Medical Policy Update Bulletin - Andy's Web Tools

34 Pages·2014·0.56 MB·English

by  Azevedo, Wanda E

AUGUST 2014
medical policy update bulletin

Medical Policy, Drug Policy & Coverage Determination Guideline Updates

UnitedHealthcare 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 Medical Policy Update Bulletin was developed to share important information
regarding UnitedHealthcare Medical Policy, Drug Policy, and Coverage Determination Guideline (CDG) updates.*

*Where information in this bulletin conflicts with applicable state and/or federal law, UnitedHealthcare follows such applicable federal and/or state law
Medical Policy, Drug Policy, and Coverage Determination Guideline (CDG) Updates

Overview

This bulletin provides complete details on UnitedHealthcare Policy Update Classifications
Medical Policy, Drug Policy, and Coverage Determination New
Guideline (CDG) updates. The appearance of a service or New clinical coverage criteria and/or documentation review requirements
procedure in this bulletin indicates only that UnitedHealthcare have been adopted for a service, procedure, test, or device
has recently adopted a new policy and/or updated, revised,
Updated
replaced or retired an existing policy; it does not imply that
An existing policy has been reviewed and changes have not been made
UnitedHealthcare provides coverage for the service or procedure.
to the clinical coverage criteria or documentation review requirements;
In the event of an inconsistency or conflict between the
however, items such as the clinical evidence, FDA information, and/or
information provided in this bulletin and the posted policy, the
list(s) of applicable codes may have been updated
provisions of the posted policy will prevail. Note that most benefit
plan documents exclude from benefit coverage health services Revised
identified as investigational or unproven/not medically necessary. An existing policy has been reviewed and revisions have been made to
Physicians and other health care professionals may not seek or the clinical coverage criteria and/or documentation review requirements
collect payment from an enrollee for services not covered by the
Replaced
applicable benefit plan unless first obtaining the enrollee’s written
An existing policy has been replaced with a new or different policy
consent, acknowledging that the service is not covered by the
benefit plan and that they will be billed directly for the service. Retired
The procedural codes and/or services previously outlined in the policy are
A complete library of Medical Policies, Drug Policies, and
no longer being managed or are considered to be proven/medically
Coverage Determination Guidelines (CDGs) is available at
necessary and are therefore not excluded as unproven/not medically
UnitedHealthcareOnline.com > Tools & Resources >
necessary services, unless coverage guidelines or criteria are otherwise
Policies, Protocols and Guides > Medical & Drug Policies
documented in another policy
and Coverage Determination Guidelines.
Note: The absence of a policy does not automatically indicate or imply

coverage. As always, coverage for a service or procedure must be
Tips for using the Medical Policy Update Bulletin:
determined in accordance with the enrollee’s benefit plan and any
 From the table of contents, click the policy title to be
applicable federal or state regulatory requirements. Additionally,
directed to the corresponding policy update summary.
UnitedHealthcare reserves the right to review the clinical evidence
 From the policy updates table, click the policy title to view a supporting the safety and effectiveness of a medical technology prior to
complete copy of a new, updated, or revised policy. rendering a coverage determination.

2 Medical Policy Update Bulletin: August 2014
Medical Policy, Drug Policy, and Coverage Determination Guideline (CDG) Updates
In This Issue

Medical Policy Updates Page
UPDATED
 Bronchial Thermoplasty - Effective Sep. 1, 2014 ............................................................................................................................. 5
 Chemosensitivity and Chemoresistance Assays in Cancer - Effective Sep. 1, 2014 ............................................................................... 6
 Cytological Examination of Breast Fluids for Cancer Screening - Effective Sep. 1 2014 ......................................................................... 7
 Discogenic Pain Treatment - Effective Sep. 1 2014 .......................................................................................................................... 8
 High Frequency Chest Wall Compression Devices - Effective Sep. 1 2014 .......................................................................................... 9
 Magnetic Resonance Spectroscopy (MRS) - Effective Sep. 1 2014 .................................................................................................... 10
 Spinal Ultrasonography - Effective Sep. 1 2014 ............................................................................................................................. 11
REVISED
 Occipital Neuralgia and Headache Treatment - Effective Sep. 1 2014 ............................................................................................... 13
 Omnibus Codes - Effective Sep. 1 2014 ........................................................................................................................................15
 Proton Beam Radiation Therapy - Effective Sep. 1 2014 ................................................................................................................. 16
 Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins - Effective Sep. 1 2014 ................................................ 19
Drug and Biologics Policy Updates
NEW
 Soliris (Eculizumab) - Effective Oct. 1 2014 .................................................................................................................................. 24
REVISED
 Anemia Drugs (Darbepoetin Alfa and Epoetin Alfa) - Effective Sep. 1 2014 ....................................................................................... 24
 Botulinum Toxins A and B - Effective Sep. 1 2014 ......................................................................................................................... 25
 Enzyme Replacement Therapy for Gaucher Disease - Effective Sep. 1 2014 ..................................................................................... 25
 Immune Globulin (IVIG and SCIG) - Effective Sep. 1 2014 ............................................................................................................ 26
 Lupron Depot / Lupron Depot-Ped (Leuprolide Acetate) - Effective Sep. 1 2014 ................................................................................ 26
 Xolair (Omalizumab) - Effective Sep. 1 2014 ................................................................................................................................ 27
Coverage Determination Guideline (CDG) Updates
NEW
 Home Health Care - Effective Sep. 1 2014 .................................................................................................................................... 28
UPDATED
 Cosmetic and Reconstructive Procedures - Effective Sep. 1 2014 ................................................................................................... 30

