Each week, the AUA publishes weekly updates on the latest insurance issues pertaining to urology. This week’s update includes prior authorization (PA) updates from Aetna, an updated drug policy from AllWays Health Partners, and updated Benign Prostatic Hyperplasia (BPH) treatments policies from Amerigroup and Humana. There is a new drug policy from BCBS Florida, and a draft policy for Prostatic Urethral Lift from BCBS Illinois. Also, there are updates to prostate cancer genetic test policies from BlueAdvantage, a new Biofeedback policy from BCBS Idaho, and an updated drug policy from HealthNet. Furthermore, Highmark has combined and revised its Erleada, Nubeqa, and Xtandi medical policies, and Medical Mutual added CPT codes and updated documentation requirements within its Urinary Incontinence medical policy. Tufts Health Plan has recently added Decipher Prostate Biopsy (Decipher Biosciences) to its Non-Covered Investigational Services policy, UnitedHealthCare published updates to its Urinary and Fecal Incontinence Diagnosis and Treatment policy for Medicare beneficiaries, and UPMC has created a new policy for urology supplies. Please see below for further details on each policy update.
Aetna
Pituitary Suppressive Agents: Aetna has reviewed and updated its Pituitary Suppressive Agents medical policy with the addition of the following drugs to the list of drugs requiring prior authorization:
- Lupaneta Pack
- Lupron Oncology
- Orilissa
- Supprelin
- Synarel
- Triptodur
- Zoladex
The criteria questions for these drugs has also been updated to include the following:
- Is the beneficiary being treated for one of the following diagnoses?
- Advanced Prostate Cancer
- Central Precocious Puberty (CPP)
- Endometriosis
- Uterine Fibroids
- Gender Dysphoria
- Breast Cancer
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For requests for a non-preferred agent, does the beneficiary have a history of trial and failure, contraindication, or intolerance to the preferred agents in this class that are indicated or recommended for the treatment of the beneficiary’s diagnosis?
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For the treatment of gender dysphoria in adolescent beneficiaries, if the prescriber is not a pediatric endocrinologist, adolescent medicine specialist, or medical provider with experience and/or training in transgender medicine, is the required medication being prescribed in consultation with one of these specialists?
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For the treatment of gender dysphoria in adolescent beneficiaries, is the requested agent being prescribed in a manner consistent with the current World Professional Association for Transgender Health (WPATH) standards of care for the health of transsexual, transgender, and gender nonconforming people?
Read the complete update.
AllWays Health Partners
Zometa: AllWays Health Partners has reviewed and updated its Zometa pharmacy policy with the following changes to criteria and supporting information:
- Added continuation of therapy policy statement for hypercalcemia of malignancy stating that authorization of 2 months will be granted for continued treatment in members requesting reauthorization for hypercalcemia of malignancy who are experiencing benefit from therapy as evidenced by disease stability or disease improvement.
- Added continuation of therapy policy statement for all diagnoses (excluding hypercalcemia of malignancy) stating that authorization of 12 months will be granted for continued treatment in members requesting reauthorization for an indication listed in section II (excluding hypercalcemia of malignancy) who are experiencing benefit from therapy as evidenced by disease stability or disease improvement.
- Removed continuation of therapy policy statement stating all members (including new members) requesting authorization for continuation of therapy must meet all initial authorization criteria.
- Revised initial approval policy statement for breast cancer to specify postmenopausal (natural or induced) and prescribed to maintain or improve bone mineral density and reduce the risk of fractures in policy statement stating authorization of 12 months may be granted for postmenopausal (natural or induced) members who are receiving adjuvant therapy for the treatment of breast cancer and are prescribed zoledronic acid or Zometa to maintain or improve bone mineral density and reduce the risk of fractures.
- Lowered Zometa authorization duration for multiple myeloma, bone metastases from a solid tumor, prostate cancer, breast cancer, and systemic mastocytosis from 24 months to 12 months.
Read the complete update.
Amerigroup Real Solutions, Anthem, BCBS Georgia, BlueChoice HealthPlan of South Carolina, Empire BCBS, Healthlink, Simply Healthcare, Unicare
Surgically and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH): This medical policy has been reviewed and updated with the following changes to criteria, coding, and supporting information:
- Revised coverage decision for the following procedures from medically necessary to not medically necessary: transurethral radiofrequency needle ablation, also called transurethral needle ablation; and water-induced thermotherapy, also called thermo urethral hot-water therapy.
