january 2017 policy update bulletin - oxhp7 oxford® policy update bulletin: january 2017 take note...

UnitedHealthcare respects the expertise of the physicians, health care professionals, and their staff who participate in our network. Our goal is to

support you and your patients in making the most informed decisions regarding the choice of quality and cost-effective care, and to support practice

staff with a simple and predictable administrative experience. The Policy Update Bulletin was developed to share important information regarding

Oxford® Medical and Administrative Policy.*

*Where information in this bulletin conflicts with applicable state and/or federal law, UnitedHealthcare follows such applicable federal and/or state law

January 2017

policy update bulletin Medical & Administrative Policy Updates

2 Oxford® Policy Update Bulletin: January 2017

Oxford® Medical and Administrative Policy Updates

Overview

Oxford

Tips for using the Policy Update Bulletin:

From the table of contents, click the policy title to be

directed to the corresponding policy update summary.

From the policy updates table, click the policy title to view a

complete copy of a new, updated, or revised policy.

Policy Update Classifications

New

New clinical coverage criteria and/or documentation review

requirements have been adopted for a service, procedure, test, or

device

Updated

An existing policy has been reviewed and changes have not been made

to the clinical coverage criteria or documentation review requirements;

however, items such as the clinical evidence, FDA information, and/or

list(s) of applicable codes may have been updated

Revised

An existing policy has been reviewed and revisions have been made to

the clinical coverage criteria and/or documentation review requirements

Replaced

An existing policy has been replaced with a new or different policy

Retired

The procedural codes and/or services previously outlined in the policy

are no longer being managed or are considered to be proven/medically

necessary and are therefore not excluded as unproven/not medically

necessary services, unless coverage guidelines or criteria are otherwise

documented in another policy

Note: The absence of a policy does not automatically indicate or imply

coverage. As always, coverage for a service or procedure must be

determined in accordance with the member’s benefit plan and any

applicable federal or state regulatory requirements. Additionally,

UnitedHealthcare reserves the right to review the clinical evidence

supporting the safety and effectiveness of a medical technology prior to

rendering a coverage determination.

This bulletin provides complete details on Oxford® Medical and

Administrative Policy updates. The appearance of a service or

procedure in this bulletin indicates only that UnitedHealthcare has

recently adopted a new policy and/or updated, revised, replaced or

retired an existing policy; it does not imply that Oxford® provides

coverage for the service or procedure. In the event of an

inconsistency or conflict between the information provided in this

bulletin and the posted policy, the provisions of the posted policy

will prevail. Note that most benefit plan documents exclude from

benefit coverage health services identified as investigational or

unproven/not medically necessary. Physicians and other health

care professionals may not seek or collect payment from a member

for services not covered by the applicable benefit plan unless first

obtaining the member’s written consent, acknowledging that the

service is not covered by the benefit plan and that they will be

billed directly for the service.

A complete library of Oxford® Medical and

Administrative Policies is available at

OxfordHealth.com > Providers > Tools & Resources >

Medical Information > Medical and Administrative Policies.

https://www.oxhp.com/secure/policy/medical_administrative_policy_index.html

https://www.oxhp.com/secure/policy/medical_administrative_policy_index.html



In This Issue

Oxford

Take Note Page

Annual CPT® and HCPCS Code Updates ............................................................................................................................................................... 7

Clinical Policy Updates

NEW

Exondys 51™ (Eteplirsen) - Effective Feb. 1, 2017 .............................................................................................................................................. 19 Office Based Program - Effective Apr. 1, 2017 .................................................................................................................................................... 19

UPDATED

Cardiovascular Disease Risk Tests - Effective Jan. 1, 2017 ................................................................................................................................... 20 Chromosome Microarray Testing - Effective Feb. 1, 2017 ..................................................................................................................................... 22 Clinical Trials - Effective Jan. 1, 2017 ................................................................................................................................................................ 23 Dental and Oral Surgical Procedures - Effective Jan. 1, 2017 ................................................................................................................................ 27 Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation - Effective Jan. 1, 2017 ............................................................................ 30 Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography - Effective Jan. 1, 2017 ................................................................. 32 Experimental/Investigational Treatment - Effective Feb. 1, 2017 .......................................................................................................................... 33 Experimental/Investigational Treatment for NJ Plans - Effective Feb. 1, 2017 ......................................................................................................... 35 Femoroacetabular Impingement Syndrome Treatment - Effective Jan. 1, 2017 ....................................................................................................... 39 Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors - Effective Jan. 1, 2017 ........................................................................ 40 Implanted Electrical Stimulator for Spinal Cord - Effective Jan. 1, 2017 ................................................................................................................. 40 Maximum Dosage Policy - Effective Jan. 1, 2017 ................................................................................................................................................ 41 Mechanical Circulatory Support Device (MCSD) - Effective Jan. 1, 2017 ................................................................................................................. 41 Off-Label/Unproven Specialty Drug Treatment - Effective Feb. 1, 2017 ................................................................................................................. 42 Outpatient Physical & Occupational Therapy for Self-Funded Groups - Effective Jan. 1, 2017 ................................................................................... 43 Physical, Occupational (OptumHealth Care Solutions Arrangement) and Speech Therapy Including Cognitive/ Neuropsychological Rehabilitation for New

Jersey Small Group and New Jersey Individual Members - Effective Jan. 1, 2017 .................................................................................................... 47 Radiopharmaceuticals and Contrast Media - Effective Jan. 1, 2017 ........................................................................................................................ 48 Surgical Treatment for Spine Pain - Effective Jan. 1, 2017 ................................................................................................................................... 49 Temporomandibular Joint Disorders - Effective Jan. 1, 2017 ................................................................................................................................ 51

REVISED

Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair - Effective Feb. 1, 2017 ..................................................................................................... 52 Drug Coverage Criteria - New and Therapeutic Equivalent Medications - Effective Feb. 1, 2017 ................................................................................ 53 Drug Coverage Guidelines - Effective Jan. 1, 2017 .............................................................................................................................................. 53

o Restasis (Cyclosporine Ophthalmic Emulsion) ............................................................................................................................................... 53



In This Issue

Oxford

o Xiidra (Lifitegrast) ..................................................................................................................................................................................... 53 Drug Coverage Guidelines - Effective Feb. 1, 2017.............................................................................................................................................. 53

o Aptiom (Eslicarbazepine Acetate) ................................................................................................................................................................ 53 o Banzel (Rufinamide) .................................................................................................................................................................................. 53 o Bunavail Film (Buprenorphine and Naloxone) ............................................................................................................................................... 53 o Buprenorphine HCl .................................................................................................................................................................................... 53 o Buprenorphine/ Naloxone (Generic Suboxone) .............................................................................................................................................. 54 o Bupropion (Generic Zyban) ........................................................................................................................................................................ 54 o Chantix (Varenicline Tartrate) ..................................................................................................................................................................... 54 o Colchicine Tablet (Manufacturer: Prasco) ..................................................................................................................................................... 54 o Cuvitru [Immune Globulin Subcutaneous (Human)] ...................................................................................................................................... 54 o Daliresp (Roflumilast) ................................................................................................................................................................................ 54 o Daraprim (Pyrimethamine) ......................................................................................................................................................................... 54 o Embeda (Morphine Sulphate and Naltrexone HCl) ......................................................................................................................................... 54 o Exalgo (Hydromorphone) ........................................................................................................................................................................... 54 o Exondys 51 (Eteplirsen) ............................................................................................................................................................................. 54 o Farxiga (Depagliflozin) ............................................................................................................................................................................... 55 o Fycompa (Perampanel) .............................................................................................................................................................................. 55 o Glyxambi (Empagliflozin/ Linagliptin) ........................................................................................................................................................... 55 o Hydrocortisone 1% Ointment in Absorbase ................................................................................................................................................... 55 o Hysingla ER (Hydrocodone Bitartrate) .......................................................................................................................................................... 55 o Impavido (Miltefosine) ............................................................................................................................................................................... 55 o Inflectra (Infliximab) ................................................................................................................................................................................. 55 o Insulins (Novolin 70/30, Novolog Pens and Vials, Novolog Mix 70/30 Pens and Vials, Apidra, Apidra Solostar, Novolin N, Novolin R) ....................... 56 o Invokana (Canagliflozin) ............................................................................................................................................................................ 56 o Intron-A (Interferon Alfa-2b) ...................................................................................................................................................................... 56 o Janumet (Sitagliptin and Metformin Hydrochloride) ....................................................................................................................................... 56 o Janumet XR (Sitagliptin and Metformin Hydrochloride, Extended Release) ........................................................................................................ 56 o Januvia (Sitagliptin) .................................................................................................................................................................................. 57 o Jardiance (Empagliflozin) ........................................................................................................................................................................... 57 o Kadian (Morphine Sulfate Extended Release) ................................................................................................................................................ 57 o Kalydeco (Ivacaftor) .................................................................................................................................................................................. 57 o Lyrica (Pregabalin) .................................................................................................................................................................................... 57 o MS Contin ................................................................................................................................................................................................ 57 o Nicotine OTC Products: .............................................................................................................................................................................. 58 o Nicotine Gum (e.g. Nicorette, Thrive), Nicotine Lozenge (e.g. Commit, Nicorette), Nicotine Patch (e.g. Nicoderm CQ), Nicotrol Inhaler (Nicotine

Inhalation System), Nicotrol NS (Nicotine Nasal Spray) ................................................................................................................................. 58 o Nicotrol Inhaler (Nicotine) .......................................................................................................................................................................... 58 o Nicotrol NS (Nicotine) ................................................................................................................................................................................ 58 o Nucynta ER (Tapentadol Extended Release) ................................................................................................................................................. 58



In This Issue

Oxford

o Onfi (Clobazam) ....................................................................................................................................................................................... 58 o Opana ER (Oxymorphone Extended Release) ................................................................................................................................................ 58 o Orkambi™ (Lumacaftor/ Ivacaftor) .............................................................................................................................................................. 58 o Oxycontin (Oxycodone Extended Release) .................................................................................................................................................... 58 o Oxycodone ER 12hr Tablet ......................................................................................................................................................................... 58 o Oxymorphone Extended Release ................................................................................................................................................................. 58 o Pegasys (Peginterferon Alfa-2a) .................................................................................................................................................................. 58 o Peg-Intron (Peginterferon Alfa-2b) .............................................................................................................................................................. 59 o Potiga (Ezogabine) .................................................................................................................................................................................... 59 o Pulmicort Flexhaler (Budesonide) ................................................................................................................................................................ 59 o Qbrelis (Lisinopril) ..................................................................................................................................................................................... 59 o Rayaldee (Calcifediol) ................................................................................................................................................................................ 59 o Rexulti (Brexpiprazole) .............................................................................................................................................................................. 59 o Sylatron (Peginterferon Alfa-2b) ................................................................................................................................................................. 59 o Stelara (Ustekinumab): Subcutaneous Injection ........................................................................................................................................... 59 o Stelara (Ustekinumab): Intravenous Infusion ............................................................................................................................................... 59 o Suboxone (Buprenorphine) ........................................................................................................................................................................ 60 o Test Strips and Meters (Diabetic) ................................................................................................................................................................ 60 o Trulicity (Dulaglutide) ................................................................................................................................................................................ 60 o Vemlidy (Tenofovir Alafenamide) ................................................................................................................................................................ 60 o Vimpat (Lacosamide): Tablet ...................................................................................................................................................................... 60 o Xifaxan (Rifaximin) ................................................................................................................................................................................... 60 o Xigduo XR (Dapagliflozin and Metformin HCl) ............................................................................................................................................... 60 o Xiidra (Lifitegrast) ..................................................................................................................................................................................... 60 o Xtampza ER (Oxycodone) .......................................................................................................................................................................... 61 o Zohydro ER (Hydrocodone Bitartrate Extended Release) ................................................................................................................................ 61 o Zyban (Bupropion) .................................................................................................................................................................................... 61

