires enhanced monitoring and potential intervention above and beyond the capabilities of the office or home infusion setting; or
o The individual’s documented history of a significant comorbidity (e.g., cardiopulmonary disorder) or fluid overload status that
precludes treatment at an alternative Site Of Care; or
o Outpatient treatment in the home or office setting presents a health risk due to a clinically significant physical or cognitive impairment; or
o Difficulty establishing and maintaining patent vascular access o To initiate, re-initiate products for a short duration (e.g., 4 weeks) or
• Documentation (e.g., infusion records, medical records) of episodes of severe or potentially life-threatening adverse events (e.g., anaphylaxis,
seizure, thromboembolism, myocardial infarction, renal failure) that have not been responsive to acetaminophen, steroids, diphenhydramine,
Clinical Policy Updates
Oxford
22 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Provider
Administered Drugs – Site of Care (continued)
Apr. 1, 2020
fluids, infusion rate reductions, or other pre-medications, thereby
increasing risk to the individual when administration is in the home or office setting; or
• Initial infusion or re-initiation of therapy after more than 6 months; or • Homecare or infusion provider has deemed that the individual, home
caregiver, or home environment is not suitable for home infusion therapy (if the prescriber cannot infuse in the office setting).
Ongoing outpatient hospital facility-based infusion duration of therapy will be no more than 6 months to allow for reassessment of the individual’s ability to receive therapy at an alternative Site Of Care.
This policy applies to these specialty medications that require healthcare provider administration: • Actemra® (Tocilizumab) • Aldurazyme® (Laronidase)
• Aralast NP™ (A1-PI) • Benlysta® (Belimumab) • Cerezyme® (Imiglucerase) • Crysvita® (Burosumab) • Elaprase® (Idursulfase) • Elelyso® (Taliglucerase)
• Entyvio® (Vedolizumab) • Exondys 51™ (Eteplirsen) • Fabrazyme® (Agalsidase beta) • Glassia™ (A1-PI) • Ilaris® (Canakinumab) • Ilumya™ (Tildrakizumab-asmn)
• Inflectra™ (Infliximab-dyyb)
• Kanuma® (Sebelipase alfa) • Lumizyme® (Alglucosidase alfa) • Mepsevii™ (Vestronidase alfa-vjbk) • Naglazyme® (Galsulfase) • Ocrevus™ (Ocrelizumab) • Onpattro™ (Patisiran) • Orencia® (Abatacept)
• Prolastin®-C™ (A1-PI)
Clinical Policy Updates
Oxford
23 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Provider
Administered Drugs – Site of Care (continued)
Apr. 1, 2020 • Radicava™ (Edaravone)
• Reblozyl® (Luspatercept-aamt) • Remicade® (Infliximab) • Renflexis™ (Infliximab-abda) • Revcovi™ (Elapegademase-lvlr)
• Simponi Aria® (Golimumab) • Soliris® (Eculizumab) • Trogarzo™ (Ibalizumab)
• Ultomiris™ (Ravulizumab-cwvz) • Vimizim® (Elosulfase alfa) • VPRIV® (Velaglucerase) • Zemaira® (A1-PI)
Rituximab (Rituxan®,
Ruxience™ & Truxima®)
Feb. 1, 2020
Notice of Revision: The following summary of changes has been
modified. Revisions to the previous policy update announcement are outlined in red below. Please take
note of the additional updates to be applied on Feb. 1, 2020. Title Change
• Previously titled Rituximab (Rituxan® & Truxima®)
Conditions of Coverage • Revised applicable sites of
service: o Added “Home” o Removed “Inpatient”
• Added language to indicate: o Precertification is not
required, however it is
strongly recommended for Ruxience: ▪ While no penalty will be
imposed for failure to request a pre-service review, if one is not
requested, a medical
Refer to the policy for complete details on the coverage guidelines for Rituximab (Rituxan®, Ruxience™ & Truxima®).
Clinical Policy Updates
Oxford
24 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Rituximab
(Rituxan®, Ruxience™ & Truxima®) (continued)
Feb. 1, 2020
necessity review will be
conducted post-service to determine coverage
▪ It is the referring physician’s responsibility
to provide medical documentation to demonstrate clinical
necessity for the medication
▪ Beginning Apr. 1, 2020, precertification will be required
o Home infusion of rituximab
requires additional precertification for the home care services
Coverage Rationale • Updated list of applicable drug
products for rituximab injections for intravenous infusion for non-oncology conditions; added: o Rituxan Hycela® (rituximab
and hyaluronidase human)
o Ruxience™ (rituximab-pvvr) • Replaced language indicating:
o “Rituximab will be used to refer to both Rituxan and Truxima” with “rituximab will
be used to refer to all rituximab products without
hyaluronidase” o “Rituximab is proven and
medically necessary for the treatment of [the listed conditions]” with “rituximab is proven for the treatment of [the listed conditions]”
Clinical Policy Updates
Oxford
25 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Rituximab
(Rituxan®, Ruxience™ & Truxima®) (continued)
Feb. 1, 2020
o “Rituximab is proven and
medically necessary in combination with plasma exchange therapy and high dose corticosteroids for
acute thrombotic thrombocytopenic purpura” with “rituximab is proven for
the treatment of thrombocytopenic purpura (TTP); rituximab is medically necessary for acute thrombotic thrombocytopenic purpura
when all of the [listed] criteria are met”
• Added language to indicate:
o Rituxan Hycela is unproven and not medically necessary for the treatment of non-oncology indications
o Rituximab is proven for the treatment of multiple sclerosis (MS)
• Added medical necessity criteria for initial and continuation of therapy for: o Autoimmune hemolytic
anemia, including chronic
cold agglutinin disease o Multiple sclerosis (MS) o Neuromyelitis optica o Pemphigus vulgaris o Post-transplant B-
lymphoproliferative disorder (PTLD)
o Thrombotic thrombocytopenic purpura
Clinical Policy Updates
Oxford
26 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
Rituximab
(Rituxan®, Ruxience™ & Truxima®) (continued)
Feb. 1, 2020 (TTP)
• Added medical necessity criteria for initial therapy dosage, initial authorization, and continuation of therapy for:
o Immune thrombocytopenic purpura (ITP)
o Rheumatoid arthritis
o Wegener’s granulomatosis or microscopic polyangiitis (both ANCA-associated vasculidities)
• Revised medical necessity criteria for immunotherapy-
related encephalitis; added criterion requiring: o Rituximab is dosed up to a
maximum of 1,225 mg per dose
o Authorization will be for no more than 3 months
• Removed language indicating rituximab is unproven and not medically necessary for the treatment of: o Chronic graft-versus-host
disease o Multiple sclerosis
Applicable Codes
• Added HCPCS codes J3590, J9311, and J9999
• Added ICD-10 diagnosis code G35
Supporting Information • Updated Clinical Evidence, FDA,
and References sections to reflect the most current information
Clinical Policy Updates
Oxford
27 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
White Blood Cell
Colony Stimulating Factors
Mar. 1, 2020
Conditions of Coverage
• Added language to indicate precertification is not required, however, it is strongly recommended for Ziextenzo
o While no penalty will be imposed for failure to request a pre-service
review, if one is not requested, a medical necessity review will be conducted post-service to determine coverage
o It is the referring physician’s
responsibility to provide medical documentation to demonstrate clinical
necessity for the medication o Beginning May 1, 2020,
precertification will be required
Coverage Rationale • Revised list of applicable long-
acting pegfilgrastim agents;
added Ziextenzo™ (pegfilgrastim-bmez)
• Added language to indicate:
Long-Acting Pegfilgrastim Agents (Fulphila, Neulasta,
Udenyca, Ziextenzo): Preferred Product o Coverage for Ziextenzo will
be provided contingent on the criteria in [the Preferred
Product Criteria] section and the coverage criteria in the Diagnosis-Specific Criteria section [of the policy]
Refer to the policy for complete details on the coverage guidelines for White
Blood Cell Colony Stimulating Factors.