- Revised coverage decision for transurethral convective water vapor thermal ablation from investigational and not medically necessary to medically necessary in members with prostate volume less than 80 mL.
- Added waterjet tissue ablation as a medically necessary procedure.
- Added the following requirement for transurethral incision of the prostate: the member’s prostate volume is less than 30 mL.
- Removed procedures that are considered investigational and not medically necessary for all genitourinary conditions other than benign prostatic hyperplasia.
- Added the following medically necessary CPT code:
- 0421T Transurethral waterjet ablation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed)
- Added the following medically necessary HCPCS code (effective 01/01/2020):
- C2596 Probe, image-guided, robotic, waterjet ablation
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Revised the following CPT codes from medically necessary to not medically necessary:
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53852 Transurethral destruction of prostate tissue; by radiofrequency thermotherapy [when specified as RF needle ablation, RF TUNA, RFNA]
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53899 Unlisted procedure, urinary system [when specified as transurethral destruction of prostate tissue: by water-induced thermotherapy (WIT)]
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Revised the following CPT code from investigational and not medically necessary to medically necessary when criteria are met:
Read the complete update.
BCBS Florida
Nubeqa: Florida has published a new medical policy for the prostate cancer drug Nubeqa. Nubeqa tablets may be considered medically necessary when the following criteria are met:
Initiation of darolutamide (Nubeqa) meets the definition of medical necessity when ALL of the following criteria are met:
Approval duration: 12 months
Read the complete update.
BCBS Illinois, BCBS Montana, BCBS New Mexico, BCBS Oklahoma, BCBS Texas, HCSC, HealthSelect Texas Employees Group Benefits Program
Prostatic Urethral Lift (PUL): BCBS has released a draft policy for Prostatic Urethral Lift with the following proposed changes to criteria and supporting information:
- Revised medically necessary indication from “lower urinary tract symptoms due to benign prostatic hyperplasia” to “moderate-to-severe lower urinary tract obstruction due to benign prostatic hyperplasia.”
- Added the following medical necessity criteria: prostate anatomy demonstrates normal bladder neck without an obstructive or protruding median lobe; member has had appropriate testing to exclude diagnosis of prostate cancer; and member does not have a known allergy to nickel, titanium or stainless steel.
- Removed the following medical necessity criteria: age 45 years or older; International Prostate System Score (IPSS) ≥ 13; and surgical intervention is indicated.
- Revised medical necessity criterion regarding previous treatment; clarified that the member should have persistent or progressive lower urinary tract symptoms despite medical therapy (e.g., α1 -adrenergic antagonists maximally titrated, 5α-reductase inhibitors, or combination medication therapy maximally titrated) over a trial period of no less than 6 months, or is unable to tolerate medical therapy.
- Revised medical necessity criterion regarding prostate gland volume; removed language stating volume should be based on ultrasound imaging.
- Revised medical necessity criterion that requires no active urinary tract infection; removed the descriptor “active;” added requirement of no urinary retention or recent prostatitis (within past year).
- Changed policy title to Prostatic Urethral Lift.
Read the complete update. (Click the link and search for “Prostatic Urethral Lift” in the search bar.)
BlueAdvantage Administrators of Arkansas
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer: BlueAdvantage Administrators of Arkansas has reviewed and updated this medical policy with the addition of the following CPT codes:
- 81542 Oncology (prostate) mRNA microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as metastasis risk score
- 0047U Oncology (prostate), mRNA, gene expression profiling by real-time RT-PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a risk score
- 0113U Oncology (prostate), measurement of PCA3 and TMPRSS2-ERG in urine and PSA in serum following prostatic massage, by RNA amplification and fluorescence-based detection, algorithm reported as risk score
Read the complete update.
Genetic testing for Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management: This medical policy has been reviewed and updated with the addition of the following CPT codes:
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81542 Oncology (prostate) mRNA microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score
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0005U Oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score
Read the complete update.
Blue Cross Idaho
Biofeedback: Blue Cross Idaho has published a new medical policy for Biofeedback. Biofeedback may be considered medically necessary when this criteria is met.
- Stress, urgency, mixed, or overflow urinary incontinence when there is failure/intolerance/contraindication of other non-pharmacologic treatment (e.g., bladder training and/or pelvic floor muscle training [PFMT]) (children and adults).