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation - Effective Feb. 1, 2017............................................................................ 61 Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable - Effective Feb. 1, 2017 ........................................................... 63 Maximum Dosage Policy - Effective Feb. 1, 2017 ................................................................................................................................................ 67 Omnibus Codes - Effective Jan. 1, 2017 ............................................................................................................................................................ 71 Oxford's Outpatient Imaging Self-Referral Policy - Effective Jan. 1, 2017 ............................................................................................................... 72 Preventive Care Services - Effective Jan. 1, 2017 ............................................................................................................................................... 74 Probuphine® (Buprenorphine) - Effective Feb. 1, 2017 ........................................................................................................................................ 80 Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs - Effective Feb. 1, 2017 .......................................................................... 82 Repository Corticotropin Injection (H.P. Acthar Gel®) - Effective Feb. 1, 2017 ........................................................................................................ 89 Specialty Medication Administration - Site of Care Review Guidelines - Effective Feb. 1, 2017 .................................................................................. 90 Stelara® (Ustekinumab) - Effective Feb. 1, 2017 ................................................................................................................................................ 91



In This Issue

Oxford

Administrative Policy Updates

UPDATED

Acquired Rare Disease Drug Therapy Exception Process - Effective Jan. 1, 2017 ..................................................................................................... 94 Transportation Services - Effective Jan. 1, 2017 ................................................................................................................................................. 96

Reimbursement Policy Updates

UPDATED

Physician Extenders - Effective Jan. 1, 2017 ...................................................................................................................................................... 99 Reimbursement for Comprehensive and Component CPT Codes - Effective Jan. 1, 2017 ......................................................................................... 102 Site of Service Differential - Effective Jan. 1, 2017 ............................................................................................................................................. 103

REVISED

Maximum Frequency Per Day - Effective Feb. 1, 2017 ........................................................................................................................................ 105 Obstetrical Policy - Effective Feb. 1, 2017 ......................................................................................................................................................... 112 Replacement Codes - Effective Feb. 1, 2017 ..................................................................................................................................................... 113

RETIRED

Moderate Sedation - Effective Jan. 1, 2017 ....................................................................................................................................................... 114


Take Note

Oxford

ANNUAL CPT® AND HCPCS CODE UPDATES

The following Clinical, Administrative and Reimbursement Policies have been modified to reflect the 2017 Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) code additions, revisions, and deletions. Refer to the sources below for information on the 2017 code updates:

American Medical Association. Current Procedural Terminology: CPT® 2017

Centers for Medicare & Medicaid Services. Healthcare Common Procedure Coding System: HCPCS Level II

Policy Title Policy Type Effective Date Summary of Changes

Ablative Treatment for Spinal Pain

Clinical Jan. 1, 2017 Revised description for 77003

Abnormal Uterine

Bleeding and Uterine Fibroids

Clinical Jan. 1, 2017 Added 58674

Removed 0336T Revised description for J7297, J7298 and J7301

Ambulance Reimbursement Jan. 9, 2017 Ambulance Bundled Code List Added A4224, A4225, A4467, A4553, A9285, A9286, A9515, A9587, A9588, A9597, A9598,

J0570, J0883, J0884, J1130, J1942, J2182, J2786, J2840, J7175, J7179, J7202, J7207, J7209, J7320, J7322, J7342, J8670, J9034, J9145, J9176, J9205, J9295, J9325, J9352,

Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4172, Q4173, Q4174 and Q4175 Removed A4466, A7011, A9544, A9545, E0450, E0460, E0461, E0463, E0464, J0760,

J0886, J1446, J1590, J7302, J7506, J9010, Q4119, Q4120, Q4129, Q9975, Q9976, Q9977, Q9978, Q9979, Q9980 and S5011

Assistant Surgeon Reimbursement Jan. 9, 2017 Assistant Surgeon Eligible List Added 22853, 22854, 22859, 22868, 22870, 28291, 28295, 33390, 33391, 43284, 43285,

58674, 61323, 62380, 93590 and 93592 Removed 21495, 22851, 28293, 28294, 31580, 31584, 31587, 31588, 33400, 33401,

33403, 35450, 35452, 35458, 36147, 47136 and 67112

Assisted Administration of

Clotting Factors and Coagulant Blood Products

Clinical Jan. 1, 2017 Added J7175, J7179, J7202, J7207, and J7209 Removed G0163 and G0164

Revised description for J7201

B Bundle Codes Reimbursement Jan. 9, 2017 B Bundle Code List Added G0501 Removed 99487 and 99489

Behavioral Health Services

Administrative Jan. 1, 2017 Revised description for 90832, 90833, 90834, 90836, 90837, 90838, 90846 and 90847

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page?

http://www.cms.gov/MedHCPCSGenInfo/


Take Note

Oxford



Bilateral Procedures Reimbursement Jan. 9, 2017 Bilateral Eligible Policy List Added 28291, 28295, 31572, 31573, 31574, 36474, 37246, 37247, 37248, 37249 and

62380

Removed 76519 and 92136 Codes with "Bilateral" in the Description Policy List Removed 77056, 77057 and 93965

Revised description for G0204

Bone or Soft Tissue Healing and Fusion

Enhancement Products

Clinical Jan. 1, 2017 Revised description for Q4131

Breast Imaging for Screening and Diagnosing Cancer

Clinical Jan. 1, 2017 Added 77065, 77066, and 77067 Removed 77051, 77052, 77055, 77056, and 77057 Revised description for G0202, G0204, and G0206

Clotting Factors and Coagulant Blood

Products

Clinical Jan. 1, 2017 Added J7175, J7179, J7202, J7207, and J7209 Revised description for J7201

Continuous Glucose Monitoring and

Insulin Delivery for Managing Diabetes

Clinical Jan. 1, 2017 Added 0446T, 0447T and 0448T

Contraceptives Clinical Jan. 1, 2017 Revised description for J7297 and J7298

Co-Surgeon/Team

Surgeon

Reimbursement Jan. 1, 2017 Co-Surgeon Eligible List

Added 22853, 22854, 22859, 22868, 22870, 27198, 28291, 28295, 31551, 31552, 31553, 31554, 31591, 31592, 33340, 33390, 33391, 36904, 36905, 36906, 43284, 43285, 58674, 62380, 93590, 93591 and 93592

Removed 37250, 37251, 47136, 47630, 67112, 77776, 77777 and G6021 Team Surgeon Eligible List Added 33340, 65855 and 93591 Removed 47136 and G6021

Dental and Oral Surgical Procedures

Clinical Jan. 1, 2017 Removed 21495

Dialysis Services Administrative Jan. 1, 2017 Added G0491 and G0492


Take Note

Oxford



Discogenic Pain Treatment

Clinical Jan. 1, 2017 Added 62380 Revised description for 62287

Drug Coverage Guidelines

Clinical Jan. 1, 2017 Abilify (Aripiprazole): IM Injection Added J1942 Acova (Argatroban)

Added J0883 and J0884 Removed C9121 Bexxar (tositumomab) Added J3490

Removed A9544, A9545 and G3001 Cinqair (Reslizumab) Added J2786 Hemophilia Drugs Added J7175, J7179, J7202, J7207 and J7209

Durable Medical Equipment Orthotics

and Prosthetics Multiple Frequency

Reimbursement Jan. 9, 2017 Codes with Flexion, Extension, Pronation or Supination in Description Removed K0901 and K0902

Codes with Each in Description Added E0956, K0045 and L3170 Items Eligible for Rental or Purchase Removed E0628

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation

Clinical Jan. 1, 2017 Removed 0282T, 0283T, 0284T and 0285T

Epidural Steroid and

Facet Injections for Spinal Pain

Clinical Jan. 1, 2017 Added 62322 and 62323

Removed 62311

Extracorporeal Shock Wave Therapy (ESWT)

Clinical Jan. 1, 2017 Removed 0019T

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood

Clinical Jan. 1, 2017 Added 81422


Take Note

Oxford



From - To Date Policy

Reimbursement

Jan. 1, 2017

From - To Policy Exceptions List Added A4224, A9515, A9587, A9588, A9597, A9598, G0502, G0503, G0504, G0506,

G0507, G9678, J0570, J0883, J0884, J1130, J1942, J2182, J2786, J2840, J7175, J7179,

J7202, J7207, J7209, J7320, J7322, J7342, J8670, J9034, J9145, J9176, J9205, J9295, J9325, J9352, L1851, L1852 and T1041

Removed 67101, 67105, A9544, A9545, B9000, E0450, E0460, E0461, E0463, E0464,

E0628, G6021, J0760, J0886, J1446, J1590, J7302, J7506, J9010, K0901, K0902, Q9975, Q9976, Q9977, Q9978, Q9979, Q9980, Q9981 and S5011

Glaucoma Surgical

Treatments

Clinical Jan. 1, 2017 Added 0449T and 0450T

Global Days

Reimbursement

Feb. 1, 2017

Global Days Assignment List Added 0446T, 0447T, 0448T, 0449T, 0450T, 0451T, 0452T, 0453T, 0454T, 0455T, 0456T,

0457T, 0458T, 0459T, 0460T, 0461T, 0462T, 0463T, 0464T, 0465T, 0466T, 0467T, 0468T, 22867, 22869, 27197, 27198, 28291, 28295, 31551, 31552, 31553, 31554, 31572, 31573,

31574, 31591, 31592, 33340, 33390, 33391, 36473, 36901, 36902, 36903, 36904, 36905, 36906, 37246, 37248, 43284, 43285, 58674, 62320, 62321, 62322, 62323, 62324, 62325,

62326, 62327, 62380, 67101, 67105, 93590 and 93591 Removed 0240T, 0241T, 0243T, 0244T, 0262T, 11752, 21495, 21805, 22305, 27193,

27194, 28290, 28293, 28294, 31582, 31588, 33400, 33401, 33403, 35450, 35452, 35458, 35460, 35471, 35472, 35475, 35476, 36870, 37202, 39400, 47136, 47500, 47505, 47510, 47511, 47525, 47530, 47560, 47561, 47630, 50392, 50393, 50394, 50398, 51784, 51785,