Clinical Policy Updates
Oxford
28 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
White Blood Cell
Colony Stimulating Factors (continued)
Mar. 1, 2020
o In order to continue
coverage, members already on Ziextenzo will be required to change therapy to Neulasta unless they meet
the criteria in [the Preferred Product Criteria] section [of the policy]
o Treatment with Ziextenzo is medically necessary for the indications specified in the policy when one of the [Preferred Product Criteria listed in the policy] is met
Diagnosis-Specific Criteria o Ziextenzo is proven for:
▪ Hematopoietic Syndrome
of Acute Radiation
Syndrome ▪ Neutropenia Associated
with Cancer Chemotherapy – Dose Dense Chemotherapy
▪ Primary Prophylaxis of
Chemotherapy-Induced Febrile Neutropenia (FN)
▪ Secondary Prophylaxis of Febrile Neutropenia (FN)
▪ Treatment of Febrile
Neutropenia (Off-Label) o Ziextenzo is medically
necessary when the criteria listed in the policy are met
Applicable Codes • Added HCPCS codes J3490 and
J3590
Supporting Information • Updated Background, FDA, and
Clinical Policy Updates
Oxford
29 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Coverage Rationale
REVISED
White Blood Cell
Colony Stimulating Factors (continued)
Mar. 1, 2020 References sections to reflect
the most current information
White Blood Cell
Colony Stimulating Factors
May 1, 2020 Conditions of Coverage
• Revised precertification requirements to indicate
precertification with review by a Medical Director or their designee is required for Ziextenzo
Refer to the policy for complete details on the coverage guidelines for White
Blood Cell Colony Stimulating Factors.
Administrative Policy Updates
Oxford
30 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes
RETIRED
Hospice Care Feb. 1, 2020 • Policy retired; refer to the member specific benefit plan document for applicable coverage guidelines
Reimbursement Policy Updates
Oxford
31 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes
UPDATED
Co-Surgeon/Team Surgeon
Jan. 21, 2020 Applicable Codes • Updated Co-Surgeon Eligible List to reflect annual code edits; added CPT codes 21601, 21602, 21603, 34717,
34718, 35702, 35703, 33858, 33859, 33871, 66987, and 66988 • Updated Team Surgeon Eligible List to reflect annual code edits; added CPT codes 66987 and 66988
Co-Surgeon/Team
Surgeon (CES)
Jan. 21, 2020 Applicable Codes
• Updated Co-Surgeon Eligible List to reflect annual code edits; added CPT codes 21601, 21602, 21603, 34717, 34718, 35702, 35703, 33858, 33859, 33871, 66987, and 66988
• Updated Team Surgeon Eligible List to reflect annual code edits; added CPT codes 66987 and 66988
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Drug Testing
Mar. 1, 2020
Overview and Reimbursement Guidelines • Revised language addressing
applicable CPT codes for
definitive drug
testing/Proprietary Laboratory Analysis; removed references to “0082U”
Applicable Codes
• Reformatted content • Revised list of applicable
CPT/HCPCS codes for definitive drug testing; removed 0082U
Questions and Answers (Q&A) • Updated Q&A #2 pertaining to
separate reimbursement for laboratory services; added
reference to the Reimbursement Policy titled Modifier Reference for additional information
This policy enforces the code description for presumptive and definitive drug testing in that the service should be reported once per day and it includes Specimen Validity Testing.
Clinical drug testing is used in pain management and in substance abuse
screening and treatment programs. The testing may be used to detect prescribed, therapeutic drugs, prescription drugs of abuse, illicit drugs, and/or other substances such as nicotine. Presumptive drug testing, also known as drug screening, is used when necessary to determine the presence or absence of drugs or a Drug Class.
Results are expressed as negative or positive. The methodology is considered when coding presumptive procedures. Per Current Procedural Terminology (CPT®) guidelines each presumptive drug testing code represents all drug and Drug Class tests performed by the respective methodology per date of service. The test is a single per patient service that should only be reported once irrespective of the number of Drug Class
procedures or results on any date of service. Definitive drug testing, also known as confirmation testing, is used when it is necessary to identify specific medications, illicit substances and metabolites. Definitive urine drug test (UDT) reports the results of drugs absent or present in concentrations of ng/ml. Definitive drug testing is qualitative or quantitative to identify possible use or non-use of a drug. These tests
identify specific drugs and associated metabolites. A presumptive drug test is not required to be provided prior to a definitive drug test. Consistent with CMS, definitive drug testing CPT codes 80320-80377 are considered non-
Reimbursement Policy Updates
Oxford
32 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Drug Testing
(continued)
Mar. 1, 2020 reimbursable and the appropriate HCPCS G0480-G0483 and G0659 should
be reported. The HCPCS codes describe a per-day service that represents the total number of different Drug Classes performed. When applicable, Proprietary Laboratory Analysis CPT Codes 0006U, 0007U or 0011U may be reported and are considered under the policy guidelines pertaining to
definitive drug testing. Some examples of drugs or a Drug Class that are commonly assayed by
presumptive tests, followed by definitive testing are: alcohols, amphetamines, barbiturates/sedatives, benzodiazepines, cocaine and metabolites, methadone, antihistamines, stimulants, opioid analgesics, salicylates, cardiovascular drugs, antipsychotics, and cyclic antidepressants. In accordance with the code descriptions and the CPT and CMS guidelines,
Oxford will only allow one drug test within the presumptive Drug Class and one drug test within the definitive Drug Class per date of service by the same or different provider.
Specimen Validity Testing to assure that a specimen has not been compromised or that a test has not been adulterated may be required. However, Specimen Validity Testing is included in the presumptive and
definitive drug testing CPT and HCPCS code descriptions and is considered a quality control which is an integral part of the collection process and is not separately reimbursable. Oxford will deny Specimen Validity Testing when performed on the same date of service as a presumptive and/or definitive drug test by the same or different provider. A modifier may be appropriate when a service commonly used for Specimen Validity Testing is performed distinctly separate from the drug test service and the documentation
supports the service was not related to the drug testing.
Drug testing services that are determined to be court ordered and/or funded by a county, state or federal agency will continue to be denied. For additional information, refer to the Reimbursement Policy titled Services and Modifiers Not Reimbursable to Healthcare Professionals.
