Insurance Updates: Week of June 17, 2019

By Policy and Advocacy Brief posted 06-17-2019 09:22

  

Each week, the AUA publishes weekly updates on the latest insurance issues pertaining to urology. This week’s update includes information from several insurance companies. United Healthcare (UHC) Community Plan has revised its Prolia/Xgeva pharmacy policy. Centene has revised its Xtandi policy, including that it must be prescribed by an oncologist or urologist. First Coast Service options has a new supplemental article for Sacral Neuromodulation. Blue Cross Blue Shield of South Carolina has revised its Percutaneous Tibial Nerve Stimulation medical policy. Quartz Unity Health Plan has revised its Prostatic Urethral Lift medical policy criteria. Blue Cross Blue Shield of Florida has revised its Abiraterone Acetate (Yonsa®/Zytiga®) medical policy, and Blue Cross Blue Shield North Carolina (BCBSNC) has a new medical policy for Erectile Dysfunction.  In addition, Blue Cross Blue Shield Tennessee has revised its Jevtana medical policy. 

UHC Community Plan

Prolia/ Xgeva Pharma Policy: United Healthcare Community Plan has revised its Prolia/Xgeva pharmacy policy with the following changes:  

  • Added that Xgeva may be considered medically necessary for the following indications (see the policy for the associated criteria):
    • Prevention of skeletal-related events in men with castration-resistant prostate cancer with bone metastases (refractory to intravenous bisphosphonate therapy)
      Osteopenia/osteoporosis for systemic mastocytosis with bone pain (not responding to bisphosphonates)

Read the complete update.

Centene Corporation

Xtandi: Centene Corporation has revised its Xtandi policy with the following changes:

  • Added that the health insurance marketplace is an applicable line of business.
  • Revised the diagnosis criterion from prostate cancer to a diagnosis of castration-resistant prostate cancer, and must be evidenced by disease progression despite bilateral orchiectomy or other androgen deprivation therapy.
  • Added a criterion that Xtandi must be prescribed by, or in consultation with, an oncologist or urologist.
  • Added member must use a gonadotropin-releasing hormone analog concurrently or has a bilateral orchiectomy for non-metastatic disease as a criterion.

Read the complete update.

First Coast Service Options

Sacral Neuromodulation: First Coast Service Options (FCSO) has a new Supplemental Article for Sacral Neuromodulation. The Indications and Limitations of Coverage for Sacral nerve stimulation is covered for the treatment of:

  • urinary urge incontinence,
  • urgency-frequency syndrome and,
  • urinary retention.

Medicare will consider the use of sacral nerve stimulation medically reasonable for the treatment of fecal incontinence in those patients who have failed or are not candidates for conservative treatments (i.e., biofeedback, dietary management, pharmacotherapy, strengthening therapy). The patient must also have a weak but structurally intact sphincter.

The following limitations for coverage apply for urinary indications:

  • Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur.
  • Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) that are associated with secondary manifestations of the above three indications are excluded.
  • Patient must have had a successful test stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement through test stimulation. Improvement is measured through voiding diaries.
  • Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.

Read the complete policy.

BCBS South Carolina

Percutaneous Tibial Nerve Stimulation: Blue Cross Blue Shield of South Carolina has revised the Percutaneous Tibial Nerve Stimulation medical policy with the following changes:

  • Revised status of percutaneous tibial nerve stimulation to be considered medically necessary for an initial 12 week course for members with non-neurogenic urinary dysfunction including overactive bladder when criteria are met;
  • and for monthly maintenance therapy for members following this 12 week initial course when stimulation resulted in improvement of urinary dysfunction;
  • and have met treatment goals.
  • Added the following criteria relevant to percutaneous tibial nerve stimulation:
    • Failed behavioral therapy following an appropriate duration of 8 to 12 weeks without meeting treatment goals;
    • Failed pharmacologic therapy following 4 to 8 weeks of treatment without meeting treatment goals.
  • Added statement to specify that percutaneous tibial nerve stimulation for all other indications is considered investigational.

Read the complete policy.

Quartz Unity Healthplan

Prostatic Urethral Lift (Urolift) Med Policy: Quartz Unity Health Plan has revised their Prostatic Urethral Lift medical policy criteria.  The prostatic urethral lift procedure will be considered medically necessary when the criteria are met. To facilitate the authorization process for the Prostatic Urethral Lift (Urolift®), referral requests must include ALL the following:

  1. Member must be under the care of an Urologist trained to perform the Urolift® procedure.
  2. Documentation of patient lower urinary tract symptoms related to benign prostatic hypertrophy (BPH).
  3. Documentation of failed medication management for lower urinary tract symptoms of BPH.
  4. Documentation of diagnostic testing for BPH.