62311, 62318, 62319, 64412, 67101, 67105, 67112, 77776, 77777, 96931, 96932, 96933, 96934, 96935, 96936, D0260, G6018, G6019, G6020, G6021, G6022, G6023, G6024, G6025, G6027 and G6028

EM Services Included in the Global Period Added G0506, G0508 and G0509

Home Health Care Clinical Jan. 1, 2017 Added G0493, G0494, G0495 and G0496 Removed G0163 and G0164

Implanted Electrical Stimulator for Spinal Cord


Infliximab (Remicade® and Inflectra™)

Clinical Jan. 1, 2017 Revised description for J1745


Take Note

Oxford



Injectable Chemotherapy Drugs: Application of

NCCN Clinical Practice Guidelines

Clinical Jan. 1, 2017 Added J9034, J9145, J9176, J9205, J9295, J9325 and J9352 Revised description for J9033

Injection and Infusion Services

Reimbursement Jan. 9, 2017 Added 96377

In-Office Laboratory Testing and Procedures List

Reimbursement Jan. 1, 2017 Removed G0477 and G0478

Manipulation Under Anesthesia

Clinical Jan. 1, 2017 Added 27198 Removed 27194

Maximum Dosage Policy


Maximum Frequency

Per Day

Reimbursement

Feb. 1, 2017

Maximum Frequency Per Day Code List

Added 22853, 22854, 22859, 22867, 22868, 22869, 22870, 27197, 27198, 28291, 28295, 31551, 31552, 31553, 31554, 31572, 31573, 31574, 31591, 31592, 33340, 33390, 33391,

36456, 36473, 36474, 36901, 36902, 36903, 36904, 36905, 36906, 36907, 36908, 36909, 37246, 37247, 37248, 37249, 43284, 43285, 58674, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62380, 76706, 77065, 77066, 77067, 80305, 80306, 80307, 81327, 81413, 81414, 81422, 81439, 81539, 84410, 87483, 90682, 90750, 92242, 93590, 93591, 93592, 96160, 96161, 96377, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97169, 97170, 97171, 97172, 99151, 99152, 99153, 99155, 99156, 99157, 0446T, 0447T, 0448T, 0449T, 0450T, 0451T, 0452T, 0453T, 0454T, 0455T, 0456T, 0457T, 0458T, 0459T,

0460T, 0461T, 0462T, 0463T, 0464T, 0465T, 0466T, 0467T, 0468T, A4224, A4225, A4467, A4553, A9285, A9286, A9515, A9587, A9588, A9597, A9598, D0414, D0600, D1575,

D4346, D6081, D6085, D9311, D9991, D9992, D9993, D9994, G0491, G0492, G0493, G0494, G0495, G0496, G0499, G0500, G0501, G0502, G0503, G0504, G0505, G0506, G0507, G0508, G0509, G9678, J0570, J0883, J0884, J1130, J1942, J2182, J2786, J2840, J7175, J7179, J7202, J7207, J7209, J7320, J7322, J7342, J8670, J9034, J9145, J9176, J9205, J9295, J9325, J9352, L1851, L1852, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171,

Q4172, Q4173, Q4174, Q4175, T1040 and T1041 Removed 11752, 21495, 21805, 22305, 22851, 27193, 27194, 28290, 28293, 28294,

31582, 31588, 31620, 33400, 33401, 33403, 35450, 35452, 35458, 35460, 35471, 35472, 35475, 35476, 36147, 36148, 36870, 37202, 37250, 37251, 39400, 47136, 47500, 47505, 47510, 47511, 47525, 47530, 47560, 47561, 47630, 50392, 50393, 50394, 50398, 62310,


Take Note

Oxford



Maximum Frequency Per Day (continued)

Reimbursement

Feb. 1, 2017

62311, 62318, 62319, 64412, 67112, 70373, 72010, 72069, 72090, 73500, 73510, 73520, 73530, 73540, 73550, 74305, 74320, 74327, 74475, 74480, 75791, 75896, 75945, 75946, 75962, 75964, 75966, 75968, 75978, 75980, 75982, 77051, 77052,

77055, 77056, 77057, 77776, 77777, 77785, 77786, 77787, 80300, 80301, 80302, 80303, 80304, 81280, 81281, 81282, 82486, 82487, 82488, 82489, 82491, 82492, 82541, 82543, 82544, 83788, 88347, 90645, 90646, 90669, 90692, 90693, 90703,

90704, 90705, 90706, 90708, 90712, 90719, 90720, 90721, 90725, 90727, 90735, 92140, 92543, 93965, 95973, 97001, 97002, 97003, 97004, 97005, 97006, 99143, 99144, 99145, 99148, 99149, 99150, 99420, 0019T, 0099T, 0103T, 0123T, 0169T, 0171T, 0172T, 0182T, 0223T, 0224T, 0225T, 0233T, 0240T, 0241T, 0243T, 0244T,

0262T, 0281T, 0282T, 0283T, 0284T, 0285T, 0286T, 0287T, 0288T, 0289T, 0291T, 0292T, 0311T, 0336T, 0392T, 0393T, A4466, A7011, A9544, A9545, B9000, D0290, E0450, E0460, E0461, E0463, E0464, E0628, G0154, G0163, G0164, G0431, G0434, G0464, G0477, G0478, G0479, G3001, G6018, G6019, G6020, G6021, G6022, G6023, G6024, G6025, G6027, G6028, G6030, G6031, G6032, G6034, G6035, G6036, G6037, G6038, G6039, G6040, G6041, G6042, G6043, G6044, G6045, G6046, G6047, G6048,

G6049, G6050, G6051, , Q9981, S0195, S2360, S2361, S3721, S3890, S5011 and S9015

Codes Restricting Modifiers LT and RT Added 22853, 22854, 22859, 22867, 22868, 22869, 22870, 27197, 27198, 31551, 31552,

31553, 31554, 31592, 33340, 33390, 33391, 36456, 36901, 36902, 36903, 36904, 36905, 36906, 36907, 36908, 36909, 43284, 43285, 58674, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 76706, 77066, 77067, 80305, 80306, 80307, 81327, 81413, 81414,

81422, 81439, 81539, 84410, 87483, 90682, 90750, 92242, 93590, 93591, 93592, 96160, 96161, 96377, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97169, 97170, 97171, 97172, 99151, 99152, 99153, 99155, 99156, 99157, 0446T, 0447T, 0448T, 0449T, 0450T, 0451T, 0452T, 0453T, 0454T, 0455T, 0456T, 0457T, 0458T, 0459T, 0460T, 0461T, 0462T, 0463T, 0466T, 0467T, 0468T, A4224, A4225, A4467, A4553, A9285, A9286, A9515, A9587, A9588, A9597, A9598, D9311, D9991, D9992, D9993, D9994, G0491, G0492,

G0493, G0494, G0495, G0496, G0499, G0500, G0502, G0503, G0504, G0505, G0506,

G0507, G0508, G0509, G9678, J0570, J0883, J0884, J1130, J1942, J2182, J2786, J2840, J7175, J7179, J7202, J7207, J7209, J7320, J7322, J7342, J8670, J9034, J9145, J9176, J9205, J9295, J9325, J9352, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4172, Q4173, Q4174, Q4175, T1040 and T1041

Removed 21495, 22305, 22851, 27193, 27194, 31582, 31588, 31620, 33400, 33401, 33403, 37202, 39400, 47136, 47500, 47505, 47510, 47530, 47560, 47561, 47630, 70373,

72010, 72069, 72090, 73520, 73540, 74305, 74320, 74327, 75896, 75945, 75946, 75962, 75964, 75968, 75978, 75980, 75982, 77056, 77057, 77776, 77777, 77785, 77786, 77787, 80300, 80301, 80302, 80303, 80304, 81280, 81281, 81282, 82486, 82487, 82488, 82489,


Take Note

Oxford




Reimbursement Feb. 1, 2017 82491, 82492, 82541, 82543, 82544, 83788, 88347, 90645, 90646, 90669, 90692, 90693, 90703, 90704, 90705, 90706, 90708, 90712, 90719, 90720, 90721, 90725, 90727, 90735, 92543, 93965, 95973, 97001, 97002, 97003, 97004, 97005, 97006,

99143, 99144, 99145, 99148, 99149, 99150, 99420, 0103T, 0123T, 0169T, 0171T, 0172T, 0182T, 0223T, 0224T, 0225T, 0233T, 0240T, 0241T, 0243T, 0244T, 0262T, 0281T, 0284T, 0285T, 0286T, 0287T, 0288T, 0291T, 0292T, 0311T, 0336T, 0392T,

0393T, A7011, A9544, A9545, B9000, E0450, E0460, E0461, E0463, E0464, E0628, G0154, G0163, G0164, G0431, G0434, G0464, G0477, G0478, G0479, G6018, G6019, G6020, G6021, G6022, G6023, G6024, G6025, G6027, G6028, G6030, G6031, G6032, G6034, G6035, G6036, G6037, G6038, G6039, G6040, G6041, G6042, G6043, G6044,

G6045, G6046, G6047, G6048, G6049, G6050, G6051, G6052, G6053, G6054, G6055, G6056, G6057, G6058, Q9975, Q9976, Q9977, Q9978, Q9979, Q9980, Q9981, S2360, S2361, S3721, S3890 and S9015

Minimally Invasive Procedures for

Gastroesophageal Reflux Disease

(GERD)

Clinical Jan. 1, 2017 Added 43284 Removed 0392T and 0393T

Multiple Procedures Reimbursement Jan. 1, 2017 Multiple Procedure Reduction Codes List Removed 11752, 21495, 22305, 27193, 27194, 28290, 28293, 28294, 31582, 31588,

33400, 33401, 33403, 35450, 35452, 35458, 35460, 35471, 35472, 35475, 35476, 36147,

36870, 62310, 62311, 62318 and 62319

Neurophysiologic Testing

Clinical Jan. 1, 2017 Added 0464T Revised description for 95873, 95874, 95885, 95886, and 95887

Obstructive Sleep Apnea Treatment

Clinical Jan. 1, 2017 Added 0466T, 0467T and 0468T

Occipital Neuralgia and Headache Treatment


Omnibus Codes Clinical Jan. 1, 2017 Implantable cardiac devices for percutaneous closure (occlusion) of the left atrial appendage (LAA) Added 33340 Removed 0281T Cardiac contractility modulation, using an implantable device Revised description for 0418T


Take Note

Oxford



Omnibus Codes (continued)

Clinical Jan. 1, 2017 Real time spectral analysis of prostate tissue by fluorescence spectroscopy Revised description for 0443T Dermal/skin substitutes: PuraPly™ or PuraPly™ Antimicrobial

Added Q4172 Removed C9349

One or More Sessions Reimbursement Jan. 9, 2017 One or More Sessions Policy List Removed 67101 and 67105

Outpatient Physical & Occupational Therapy for Self-Funded Groups

Clinical Jan. 1, 2017 Added 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97169, 97170, 97171, and 97172