Reimbursement Policy Updates
Oxford
33 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Maximum
Frequency Per Day
Feb. 1, 2020
Notice of Revision: The following summary of changes has been modified. Revisions to the previous policy update
announcement are outlined in red below. Please take note of the additional updates to be applied on Feb. 1, 2020. Reimbursement Guidelines
Maximum Frequency per Day (MFD) Determination: Part I
• Replaced language indicating: o “Where the criteria [listed in the policy] have not defined an MFD value, the Centers for Medicare and
Medicaid Services (CMS) Medically Unlikely Edit (MUE) value, where available, will be utilized to establish an MFD value” with “The CMS MUE value, where available, may be utilized to establish an MFD value, including unlisted codes”
o “Where no other definitive value has been established based on the criteria above, drug HCPCS codes will
have an MFD value of 999 which indicates they are exempt from the MFD policy” with “Where no other definitive value has been established based on the criteria above, drug HCPCS codes will have an MFD value of 999 which indicates they bypass the MFD policy”
• Added language to indicate when no MUE value has been established for bilateral codes, the MFD value is one (1)
• Removed language indicating:
o Where the CPT or HCPCS code description/verbiage references reporting the code once per day, the MFD
value is 1 o Where no other definitive value has been established based on the criteria [listed in the policy], unlisted CPT
and HCPCS codes will have an MFD value of 999 which indicates they are exempt from the MFD policy
MFD Determination: Part II • Added language to indicate the limits on code claim occurrences in a data set excludes HCPCS drug codes
Reimbursement • Removed language indicating when reporting the same CPT or HCPCS code on multiple and/or separate claim
lines, the claim line may be subject to additional Oxford reimbursement policies
Medically Unlikely Edit Adjudication Indicator (MAI) 2 • Added language to indicate anatomic modifiers may be considered when appropriate for CPT/HCPCS codes
assigned an MAI indicator of “2”
Questions and Answers (Q&A) • Updated Q&A #2, #6, #10, and #11
• Removed Q&A pertaining to: o Unlisted CPT and HCPCS codes with an MFD value of 999 o Clinical circumstances where Oxford would assign a specific MFD value
Applicable Codes • Added list of 5,461 5,543* MAI2 Indicator Codes (codes previously addressed in the CMS MUE file) (*added 82
codes to reflect annual code edits; revised Feb. 1, 2020)
Reimbursement Policy Updates
Oxford
34 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Maximum
Frequency Per Day (continued)
Feb. 1, 2020
Codes Restricting Modifiers LT and RT • Added CPT/CDT/HCPCS codes 0139U*, 0140U*, 0141U*, 0142U*, 0143U*, 0144U*, 0145U*, 0146U*, 0147U*,
0148U*, 0149U*, 0150U*, 0151U*, 0152U*, 0153U*, 0154U*, 0155U*, 0156U*, 0157U*, 0158U*, 0159U*, 0160U*, 0161U*, 0162U*, 0563T*, 0564T*, 0565T*, 0566T*, 0567T*, 0568T*, 0569T*, 0570T*, 0571T*,
0572T*, 0573T*, 0574T*, 0575T*, 0576T*, 0577T*, 0578T*, 0579T*, 0580T*, 0581T*, 0582T*, 0584T*,
0585T*, 0586T*, 0587T*, 0588T*, 0589T*, 0590T*, 0591T*, 0592T*, 0593T*, 15769*, 15771*, 15772*, 15773*, 15774*, 20560*, 20561*, 20700*, 20701*, 20702*, 20703*, 20704*, 20705*, 21601*, 21602*, 21603*, 33016*, 33017*, 33018*, 33019*, 33858*, 33859*, 33871*, 34717*, 46948*, 49013*, 49014*, 62328*, 62329*, 64451*, 64454*, 64624*, 64625*, 74221*, 74248*, 78429*, 78430*, 78431*, 78432*, 78433*, 78434*, 78830*, 78831*, 78832*, 78835*, 80145*, 80187*, 80230*, 80235*, 80280*, 80285*, 81277*, 81307*, 81308*, 81309*, 81522*, 81542*, 81552*, 87563*, 90694*, 90912*, 90913*, 92201*,
92202*, 92549*, 93356*, 93985*, 93986*, 95700*, 95705*, 95706*, 95707*, 95708*, 95709*, 95710*, 95711*, 95712*, 95713*, 95714*, 95715*, 95716*, 95717*, 95718*, 95719*, 95720*, 95721*, 95722*, 95723*, 95724*, 95725*, 95726*, 96156*, 96158*, 96159*, 96164*, 96165*, 96167*, 96168*, 96170*, 96171*, 97129*, 97130*, 98970*, 98971*, 98972*, 99421*, 99422*, 99423*, 99458*, 99473*, 99474*, D0419*, A4226*, A9590*, B4187*, G2021*, G2022*, G2058*, G2061*, G2062*, G2063*, G2064*, G2065*, G2066*, G2067*, G2068*, G2069*, G2070*, G2071*, G2072*, G2073*, G2074*, G2075*, G2076*, G2077*,
G2078*, G2079*, G2080*, G2082*, G2083*, G2086*, G2087*, G2088*, J0642, K1001*, K1002*, K1003*,
K1004*, K1005*, L8033*, and P9099*
Maximum Frequency Per Day Code List • Added CPT/CDT/HCPCS codes 0139U*, 0140U*, 0141U*, 0142U*, 0143U*, 0144U*, 0145U*, 0146U*, 0147U*,
0148U*, 0149U*, 0150U*, 0151U*, 0152U*, 0153U*, 0154U*, 0155U*, 0156U*, 0157U*, 0158U*, 0159U*, 0160U*, 0161U*, 0162U*, 0563T*, 0564T*, 0565T*, 0566T*, 0567T*, 0568T*, 0569T*, 0570T*, 0571T*, 0572T*, 0573T*, 0574T*, 0575T*, 0576T*, 0577T*, 0578T*, 0579T*, 0580T*, 0581T*, 0582T*, 0583T*, 0584T*, 0585T*, 0586T*, 0587T*, 0588T*, 0589T*, 0590T*, 0591T*, 0592T*, 0593T*, 15769*, 15771*, 15772*, 15773*, 15774*, 20560*, 20561*, 20700*, 20701*, 20702*, 20703*, 20704*, 20705*, 21601*, 21602*, 21603*, 33016*, 33017*, 33018*, 33019*, 33858*, 33859*, 33871*, 34717*, 34718*, 35702*, 35703*, 46948*, 49013*, 49014*, 62328*, 62329*, 64451*, 64454*, 64624*, 64625*, 66987*, 66988*,
74221*, 74248*, 78429*, 78430*, 78431*, 78432*, 78433*, 78434*, 78830*, 78831*, 78832*, 78835*,
80145*, 80187*, 80230*, 80235*, 80280*, 80285*, 81277*, 81307*, 81308*, 81309*, 81522*, 81542*, 81552*, 87563*, 90694*, 90912*, 90913*, 92201*, 92202*, 92549*, 93356*, 93985*, 93986*, 95700*, 95705*, 95706*, 95707*, 95708*, 95709*, 95710*, 95711*, 95712*, 95713*, 95714*, 95715*, 95716*, 95717*, 95718*, 95719*, 95720*, 95721*, 95722*, 95723*, 95724*, 95725*, 95726*, 96156*, 96158*, 96159*, 96164*, 96165*, 96167*, 96168*, 96170*, 96171*, 97129*, 97130*, 98970*, 98971*, 98972*,
99421*, 99422*, 99423*, 99458*, 99473*, 99474*, D0419*, D1551*, D1552*, D1553*, D1556*, D1557*, D1558*, D2753*, D5284*, D5286*, D6082*, D6083*, D6084*, D6086*, D6087*, D6088*, D6097*, D6098*, D6099*, D6120*, D6121*, D6122*, D6123*, D6195*, D6243*, D6753*, D6784*, D7922*, D8696*, D8697*, D8698*, D8699*, D8701*, D8702*, D8703*, D8704*, D9997*, A4226*, A9590*, B4187*, E0787*, E2398*,
Reimbursement Policy Updates
Oxford
35 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Maximum
Frequency Per Day (continued)