3 Medical Policy Update Bulletin: August 2014
Medical Policy, Drug Policy, and Coverage Determination Guideline (CDG) Updates

In This Issue

REVISED
 Blepharoplasty, Blepharoptosis and Brow Ptosis Repair - Effective Aug. 1 2014 ................................................................................. 30
 Gender Identity Disorder/Gender Dysphoria Treatment - Effective Sep. 1 2014 ................................................................................. 30
 Skilled Care and Custodial Care Services - Effective Sep. 1 2014 .................................................................................................... 31
Utilization Review Guideline (URG) Updates
NEW
 Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Specialty Medication Infusion - Effective
Oct. 1, 2014 ............................................................................................................................................................................. 33
Quality of Care Guideline (QOC) Updates
UPDATED
 Hospital Readmissions - Effective Aug. 1 2014 .............................................................................................................................. 34
RETIRED
 Cost Effective Review (Least Costly, Medically Necessary, Medical Necessity, Reasonable and Necessary) - Effective Aug. 1 2014 ........... 34

4 Medical Policy Update Bulletin: August 2014
Medical Policy Updates

UPDATED
Policy Title Effective Date Summary of Changes Coverage Rationale
Bronchial Sep. 1, 2014  Reorganized policy content Bronchial thermoplasty is unproven and not
Thermoplasty  Added benefit considerations language for medically necessary for treating asthma.
Essential Health Benefits for Individual and There is insufficient high-quality evidence
Small Group plans to indicate: supporting the use of bronchial thermoplasty in
o For plan years beginning on or after patients with severe asthma resistant to standard
January 1, 2014, the Affordable Care Act of therapies. Additional studies are needed to

2010 (ACA) requires fully insured non- identify its efficacy and long-term safety in severe
grandfathered individual and small group asthma populations.

plans (inside and outside of Exchanges) to

provide coverage for ten categories of
Essential Health Benefits (“EHBs”)

o Large group plans (both self-funded and
fully insured), and small group ASO plans,

are not subject to the requirement to offer
coverage for EHBs; however, if such plans

choose to provide coverage for benefits
which are deemed EHBs (such as

maternity benefits), the ACA requires all

dollar limits on those benefits to be

removed on all Grandfathered and Non-

Grandfathered plans

o The determination of which benefits

constitute EHBs is made on a state by
state basis; as such, when using this
guideline, it is important to refer to the
enrollee’s specific plan document to
determine benefit coverage
 Updated coverage rationale; added language
to indicate the unproven service is “not
medically necessary”

 Updated list of applicable CPT codes:

o Removed 31899 and 94799

o Removed coding clarification language

5 Medical Policy Update Bulletin: August 2014
Medical Policy Updates

UPDATED
Policy Title Effective Date Summary of Changes Coverage Rationale
Bronchial Sep. 1, 2014  Updated supporting information to reflect the
Thermoplasty most current description of services, clinical
(continued) evidence, CMS information, and references

Chemosensitivity Sep. 1, 2014  Reorganized policy content Chemoresistance assays and
and  Added benefit considerations language for chemosensitivity assays (including, but not
Chemoresistance Essential Health Benefits for Individual and limited to, the ChemoFx® assay) are
Assays in Cancer Small Group plans to indicate: unproven and not medically necessary for
o For plan years beginning on or after predicting response to chemotherapy.
January 1, 2014, the Affordable Care Act of Results of the available studies fail to provide
2010 (ACA) requires fully insured non- convincing evidence that information obtained
grandfathered individual and small group with chemoresistance and chemosensitivity
plans (inside and outside of Exchanges) to testing is beneficial for health outcomes in
provide coverage for ten categories of patients with cancer. Although numerous studies
Essential Health Benefits (“EHBs”) have been conducted, the evidence does not
o Large group plans (both self-funded and demonstrate that there is an improved survival
fully insured), and small group ASO plans, among patients in whom chemosensitivity and

are not subject to the requirement to offer chemoresistance assays were used to select
coverage for EHBs; however, if such plans chemotherapy regimens. Well-designed

choose to provide coverage for benefits prospective, randomized controlled clinical trials
which are deemed EHBs (such as are needed to determine the impact of

maternity benefits), the ACA requires all chemosensitivity and chemoresistance assays on
dollar limits on those benefits to be tumor response and patient survival.
removed on all Grandfathered and Non-