Removed 97001, 97002, 97003, 97004, 97005 and 97006

Outpatient Physical and Occupational

Therapy (Optumhealth Care Solutions

Arrangement)

Clinical Jan. 1, 2017 Added 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97169, 97170, 97171, and 97172

Removed 97001, 97002, 97003, 97004, 97005, and 97006

Oxford's Outpatient Imaging Self-Referral

Policy

Clinical Jan. 1, 2017 Nephrologists: Removed 75791 and 75978

Reproductive Endocrinologists, Infertility Specialists practicing within an Infertility Clinic: Removed 77052 OB/GYNs: Removed 77052 Maternal and Fetal Medicine, Neonatal/Perinatal Medicine: Removed 77052

Pain Management Specialists (Physiatrists, Physical Rehabilitation Medicine, Anesthesiologists, Neurologists, and Neurosurgeons):

Revised description for 77002 and 77003 Cardiologists - Nuclear Medicine: Added 78492 Cardiologists - Pediatric only: Added 78492


Take Note

Oxford



Physical Medicine & Rehabilitation: Multiple Therapy

Procedure Reduction

Reimbursement Jan. 9, 2017 Reformatted and reorganized policy; transferred content to new template Multiple Therapy Reducible Codes Added 97161, 97162, 97163, 97164, 97165, 97166, 97167 and 97168

Removed 97001, 97002, 97003 and 97004 Revised values for 92508, 92521, 92522, 92523, 92524, 92597, 92607, 96125, 97012,

97016, 97022, 97024, 97033, 97110, 97112, 97113, 97140, 97530, 97533, 97537, 97760,

97761, 97762 and G0329

Physical, Occupational

(Optumhealth Care Solutions Arrangement) and Speech Therapy Including Cognitive/ Neuropsychological

Rehabilitation for NJ Small Group and NJ

Individual Members

Clinical Jan. 1, 2017 Added 97161, 97162, 97163, 97164, 97165, 97166, 97167, and 97168 Removed 97001, 97002, 97003, and 97004

Precertification Exemptions for Outpatient Services

Administrative Jan. 1, 2017 Removed 77051, 77052, 77055, 77057, G0477 and G0478

Preventive Care Services

Clinical

Jan. 1, 2017

Abdominal Aortic Aneurysm Screening Added 76706 Removed 76700, 76705, 76770, 76775 and G0389 Hepatitis B Virus Infection Screening Added G0499

HIV – Human Immunodeficiency Virus – Screening for Adolescents and Adults Added 87389 and 87390

Screening Mammography Added 77067 Removed 77052 and 77057 Screening for Depression in Adults Added 96127

Removed 99420 Depression in Children and Adolescents (Screening) Added 96127 Removed 99420


Take Note

Oxford



Preventive Care Services (continued)

Clinical

Jan. 1, 2017

Meningococcal Revised description for 90734 Seasonal Influenza (‘flu’)

Added 90682 Revised description for 90655, 90656, 90657, 90658, 90661, 90685, 90686, 90687, 90688

and Q2039

Diphtheria, tetanus toxoids, acellular pertussis, haemophilus influenza B, and polio inactive (DTap-IPV/Hib) Revised description for 90698 Contraceptive Methods (Including Sterilizations)

Revised description for J7297

Preventive Medicine and Screening

Reimbursement Jan. 1, 2017 Revised description for 0333T

Probuphine®

(Buprenorphine)

Clinical Jan. 1, 2017 Added J0570

Procedure and Place

of Service

Reimbursement Jan. 9, 2017 Reformatted and reorganized policy; transferred content to new template

Procedure and Place of Service List Added:

o POS 03 for 99201, 99202, 99203, 99204 and 99205 o POS 12 for G0493, G0494, G0495 and G0496

o POS 34 for G0493, G0494, G0495 and G0496 Removed:

o G0154 with POS 12 and 34

Radiopharmaceuticals and Contrast Media

Clinical Jan. 1, 2017 Added A9515, A9587, A9588, A9597 and A9598 Removed A9544

Replacement Codes Reimbursement Jan. 1, 2017 Reformatted and reorganized policy; transferred content to new template

Replacement Codes Added:

o I status code 77065 with replacement code G0202 o I status code 77066 with replacement code G0204 o I status code 77067 with replacement code G0206

Respiratory Interleukins (IL) Policy

Clinical Jan. 1, 2017 Added J2182 and J2786


Take Note

Oxford



Routine Foot Care Clinical Jan. 1, 2017 Added A9285 Revised description for L3600, L3610, L3620, L3630 and L3640

Services and Modifiers not Reimbursable to

Healthcare Professionals

Reimbursement

Jan. 1, 2017

Removed G8401, G8458, G8460, G8461, G8485, G8486, G8487, G8489, G8490, G8491, G8494, G8495, G8496, G8497, G8498, G8499, G8500, G8544, G8545, G8548, G8549, G8551, G8634, G8645, G8646, G8725, G8726, G8728, G8757, G8758, G8759, G8761,

G8762, G8765, G8784, G8848, G8853, G8868, G8898, G8899, G8900, G8902, G8903, G8906, G8927, G8928, G8929, G8940, G8948, G8953, G8977, G9203, G9204, G9205, G9206, G9207, G9208, G9209, G9210, G9211, G9217, G9219, G9222, G9233, G9234, G9235, G9236, G9237, G9238, G9244, G9245, G9324, G9435, G9436, G9437, G9438,

G9439, G9440, G9441, G9442, G9443, G9463, G9464, G9465, G9466, G9467, G9499, G9572, G9581, G9619, G9650, G9652, G9653, G9657, G9667, G9669, G9670, G9671, G9672, G9673 and G9677

Sodium Hyaluronate Clinical Jan. 1, 2017 Added J7320 and J7322

Stelara®

(Ustekinumab) Injection for

Intravenous Infusion


Supply Policy Reimbursement Feb 1, 2017 Supply Codes List Removed A7011

Supply Facility J-Code Denial Code List Added J0570, J0883, J0884, J1130, J1942, J2182, J2786, J2840, J7175, J7179, J7202,

J7207, J7209, J7320, J7322, J7342, J8670, J9034, J9145, J9176, J9205, J9295, J9325 and J9352

Removed J0760, J0886, J1446, J1590, J7302, J7506 and J9010 Supply DME Codes in an Ambulatory Surgical Center

Removed Q4119 Supply DME Codes in a Skilled Nursing Facility

Removed E0628, E0450, E0460, E0461, E0463 and E0464

Surgical and Ablative Procedures for Venous Insufficiency

and Varicose Veins

Clinical Jan. 1, 2017 Reformatted and reorganized policy; transferred content to new template Added 36473 and 36474 Revised description for 36476 and 36479

Surgical Treatment for Spine Pain

Clinical Jan. 1, 2017 Added 22853, 22854, 22859, 22867, 22868, 22869 and 22870 Removed 22851, 0171T and 0172T Revised description for 0274T and 0275T


Take Note

Oxford



T Status Codes Reimbursement Jan. 9, 2017 T Status Indicator A R Codes List Added 22853, 22854, 22859, 22867, 22868, 22869, 22870, 27197, 27198, 28291, 28295,

31551, 31552, 31553, 31554, 31572, 31573, 31574, 31591, 31592, 33340, 33390, 33391,

36456, 36473, 36474, 36901, 36902, 36903, 36904, 36905, 36906, 36907, 36908, 36909, 37246, 37247, 37248, 37249, 43284, 43285, 58674, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 76706, 92242, 93590, 93591, 93592, 96160, 96161, 96931, 96932,

96933, 96934, 96935, 96936, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 99151, 99152, 99153, 99155, 99156, 99157, 99358, 99359, 99487, 99489, D0600, D1575, G0436, G0437, G0500, G0502, G0503, G0504, G0505, G0506, G0507, G0508 and G0509

Telemedicine Reimbursement Jan. 1, 2017 Recognized with Modifier GT Added 90967, 90968, 90969, 90970, 99497, 99498, G0508 and G0509 Codes Recognized with Modifier GQ Added 90967, 90968, 90969, 90970, 99497, 99498, G0508 and G0509

Time Span Codes Reimbursement Feb. 1, 2017 Time Span Codes List

Added A4224, G9678, T1041, G0502, G0503, G0504, G0506 and G0507

Vision Services Administrative Jan. 1, 2017 Revised description for 92235



Oxford

Policy Title Effective Date Coverage Rationale

NEW

Exondys 51™ (Eteplirsen)

Feb. 1, 2017

Exondys 51™ (eteplirsen) may be covered for: The treatment of Duchenne muscular dystrophy (DMD) in patients who meet ALL of the following criteria:

For initial therapy, ALL of the following: o Diagnosis of Duchenne muscular dystrophy; and o Submission of medical records (e.g., chart notes, laboratory values) confirming the mutation of the DMD

gene is amenable to exon 51 skipping; and o Exondys 51 dosing for DMD is in accordance with the United States Food and Drug Administration approved

labeling: maximum dosing of 30 mg/kg infused once weekly; and

o Initial authorization will be for no more than 4 weeks

For continuation therapy, ALL of the following: o Exondys 51 dosing for DMD is in accordance with the United States Food and Drug Administration approved

labeling: maximum dosing of 30 mg/kg infused once weekly; and o Reauthorization will be for no more than 6 months

Exondys 51 will not be covered for other forms of muscular dystrophy.

Office Based Program

Apr. 1, 2017

Introduction

In an effort to minimize out-of-pocket costs for Oxford members and to improve cost efficiencies for the overall health care system, we are implementing prior authorization guidelines that aim to encourage more cost-effective sites of service for certain outpatient surgical procedures, when medically appropriate. These prior authorization requirements apply to participating providers located in Connecticut (CT) and New York (NY) that are providing services to members enrolled on Oxford commercial plans that require services to be

medically necessary, including being cost-effective. Refer to the member specific benefit plan document to determine if medical necessity applies. Note: This policy does not apply to participating providers located in New Jersey (NJ). Coverage Rationale

With the exception of the qualifying conditions below, certain elective procedures should be performed in an Office setting.

The following will be taken into account to determine whether the elective procedure is being performed in a cost effective setting: Member’s benefit plan Geographic availability of an in network provider Office capability (i.e., appropriate equipment)



Oxford

Policy Title Effective Date Coverage Rationale

NEW

Office Based Program (continued)

Apr. 1, 2017 Significant member comorbidities (see list of examples of Qualifying Conditions) Certain Qualifying Conditions

Some patients may require more complex care due to certain medical factors or functional limitations and it may be appropriate to have the procedure in an outpatient hospital setting or ambulatory surgery center. (Not an all-

inclusive list). Patient unable to cooperate with procedure due to mental status, severe anxiety, or extreme pain sensitivity Failed office based procedure attempt due to body habitus, abnormal anatomy, or technical difficulties Bleeding disorder that would cause a significant risk of morbidity Allergy to local anesthetic Potential Documentation Requirements

Physician office notes Elective Procedures List

Prior authorization is required for the listed procedures if not performed in an office setting (see Applicable Codes

table).