Feb. 1, 2020 G2021*, G2022*, G2058*, G2061*, G2062*, G2063*, G2064*, G2065*, G2066*, G2067*, G2068*, G2069*,
G2070*, G2071*, G2072*, G2073*, G2074*, G2075*, G2076*, G2077*, G2078*, G2079*, G2080*, G2082*, G2083*, G2086*, G2087*, G2088*, J0179*, J0642, J9199*, J9309*, K1001*, K1002*, K1003*, K1004*, K1005*, L2006*, L8033*, and P9099*
• Revised MFD value for CPT/CDT/HCPCS codes 0093U*, 0546T*, 0550T*, 0553T*, 0560T*, 0562T*, 34713*,
34714*, 34715*, 34716*, 64420*, 76983*, 90284*, 93657*, A0080*, A0090*, A0120*, A0160*, A0170*, A0180*, A0190*, A0380*, A0382*, A0390*, A0394*, A0398*, A0424*, A4207*, A4208*, A4209*, A4211*, A4213*, A4217*, A4218*, A4222*, A4231*, A4244*, A4245*, A4248*, A4280*, A4283*, A4285*, A4305*,
A4306*, A4320*, A4326*, A4327*, A4335*, A4397*, A4400*, A4404*, A4421*, A4455*, A4553*, A4558*, A4605*, A4628*, A4629*, A4630*, A4641*, A4651*, A4657*, A4674*, A4680*, A4690*, A4706*, A4720*, A4736*, A4750*, A4755*, A4766*, A4770*, A4860*, A4890*, A4913*, A4930*, A5055*, A5063*, A5093*, A5121*, A5122*, A5126*, A6021*, A6022*, A6024*, A6025*, A6199*, A6203*, A6204*, A6206*, A6207*, A6209*, A6210*, A6211*, A6213*, A6217*, A6219*, A6220*, A6223*, A6224*, A6230*, A6237*, A6240*, A6245*, A6248*, A6255*, A6256*, A6257*, A6259*, A6260*, A6261*, A6262*, A6266*, A6403*, A6404*,
A6407*, A6413*, A6441*, A6442*, A6448*, A6449*, A6450*, A6451*, A6452*, A6453*, A6455*, A6456*, A6457*, A6512*, A6549*, A6550*, A7008*, A7523*, A9150*, A9153*, A9180*, A9270*, A9273*, A9279*, A9280*, A9300*, A9597*, A9598*, A9699*, A9901*, B4102*, B4104*, B4162*, B4185*, B5100*, B5200*,
B9998*, B9999*, D0411*, D0414*, D0600*, D0999*, D2999*, D3999*, D4346*, D4999*, D5511*, D5512*, D5611*, D5612*, D5621*, D5622*, D5899*, D5999*, D6096*, D6118*, D6119*, D6199*, D6999*, D7296*, D7297*, D7521*, D7899*, D7999*, D8695*, D8999*, D9311*, D9995*, D9996*, D9999*, E0625*, E0700*, E0769*, E1575*, E1699*, E2599*, G0176*, H0033*, H0046*, H0047*, J0130, J2787, J0571*, J0572*, J0573*,
J0574*, J0575*, J0638*, J7311*, J7401*, J7665*, K0108*, K0552*, K0603*, L0999*, L2840*, L2999*, L3320*, L3649*, L3999*, L5999*, L7499*, L8699*, L9900*, Q2017, Q2026*, Q2049*, Q4005*, Q4007*, Q4008*, Q4009*, Q4011*, Q4016*, Q4017*, Q4018*, Q4023*, Q4032*, Q4034*, Q4035*, Q4036*, Q4039*, Q4041*, Q4042*, Q4043*, Q4044*, Q4045*, Q4048*, Q4049*, Q4100*, S0207*, S0209*, S0270*, S0271*, S0272*, S0320*, S0354*, S0400*, S1015*, S1016*, S2095*, S2409*, S4026*, S4027*, S4993*, S5000*, S5001*, S5010*, S5170*, S5199*, S5521*, S8040*, S8189*, S8301*, S8415*, S8431*, S8940*, S9110*, S9430*, S9434*, S9435*, S9977*, S9982*, S9986*, T1010*, T1014*, T1999*, T2003*, T2025*, T2049*,
T4521*, T4536*, T4543*, T5999*, V2799*, and V5274*
(*annual code edit)
Maximum Frequency Per Day (CES)
Feb. 1, 2020
Notice of Revision: The following summary of changes has been modified. Revisions to the previous policy update announcement are outlined in red below. Please take note of the additional updates to be applied on Feb. 1, 2020. • Replaced references to “other health care professional” with “other qualified health care professional”
Reimbursement Guidelines
Maximum Frequency per Day (MFD) Determination: Part I • Replaced language indicating:
o “Where the criteria [listed in the policy] have not defined an MFD value, the Centers for Medicare and
Reimbursement Policy Updates
Oxford
36 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Maximum
Frequency Per Day (CES) (continued)
Feb. 1, 2020
Medicaid Services (CMS) Medically Unlikely Edit (MUE) value, where available, will be utilized to establish an
MFD value” with “The CMS MUE value, where available, may be utilized to establish an MFD value, including unlisted codes”
o “Where no other definitive value has been established based on the criteria above, drug HCPCS codes will have an MFD value of 999 which indicates they are exempt from the MFD policy” with “Where no other
definitive value has been established based on the criteria above, drug HCPCS codes will have an MFD value of 999 which indicates they bypass the MFD policy”
• Added language to indicate when no MUE value has been established for bilateral codes, the MFD value is one
(1) • Removed language indicating:
o Where the CPT or HCPCS code description/verbiage references reporting the code once per day, the MFD value is 1
o Where no other definitive value has been established based on the criteria [listed in the policy], unlisted CPT and HCPCS codes will have an MFD value of 999 which indicates they are exempt from the MFD policy
MFD Determination: Part II • Added language to indicate the limits on code claim occurrences in a data set excludes HCPCS drug codes
Reimbursement
• Removed language indicating when reporting the same CPT or HCPCS code on multiple and/or separate claim lines, the claim line may be subject to additional Oxford reimbursement policies
Medically Unlikely Edit Adjudication Indicator (MAI) 2 • Added language to indicate anatomic modifiers may be considered when appropriate for CPT/HCPCS codes
assigned an MAI indicator of “2”
Questions and Answers (Q&A) • Updated Q&A #2, #6, #10, and #11 • Removed Q&A pertaining to:
o Unlisted CPT and HCPCS codes with an MFD value of 999 o Clinical circumstances where Oxford would assign a specific MFD value
Applicable Codes
• Added list of 5,461 5,543* MAI2 Indicator Codes (codes previously addressed in the CMS MUE file) (*added 82 codes to reflect annual code edits; revised Feb. 1, 2020)
Codes Restricting Modifiers LT and RT • Added CPT/CDT/HCPCS codes 0139U*, 0140U*, 0141U*, 0142U*, 0143U*, 0144U*, 0145U*, 0146U*, 0147U*,
0148U*, 0149U*, 0150U*, 0151U*, 0152U*, 0153U*, 0154U*, 0155U*, 0156U*, 0157U*, 0158U*, 0159U*, 0160U*, 0161U*, 0162U*, 0563T*, 0564T*, 0565T*, 0566T*, 0567T*, 0568T*, 0569T*, 0570T*, 0571T*,
0572T*, 0573T*, 0574T*, 0575T*, 0576T*, 0577T*, 0578T*, 0579T*, 0580T*, 0581T*, 0582T*, 0584T*, 0585T*, 0586T*, 0587T*, 0588T*, 0589T*, 0590T*, 0591T*, 0592T*, 0593T*, 15769*, 15771*, 15772*, 15773*, 15774*, 20560*, 20561*, 20700*, 20701*, 20702*, 20703*, 20704*, 20705*, 21601*, 21602*,
Reimbursement Policy Updates
Oxford
37 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Maximum
Frequency Per Day (CES) (continued)
Feb. 1, 2020
21603*, 33016*, 33017*, 33018*, 33019*, 33858*, 33859*, 33871*, 34717*, 46948*, 49013*, 49014*,
