Insurance Updates: September 1

By Policy and Advocacy Brief posted 09-01-2021 14:51

  

Insurance Updates:  September 1, 2021

Each week, the AUA publishes weekly updates on the latest insurance issues pertaining to urology. This week’s update includes the release of policies regarding erectile dysfunction and extracorporeal shock wave therapy for peyronie’s disease.

Aetna

Aetna reviewed its Erectile Dysfunction (Commercial) Policy adding investigational statements for:

  • Genetic polymorphism testing for the evaluation of response to phosphodiesterase 5 (PDE5) inhibitors in members with erectile dysfunction;
  • Xiaflex for all other indications except for Dupuytren’s contracture (refer to related policy CPB 0800 on Dupuytren’s contracture treatments)

Read the update.

BCBS Health Advantage

BCBS Health Advantage reviewed its Extracorporeal Shock Wave Therapy for Peyronie’s Disease Policy removing a statement regarding prior authorization requirement for members of plans that utilize a radiation oncology benefits management program.

Read the update.

BCBS Health Advantage reviewed its Minimally Invasive Benign Prostatic Hyperplasia (BPH) Treatments Policy with the following changes:

  • Added the following criterion for prostatic urethral lift:
    • Member does not have a known allergy to nickel, titanium, or stainless steel
  • Revised the following criterion for prostatic urethral lift:
    • Removed requirement for prostate-specific antigen level as an alternative to testing to exclude diagnosis of prostate cancer
  • Added investigational policy statement for the use of transurethral waterjet ablation (e.g., Aquablation) as a treatment of benign prostatic hyperplasia.
  • Added the following CPT and HCPCS codes:
    • 0421T
    • 55899
    • C9739
    • C9740

Read the update.

Highmark BCBS of Western New York

Highmark BCBS of Western New York released its Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hyperplasia (Commercial, Medicaid Advantage) Policy with the following changes:

  • Added medically necessary statement applicable to Medicare Advantage for use of an FDA approved fluid jet system, for the treatment of lower urinary tract symptoms attributable to benign prostatic hyperplasia (LUTS/BPH) once when criteria are met.
  • Added investigational statement applicable to Commercial plans for transurethral waterjet ablation (Aquablation) as a treatment of benign prostatic hyperplasia.

For explanation of experimental and investigational, please refer to the Technology Assessment and Medically Necessary Services Protocol.
Read the update.

WPS Government Health Administrators

WPS Government Health Administrators reviewed its Molecular Diagnostic Tests (MDT) (MolDX) (J05, J08) (A57772) Local Coverage Article (LCA) adding the following codes to CPT/HCPCS code group 1:

  • 0016M – Oncology (bladder), mRNA, microarray gene expression profiling of 209 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like)
  • 0250U – Oncology (solid organ neoplasm), targeted genomic sequence DNA analysis of 505 genes, interrogation for somatic alterations (SNVs [single nucleotide variant], small insertions and deletions, one amplification, and four translocations), microsatellite instability and tumor-mutation burden

Read the update.

 

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