Policy Title Effective Date Summary of Changes Coverage Rationale

UPDATED

Cardiovascular Disease Risk Tests

Jan. 1, 2017

Reformatted and reorganized policy; transferred content to new template

Updated benefit considerations; added instruction to check the member specific benefit plan document and any federal or state mandates, if applicable,

before using this policy Updated non-coverage rationale;

added language to indicate the clinical evidence is insufficient to show an added benefit of carotid intima-media thickness (CIMT) testing beyond traditional lipid risk assessment

Updated list of applicable CPT codes; removed descriptor

Due to insufficient evidence to support medical efficacy, cardiovascular disease risk tests will not be reimbursed by Oxford®.

Arterial compliance testing, using waveform analysis is unproven and not medically necessary as a method to determine risk for cardiovascular disease. There is insufficient evidence to conclude that noninvasive arterial compliance testing is effective as a screening tool for the early detection of

cardiovascular disease (CVD). There is inadequate clinical evidence from prospective studies that the use of this technology alters patient

management and improves clinical outcomes. Additional research involving larger, well-designed studies is needed to establish the role of arterial compliance in the early identification, prevention and management of CVD. Carotid intima-media thickness (CIMT) measurement is unproven not medically necessary as an effective screening tool for the

management of cardiovascular disease. The clinical evidence is insufficient to show an added benefit of CIMT testing



Oxford


UPDATED

Cardiovascular Disease Risk Tests (continued)

Jan. 1, 2017

classifying codes as “non-reimbursable”

Updated supporting information

to reflect the most current clinical evidence, FDA information, and references

beyond traditional lipid risk assessment. There is inadequate clinical evidence from prospective studies that the use of this technology alters patient management and improves clinical outcomes. Additional research involving

larger, well-designed studies is needed to establish the role of arterial compliance in the early identification, prevention and management of CVD.

Advanced lipoprotein analysis (e.g., apolipoprotein, lipoprotein (a) subfractions or particle size) is unproven and not medically necessary as a method to determine risk of cardiovascular disease. Studies report inconsistent results regarding the usefulness of advanced

lipoprotein testing. Research has shown a lack of universal, standardized testing modalities and patient-selection criteria. Additional large, prospective studies are needed to establish whether measurement of these emerging markers will be more predictive of CVD than conventional lipid risk factors. Tests that measure the lipoprotein-associated phospholipase A2 (Lp-

PLA2) enzyme and other human A2 phospholipases such as secretory phospholipase A2 (sPLA2-IIA) are unproven and not medically

necessary as a method to determine risk of cardiovascular disease or ischemic stroke. Additional well-designed clinical trials are necessary to establish the clinical utility of Lp-PLA2 and sPLA2-IIA for cardiovascular risk assessment and to determine the role of Lp-PLA2 as a potential adjunct to traditional risk

assessment in the management of stroke in adults. Tests that measure long-chain omega-3 fatty acids are unproven and not medically necessary as a method to determine risk for cardiovascular disease. There is insufficient evidence to conclude that measuring long-chain omega-3

fatty acids is effective as a screening tool for the early detection of

cardiovascular disease (CVD). There is inadequate clinical evidence from prospective studies that the use of this technology alters patient management and improves clinical outcomes. Additional research involving larger, well-designed studies is needed to establish the role of arterial compliance in the early identification, prevention and management of CVD.

Endothelial function assessment using tools such as peripheral arterial tonometry (PAT) or brachial artery pressure ultrasound is unproven and not medically necessary as a prognostic indicator to



Oxford


UPDATED

Cardiovascular Disease Risk Tests (continued)

Jan. 1, 2017 determine risk of cardiovascular disease. There is insufficient evidence in the peer-reviewed medical literature to support the effectiveness and prognostic clinical utility of endothelial function

assessment to establish the risk of cardiovascular disease. The majority of the identified studies reported some measure of statistical association of either PAT or brachial artery ultrasound with cardiovascular disease.

However, these associations are insufficient to directly demonstrate their clinical utility to effectively predict cardiovascular morbidity. Well-designed studies that extend beyond measures of simple statistical association are needed to demonstrate the clinical usefulness of such assessment tools to

effectively predict cardiovascular events and classify patients according to their individual cardiovascular risk.

Chromosome Microarray Testing

Feb. 1, 2017

Updated definitions; added definition of “intrauterine fetal demise or stillbirth”

Updated list of applicable ICD-10 diagnosis codes; added

O36.4XX0, O36.4XX1, O36.4XX2, O36.4XX3, O36.4XX4, O36.4XX5, O36.4XX9, and P95


to reflect the most current references

Comparative genomic hybridization microarray testing or single nucleotide polymorphism (SNP) chromosomal microarray analysis is proven and medically necessary to evaluate an embryo/fetus in the

following cases: Women undergoing invasive prenatal testing (i.e., amniocentesis,

chorionic villus sampling or fetal tissue sampling) Intrauterine fetal demise or stillbirth, refer to the Definitions section of

the policy. Comparative genomic hybridization microarray testing or single

nucleotide polymorphism (SNP) chromosomal microarray analysis is proven and medically necessary in the evaluation of patients with one or more of the following: Multiple anomalies not specific to a well-delineated genetic syndrome and

cannot be identified by a clinical evaluation alone Non-syndromic developmental delay/intellectual disability Autism spectrum disorders.

Comparative genomic hybridization microarray testing and single nucleotide polymorphism (SNP) chromosomal microarray analysis are unproven and not medically necessary for all other patient populations and conditions including but not limited to the following: Preimplantation genetic diagnosis or screening in embryos

Diagnosis, management, and prognosis of cancer. There is insufficient evidence in the clinical literature demonstrating that comparative genomic hybridization (CGH) microarray testing or single



Oxford


UPDATED

Chromosome Microarray Testing (continued)

Feb. 1, 2017 nucleotide polymorphism (SNP) chromosomal microarray analysis has a role in clinical decision-making or has a beneficial effect on health outcomes for other conditions such as preimplantation genetic diagnosis or screening in

embryos or aiding diagnosis or tumor classification or determining the most appropriate treatment and establishing an accurate prognosis for cancer. Further studies are needed to determine the analytic validity, clinical validity

and clinical utility of this test for indications other than those listed above as proven / medically necessary. Genetic Counseling

Genetic counseling is strongly recommended prior to this test in order to inform persons being tested about the advantages and limitations of the test

as applied to a unique person.

Clinical Trials

Jan. 1, 2017

Updated definitions; revised definition of “experimental or investigational service(s)”

Updated lists of applicable

codes; added coding clarification language to indicate: o Clinical trial claims are not

limited to the listed modifiers/diagnoses; however, if a claim has a listed modifier/diagnosis

code, it is considered a clincial trial claim

Indications for Coverage

Effective for plan years starting on or after January 1, 2014, the Patient Protection and Affordable Care Act (“PPACA”) requires non-grandfathered health plans to cover “Routine Patient Costs” incurred by a “Qualifying

Individual” who is participating in an “Approved Clinical Trial.” Benefits include the reasonable and necessary items and services used to

prevent, diagnose and treat complications arising from participation in a qualifying clinical trial. Benefits are available only when the Member is clinically eligible for participation in the qualifying clinical trial as defined by the researcher. Approved Clinical Trial

An “Approved Clinical Trial” is defined as:

Phase 1, Phase 2, Phase 3, or Phase 4 clinical trial

Being conducted in relation to the prevention, detection or treatment for cancer or other life threatening disease or condition, and

That meets the requirements under Criteria For Approved Clinical Trials For purposes of this benefit, a “life-threatening disease or condition” is one from which the likelihood of death is probable unless the course of the

disease or condition is interrupted. Additional Clinical Trials



Oxford


UPDATED

Clinical Trials (continued)

Jan. 1, 2017

The following clinical trials are not currently required by PPACA; however, these clinical trials are covered under Oxford’s clinical trial benefit. Phase 1, Phase 2 or Phase 3 clinical trial

Being conducted in relation to the detection or treatment of non-life threatening: o Cardiovascular disease (cardiac/stroke)

o Surgical musculoskeletal disorders of the spine, hip and knees, and/or

o Other clinical trials: Certain plans may allow clinical trials relating to other diseases or disorders which are not life-threatening. Please

refer to the member specific benefit plan document for coverage. o That meets the requirements under Criteria For Approved Clinical

Trials

Criteria for Approved Clinical Trials

The clinical trial must be described as one of the following: The study or investigation is approved or funded (which may include

funding through in-kind contributions) by one or more of the following: o National Institutes of Health (NIH); includes National Cancer Institute

(NCI)

o Centers for Disease Control and Prevention (CDC) o Agency for Healthcare Research and Quality (AHRQ) o Centers for Medicare and Medicaid Services (CMS) o A cooperative group or center of any of the entities described above

or the Department of Defense (DOD) or the Veterans Administration (VA)

o A qualified non-governmental research entity identified in the guidelines issued by the NIH for center support grants

o The Department of Veterans Affairs, the Department of Defense or

the Department of Energy as long as the study or investigation has been reviewed and approved through a system of peer review that is determined by the Secretary of Health and Human Services to meet both of the following criteria:

Comparable to the system of peer review of studies and investigations used by the NIH

Ensures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review

or



Oxford


UPDATED


Jan. 1, 2017

The study or investigation is conducted under an investigational new drug application reviewed by the U.S. Food and Drug Administration, or

The study or investigation is a drug trial that is exempt from having such

an investigational new drug application.

Additional Requirements

The clinical trial must have a written protocol that describes a scientifically sound study that has been approved by all relevant institutional review boards (IRBs) before participants are enrolled in the trial. We may, at any time, request documentation about the trial.

The subject or purpose of the trial must be the evaluation of an item or service that meets the definition of a Covered Health Service and is not

otherwise excluded under the Policy. Qualified Individual

To be a qualified individual an individual must be: Covered under the health plan, and

Eligible to participate in an approved clinical trial according to the trial protocol based upon: o The individual was referred to the clinical trial by an in-network health

care professional who has concluded that the individual's participation

would be appropriate because the individual is eligible for the trial according to its protocol, or

o The individual provides the plan with medical and scientific information that establishes that participation would be appropriate because the individual is eligible for the trial according to its protocol.

Routine Patient Costs During Clinical Trials Include:

Covered Health Services for which Benefits are typically provided absent

a clinical trial.

Covered Health Services required solely for: o The provision of the Experimental or Investigational service(s) or item

(e.g., the infusion administration services to deliver an investigational drug), and/or

o The clinically appropriate monitoring of the effects of the service or item (e.g., lab tests and imaging done at a frequency consistent with

signs and symptoms and other standards of care for that diagnosis or treatment type), and/or

o The prevention of complications.



Oxford


UPDATED


Jan. 1, 2017

Covered Health Services needed for reasonable and necessary care arising from the provision of an Experimental or Investigational service(s) item.