62328*, 62329*, 64451*, 64454*, 64624*, 64625*, 74221*, 74248*, 78429*, 78430*, 78431*, 78432*, 78433*, 78434*, 78830*, 78831*, 78832*, 78835*, 80145*, 80187*, 80230*, 80235*, 80280*, 80285*, 81277*, 81307*, 81308*, 81309*, 81522*, 81542*, 81552*, 87563*, 90694*, 90912*, 90913*, 92201*, 92202*, 92549*, 93356*, 93985*, 93986*, 95700*, 95705*, 95706*, 95707*, 95708*, 95709*, 95710*,
95711*, 95712*, 95713*, 95714*, 95715*, 95716*, 95717*, 95718*, 95719*, 95720*, 95721*, 95722*, 95723*, 95724*, 95725*, 95726*, 96156*, 96158*, 96159*, 96164*, 96165*, 96167*, 96168*, 96170*, 96171*, 97129*, 97130*, 98970*, 98971*, 98972*, 99421*, 99422*, 99423*, 99458*, 99473*, 99474*,
D0419*, A4226*, A9590*, B4187*, G2021*, G2022*, G2058*, G2061*, G2062*, G2063*, G2064*, G2065*, G2066*, G2067*, G2068*, G2069*, G2070*, G2071*, G2072*, G2073*, G2074*, G2075*, G2076*, G2077*, G2078*, G2079*, G2080*, G2082*, G2083*, G2086*, G2087*, G2088*, J0642, K1001*, K1002*, K1003*, K1004*, K1005*, L8033*, and P9099*
Maximum Frequency Per Day Code List • Added CPT/CDT/HCPCS codes 0139U*, 0140U*, 0141U*, 0142U*, 0143U*, 0144U*, 0145U*, 0146U*, 0147U*,
0148U*, 0149U*, 0150U*, 0151U*, 0152U*, 0153U*, 0154U*, 0155U*, 0156U*, 0157U*, 0158U*, 0159U*, 0160U*, 0161U*, 0162U*, 0563T*, 0564T*, 0565T*, 0566T*, 0567T*, 0568T*, 0569T*, 0570T*, 0571T*, 0572T*, 0573T*, 0574T*, 0575T*, 0576T*, 0577T*, 0578T*, 0579T*, 0580T*, 0581T*, 0582T*, 0583T*,
0584T*, 0585T*, 0586T*, 0587T*, 0588T*, 0589T*, 0590T*, 0591T*, 0592T*, 0593T*, 15769*, 15771*,
15772*, 15773*, 15774*, 20560*, 20561*, 20700*, 20701*, 20702*, 20703*, 20704*, 20705*, 21601*, 21602*, 21603*, 33016*, 33017*, 33018*, 33019*, 33858*, 33859*, 33871*, 34717*, 34718*, 35702*, 35703*, 46948*, 49013*, 49014*, 62328*, 62329*, 64451*, 64454*, 64624*, 64625*, 66987*, 66988*, 74221*, 74248*, 78429*, 78430*, 78431*, 78432*, 78433*, 78434*, 78830*, 78831*, 78832*, 78835*, 80145*, 80187*, 80230*, 80235*, 80280*, 80285*, 81277*, 81307*, 81308*, 81309*, 81522*, 81542*, 81552*, 87563*, 90694*, 90912*, 90913*, 92201*, 92202*, 92549*, 93356*, 93985*, 93986*, 95700*,
95705*, 95706*, 95707*, 95708*, 95709*, 95710*, 95711*, 95712*, 95713*, 95714*, 95715*, 95716*, 95717*, 95718*, 95719*, 95720*, 95721*, 95722*, 95723*, 95724*, 95725*, 95726*, 96156*, 96158*, 96159*, 96164*, 96165*, 96167*, 96168*, 96170*, 96171*, 97129*, 97130*, 98970*, 98971*, 98972*, 99421*, 99422*, 99423*, 99458*, 99473*, 99474*, D0419*, D1551*, D1552*, D1553*, D1556*, D1557*, D1558*, D2753*, D5284*, D5286*, D6082*, D6083*, D6084*, D6086*, D6087*, D6088*, D6097*, D6098*,
D6099*, D6120*, D6121*, D6122*, D6123*, D6195*, D6243*, D6753*, D6784*, D7922*, D8696*, D8697*, D8698*, D8699*, D8701*, D8702*, D8703*, D8704*, D9997*, A4226*, A9590*, B4187*, E0787*, E2398*,
G2021*, G2022*, G2058*, G2061*, G2062*, G2063*, G2064*, G2065*, G2066*, G2067*, G2068*, G2069*, G2070*, G2071*, G2072*, G2073*, G2074*, G2075*, G2076*, G2077*, G2078*, G2079*, G2080*, G2082*, G2083*, G2086*, G2087*, G2088*, J0179*, J0642, J9199*, J9309*, K1001*, K1002*, K1003*, K1004*, K1005*, L2006*, L8033*, and P9099*
• Revised MFD value for CPT/CDT/HCPCS codes 0093U*, 0546T*, 0550T*, 0553T*, 0560T*, 0562T*, 34713*, 34714*, 34715*, 34716*, 64420*, 76983*, 90284*, 93657*, A0080*, A0090*, A0120*, A0160*, A0170*, A0180*, A0190*, A0380*, A0382*, A0390*, A0394*, A0398*, A0424*, A4207*, A4208*, A4209*, A4211*,
Reimbursement Policy Updates
Oxford
38 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Maximum
Frequency Per Day (CES) (continued)
Feb. 1, 2020 A4213*, A4217*, A4218*, A4222*, A4231*, A4244*, A4245*, A4248*, A4280*, A4283*, A4285*, A4305*,
A4306*, A4320*, A4326*, A4327*, A4335*, A4397*, A4400*, A4404*, A4421*, A4455*, A4553*, A4558*, A4605*, A4628*, A4629*, A4630*, A4641*, A4651*, A4657*, A4674*, A4680*, A4690*, A4706*, A4720*, A4736*, A4750*, A4755*, A4766*, A4770*, A4860*, A4890*, A4913*, A4930*, A5055*, A5063*, A5093*, A5121*, A5122*, A5126*, A6021*, A6022*, A6024*, A6025*, A6199*, A6203*, A6204*, A6206*, A6207*,
A6209*, A6210*, A6211*, A6213*, A6217*, A6219*, A6220*, A6223*, A6224*, A6230*, A6237*, A6240*, A6245*, A6248*, A6255*, A6256*, A6257*, A6259*, A6260*, A6261*, A6262*, A6266*, A6403*, A6404*, A6407*, A6413*, A6441*, A6442*, A6448*, A6449*, A6450*, A6451*, A6452*, A6453*, A6455*, A6456*,
A6457*, A6512*, A6549*, A6550*, A7008*, A7523*, A9150*, A9153*, A9180*, A9270*, A9273*, A9279*, A9280*, A9300*, A9597*, A9598*, A9699*, A9901*, B4102*, B4104*, B4162*, B4185*, B5100*, B5200*, B9998*, B9999*, D0411*, D0414*, D0600*, D0999*, D2999*, D3999*, D4346*, D4999*, D5511*, D5512*, D5611*, D5612*, D5621*, D5622*, D5899*, D5999*, D6096*, D6118*, D6119*, D6199*, D6999*, D7296*, D7297*, D7521*, D7899*, D7999*, D8695*, D8999*, D9311*, D9995*, D9996*, D9999*, E0625*, E0700*, E0769*, E1575*, E1699*, E2599*, G0176*, H0033*, H0046*, H0047*, J0130, J2787, J0571*, J0572*, J0573*,
J0574*, J0575*, J0638*, J7311*, J7401*, J7665*, K0108*, K0552*, K0603*, L0999*, L2840*, L2999*, L3320*, L3649*, L3999*, L5999*, L7499*, L8699*, L9900*, Q2017, Q2026*, Q2049*, Q4005*, Q4007*, Q4008*, Q4009*, Q4011*, Q4016*, Q4017*, Q4018*, Q4023*, Q4032*, Q4034*, Q4035*, Q4036*, Q4039*,
Q4041*, Q4042*, Q4043*, Q4044*, Q4045*, Q4048*, Q4049*, Q4100*, S0207*, S0209*, S0270*, S0271*, S0272*, S0320*, S0354*, S0400*, S1015*, S1016*, S2095*, S2409*, S4026*, S4027*, S4993*, S5000*, S5001*, S5010*, S5170*, S5199*, S5521*, S8040*, S8189*, S8301*, S8415*, S8431*, S8940*, S9110*, S9430*, S9434*, S9435*, S9977*, S9982*, S9986*, T1010*, T1014*, T1999*, T2003*, T2025*, T2049*,
T4521*, T4536*, T4543*, T5999*, V2799*, and V5274* (*annual code edit)
Multiple Procedure Payment Reduction (MPPR) for Diagnostic
Cardiovascular and Ophthalmology
Procedures
Feb. 1, 2020
Notice of Revision: The following summary of changes has been modified. Revisions to the previous policy update announcement are
outlined in red below. Please take note of the additional updates to be
applied on Feb. 1, 2020. Overview • Removed language indicating:
o Oxford will apply MPPR
cardiovascular reductions to Diagnostic Cardiovascular Procedures identified as Global Test Only Codes
Multiple Diagnostic Cardiovascular Reductions (MDCR)
Oxford utilizes the CMS NPFS MPI of 6 and Non-Facility Total Relative Value Units (RVUs) to determine which Diagnostic Cardiovascular Procedures are eligible for MDCR to the TC portion of the procedure.