Read the complete update.
HealthNet
Nubeqa: HealthNet has reviewed and updated its pharmacy policy for the prostate cancer drug Nubeqa with the following changes to criteria:
- Added footnote to initial approval criteria option for Nubeqa for prostate cancer requiring that the drug is prescribed concurrently with gonadotropin-releasing hormone (GnRH) analog therapy stating that prior authorization may now be required.
Read the complete update.
Highmark Inc.
Erleada, Nubeqa and Xtandi: Highmark Inc. has combined its pharmacy policies for Erleada, Nubeqa and Xtandi into a single document on androgen receptor inhibitors. Erleada, Nubeqa or Xtandi may be considered medically necessary when the following criteria are met:
Initial Authorization – Erleada
When a benefit, coverage of Erleada may be approved when all of the following criteria are met:
Initial Authorization – Nubeqa
When a benefit, coverage of Nubeqa may be approved when all of the following criteria are met:
Initial Authorization – Xtandi
Reauthorization
When a benefit, reauthorization of an androgen receptor inhibitor may be approved when the following criterion is met:
Read the complete update.
Humana
BPH Treatments: Humana has been reviewed and updated its BPH Treatments medical policy with the following changes to coding:
Added the following not covered HCPCS code:
- C2596 Probe, image-guided, robotic, waterjet ablation
Removed the following deleted HCPCS code:
- C9748 Transurethral destruction of prostate tissue; by radiofrequency water vapor (steam) thermal therapy
Read the complete update.
Medical Mutual
Urinary Incontinence: Medical Mutual has reviewed and updated its Urinary Incontinence medical policy with the addition of the following CPT codes:
· 97014 Application of a modality to 1 or more areas; electrical stimulation (unattended)
· 97032 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
The documentation requirements have also been updated to include the statement that after reviewing the relevant documentation, the Company reserves the right to apply this policy to the procedure performed regardless of how the procedure was coded by the provider.
Read the complete update.
Tufts Health Plan
Non-covered Investigational Services: Tufts Health Plan has updated its Non-covered Investigational Services medical policy with the following additions to investigational items:
- Endolumenal Functional Lumen Imaging Probe (EndoFLIP; Medtronic Inc.)
- Decipher Prostate Biopsy (Decipher Biosciences)
Read the complete update.
UnitedHealthcare
Urinary and Fecal Incontinence Diagnosis and Treatment: UnitedHealthcare has reviewed and updated its Urinary and Fecal Incontinence Diagnosis and Treatment medical policy with the following changes to coverage, language, and supporting information:
- Removed the following LCD ID:
- A56331 Posterior Tibial Nerve Stimulation Billing and Coding Guidelines
- Replaced criteria language to state that some states have LCDs/LCAs and that if a state does not then refer to the Novitas LCD for surgery (Posterior Tibial Nerve Stimulation for Urinary Control-L35011).
Read the complete update.
UPMC Health Plan
Urology Supplies: UPMC Health Plan has published a new Urology Supplies medical policy. Urology supplies may be considered medically necessary when the following criteria are met.
- Urinary catheters and external urinary collection devices are considered medically necessary prosthetics for patients who have permanent urinary incontinence or permanent urinary retention.
- If the catheter or the external urinary collection device meets the coverage criteria listed below, then the related supplies that are necessary for their effective use are also covered.
- Urological supplies that are used for purposes not related to the covered use of catheters or external urinary collection devices (i.e., drainage and/or collection of urine from the bladder) will be denied as non-covered.*(Refer to Variations for Medical Assistance).
- The patient must have a permanent impairment of urination.
- This does not require a determination that there is no possibility that the patient’s condition may improve sometime in the future.
- If the medical record, including the judgment of the attending physician, indicates the condition is of long and indefinite duration (ordinarily at least 3 months), the test of permanence is considered met.
- Catheters and related supplies will be denied as non-covered in situations in which it is expected that the condition will be temporary. *(Refer to Variations for Medical Assistance).
- The use of a urological supply for the treatment of chronic urinary tract infection or other bladder condition in the absence of permanent urinary incontinence or retention is non-covered.
- Since the patient’s urinary system is functioning, the criteria for coverage under the prosthetic benefit provision are not met.
Read the complete update.