Grandfathered plans
o The determination of which benefits
constitute EHBs is made on a state by
state basis; as such, when using this
guideline, it is important to refer to the
enrollee’s specific plan document to
determine benefit coverage
 Updated coverage rationale; added language
to indicate the unproven services are “not

6 Medical Policy Update Bulletin: August 2014
Medical Policy Updates

UPDATED
Policy Title Effective Date Summary of Changes Coverage Rationale
Chemosensitivity medically necessary”
and  Updated list of applicable CPT codes; added
Chemoresistance 81287
Assays in Cancer
(continued)

Cytological Sep. 1, 2014  Reorganized policy content Breast ductal lavage is unproven and not
Examination of  Added benefit considerations language for medically necessary for use in breast cancer
Breast Fluids for Essential Health Benefits for Individual and screening of either low-risk or high-risk
Cancer Screening Small Group plans to indicate: women.
o For plan years beginning on or after There is inadequate clinical evidence that breast
January 1, 2014, the Affordable Care Act of ductal lavage either allows for better clinical
2010 (ACA) requires fully insured non- decision-making or reduces breast cancer
grandfathered individual and small group mortality. Further studies are necessary to
plans (inside and outside of Exchanges) to determine the efficacy of cytological examination

provide coverage for ten categories of of ductal fluid in detecting atypical cells to identify

Essential Health Benefits (“EHBs”) women at increased risk of breast cancer as well

o Large group plans (both self-funded and as comparing the results to established methods

fully insured), and small group ASO plans, of detecting and diagnosing breast cancer. Ductal

are not subject to the requirement to offer lavage is intended for use in high-risk women but
coverage for EHBs; however, if such plans no definite patient selection criteria for ductal
choose to provide coverage for benefits lavage of the breast have been established.
which are deemed EHBs (such as

maternity benefits), the ACA requires all The HALO® Breast Pap Test is unproven and
dollar limits on those benefits to be not medically necessary for use in breast

removed on all Grandfathered and Non- cancer screening of either low-risk or high-
Grandfathered plans risk women.

o The determination of which benefits
There is inadequate clinical evidence that
constitute EHBs is made on a state by
automated nipple aspiration either allows for
state basis; as such, when using this
better clinical decision-making or reduces breast
guideline, it is important to refer to the
cancer mortality. Further studies are necessary to
enrollee’s specific plan document to
determine the efficacy of cytological examination
determine benefit coverage

7 Medical Policy Update Bulletin: August 2014
Medical Policy Updates

UPDATED
Policy Title Effective Date Summary of Changes Coverage Rationale
Cytological Sep. 1, 2014  Updated coverage rationale; added language of ductal fluid in detecting atypical cells to identify
Examination of to indicate the unproven services are “not women at increased risk of breast cancer as well
Breast Fluids for medically necessary” as comparing the results to established methods
Cancer Screening  Updated supporting information to reflect the of detecting and diagnosing breast cancer.
(continued) most current FDA and CMS information and
references Fiberoptic ductoscopy, with or without ductal
lavage, is unproven and not medically
necessary for use in breast cancer diagnosis
or screening or as an intraoperative tool to
guide surgery.

There is insufficient clinical evidence
demonstrating that fiberoptic ductoscopy allows
for better clinical decision-making, reduces breast
cancer mortality or serves as a useful adjunct to
or replacement of open surgical excision.

Discogenic Pain Sep. 1, 2014  Reorganized policy content The following thermal intradiscal procedures
Treatment  Added benefit considerations language for (TIPs) and percutaneous discectomy using
Essential Health Benefits for Individual and other methods are unproven and not
Small Group plans to indicate: medically necessary for the treatment of
o For plan years beginning on or after discogenic pain:
January 1, 2014, the Affordable Care Act of  Intradiscal electrothermal therapy (IDET)
2010 (ACA) requires fully insured non-  Intradiscal biacuplasty (IDB)
grandfathered individual and small group  Percutaneous intradiscal radiofrequency

plans (inside and outside of Exchanges) to thermocoagulation (PIRFT)

provide coverage for ten categories of  Nucleoplasty (percutaneous disc

Essential Health Benefits (“EHBs”) decompression)

o Large group plans (both self-funded and  Percutaneous lumbar discectomy (by other

fully insured), and small group ASO plans, method)
are not subject to the requirement to offer  Percutaneous laser disc decompression (PLDD)
coverage for EHBs; however, if such plans
 Percutaneous endoscopic diskectomy with or
choose to provide coverage for benefits
without laser (PELD)
which are deemed EHBs (such as