Criteria for Medical Necessity: Prostatic Urethral Lift (Urolift®) is considered Medically Necessary when ALL the following criteria are met:

  1. Prostate volume of < 80 ml on ultrasound imaging; AND
  2. Absence of obstructive middle lobe; AND
  3. Failure of or intolerance to at least 6 months of conventional medical therapy for lower urinary tract symptoms of BPH including an adequate trial of at least 2 different medications or documentation of contraindications.

CPT Codes:

  • 52441- Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant.
  • 52442- Each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure).

Read the complete policy.

BCBS Florida

Abiraterone Acetate (Yonsa®/Zytiga®): Blue Cross Blue Shield of Florida has revised their Abiraterone Acetate (Yonsa®/Zytiga®) medical policy and has made the following changes to criteria:

  • Added that for the brand name Zytiga, either of the following must be true:
    • Member has a contraindication to both generic abiraterone and Yonsa, and the contraindication is not applicable to brand Zytiga (specific contraindication(s) and rationale for using brand Zytiga must be provided);
    • Member has tried and had intolerable adverse effects to both generic abiraterone and Yonsa, and the intolerance is not expected to occur with brand Zytiga - the specific intolerance(s) and rationale for using brand Zytiga must be provided.
  • Added that FDA-approved or NCCN supported diagnosis other than prostate cancer may be considered medically necessary if one of the following is met:
    • Member is diagnosed with a condition that is consistent with an indication listed in the product's FDA-approved prescribing information (or package insert); and,
    • Member meets any additional requirements listed in the "Indications and Usage" section of the FDA-approved prescribing information (or package insert);
    • Indication and usage is recognized in NCCN Drugs and Biologics Compendium as a Category 1 or 2A recommendation.
  • Clarified that abiraterone combination therapy with prednisone or methylprenisolone and androgen deprivation therapy (ADT) applies only for prostate cancer indications only.

Read the complete policy.

BCBS North Carolina

Erectile Dysfunction: Blue Cross Blue Shield North Carolina (BCBSNC) has a new medical policy for Erectile Dysfunction.  BCBSNC will provide coverage for testing for erectile dysfunction when it is determined to be medically necessary because the medical criteria and guidelines are met. Diagnostic testing for erectile dysfunction may be considered medically necessary when the following lab tests are performed:

  • Blood glucose (Fasting / HbA1c)
  • Complete blood count
  • Creatinine and Blood Urea Nitrogen
  • Hepatic panel
  • Lipid profile
  • Prostate specific antigen
  • Serum testosterone (Total/ Free or Bioavailable)
  • Thyroid function studies
  • Urinalysis Tests for evaluation of pituitary dysfunction (e.g., measurement of luteinizing hormone, follicle stimulating hormone, and prolactin levels) are considered medically necessary if serum testosterone level is below normal.

Read the complete update.

BCBS Tennessee

Jevtana: Blue Cross Blue Shield Tennessee has revised its Jevtana medical policy with the following changes to criteria:

  • Revised the following criteria relevant to the initial approval of Jevtana:
    • Member is diagnosed with hormone-refractory metastatic prostate cancer;
    • Administration is in combination with a corticosteroid (prednisone or dexamethasone)
  • Added criterion relevant to renewal of Jevtana to specify member must continue to meet initial approval criteria.
  • Removed criterion relevant to renewal of Jevtana that administration must be in combination with prednisone but no other chemotherapy agent.
  • Revised criterion relevant to renewal of Jevtana to specify that there must be an absence of unacceptable toxicity from the drug, including, but not limited to:
    • neutropenia,
    • anemia,
    • leukopenia,
    • thrombocytopenia,
    • severe hypersensitivity reactions,
    • severe diarrhea,
    • nausea,
    • vomiting,
    • severe hemorrhagic cystitis,
    • renal or hepatic toxicity,
    • interstitial lung disorders, etc.

Cabazitaxel may not be used with other chemotherapy agents.

Read the complete policy.
 

Medicare Tips for billing for Urological Supplies

For the 2018 reporting period, the Medicare Fee-For-Service improper payment rate for urological supplies was 26.1 percent, representing a projected improper payment amount of approximately $72.2 million. Insufficient documentation accounted for 62.7 percent of improper payments for urological supplies. Additional types of errors for urological supplies were no documentation (2.6 percent) and for other reasons (32.3 percent).

How to prevent claim denials:

For DME items, remember to meet the following requirements:

  1. Have a Prescription (orders)
  2. Include Medical Record Information (including continued need if applicable)
  3. Ensure Correct Coding
  4. Maintain a proof of delivery (Suppliers are required to maintain proof of delivery documentation files)
  5. Have a detailed written order received by the supplier before a claim is submitted.

For more information regarding the specific criteria for urological supplies, see the article here

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