February 2020

February 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.

Pre-authorization list updates

Commercial Pre-authorization List
The following code was added effective February 1, 2020:

  • Genetic Testing; Familial Hypercholesterolemia (Genetic Testing #11)

    • CPT 81407

The following code was added effective February 9, 2020:

  • Radiology

    • CPT 76391

Uniform Medical Plan Pre-authorization List
The following code was added effective February 1, 2020:

  • Genetic Testing; Familial Hypercholesterolemia (Genetic Testing #11)

    • CPT 81407

The following code was added effective February 9, 2020:

  • Radiology

    • CPT 76391

Medicare Pre-authorization List
The following code was added effective February 9, 2020:

  • Radiology

    • CPT 76391

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

Dental reimbursement policy updates

We review our reimbursement policies on an annual basis. Included below are changes to our policies. View our Dental Reimbursement Policy Manual.

Revised policies effective February 1, 2020:

  • Bacteriologic Studies, Culture (Diagnostic #4)
  • Cone Beam Computed Tomography (CT) (Diagnostic #74)
  • Occlusal Adjustment (Adjunctive General Services #61)
  • Reimbursement for Dental Anesthesia Procedures (Adjunctive General Services #56)

Read the February 2020 issue of our newsletter for details.

Administrative Manual updates

The following updates have been or will be made to our manual sections.

  • Facility Guidelines - Effective February 1, 2020: Removed skilled nursing facility Quality Rating section; Effective May 1, 2020: Adding inpatient concurrent review for acute inpatient medical and behavioral health hospital stays (posted on February 1, 2020)
  • Medical Management - Effective February 1, 2020: Added information about Livongo Diabetes Prevention Program (DPP) and Livongo Weight Management
  • Medicare Advantage Compliance Requirements - Effective February 1, 2020: Updated wording in provision 14

View our manual.

Medication policy updates

Listed below is a summary of medication policy additions and changes.

New policy effective February 15, 2020:

  • Intravitreal Vascular Endothelial Growth Factor (VEGF) Inhibitors, dru621
    Revised policies effective February 15, 2020:
  • Botulinum toxin type A injection, dru006
  • Darzalex, daratumumab, dru452
  • Empliciti, elotuzumab, dru453
  • Intra-articular Hyaluronic Acid Derivatives, dru351
  • Kyprolis, carfilzomib, dru282
  • Non-Preferred Injectable Insulins, dru372
  • Opdivo, nivolumab, dru390
    Archived policies effective February 1, 2020:
  • Benlysta, belimumab, dru248
  • bevacizumab-containing medications, dru215
  • doxorubicin liposomal injection-containing products, dru239
  • hydroxyprogesterone caproate (Makena, generic), dru255
  • Jevtana, cabazitaxel, dru232
  • Krystexxa, pegloticase, dru230
  • Velcade, bortezomib, dru190

AIM revising clinical guidelines

AIM is revising the following clinical guidelines for our radiology and Sleep Medicine programs effective February 9, 2020:

Radiology: Abdomen and pelvic imaging

  • Pelvic pain
  • Splenomegaly
  • Prostate cancer
  • Abdominal pain
  • Pancreatic mass
  • Enteritis and colitis
  • Diffuse liver disease
  • Splenic mass, benign
  • Lower extremity edema
  • Gastrointestinal bleeding
  • Henoch-Schonlein purpura
  • Inflammatory bowel disease
  • Splenic mass, indeterminate
  • Foreign body (pediatric only)

Sleep Medicine

  • Polysomnography and Home Sleep Testing
  • Management of Obstructive Sleep Apnea (OSA) using automatic positive airway pressure (APAP) and continuous positive airway pressure (CPAP) devices

Revised guidelines are available on AIM’s website.