When the TC for two or more Diagnostic Cardiovascular Procedures are
performed on the same patient by the Same Group Physician and/or Other Health Care Professional on the same day, Oxford will apply a MDCR to reduce the Allowable Amount for the TC of the second and each subsequent procedure by 25%. No reduction is taken on the TC with the highest TC Non-facility Total RVU according to the NPFS. The MDCR applies to the Technical Component Only codes (PC/TC Indicator
3), and to the TC portion of Global Procedure Codes (PC/TC Indicator 1) and codes that represent the TC of Global Test Only Codes (PC/TC Indicator 4).
Reimbursement Policy Updates
Oxford
39 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Multiple Procedure
Payment Reduction (MPPR) for Diagnostic Cardiovascular and
Ophthalmology Procedures (continued)
Feb. 1, 2020
assigned an MPI of 6 on the
CMS NPFS (CPT codes 93000, 93015, 93040, 93224, 93268 and 93784); these codes will also be
considered in ranking other Diagnostic Cardiovascular Procedures assigned an MPI
of 6
Reimbursement Guidelines • Replaced language indicating
“the MDCR applies to the Technical Component Only codes (PC/TC Indicator 3), and to the TC portion of Global Procedure Codes (PC/TC Indicator 1); for Diagnostic Cardiovascular
Procedures represented by a
Global Test Only code (PC/TC Indicator 4), the reduction will be 25% of the corresponding Technical Component Only Code(s)” with “the MDCR applies to the Technical Component
Only codes (PC/TC Indicator 3), to the TC portion of Global Procedure Codes (PC/TC Indicator 1), and to codes that represent the TC of Global Test
Only Codes (PC/TC Indicator 4)” • Added reference link to the
Applicable Codes section of the policy for a list of PC/TC Indicator 1, 3, and 4 codes
Definitions • Updated definition of:
o Gap Fill Codes o Global Service
The MDCR will apply when: • Multiple Diagnostic Cardiovascular Procedures with an MPI of 6 are
performed on the same patient by the Same Group Physician and/or Other Health Care Professional on the same day.
• A single Diagnostic Cardiovascular Procedure subject to the MDCR is
submitted with multiple units. For example, code 78445 is submitted
with 2 units. A MDCR would apply to the TC of the second unit. The units allowed are also subject to Oxford's Maximum Frequency Per Day policy.
The MDCR will not apply when: • Multiple Diagnostic Cardiovascular Procedures are billed, appended with
modifier 26 for the Professional Component (PC) only. MDCRs will not be applied to the PC.
• The procedure does not have an MPI of 6 and is not included on the Diagnostic Cardiovascular Procedures Subject to MPPR lists in the Applicable Codes section of the policy.
Refer to the Applicable Codes section of the policy for a listing of PC/TC Indicator 1, 3, and 4 codes.
Multiple Diagnostic Ophthalmology Reductions (MDOR)
Oxford utilizes the CMS NPFS MPI of 7 and Non-Facility Total RVUs to
determine which Diagnostic Ophthalmology Procedures are eligible for MDOR to the TC portion of the procedure. When the TC for two or more Diagnostic Ophthalmology Procedures are performed on the same patient by the Same Group Physician and/or Other Health Care Professional on the same day, Oxford will apply a MDOR to
reduce the Allowable Amount for the TC of the second and each subsequent procedure by 20%. No reduction is taken on the TC with the highest TC Non-Facility Total RVU according to the NPFS. The MDOR applies to TC only services and the TC portion of Global Procedure Codes.
The MDOR will apply when: • Multiple Diagnostic Ophthalmology Procedures with an MPI of 7 are
performed on the same patient by the Same Group Physician and/or
Reimbursement Policy Updates
Oxford
40 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Multiple Procedure
Payment Reduction (MPPR) for Diagnostic Cardiovascular and
Ophthalmology Procedures (continued)
Feb. 1, 2020
Applicable Codes • Revised list of Diagnostic
Ophthalmology Procedures Subject to MPPR (PC/TC
Indicator 1) to reflect annual
code edits; added CPT code 0508T with TC Non-Facility Total RVU value 0.63
• Revised list of Diagnostic Cardiovascular Procedures Subject to MPPR (PC/TC
Indicator 4); updated Non-Facility Total RVU values for CPT codes 93000, 93015, 93040, 93224, 93268, and 93784
Questions and Answers (Q&A) • Updated Q&A #3 and #5
pertaining to how the TC portion is obtained in order to rank and apply MDCR to the listed Diagnostic Cardiovascular
Procedures • Removed Q&A pertaining to the
Oxford effective date for including the reduction of the TC of multiple Diagnostic Cardiovascular and Ophthalmology Procedures
Other Health Care Professional on the same day.
• A single Diagnostic Ophthalmology Procedure subject to MDOR is submitted with multiple units. For example, code 92060 is submitted with 2 units. A MDOR would apply to the TC of the second unit. The units allowed are also subject to Oxford's Maximum Frequency Per Day policy.
The MDOR will not apply when: • Multiple Diagnostic Ophthalmology Procedures are billed, appended with
modifier 26 for the PC only. MDORs will not be applied to the PC. • The procedure does not have an MPI of 7 and is not included on the
Diagnostic Ophthalmology Procedures Subject to MPPR list in the Applicable Codes section of the policy.
Multiple Diagnostic Cardiovascular and Ophthalmology Procedures
Billed Globally
When the Same Group Physician and/or Other Health Care Professional bills multiple Diagnostic Cardiovascular Procedure Global Procedure Codes (PC/TC
indicator 1) and/or Global Test Only Codes (PC/TC indicator 4); or multiple Diagnostic Ophthalmology Procedure Global Procedure Codes (PC/TC indicator 1) the procedures will be ranked to determine which procedure(s) are considered secondary or subsequent as indicated below: For Diagnostic Cardiovascular or Diagnostic Ophthalmology Global Procedure
Codes (assigned PC/TC Indicator 1): • When a provider bills globally for two or more procedures subject to
multiple diagnostic cardiovascular or ophthalmology reduction, the charge for the Global Procedure Codes will be divided into the PC and TC (indicated by modifiers 26 and TC) using Oxford's standard Professional/Technical percentage splits. Refer to the Reimbursement
Policy titled Professional/Technical Component for applicable PC/TC
splits. Ranking is based on the TC Non-Facility Total RVU and a reduction of 25% will be applied for MDCR and 20% will be applied for MDOR.