Network Plans

If one or more network providers are participating in a clinical trial, then Oxford may require that the Qualified Individual participate in the clinical trial using a network provider, as long as the network provider will accept the qualifying individual as a participant in the trial. However, if an Approved Clinical Trial is conducted outside of the Qualified Individual’s state of residence, then Oxford may not deny or otherwise limit payment for Routine Patient Services solely on the basis that the trial is conducted out-of-state.

Coverage Limitations and Exclusions

Benefits for clinical trials do not include: The Experimental or Investigational Service(s) or item that is used in the

clinical trial is not covered, except for the following:

o Certain Category B devices (see Definitions section of the policy) o Certain promising interventions for patients with terminal illnesses o Other items and services that, in our determination, meet specified

criteria in accordance with our medical and drug policies Items and services provided solely to satisfy data collection and analysis

needs and that are not used in the direct clinical management of the

patient. Examples include, but are not limited to: o Laboratory tests and imaging studies done at a frequency dictated by

the study protocol and not consistent with signs and symptoms and other standards of care for that diagnosis or treatment type.

A service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis.

Items and services provided by the research sponsors free of charge for

any person enrolled in the trial. Travel and transportation expenses are excluded from coverage. These

include, but are not limited to, the following examples: o Fees for all types of transportation. Examples include, but are not

limited to: personal vehicle, taxi, medical van, ambulance, commercial airline, and train

o Rental car expenses o Mileage reimbursement for driving a personal vehicle o Lodging



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UPDATED


Jan. 1, 2017 o Meals Routine patient costs obtained out-of-network where non-network

benefits do not exist under the plan.

Clinical Trials that do not meet the requirements listed in the Indications for Coverage section above. An example includes, but is not limited to, Phase 0 drug clinical trials.


Jan. 1, 2017


Added benefit considerations language to indicate: o Check the member specific

benefit plan document and any federal or state mandates, if applicable,

before using this policy o For Essential Health Benefits

for Individual and Small Group plans:

For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010

(ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”)

Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs; however, if such plans choose to

provide coverage for benefits which are deemed EHBs (such as maternity benefits), the ACA requires all dollar limits on those

Oxford will cover certain oral surgical and dental procedures under the general benefits package when determined to be medical in nature. Refer to Member's Certificate of Coverage and/or health benefits plan documentation

for specific coverage guidelines. Procedures that are deemed dental in nature rather than medical will not be covered unless the Member has dental coverage as part of their health benefits plan.

Under certain circumstances, coverage for anesthesia services in conjunction with dental or oral surgical services may be certified if any of the following

conditions apply: Note: Analgesia and anxiolytic services (including oral sedation and nitrous oxide sedation) are considered inclusive to the surgical procedure. 1. The Member has an underlying medical condition (e.g. cardiovascular

disease, uncontrolled hypertension, bleeding disorder, allergy to local anesthesia etc.), is severely disabled, or is unable to cooperate due to psychological or cognitive disability or age.

2. The procedure to be performed is extensive, there are local complicating factors including acute infection, or the procedure is expected to be of such duration that it cannot be reasonably expected to be completed under local anesthesia alone.

3. The Member is a pediatric patient with dental needs of significant complexity such that delay in treatment could lead to infection or other systemic complications. Anesthesia services for procedures that are not needed due to dental disease or pathology (e.g. extraction of teeth or surgical exposure of impacted teeth to prepare a child for orthodontic treatment) are not covered.

4. The Member cannot be treated in a conventional office setting due to severe anxiety or uncooperative behavior and attempts at treatment in a conventional office setting have failed. Failure to complete treatment may result in infection or other complications.



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(continued)

Jan. 1, 2017

benefits to be removed on all Grandfathered and Non-Grandfathered plans

The determination of which benefits constitute EHBs is made on a state by state basis; as

such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit

coverage Updated list of applicable CPT

codes to reflect annual code edits; removed 21495

Removed reference link to retired policy titled Moderate

Sedation

Coverage Guidelines for all Lines of Business

The following procedures may qualify for coverage under the Medical Plan: 1. Oral surgical procedures for the correction of a non-dental physiological

condition which results in a severe functional impairment. a. Diagnostic radiographs, study models, photographs, and treatment

record/consultation notes are required. 2. Oral surgical procedures for the excision of cysts and tumors of the

maxilla, mandible and surrounding tissues (cysts and tumors associated with the teeth are not covered).

Exception: NJ Individual and NJ Small Group Commercial Plans cover excision of cysts and tumors associated with teeth). a. Diagnostic radiographs, treatment record/consultation

notes/operative report, and pathology report are required. b. Bone grafting of surgical sites is generally not medically necessary as

bone fill should occur naturally after enucleation and curettage of the site except under the following circumstances:

Extensive size of surgical site such that there is increased risk for

pathological jaw fracture, sinus perforation, etc. 3. Dental services for the repair (not replacement*) of sound and natural

teeth, maxilla, mandible, and surrounding tissues following accidental injury (not including injuries caused by eating, biting, or chewing). a. Treatment must be rendered within 12 months** of the injury.

Exception: NJ Individual and NJ Small Group Commercial Plans

cover replacement of teeth following accidental injury and require completion of treatment within 6 months of injury).

b. Accidental injury must be documented. c. Pre- and post-accident x-rays are required. d. Teeth were stable and functional immediately prior to the time of the

accident without evidence of decay, periodontal disease, or

endodontic pathology. 4. Surgical removal of bony impacted teeth.

Note: This benefit is limited to specific lines of business. Please refer to the Member's Certificate of coverage and/or health benefits plan documentation for specific information.

5. Dental services that are medically necessary and incident to a covered medical service including:

a. Extraction of teeth before radiation treatment of the head and neck b. Extraction of teeth incidental to reducing a fracture of the jaw c. Dental examination prior to major surgery



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(continued)

Jan. 1, 2017

d. Reconstructive surgery and grafting procedures in conjunction with oral resective surgery if completed at the same time as resective surgery (not including replacement of teeth.

6. Obturators and obturator prosthesis after resective surgery. 7. Removal of odontogenic cysts or tumors >1.5 cm in diameter. 8. Removal of soft tissue neoplasms of the lips, tongue, palate, floor of

mouth, and vestibule (e.g., fibromas, mucocoeles, etc.)

Except for the conditions listed above, dental and oral surgical treatment needed directly or indirectly because of systemic disease or surgery is

excluded from coverage (including dental care needed due to radiation caries, gastric reflux disease, extractions prior to surgery, etc.). Dental or oral surgical services needed primarily to prepare the mouth for the replacement of teeth are not covered (including bone grafting, soft tissue grafting, ridge augmentation, sinus lift procedures, barrier membranes, etc.).

Additional Specific Coverage Requirements

Connecticut Members: Coverage must be provided for general

anesthesia; nursing and related hospital services provided in conjunction with inpatient, outpatient or one-day dental services when: o The anesthesia, nursing and related hospital services are deemed

medically necessary by the treating dentist or oral surgeon and the patient's primary care physician in accordance with the health plans requirements for prior authorization of services; and

o The patient is either (A) determined by a licensed dentist, in conjunction with a licensed physician who specializes in primary care, to have a dental condition of significant dental complexity that it requires certain dental procedures to be performed in a hospital, or

(B) a person who has a developmental disability, as determined by a licensed physician who specializes in primary care, that places the person at serious risk.

Coverage will be provided for medically necessary orthodontic processes and appliances for the treatment of craniofacial disorders for individuals eighteen years of age or younger if such processes and appliances are prescribed by a craniofacial team recognized by the American Cleft Palate-Craniofacial Association, except that no coverage shall be required for cosmetic surgery.



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(continued)

Jan. 1, 2017 *New Jersey Members: A medical condition covered by the contract which requires hospitalization or general anesthesia for dental services rendered by a dentist regardless of where the dental services are

provided. **New York Members: Oxford will provide coverage for (i) dental care

or treatment due to accidental injury to sound natural teeth within 12

months of the accident and (ii) dental care or treatment necessary due to congenital disease or anomaly.

Electrical

Stimulation for the Treatment of Pain and Muscle Rehabilitation

Jan. 1, 2017

Reformatted and reorganized

policy; transferred content to new template

Updated benefit considerations; added instruction to check the member specific benefit plan document and any federal or

state mandates, if applicable, before using this policy

Updated list of applicable CPT codes to reflect annual code edits; removed 0282T, 0283T, 0284T and 0285T

Functional electrical stimulation (FES), a form of neuromuscular

electrical stimulation is proven and medically necessary when used as one component of a comprehensive rehabilitation program in persons with paralyzed lower limbs due to spinal cord injury (SCI) with ALL of the following characteristics: Intact lower motor units (L1 and below) (both muscle and peripheral

nerves);

Muscle and joint stability for weight bearing at upper and lower extremities that can demonstrate balance and control to maintain an

upright support posture independently; Demonstrate brisk muscle contraction to NMES and have sensory

perception of electrical stimulation sufficient for muscle contraction; Possess high motivation, commitment and cognitive ability to use such

devices for walking;

Able to transfer independently and can demonstrate independent standing tolerance for at least 3 minutes;

Demonstrate hand and finger function to manipulate controls; Post recovery from spinal cord injury and restorative surgery of at least 6

months; No hip and knee degenerative disease and no history of long bone

fracture secondary to osteoporosis.

Functional electrical stimulation is unproven and not medically necessary for the treatment of disuse muscle atrophy in persons with

spinal cord injury (who do not meet the requirements above) or multiple sclerosis. Further studies are needed to confirm that functional electrical stimulation promotes bone remineralization and prevents or reverses muscle atrophy. Only a few studies have looked at FES as a modality of treatment of multiple sclerosis, and the results are limited and conflicting regarding whether FES



Oxford


UPDATED

Electrical Stimulation for the Treatment of Pain

and Muscle Rehabilitation (continued)

Jan. 1, 2017

improves treatment outcomes in multiple sclerosis when offered in addition to other rehabilitative treatment modalities.

Functional electrical stimulation is unproven and not medically necessary for the treatment of gait disorders (e.g., foot drop) of central neurologic origin including but not limited to stroke or

multiple sclerosis. There is insufficient evidence in the peer reviewed literature that use of functional electrical stimulation will improve health outcomes in patients with gait disorders. Published studies have included small heterogeneous patient

populations, short-term follow-ups, and various treatment protocols, outcome measure, and FES devices. Only a few studies have looked at FES as a modality of treatment of multiple sclerosis, and the results are limited and conflicting regarding whether FES improves treatment outcomes in multiple sclerosis when offered in addition to other rehabilitative treatment modalities.

Neuromuscular electrical stimulation (NMES) is proven and medically

necessary for: Treatment of disuse muscle atrophy if:

o The nerve supply to the muscle is intact; and

o The disuse muscle atrophy is not of neurological origin but originates from conditions such as casting, splinting or contractures; or

Treatment to improve wrist and finger function and prevent or correct shoulder subluxation in persons with partial paralysis following stroke.