8 Medical Policy Update Bulletin: August 2014
Medical Policy Updates

UPDATED
Policy Title Effective Date Summary of Changes Coverage Rationale
Discogenic Pain Sep. 1, 2014 maternity benefits), the ACA requires all  Yeung Endoscopic Spinal Surgery (YESS)
Treatment dollar limits on those benefits to be  Percutaneous intradiscal annuloplasty
(continued) removed on all Grandfathered and Non-
Grandfathered plans The evidence is insufficient to demonstrate short
o The determination of which benefits or long-term health benefits. Studies are primarily
constitute EHBs is made on a state by uncontrolled and limited to small sample size.
state basis; as such, when using this Larger comparative studies are needed to
guideline, it is important to refer to the evaluate the safety and effectiveness of these
enrollee’s specific plan document to procedures.
determine benefit coverage
 Updated coverage rationale: Annulus fibrosis repair following spinal
o Added language to indicate the unproven surgery is unproven and not medically
services are “not medically necessary” necessary.
o Removed reference to specific product Further studies are needed to establish whether
names used for annulus fibrosis repair annulus fibrosis repair is beneficial for health
 Updated supporting information to reflect the outcomes in patients with low back pain following
most current clinical evidence, FDA and CMS spinal surgery.
information, and references

High Frequency Sep. 1, 2014  Reorganized policy content High-frequency chest wall compression
Chest Wall  Added benefit considerations language for (HFCWC), as a form of chest physical
Compression Essential Health Benefits for Individual and therapy, is proven and medically necessary
Devices Small Group plans to indicate: for treating or preventing pulmonary
o For plan years beginning on or after complications of the following conditions:
January 1, 2014, the Affordable Care Act of  Cystic fibrosis (CF)
2010 (ACA) requires fully insured non-
 Bronchiectasis
grandfathered individual and small group

plans (inside and outside of Exchanges) to
High-frequency chest wall compression
provide coverage for ten categories of
(HFCWC), as a form of chest physical
Essential Health Benefits (“EHBs”)
therapy, is unproven and not medically

o Large group plans (both self-funded and
necessary for diagnoses other than cystic

fully insured), and small group ASO plans,
fibrosis and bronchiectasis, including, but

9 Medical Policy Update Bulletin: August 2014
Medical Policy Updates

UPDATED
Policy Title Effective Date Summary of Changes Coverage Rationale
High Frequency Sep. 1, 2014 are not subject to the requirement to offer not limited to respiratory symptoms
Chest Wall coverage for EHBs; however, if such plans attributed to neuromuscular disorders when
Compression choose to provide coverage for benefits they compromise respiration, such as
Devices which are deemed EHBs (such as amyotrophic lateral sclerosis (ALS), cerebral
(continued) maternity benefits), the ACA requires all palsy, familial dysautonomia, muscular
dollar limits on those benefits to be dystrophy or quadriplegia.
removed on all Grandfathered and Non-
The clinical evidence is insufficient to support
Grandfathered plans
conclusions regarding the use of HFCWC therapy
o The determination of which benefits
in these patient populations. Additional research
constitute EHBs is made on a state by
involving larger study populations and longer
state basis; as such, when using this
treatment and follow-up periods is needed to
guideline, it is important to refer to the
establish the safety and efficacy of HFCWC for
enrollee’s specific plan document to
patients with impaired airway clearance disorders
determine benefit coverage
in these patient populations.
 Updated coverage rationale:
o Reformatted and relocated information
pertaining to medical necessity review;
added language to indicate if service is
“medically necessary” or “not medically
necessary” to applicable proven/unproven
statement
 Updated list of applicable ICD-9 diagnosis
codes; added 748.61
 Updated supporting information to reflect the
most current clinical evidence, FDA and CMS
information, and references

Magnetic Sep. 1, 2014  Reorganized policy content Magnetic resonance spectroscopy (MRS) is
Resonance  Added benefit considerations language for unproven and not medically necessary.
Spectroscopy Essential Health Benefits for Individual and There is a lack of evidence demonstrating that the
(MRS) Small Group plans to indicate: use of MRS improves health outcomes such as
o For plan years beginning on or after increasing diagnosis rates, reducing the number
January 1, 2014, the Affordable Care Act of

10 Medical Policy Update Bulletin: August 2014