For Diagnostic Cardiovascular Procedures Global Test Only Codes (PC/TC Indicator 4): • When a provider bills for two or more Diagnostic Cardiovascular
Procedures represented by a Global Test Only code, a reduction of 25%
will be applied to the corresponding Technical Component Only Code(s)
Reimbursement Policy Updates
Oxford
41 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Multiple Procedure
Payment Reduction (MPPR) for Diagnostic Cardiovascular and
Ophthalmology Procedures (continued)
Feb. 1, 2020 (PC/TC Indicator 3). No reduction will apply to the corresponding
Professional Component Only Code(s). Refer to Q&A #3 for an example of how the MDCR reduction is applied.
Diagnostic Cardiovascular and Ophthalmology Procedures with No
Assigned CMS RVU
Services that CMS indicates may be carrier-priced, or those for which CMS does not develop RVUs are considered Gap Fill Codes and are addressed as follows: • Gap Fill Codes: When data is available for Gap Fill Codes, Oxford uses
the RVUs published in the first quarter update of the Optum The Essential RBRVS publication for the current calendar year. A Diagnostic Cardiovascular Procedure or Diagnostic Ophthalmology Procedure assigned a gap value, will be denoted with an asterisk (*) next to the code in the applicable list.
• 0.00 RVU Codes: Some codes cannot be assigned a gap value or remain without an RVU due to the nature of the service (example:
unlisted codes). Codes assigned an RVU value of 0.00 will not be included in the Diagnostic Cardiovascular Procedures or Diagnostic Ophthalmology Procedures Subject to MPPR Policy Lists and therefore, will be excluded from ranking.
Nonphysician Health Care
Professionals Billing Evaluation and Management Codes
Mar. 1, 2020
Attachments • Revised list of nonphysician
health care professionals not allowed to report evaluation and management (E/M) services: o Added:
▪ Case Management
▪ Certified Diabetic
Educator ▪ Psychology, Clinical
(Doctor of Psychology) ▪ Social Worker
(Registered Social Worker)
▪ Social Worker (Licensed
Clinical/Medical) ▪ Social Worker (Marriage
The Current Procedural Terminology (CPT®) book has specific guidelines that give the following instruction: "Select the name of the procedure or service
that accurately identifies the service performed." The National Correct Coding Initiative Policy Manual gives the following instruction: "Procedures should be reported with the most comprehensive CPT code that describes the services performed."
CPT guidance instructs that E/M (CPT codes 99091, 99201-99499) should only be reported by Physicians or other qualified health care professionals. In accordance with CMS guidelines, the only qualified health care professionals that may report E/M services are nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse midwives (CNM) and physician assistants (PA), none of which are considered nonphysician health care professionals for purposes of this policy.
Oxford will not reimburse E/M services (CPT codes 99091, 99201-99499)
Reimbursement Policy Updates
Oxford
42 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Nonphysician
Health Care Professionals Billing Evaluation and Management
Codes (continued)
Mar. 1, 2020 & Family)
▪ Substance Abuse Services (Alcohol & Drug)
▪ Surgical Technician
▪ Visiting Nurse ▪ Waiver Nursing
o Removed:
▪ Psychoanalyst
when reported by nonphysician health care professionals reporting under
their own individual or group tax identification number (TIN). For purposes of this policy, the specialties that are considered nonphysician health care professionals are listed in the Attachments section of the policy.
There is a wide variety of CPT and Healthcare Common Procedure Coding System (HCPCS) codes that specifically and accurately identify and describe the services and procedures performed by nonphysician health care
professionals.
Procedure and Place of Service
Mar. 1, 2020 Applicable Codes • Revised list of HCPCS codes
allowed for place of service 58: o Added G2067, G2068,
G2069, G2070, G2071,
G2072, G2073, G2074, G2075, G2076, G2077, G2078, G2079, and G2080
o Removed G2086, G2087, and G2088
Oxford will reimburse CPT and HCPCS codes when reported with an appropriate Place of Service (POS).
Oxford aligns with The Centers for Medicare & Medicaid Services (CMS) POS Code set, which are two-digit codes submitted on the CMS 1500 Health Insurance Claim Form or its electronic equivalent to indicate the setting in
which a service was provided. The website containing the POS Code set can be accessed via this link: CMS Place of Service Code Set.
Many CPT and HCPCS codes include a Place of Service in their description or coding guidelines include the place(s) of service where the code may be performed. For example, CPT code 94002 (Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted
or controlled breathing; hospital inpatient/observation, initial day) would not be appropriate for reporting in an office or home POS because its code description identifies hospital inpatient or observation.
Oxford has established a list of CPT and HCPCS codes along with their appropriate places of service. Refer to the list located in the Applicable Codes section.
Oxford will not reimburse CPT and HCPCS codes assigned the Non-Facility
Indicator “NA” when reported without an appropriate POS.
According to the CMS National Physician Fee Schedule Relative Value File, the Non-Facility Indicator identified as “NA” indicates that “this procedure is rarely or never performed in the non-facility setting.” The website containing the National Physician Fee Schedule Relative Value File can be accessed via this link: CMS National Physician Fee Schedule. Relative Value File.
Reimbursement Policy Updates
Oxford
43 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Supply Policy
Feb. 1, 2020
Notice of Revision: The following
summary of changes has been modified. Revisions to the previous policy update announcement are outlined in red below. Please take
note of the additional updates to be applied on Feb. 1, 2020.
Reimbursement Guidelines • Updated language to clarify
place of service (POS) codes: o 1, 3, 4, 9, 11, 13, 14, 15,
16, 17, 20, 33, 49, 50, 54, 55, 57, 60, 62, 65, 71, 72,
81, and 99 are considered a non-facility place of service
o 19, 21, 22, 23, and 24 are
considered a facility place of service
o 31 and 32 are considered a skilled nursing facility or
nursing facility place of service
Supply Reimbursement in a Physician’s or Other Qualified Health Care Professional’s Office and Other Non-Facility Places of Service • Removed references to:
o Centers for Medicare and Medicaid Services (CMS)
o The CMS National Physician Fee Schedule (NPFS) Relative Value File
o Relative Value Unit (RVU) • Replaced language indicating
“Oxford will not separately reimburse the HCPCS supply
Supply Reimbursement in a Physician’s or Other Qualified Health
Care Professional’s Office and Other Non-Facility Places of Service
Certain HCPCS supply codes are not separately reimbursable as the cost of
supplies is incorporated into the Evaluation and Management (E/M) service or procedure code. Oxford will not separately reimburse the HCPCS supply
codes when those supplies are provided on the same day as an E/M service and/or procedure performed in non-facility places of service by a physician or other qualified health care professional. Refer to the Supply Codes list. For the purposes of this policy, a nonfacility place of service is considered
POS 1, 3, 4, 9, 11, 13, 14, 15, 16, 17, 20, 33, 49, 50, 54, 55, 57, 60, 62, 65, 71, 72, 81, and 99. Casting and Splint Supplies
HCPCS codes A4570, A4580, and A4590 which were previously used for billing of splints and casts are invalid for Medicare use effective July 1, 2001, and new temporary Q codes were established to reimburse physicians and
other practitioners for the supplies used in creating casts. Consistent with CMS, Oxford will no longer reimburse HCPCS codes A4570, A4580, and
A4590 for casting and splint supplies. Physicians and other qualified health care professionals should be using the temporary Q codes (Q4001-Q4051) for reimbursement of casting and splint supplies. Implantable Tissue Markers
CMS clarifies that implantable tissue markers (HCPCS code A4648) and implantable radiation dosimeters (HCPCS code A4650) are separately billable and payable when used in conjunction with CPT codes 19499, 32553, 49411 or 55876 on a claim for physician services. Consistent with CMS, Oxford will
allow separate reimbursement for HCPCS codes A4648 and A4650 when billed on the same date of service with either CPT codes 19499, 32553, 49411 or 55876. If A4648 and A4650 are reported in a facility setting or without CPT codes 19499, 32553, 49411, or 55876 they are not separately reimbursable.