Neuromuscular electrical stimulation (NMES) is unproven and not

medically necessary for ANY other indication not listed above as proven and medically necessary. There is insufficient evidence in the peer reviewed literature that use of

electrical stimulation will improve health outcomes for the treatment of multiple conditions other than those identified above as proven. Overall, studies in the form of randomized controlled trials and case series included small, heterogeneous patient populations and short-term follow-ups. Some

systematic reviews have reported that no improvement was seen with NMES, outcomes were conflicting and/or in some cases, when improvement was noted, the effects did not last. Heterogeneity of treatment regimens and outcome measures make it difficult to establish that NMES resulted in meaningful clinical outcomes (e.g., decrease pain, functional improvement, improvement in quality of life and ability to carry out activities of daily living)



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UPDATED



Jan. 1, 2017 for these other conditions and indications. Interferential therapy (IFT) is unproven and not medically necessary

for the following indications: For the treatment of musculoskeletal disorders or injuries For stimulating healing of nonsurgical soft tissue injuries

To facilitate the healing of bone fractures

There is limited evidence from the available studies to conclude that interferential therapy reduces the pain or promotes healing of bone fractures,

musculoskeletal or nonsurgical soft tissue injuries. Although a few studies reported some improvement in pain or disability following interferential therapy for these conditions, none of the double-blind, randomized, placebo-controlled studies reported a positive treatment effect of interferential therapy for nonsurgical soft tissue injuries or bone fractures.

Pulsed electrical stimulation (PES) is unproven and not medically necessary for the treatment of osteoarthritis.

There is insufficient evidence to conclude that PES provides health benefits to patients with osteoarthritis. Randomized, controlled trials are necessary to assess the durability of this procedure in comparison to other types of treatment.

Peripheral subcutaneous field stimulation (PSFS) or peripheral nerve

field stimulation (PNFS) is unproven and not medically necessary for the treatment of pain. Evidence for the effectiveness of PSFS or PNFS based on controlled studies is

lacking. Randomized controlled trials are needed to evaluate the efficacy of this treatment.

Epiduroscopy, Epidural Lysis of Adhesions and Functional

Anesthetic Discography

Jan. 1, 2017


Updated benefit considerations;

added instruction to check the member specific benefit plan document and any federal or state mandates, if applicable, before using this policy

Epiduroscopy (including spinal myeloscopy) is unproven and not medically necessary for the diagnosis of back pain. There is insufficient evidence to conclude that epiduroscopy can improve patient management or disease outcomes. The available studies primarily

evaluated the feasibility of the procedure and the ability to visualize normal and pathological structures with an epiduroscope. None of the studies systematically evaluated the accuracy of epiduroscopy for diagnosis of causes of back pain and neurological signs.



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UPDATED

Epiduroscopy, Epidural Lysis of Adhesions and

Functional Anesthetic Discography

(continued)

Jan. 1, 2017

Updated supporting information to reflect the most current description of services, clinical

evidence, and references; no change to coverage rationale or list of applicable codes

Percutaneous and endoscopic epidural lysis of adhesions is unproven and not medically necessary for the treatment of back pain. There is insufficient evidence to conclude that epidural lysis of adhesions can

provide sustained reduction in chronic back pain in patients with a presumptive diagnosis of epidural adhesions. No published studies have evaluated this procedure relative to open surgical procedures for chronic back

pain. Further validation with larger study populations and long term follow-up is needed to verify the effectiveness of epidural adhesiolysis in the treatment of back pain.

Functional anesthetic discography (FAD) is unproven and not medically necessary for the diagnosis of back pain. Although researchers are presently investigating the use of FAD for diagnosing discogenic pain, there is insufficient evidence at this time to draw conclusions.

Experimental/ Investigational

Treatment

Feb. 1, 2017

Reformatted and reorganized policy; transferred content to

new template Added benefit considerations

language to indicate: o Check the member specific

benefit plan document and any federal or state

mandates, if applicable, before using this policy

o For Essential Health Benefits for Individual and Small Group plans: For plan years beginning

on or after January 1,

2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to

provide coverage for ten categories of Essential

Requests for treatments or therapies can be initiated by any of the following, including but not limited to:

Member Provider Internal sources such as medical management coordinators, case

managers, medical directors, sales representatives, marketing, etc. Unless otherwise required by law with respect to drugs which have

been prescribed for the treatment of a condition for which the drug has not been approved by the United States Food and Drug Administration (FDA), Oxford will not cover any services or supplies, including treatment, procedures, drugs, biological products or medical devices or any hospitalizations in connection with experimental or investigational services or supplies.

Oxford will also not cover any technology or any hospitalization in connection with such technology if such technology is obsolete or ineffective and is not used generally by the medical community for the particular diagnosis or treatment of a member's particular condition. Governmental approval of a technology is not necessarily sufficient to

render it of proven benefit or appropriate or effective for a particular diagnosis or treatment of a member's particular condition, as explained



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UPDATED

Experimental/ Investigational Treatment

(continued)

Feb. 1, 2017

Health Benefits (“EHBs”) Large group plans (both

self-funded and fully

insured), and small group ASO plans, are not subject to the

requirement to offer coverage for EHBs; however, if such plans choose to provide

coverage for benefits which are deemed EHBs (such as maternity benefits), the ACA requires all dollar limits on those benefits to be

removed on all Grandfathered and Non-

Grandfathered plans The determination of

which benefits constitute EHBs is made on a state by state basis; as such,

when using this guideline, it is important to refer to the member specific benefit plan document to determine benefit coverage

below. Any medical device, drug, or biological product must have received final

approval to market by the United States Food and Drug Administration

(FDA) for the particular diagnosis or condition. Any other approval granted as an interim step in the FDA regulatory process, e.g., an Investigational Device Exemption or an Investigational New Drug

Exemption, is not sufficient. Once FDA approval has been granted for a particular diagnosis or condition, use of the medical device, drug or biological product for another diagnosis or condition will require that one or more of the following established reference compendia:

o American Medical Association Drug Evaluations o American Hospital Formulary Service Drug Information o United States Pharmacopoeia Drug Information, recognizes the usage

as appropriate medical treatment. As an alternative to such recognition in one or more of the compendia, the usage of the drug will be recognized as appropriate if it is recommended by a clinical

study or recommended by a review article in a major peer-reviewed professional journal. A medical device, drug, or biological product

that meets the above tests will not be considered experimental or investigational. In any event, any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment for which the drug has been prescribed will be considered experimental or investigational.

Conclusive evidence from the published peer-reviewed medical literature

must exist that the technology has a definite positive effect on health outcomes; such evidence must include well-designed investigations that have been reproduced by nonaffiliated authoritative sources, with measurable results, backed up by the positive endorsements of national

medical bodies or panels regarding scientific efficacy and rationale.

Demonstrated evidence as reflected in the published peer-reviewed

medical literature must exist that over time the technology leads to improvement in health outcomes, i.e., the beneficial effects outweigh any harmful effects.

Proof as reflected in the published peer-reviewed medical literature must exist that the technology is at least as effective in improving health outcomes as established technology, or is usable in appropriate clinical



Oxford


UPDATED

Experimental/ Investigational Treatment

(continued)

Feb. 1, 2017 contexts in which established technology is not employable.

Proof as reflected in the published peer-reviewed medical literature must

exist that improvements in health outcomes, as defined in paragraph 3, is possible in standard conditions of medical practice, outside clinical investigatory settings.

Experimental/ Investigational Treatment for NJ

Plans

Feb. 1, 2017


Updated benefit considerations: o Added instruction to check

the member specific benefit plan document and any federal or state mandates, if applicable, before using this

policy o Added language for Essential

Health Benefits for Individual and Small Group plans to indicate: For plan years beginning

on or after January 1,

2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to

provide coverage for ten categories of Essential Health Benefits (“EHBs”)

Large group plans (both self-funded and fully insured), and small

group ASO plans, are not subject to the requirement to offer coverage for EHBs;

Experimental and/or Investigational Treatment

Oxford recognizes that peer reviewed documents in scientific and medical literature may establish that an experimental and/or investigational treatment or procedure may be better than the standard treatments available to treat a member’s life threatening or disabling condition and/or disease.

Oxford has determined that it will create a limited exception to the exclusion of experimental and investigational treatments and provide coverage for in-network experimental and investigational procedures that meet the criteria set forth in this policy. Such coverage is subject to the member’s other benefits and exclusions. Oxford’s determination of whether the criteria have been met will be based upon the opinion of an independent consultant/peer

reviewer with expertise in the area of practice appropriate to treat the member’s condition or disease. Exception: For New York Plans, the member's condition and/or disease is not required to be life threatening or disabling. Unproven Therapies

Under no circumstances will this policy extend coverage to unproven therapies. Unproven therapies are treatments or procedures that lack

significant medical documentation to support their medical effectiveness. Oxford does not provide coverage for any treatment modality that has not

been proven medically effective or is not generally recognized as effective or appropriate for the particular diagnosis or treatment of the member’s particular condition. The proposed experimental/investigational treatment must meet all of the

criteria outlined below before approval is granted. In addition, documentation must be submitted to Oxford demonstrating that the criteria below have been satisfied. Without all such documentation, Oxford will deny any such request. Coverage Criteria



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UPDATED


Plans (continued)

Feb. 1, 2017

however, if such plans choose to provide coverage for benefits

which are deemed EHBs (such as maternity benefits), the ACA

requires all dollar limits on those benefits to be removed on all Grandfathered and Non-

Grandfathered plans The determination of

which benefits constitute EHBs is made on a state by state basis; as such, when using this

guideline, it is important to refer to the member

specific benefit plan document to determine benefit coverage

*Note: For New York Plans the member's condition and/or disease is not required to be life threatening or disabling. The member must have a life threatening or disabling condition or

disease.* For purposes of this policy, a disabling condition means that the member is unable to engage in any substantial gainful activities by reason of any medically determinable physical or mental impairment

which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months. In the case of a child under the age of eighteen, disabling condition means that the child suffers from a medically determinable physical or

mental impairment of comparable severity. The member’s medical record, in conjunction with at least two (2)

published peer-reviewed documents from the available scientific and medical evidence and any other pertinent information supplied, must establish that the proposed experimental or investigational treatment is likely to be more beneficial that any standard treatment(s) for the

member’s life-threatening or disabling condition or disease.* The opinion of the attending physician recommending that the treatment

or procedure is likely to be more beneficial to the member than any covered standard health service or procedure, must be based upon at least two (2) peer-reviewed documents from the available medical and scientific evidence.

In the absence of any evidence of a standard treatment with which to

compare the experimental treatment, the attending physician’s opinion must be based upon at least two (2) peer-reviewed medical and scientific publications which show a definite positive effect of the proposed treatment on health outcomes for the disease or condition from which the patient suffers or the diagnosis for which it is being prescribed. In other words, the literature must show that well designed investigations with

measurable results (that can be duplicated) support that the treatment

would be scientifically effective and that the beneficial effects of the treatment outweigh the harmful effects of the treatment.

