Each week, the AUA publishes weekly updates on the latest insurance issues pertaining to urology. This week’s update includes important information from Aetna and its updated Benign Prostatic Hyperplasia (BPH) policy, as well as information from CMS regarding the new HCPCS code J9030 for BCG. We have also included information for reporting BCG during the drug shortage. A few more updates include carriers such as the University of Pittsburgh Medical Center (UPMC) Health Plan, Horizon BCBS New Jersey, BCBS Mississippi and Centene Corporation.
Anthem Blue Cross Blue Shield
Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions: Anthem BlueCross Blue Shield has updated its Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions medical policy. Effective June 13, UroLift is now covered by Anthem for prostates less than 80ml when there is an image-confirmed absence of an obstructing middle lobe.
Read the complete update.
Centers for Medicare & Medicaid Services
MLN Matters Number MM11296 Revised: Beginning on July 1, 2019, HCPCS code J9030 will be established and may be used in submitting claims under Medicare effective for claims with dates of service on or after July 1, 2019:
- J9030 -
- Short Descriptor- BCG live intravesical 1mg
- Long Descriptor- BCG live intravesical instillation, 1 mg
- TOS- 1, P
HCPCS code J9031 (BCG [intravesical] per instillation) is being discontinued effective July 1, 2019, and may not be used in submitting claims under Medicare effective for claims with dates of service on or after July 1, 2019. Please see AUA response below for more guidance on the use J9030 when billing for BCG.
Read the complete update.
Dr. Jonathan Rubenstein, AUA Coding and Reimbursement Committee Chair, outlined some considerations for reporting BCG during the drug shortage. Read more.
University of Pittsburgh Medical Center (UPMC) Health Plan
Sacral Nerve Stimulators: University of Pittsburgh Medical Center (UPMC) has revised its Sacral Nerve Stimulators medical policy with the following changes to criteria:
- Added limitations for sacral nerve stimulation (SNS) for urinary indications, stating that SNS may not be considered medically necessary for urinary urge incontinence due to a neurologic condition, and any type of chronic voiding dysfunction other than those specified.
- Added limitation stating that SNS may not be considered medically necessary for certain procedures for the treatment of incontinence that are considered experimental and investigational.
- Added limitation stating that implantation of a neurostimulation system is contraindicated for members who have not demonstrated an appropriate response to test stimulation and members who are unable to operate the neurostimulator.
- Added limitation stating that after implantation of any system component, shortwave diathermy, microwave diathermy, or therapeutic ultrasound diathermy may not be used on any member implanted with a neurostimulator system.
- Added limitation stating that SNS device must be FDA approved.
- Specified that the surgical therapies must be surgical corrective therapies, in criterion for urinary incontinence stating that other treatment modalities (e.g. documented behavioral interventions such as bladder or pelvic floor training, timed voiding, biofeedback, pharmacologic agents such as anticholinergics and beta-3 agonists, and/or surgical corrective therapies) must have been tried and failed for sacral nerve stimulation to be considered medically necessary, given that all other criteria have been met.
- Added the following experimental and investigational codes:
- L8605 - Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, anal canal, 1 ml, includes shipping and necessary supplies
- 0377T - Anoscopy with directed submucosal injection of bulking agent for fecal incontinence
- 53860 - Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence
Read the complete update.
Horizon BCBS New Jersey
Gonadotropin Releasing Hormone Analogs: Horizon Blue Cross Blue Shield New Jersey has revised with the following changes to criteria:
- Added marketed names for drugs.
- Added statement that only physicians who have enrolled in the Plenaxis PLUS Program (Plenaxis User Safety Program), based on their attestation of qualifications and acceptance of prescribing responsibilities, may prescribe Plenaxis. Qualifications and acceptance of prescribing responsibilities may prescribe Plenaxis.
- Added the following medically necessary off-label uses:
- Effective August 6, 2019, Horizon BCBSNJ will change the way we consider certain professional claims based on revisions to our medical policy, Gonadotropin-Releasing Hormone (GnRH) Receptor Antagonist [Degarelix (Firmagon™)].
