May 2020

May 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.

Concurrent review

Concurrent review is a method of reviewing patient care and services during a hospital stay to evaluate the course of treatment. To better enhance care coordination, member transitions and payment transparency, we will implement concurrent review for acute inpatient medical and behavioral health hospital stays beginning May 1, 2020.

Read the February 2020 issue of our newsletter for details.

Medical reimbursement policy updates

We review our reimbursement policies on an annual basis. Included below are changes to our policies. View our [Reimbursement Policy Manual](href: '/provider/library/policies-guidelines/reimbursement-policy").

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

Revised policies effective May 1, 2020:

  • Non Reimbursable Services (Administrative #107)
  • Pneumatic Compression Device (Administrative #134)
  • Blood Processing (Medicine #110)
  • Maternity Care (Medicine #107)
  • Modifier 22; Increased Procedural Services (Modifiers #111)
  • New Patient Visit (Medicine #101)

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

Medical policy updates

We publish updates to medical policies, dental policies and Clinical Position Statements in our monthly publication The Bulletin.

We provided 90-day notice in the February and March 2020 issues of The Bulletin about the following
medical policies:

  • Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia (Transplant #45.36), effective May 1, 2020
  • Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and Extremities (Medicine #165), effective June 1, 2020
  • Oxygen Concentrators (Medicare Durable Medical Equipment #22), effective May 1, 2020

You can read issues of The Bulletin or subscribe to receive an email notification when issues are published on our website. The Medical Policy Manual includes a list of recent updates and archived policies.

Pre-authorization list updates

Commercial and Uniform Medical Plan Pre-authorization Lists
Added clarification effective May 1, 2020:

  • Surgical Treatments for Hyperhidrosis (Surgery #165)

    • CPT 32664 only requires pre-authorization for hyperhidrosis diagnoses L74.510 L74.511, L74.512, L74.513, L74.519, L74.52, R61

Medicare Pre-authorization List
The following codes will be added effective May 1, 2020:

  • Gender Affirming Interventions for Gender Dysphoria (Medicare Medicine #153)

    • CPT 58150

Oxygen concentrators to require authorization

In our February and April 2020 issues of The Connection, we notified you that oxygen concentrators used by Medicare Advantage members for more than 90 days will require pre-authorization. The effective date of this requirement has changed to August 1, 2020.

Failure to receive authorization for use beyond 90 days will result in an administrative denial.

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

Pre-authorization for specialty medications

Effective May 1, 2020, the following specialty medications will be added to the pre authorization lists for CHG Healthcare Services (group #70000004), IEC Group (group #70000000) and Alsco, Inc. (group #70000002) members: HCPCS J0222, J0642, J1303, J3111, J9019, J9119, J9181, J9210, J9269 and Q5117.

AIM clinical guidelines review

AIM Specialty Health (AIM) is revising the following vascular imaging clinical guidelines for our radiology program effective May 17, 2020:

  • Aneurysm of the abdominal aorta or iliac arteries
  • Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified

Revised guidelines are available on AIM’s website.

Medication policy updates

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

New medication policies effective May 1, 2020:

  • Enhertu, fam-trastuzumab deruxtecan, dru623
  • Givlaari, givosiran, dru630
  • Medications for Sickle Cell Disease, dru628
  • Padcev, enfortumab vedotin, dru622
  • Palforzia, Peanut (Arachis hypogaea) Allergen Powder-dnfp, dru634
  • Reblozyl, luspatercept, dru631
  • Scenesse, afamelanotide, dru625
  • Tepezza, teprotumumab, dru632
  • Non-Preferred Products with Available Biosimilars, dru620
  • Zilretta, triamcinolone acetonide extended-release (ER) injectable suspension, dru616

New medication policies effective May 15, 2020:

  • Enhertu, fam-trastuzumab deruxtecan, dru623
  • Givlaari, givosiran, dru630
  • Medications for Sickle Cell Disease, dru628
  • Padcev, enfortumab vedotin, dru622
  • Palforzia, Peanut (Arachis hypogaea) Allergen Powder-dnfp, dru634
  • Reblozyl, luspatercept, dru631
  • Scenesse, afamelanotide, dru625
  • Tepezza, teprotumumab, dru632

Revised medication policies effective May 1, 2020:

  • Besponsa, inotuzumab ozogamicin, dru529
  • Botulinum toxin type A injection, dru006
  • Dupixent, dupilumab, dru493
  • Keytruda, pembrolizumab, dru367
  • Non-Preferred DPP4-Inhibitor-Containing Medications, dru385
  • Perjeta, pertuzumab, dru281
  • Site of Care Review, dru408
  • Spinraza, nusinersen, dru485
  • Site of Care Review (SOC), dru408

Revised medication policies effective May 15, 2020:

  • Besponsa, inotuzumab ozogamicin, dru529
  • Botulinum toxin type A injection, dru006
  • Dupixent, dupilumab, dru493
  • Keytruda, pembrolizumab, dru367
  • Non-Preferred DPP4-Inhibitor-Containing Medications, dru385
  • Perjeta, pertuzumab, dru281
  • Site of Care Review, dru408
  • Spinraza, nusinersen, dru485

Administrative Manual update

On May 1, 2020, we will add inpatient concurrent review for acute inpatient medical and behavioral health hospital stays (posted on February 1, 2020) to the Facility Guidelines section of the manual.