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.
Clinical Practice Guidelines
The following Clinical Practice Guidelines were revised effective November 1, 2018:
- Identification, Evaluation, and Treatment of Overweight and Obesity in Adults
- Screening and Management of Substance Use Disorders in Adults
The following CPT codes were added to our pre-authorization lists effctive November 1, 2018.
Uniform Medical Plan
Hip Surgery for Femoroacetabular Impingement Syndrome (FAI)
Charged-Particle (Proton or Helium Ion) Radiotherapy (Medicine #49)
- 32701, 61796-61800, 63620, 63621, 77371-77373, 77432, 77435, G0339, G0340
Genetic Testing for Epilepsy (Genetic Testing #80)
- 81401, 81403-81407
Genetic and Molecular Diagnostics–Next Generation Sequencing and Genetic Panel Testing (Medicare Genetic Testing #64)
- 0009M (previously in Medicare Genetic Testing #20)
In Vivo Analysis of Colorectal Polyps (Medicare Medicine #104)
Please review our pre-authorization lists for all updates and pre-authorize services accordingly.
Pre-authorization for many services for UMP members are subject to Health Technology Clinical Committee (HTCC) decisions. The following Health Technology Assessments were updated by HTCC effective November 1, 2018:
Continuous Glucose Monitoring
- Pre-authorization was removed from HCPCS K0553 and A9276.
Hip Surgery for Femoracetabular Impingement Syndrome (FAI)
- Hip surgery for FAI is not a covered benefit.
- CPT 29914-29916 require pre-authorization. These codes were formerly not covered.
View all determination criteria on the HTCC website.
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 August 2018 issue of The Bulletin about the following medical policy:
- Spinal Fusion (Surgery #187), effective November 1, 2018
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.
Reimbursement policy updates
We review our reimbursement policies on an annual basis. Included below are updates to existing policies that will be added to our Reimbursement Policy Manual. To see how a claim will pay, access the Clear Claim Connection tool on the Availity Portal.
Effective November 1, 2018:
Associated Claims (#119)
- Adding contract exclusions as an example of a type of non-covered service
Medication policy updates
Listed below is a summary of medication policy 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 on our website. Read more about these changes in the August 1, 2018, issue of our newsletter.
New medication policies effective November 1, 2018:
- Compounded Medications, dru135
- Supprelin LA, histrelin acetate, dru541
- Lucemyra, lofexidine, dru557
- Braftovi, encorafenib, dru555
- Mektovi, binimetinib, dru556
- Rituxan Hycela, rituximab SC, dru559
Revised medication policies effective November 1, 2018:
- Actonel, risedronate, dru155
- Afinitor, Afinitor Disperz, everolimus dru178
- Keytruda, pembrolizumab, dru367
- Mekinist, trametinib, dru307
- Tafinlar, dabrafenib, dru308
- Opdivo, nivolumab, dru390
- Tagrisso, osimertinib, dru441
- Triptan products, dru475
- Rituxan, rituximab containing products, dru214
eviCore acupuncture guidelines to be revised
Effective November 2, 2018, eviCore healthcare (eviCore) will revise its acupuncture guidelines, including removing a section for non-musculoskeletal conditions.
The guidelines, which are part of our Physical Medicine program, are published on the eviCore website.
Pre-authorization for specialty medications to be required for CHG Healthcare Services members
Effective November 1, 2018, pre-authorization for certain specialty medications will be required for CHG Healthcare Services (group #70000004) members.
A complete list of codes is available on the Pharmacy and Commercial Pre-authorization List pages of our website. Submit pre-authorizations for these specialty medications to VIVIO Health Help Desk at 1 (800) 470-4034.