April 2020

April 2020

In addition to the summary of monthly changes below, please also review our monthly Bulletin for recent and upcoming changes to our medical and dental policies, and associated changes to pre-authorization requirements. The Medical Policy Manual includes a list of recent updates and archived policies.

New behavioral health form for clinical focus information

Our new Behavioral Health Practitioner Areas of Clinical Focus Form replaces the Behavioral Health Information Form and is now used only for changes to your areas of clinical focus and modalities. The information you share helps our members make informed decisions about their health care and who they select for services.

If you have changes to your practice information (e.g., the provider networks you participate in, your phone number, your address or whether you offer telehealth services), please notify us immediately by completing the Provider Information Update Form.

Behavioral health resources for PCPs

Many people experiencing mental health concerns often first disclose these concerns to their primary care provider (PCP). Others may not disclose these concerns at all and would benefit from a routine screening by their PCP.
To support PCPs with these conversations, we are pleased to offer new resources to use when screening patients for depression and anxiety:

  • Anxiety: Screening & Treatment in the Primary Care Setting includes information about the Generalized Anxiety Disorder 7-item (GAD-7), a validated tool that can be used to diagnose several anxiety disorders and measure anxiety severity.
  • Depression: Screening & Treatment in the Primary Care Setting includes information about the Patient Health Questionnaire-9 (PHQ-9), a validated tool that can be used to diagnose major depression and measure treatment response.

The resources are available on our website. Not all plans will have the same benefits, so it is important for you to verify member eligibility and benefits using the Availity Portal at availity.com.

Administrative Manual updates

The Appeals for Providers section will be available on our provider website on March 1, 2020, with an April 1, 2020, effective date. For Idaho, Oregon and Utah, we are adding the Dispute Resolution exhibit. For Washington, we are updating the Dispute Resolution exhibit.

Medical and dental reimbursement policy updates

View our Reimbursement Policy Manual and our Dental Reimbursement Policy Manual.

To see how a medical claim will pay, access the Clear Claim Connection tool on the Availity Provider Portal.

Revised medical reimbursement policies effective April 1, 2020:

  • Virtual Care (Administrative #132)
  • Anesthesia Reimbursement (Anesthesia #102)
  • Modifier 50; Bilateral Procedure (Modifiers #108)
  • Modifier 50; Bilateral Procedure (Medicare Modifiers #108)

Revised diagnostic dental reimbursement policies effective April 1, 2020:

  • Biopsy of Oral Tissue (#47)
  • Blood Glucose Level Test, in-office using a glucose meter (#71)
  • Endodontic Therapy, Root Canal (#26)
  • Gross Pulpal Debridement (#22C)
  • HbA1C In-office Point of Service Testing (#69)
  • Oral Pathology Laboratory (#07)
  • Pulp Capping, Indirect (#22A)
  • Pulp Vitality Tests (#05)

New medical reimbursement policies effective April 10, 2020:

  • Temporary COVID-19 Antibody Testing (Administrative #137)
  • Temporary COVID-19 Antibody Testing (Medicare Administrative #137)

Read the April 2020 and June 2020 issues of our newsletter for details.

Pre-authorization list updates

Commercial

Added CPT codes effective April 1, 2020:

  • Laboratory and Genetic Testing for use of Thiopurines (Laboratory #70)
    • 0169U
  • Whole Exome and Whole Genome Sequencing (Genetic Testing #76)

    • 81415, 81416

Uniform Medical Plan

Added CPT codes effective April 1, 2020:

  • Laboratory and Genetic Testing for use of Thiopurines (Laboratory #70)
    • 0169U
  • HTCC Decision: Pharmacogenomic testing for selected conditions
    • 0169U
  • Whole Exome and Whole Genome Sequencing (Genetic Testing #76)

    • 81415, 81416

Medicare Pre-authorization List

The following CPT codes will be added effective April 1, 2020:

  • Deep Brain Stimulation (DBS) (Medicare Surgery #84)
    • 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886
  • Genetic and Molecular Diagnostics– Next Generation Sequencing and Genetic Panel Testing (Medicare Genetic Testing #64)
    • 0169U
  • Hypoglossal Nerve Stimulation (Medicare Surgery #215)
    • 0466T
  • Leadless Pacemakers (Medicare Surgery #217)
    • 33274
  • Occipital Nerve Stimulation (Medicare Surgery #174)
    • 0466T, 61885, 61886
  • Responsive Neurostimulation (Medicare Surgery #216)
    • 61850, 61860, 61863, 61864, 61885, 61886
  • Sacroiliac Joint Fusion (Medicare Surgery #193)
    • 27279, 27280
  • Vagus Nerve Stimulation (Medicare Surgery #74)

    • 0466T, 61885, 61886

Please review our pre-authorization lists for all updates and pre-authorize services accordingly.

Medication policy updates

Listed below is a summary of medication policy additions and changes. Links to all medication policies, medication lists and pre-authorization information for our members, including real-time deletions from our pre-authorization lists, are available onlinen our website: Programs>Pharmacy.

New policies effective April 1, 2020:

  • Inrebic, fedratinib, dru617
  • Rozlytrek, entrectinib, dru610
  • Wakix, pitolisant, dru618

Revised policies effective April 1, 2020:

  • Extended-release (ER) Opioid Medication Products for Pain, dru515
  • Farydak, panobinostat, dru397
  • High Cost Medications for Chronic Constipation, dru519
  • Immediate-release (IR) Opioid Medication Products for Pain, dru516
  • Keytruda, pembrolizumab, dru367
  • Lenvima, lenvatinib, dru398
  • Lynparza, olaparib, dru389
  • Medications for Hereditary Angioedema (HAE), dru535
  • Ninlaro, ixazomib, dru455
  • Non-preferred multiple sclerosis treatments, dru511
  • Non-preferred testosterone replacement therapy products, dru548
  • Ocrevus, ocrelizumab, dru479
  • Pomalyst, pomalidomide, dru293
  • Revlimid, lenalidomide, dru127
  • Rubraca, rucaparib, dru494
  • Sunosi, solriamfetol, dru596
  • Tysabri, natalizumab, dru111
  • Xyrem, sodium oxybate, dru093
  • Zejula, niraparib, dru503
    Archived policies effective April 1, 2020:
  • abiraterone-containing medications, dru252
  • Erleada, apalutamide, dru546
  • Extended-release (ER) Opioid Medication Products for Pain, dru515
  • Immediate-release (IR) Opioid Medication Products for Pain, dru516
  • Non-preferred testosterone replacement therapy products, dru548
  • Nubeqa, darolutamide, dru614
  • Xtandi, enzalutamide, dru280