- Claims submitted for services provided on and after August 6, 2019 to patients enrolled in Horizon BCBSNJ commercial, Administrative Services Only (ASO) or Medicare Advantage (MA) plans will be processed as follows:
For services provided to patients 18 years of age or older:
- Based on the submitted diagnosis code(s), information may be requested to help us determine the medical appropriateness of the services represented by HCPCS code J9155. Following our review of medical record information, the code above may be denied as an experimental/investigational, non-covered service.
For services provided to patients under 18 years of age:
- Regardless of the submitted diagnosis code(s), the administration of drugs represented by HCPCS code J9155 will be denied as an experimental/investigational, non-covered service.
Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been canceled or postponed, the changes will be applied to claims for dates of service on and after August 6, 2019.
Read the complete policy here by clicking on the G in the Alphabet and searching Gonadotropin Releasing Hormone Analogs to review this medical policy content.
Provenge: Horizon Blue Cross Blue Shield NJ has reviewed and updated its Provenge medical policy with the following changes to criteria:
- Sipuleucel-T (Provenge®) is medically necessary for the FDA-approved treatment of prostate cancer in members who meet all of the following criteria:
- Adult men(18 years or older);
- Androgen-independent (hormone refractory) prostate cancer has been confirmed by histology;
- Serum testosterone less than 50 ng/dL in men who have not undergone prior surgical castration;
- Radiological evidence of peripheral metastases (see Informational Note A);
- Evidence of progressive disease based on successive radiographic studies or prostate specific antigen (PSA) progression as defined by PSA Consensus Criteria (see Informational Note B);
- Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1 (see Informational Note C);
- Asymptomatic or minimally symptomatic (see Informational Note D); and
- Member has no hepatic metastases.
Read more here by clicking on the link, and searching for “Sipuleucel-T (Provenge®).”
BCBS Mississippi
Botulinum Toxin (Botox): Blue Cross Blue Shield Mississippi has revised its Botulinum Toxin medical policy with the following changes to criteria:
- Revised criteria for the following existing approved clinically supported diagnoses for Botox:
- Overactive Bladder;
- Urinary Incontinence (neurogenic bladder); and
- Cervical Dystonia (spasmodic torticollis).
- Changed “nurse practitioner” to “non-physician practitioner” throughout policy in Botox Administration and Policy Exceptions sections.
- Added statement to policy section that the use of samples by a member will not be considered current or stable therapy for purposes of Medical Policy review.
- Added statement to perform a formulary drug search on the patient's member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member's benefit plan.
- Revised statement to now state before consideration of coverage may be made, it should be established that the patient does not have any FDA labeled contraindications to the requested agent.
- Added the following covered HCPCS code (if determined to be medically necessary in members ages 2-18 years old only):
- J0586 - Injection, abobotulinumtoxinA (Dysport), 5 units (If determined to be medically necessary in patients age 2-18 years old only.)
- Added the following not medically necessary HCPCS code:
- J0588 - Injection, incobotulinumtoxinA (Xeomin), 1 unit
Read the complete policy.
Centene Corporation
Prolia & Xgeva: Centene Corporation Health Plan has revised its clinical policy for denosumab (Prolia, Xgeva) with the following changes:
- Added commercial and health insurance marketplace as lines of business.
- Revised the Reclast criterion to require the member to have a 12-month failure of Reclast or experienced clinically significant adverse or contraindicated effects were experienced.
- Removed pregnancy as a contraindication from osteoporosis as well as from induced bone loss from prostate cancer treatment.
- Removed any prior to therapy criterion from criteria for induced bone loss from prostate cancer treatment.
- Removed the need for a recent lab results that clears the member of hypocalcemia as a criterion for induced bone loss from prostate cancer treatment.
- Removed the need for a recent lab results to clear the member of hypocalcemia for bone metastases, giant cell tumor of bone, hypercalcemia of malignancy and multiple melanoma as well as prostate or breast cancer treatment.
- Added a commercial approval duration of 6 months or to the member's renewal date, whichever is longer to all indications.
Read the complete policy.