Reimburesment for Supplies, Durable Medical Equipment (DME), Orthotics, Prosthetics, Biologicals and Drugs Reported with a Facility Place of Service 19, 21, 22, 23, and 24
Reimbursement Policy Updates
Oxford
44 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Supply Policy
(continued)
Feb. 1, 2020
codes when those supplies are
provided on the same day as an Evaluation and Management (E/M) service and/or procedure performed in a physician’s or
other qualified health care professional’s office and other non-facility places of service”
with “Oxford will not separately reimburse the HCPCS supply codes when those supplies are provided on the same day as an E/M service and/or procedure performed in non-facility places
of service by a physician or other qualified health care professional”
HCPCS Code L8680 • Revised language to indicate
HCPCS code L8680 (implantable neurostimulator electrode), in alignment with CMS, is denied in: o All facility places of service
because it is considered included in the reimbursement to the facility (refer to the list of Supply DME Codes in a Facility
Setting) o Non-facility places of service
when reported with CPT code 63650 (percutaneous implantation of neurostimulator electrode array, epidural) because the electrodes are considered included in the
CMS follows a Prospective Payment System (PPS) where Medicare payment
is based on a predetermined, fixed amount payable to a facility for inpatient or outpatient hospital services. With these fixed rates all costs associated with supplies, DME, orthotics, Prosthetics, biologicals and drugs are deemed included in the global payment to the facility and are not considered
separately reimbursable when reported on a CMS-1500 claim form by a physician or other qualified healthcare professional.
Consistent with CMS, Oxford will not allow separate reimbursement for specific HCPCS supplies, DME, orthotics, prosthetics, biological, and drugs submitted on a CMS-1500 claim form by any physician or other qualified healthcare professional in the following facility POS 19, 21, 22, 23, and 24. The Oxford Supply Facility J-Code Denial Codes list and Supply DME Codes in a Facility Setting contains the codes that are not separately reimbursable in
a facility place of service. For the purposes of this policy, a facility place of service is considered POS
19, 21, 22, 23, and 24.
Durable Medical Equipment, Orthotics, Prosthetics, and Related Supplies Reported with Facility Places of Service 31 and 32
In alignment with the CMS PPS reimbursement methodology, Oxford considers payment for certain DME, orthotics, prosthetics and related supply items on the CMS Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) fee schedule to be included in the payment to a skilled nursing facility (POS 31) and nursing facility (POS 32) and not reimbursed
separately when reported by a physician or other qualified health care professional on a CMS-1500 claim form. Refer to the Supply DME Codes in a
Skilled Nursing Facility list. For the purposes of this policy, skilled nursing facility and nursing facility places of service are considered POS 31 and 32.
HCPCS Code L8680
HCPCS code L8680 (implantable neurostimulator electrode) is denied in all facility places of service because it is considered included in the reimbursement to the facility (refer to the list of Supply DME Codes in a
Reimbursement Policy Updates
Oxford
45 Oxford® Policy Update Bulletin: February 2020
Policy Title Effective Date Summary of Changes Reimbursement Guidelines
REVISED
Supply Policy
(continued)
Feb. 1, 2020 reimbursement for the
procedure
Definitions • Removed definition of:
o National Physician Fee
Schedule (NPFS) Relative Value File
o Relative Value Units
Applicable Codes • Revised list of:
o Supply Codes; added HCPCS code A4226*
o Supply Facility J-Code Denial Codes; added HCPCS codes
J0179*, J0642, J9199*, and J9309*
o Supply DME Codes in a
Facility Setting; added HCPCS codes A4226*, B4187*, E0787*, E2398*, K1001*, K1002*, K1003*,
K1004*, K1005*, L2006*, L8033*, L8680, and P9099*
(*annual code edit)
Facility Setting). Code L8680 is also denied in nonfacility places of service
when reported with CPT code 63650 (percutaneous implantation of neurostimulator electrode array, epidural) because the electrodes are considered included in the reimbursement for the procedure. This is in alignment with CMS.
Supply Code 99070
For reimbursement of covered medical and surgical supplies, an appropriate Level II HCPCS code must be submitted. The non-specific CPT code 99070 [supplies and materials, except spectacles, provided by the physician or
other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)] is not reimbursable in any setting.
General Information
Oxford
46 Oxford® Policy Update Bulletin: February 2020
Policy Update Classifications
New
New clinical coverage criteria and/or documentation review
requirements have been adopted for a health service (e.g., test, drug,
device or procedure)
Updated
An existing policy has been reviewed and changes have not been made
to the clinical coverage criteria or documentation review requirements;
however, items such as the clinical evidence, FDA information, and/or
list(s) of applicable codes may have been updated
Revised
An existing policy has been reviewed and revisions have been made to
the clinical coverage criteria and/or documentation review requirements
Replaced
An existing policy has been replaced with a new or different policy
Retired
The health service(s) addressed in the policy are no longer being
managed or are considered to be proven/medically necessary and are
therefore not excluded as unproven/not medically necessary services,
unless coverage guidelines or criteria are otherwise documented in
another policy
The inclusion of a health service (e.g., test, drug, device or procedure)
in this bulletin indicates only that UnitedHealthcare is adopting a new
policy and/or updated, revised, replaced or retired an existing policy;
it does not imply that Oxford® provides coverage for the health service.
Note that most benefit plan documents exclude from benefit coverage
health services identified as investigational or unproven/not medically
necessary. Physicians and other health care professionals may not seek
or collect payment from a member for services not covered by the
applicable benefit plan unless first obtaining the member’s written
consent, acknowledging that the service is not covered by the benefit
plan and that they will be billed directly for the service.
Note: The absence of a policy does not automatically indicate or imply
coverage. As always, coverage for a health service must be determined
in accordance with the member’s benefit plan and any applicable
federal or state regulatory requirements. Additionally, Oxford® reserves
the right to review the clinical evidence supporting the safety and
effectiveness of a medical technology prior to rendering a coverage
determination.
Oxford® respects the expertise of the physicians, health care
professionals, and their staff who participate in our network. Our goal is
to support you and your patients in making the most informed
decisions regarding the choice of quality and cost-effective care, and to
support practice staff with a simple and predictable administrative
experience. The Policy Update Bulletin was developed to share
important information regarding Oxford® Medical and Administrative
Policy updates. When information in this bulletin conflicts with
applicable state and/or federal law, Oxford® follows such applicable
federal and/or state law.
Tips for using the Policy Update Bulletin
• From the table of contents, click the policy title to be directed to the
corresponding policy update summary.
• From the policy updates table, click the policy title to view a
complete copy of a new, updated, or revised policy.
A complete library of Oxford Medical and Administrative Policies is available at OxfordHealth.com > Providers > Tools & Resources > Medical
Information > Medical and Administrative Policies or at UHCprovider.com > Policies and Protocols > Commercial Policies > UnitedHealthcare
Oxford Clinical, Administrative and Reimbursement Policies. Refer to the back of the member's health care ID card for the applicable website.