Documentation: Necessary Information

The following supporting documentation must be provided by the member and/or the member’s provider for consideration: Certification from the Member’s attending physician which includes:

o A statement that the Member has a life threatening or disabling condition or disease for which (a) standard health service or



Oxford


UPDATED


Plans (continued)

Feb. 1, 2017

procedures have been ineffective or would be medically inappropriate; or (b) there does not exist a more beneficial standard health service or procedure covered by the health care plan

o A statement of the evidence relied upon to recommend the proposed treatment or procedure and a statement of why the standard therapy available would not be beneficial, would be ineffective or would be

inappropriate, including an assessment of the risks and benefits of the proposed treatment

o Citation to two documents from the available medical and scientific evidence, upon which the attending physician based his

recommendation for the proposed treatment and an explanation why, in the opinion of the physician, these documents establish that the treatment or procedure is likely to be more beneficial to the member than any covered standard health service or procedure or would provide a positive effect on the member’s condition or illness and that the benefits outweigh the harmful effects the treatment

The attending physician must be a board certified or board eligible physician qualified to practice in the area of practice

appropriate to treat the member’s condition A copy of the two documents from the available medical and

scientific evidence, upon which the attending physician based his recommendation for the proposed treatment

A written description of the proposed treatment (or protocol if available), which must include: o Specific goals o A rational and background for the plan o Criteria for patient selection o Specific directions for administering the therapy or intervention o Specific directions for the monitoring of patients o A definition of quantitative measures for determining treatment or

intervention response; and o Methods for documenting and treating adverse reactions to the

treatment or intervention A copy of the member’s informed consent form

A copy of the member’s medical and treatment records, including results of tests or studies, showing the member’s current condition and any treatment the member has received for the condition



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UPDATED


Plans (continued)

Feb. 1, 2017

The available clinical or pre-clinical data that indicate the treatment’s effectiveness for treatment, prevention, or palliation of the member’s condition

Additional Information

The outside consultant or Oxford, depending upon the nature of the

proposed treatment and/or the member’s condition or disease, may require additional documentation to review the requested treatment.

Oxford will also accept and consider any additional pertinent clinical documentation, peer review publications and/or relevant data concerning the protocol that the member and/or the member’s physician would like to provide in support of the request for the experimental treatment.

Connecticut Plans Only

For members having a Connecticut Plans, Oxford will also provide coverage, under this policy, for: Off-label use of cancer drugs for another type of cancer, unless

specifically contraindicated by the Food and Drug Administration; and

Procedures, treatments or usage of any drug, if the procedure, treatment

or usage has successfully completed a Phase III clinical trial of the FDA for (a) the illness or condition being treated or (b) the diagnosis for which it is being prescribed

New York Plans Only

When an anti-cancer drug is being used to treat a type of cancer for which it is not specifically FDA approved, NY insurance law requires coverage if the drug/cancer combination is recognized in any of the following pharmaceutical reference compendia: American Hospital Formulary Service-Drug Information (AHFS-DI) Elsevier Gold Standard's Clinical Pharmacology

NCCN Drugs and Biologics Compendium

Thomson Micromedex DrugDex Other authoritative compendia as identified by the Federal Secretary of

Health and Human Services or the Centers for Medicare & Medicaid Services (CMS); or recommended by review article or editorial comment in a major peer reviewed professional journal



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UPDATED

Femoroacetabular Impingement Syndrome

Treatment

Jan. 1, 2017


Updated benefit considerations; added instruction to check the member specific benefit plan

document and any federal or state mandates, if applicable, before using this policy


to reflect the most current description of services, clinical evidence, and references; no change to coverage rationale or list of applicable codes

Information Pertaining to Medical Necessity Review

Surgical treatment for femoroacetabular impingement (FAI) syndrome is medically necessary in patients who have ALL of the following criteria:** Pain unresponsive to medical management (e.g., restricted activity,

nonsteroidal anti-inflammatory drugs) Moderate-to-severe persistent hip or groin pain that limits activity and is

worsened by flexion activities (e.g., squatting or prolonged sitting) Positive impingement sign (i.e., sudden pain on 90 degree hip flexion

with adduction and internal rotation or extension and external rotation) Radiographic confirmation of FAI (e.g., pistol-grip deformity, alpha angle

greater than 50 degrees, coax profunda, and/or acetabular retroversion)

Do not have advanced osteoarthritis (i.e., Tönnis grade 2 or 3) and/or severe cartilage damage (i.e., Outerbridge grade III or IV)

** (Tannast, 2007; Filigenzi, 2008; Zebala, 2007; Clohisy 2010) Tonnis Classification of Osteoarthritis by Radiographic Changes

Grade 0: No signs of osteoarthritis (OA) Grade 1: Increased sclerosis of femoral head or acetabulum, slight joint

space narrowing or slight slipping of joint margin, no or slight loss of head sphericity

Grade 2: Small cysts in femoral head or acetabulum, moderate joint space narrowing, moderate loss of head sphericity

Grade 3: Large cysts, severe joint space narrowing or obliteration of joint space, severe deformity of the head, avascular necrosis

Outerbridge Grades

Grade 0: Normal Grade I: Cartilage with softening and swelling

Grade II: Partial-thickness defect with fissures on the surface that do

not reach subchondral bone or exceed 1.5 cm in diameter Grade III: Fissuring to the level of subchondral bone in an area with a

diameter more than 1.5 cm Grade IV: Exposed subchondral bone head



Oxford


UPDATED

Implantable Beta-Emitting Microspheres for

Treatment of Malignant Tumors

Jan. 1, 2017 Reformatted and reorganized policy; transferred content to new template

Updated benefit considerations: o Removed/replaced language

indicating some benefit

documents allow coverage of experimental/investigational/unproven treatments for life-threatening illnesses when

certain conditions are met; the member specific benefit document must be consulted to make coverage decisions for this service

o Added instruction to check

the member specific benefit plan document and any

federal or state mandates, if applicable, before using this policy

Updated supporting information to reflect the most current

clinical evidence and references

Yttrium-90 (90Y) microsphere radioembolization is proven and medically necessary for the following indications: Unresectable metastatic liver tumors from primary colorectal cancer

(CRC) Unresectable metastatic liver tumors from neuroendocrine tumors Unresectable primary hepatocellular carcinoma (HCC)

Yttrium-90 (90Y) microsphere radioembolization is unproven and not medically necessary for all other indications. Limited evidence suggests that treatment with intrahepatic microsphere

radiation (IMR) might shrink tumors and relieve symptoms in some patients, sometimes enough to render some inoperable tumors operable. However, limited available evidence has not shown improved survival. In addition, the treatment's potential impact on quality of life has not been studied. No studies have yet compared the effects of IMR therapy with alternative treatments, such as chemoembolization. Randomized controlled trials are

needed to determine the clinical utility of this treatment.

Implanted Electrical Stimulator for Spinal Cord

Jan. 1, 2017


Updated benefit considerations; added instruction to check the

member specific benefit plan document and any federal or state mandates, if applicable, before using this policy

Updated list of applicable CPT codes to reflect annual code

edits; removed 0282T, 0283T, 0284T and 0285T

For information regarding medical necessity review, when applicable, see MCG™ Care Guidelines, 20th edition, 2016, Implanted Electrical Stimulator, Spinal Cord. ACG: A-0243 (AC).



Oxford


UPDATED


Jan. 1, 2017 Reformatted and reorganized policy; transferred content to new template



Updated list of applicable HCPCS

codes to reflect annual code edits; revised description for J1745

Refer to the policy for complete details on Maximum Dosage guidelines.

Mechanical Circulatory Support

Device (MCSD)

Jan. 1, 2017


new template (no change to administrative guidelines or list

of applicable codes)

Oxford has engaged OptumHealth to perform reviews of precertification requests for the use of long term, durable mechanical circulatory devices.

Oxford continues to be responsible for decisions regarding coverage determinations and for appeals. Optum has established an infrastructure to

support the review, development, and implementation of comprehensive clinical guidelines. The evidence-based clinical guidelines are available at: UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines > Clinical Guidelines > Mechanical Circulatory Support Device (MCSD) Clinical

Guideline. All pre-certification requests are handled by OptumHealth. To pre-certify a procedure related to mechanical circulatory devices, please call OptumHealth at 888-936-7246. New Jersey (NJ) Small, NJ Individual, NJ School Board and NJ Municipality

products, services indicated as requiring a precertification require medical necessity review. This review may be requested prior to service. If a medical necessity review is not requested by the provider prior to service, the medical necessity review will be conducted after the service is rendered with no penalty imposed for failure to request the review prior to rendering the service. It is the referring physician’s responsibility to provide medical

documentation to demonstrate clinical necessity for the study that is being requested (for review prior to service) or has been rendered (for review after service was provided).



Oxford


UPDATED

Off-Label/ Unproven Specialty Drug Treatment

Feb. 1, 2017




Updated coverage rationale;

added language to indicate: o This policy provides

parameters for coverage of off-label and unproven indications of FDA-approved medications covered under

the medical benefit o This policy does not address

coverage for medications covered under the pharmacy benefit; refer to pharmacy benefit coverage

Description

This policy provides parameters for coverage of off-label and unproven indications of FDA-approved medications covered under the medical benefit for one of the following: Injectable specialty drug with a corresponding Oxford Health Plan policy

that does not address the requested indication Injectable specialty drug with a corresponding Oxford Health Plan policy

that lists the drug as unproven for the requested indication Injectable specialty drug without an Oxford Health Plan drug policy This policy does not address coverage for medications covered under the pharmacy benefit. Please refer to pharmacy benefit coverage.

This policy does not address coverage of injectable oncology medications (J9000 - J9999) and select other medications used for oncology conditions [including, but not limited to octreotide acetate (J2353 and J2354) and leuprolide acetate (J1950)] covered under the medical benefit based upon

the National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium™. Please refer to policy Injectable Chemotherapy Drugs:

Application of NCCN Clinical Practice Guidelines, for more information. This policy does not address coverage of vaccines. Please refer to policies Vaccines and Preventative Care Services for additional information on vaccines covered as preventive services. Coverage Rationale

A specialty drug may be determined medically necessary for the

requested off-label or unproven indication when all of the following criteria are met:

The drug is approved by the U.S. Food and Drug Administration; and One of the following:

o The requested drug is considered ‘unproven or not medically necessary’ per Oxford Health Plan drug policy, where applicable

o The indication for the requested drug is not addressed by an Oxford

Health Plan drug policy, where applicable o An Oxford Health Plan drug policy does not exist for the requested

drug. and

The drug is prescribed by a licensed health care professional; and



Oxford


UPDATED

Off-Label/ Unproven Specialty Drug Treatment

(continued)

Feb. 1, 2017 The requested drug is intended to treat a chronic and seriously debilitating condition; and

Documented history of failure, contraindication, or intolerance to

standard, conventional therapies to treat or manage the disease or condition, where available; and

Diagnosis is clinically supported as a use by at least one of the following:

o One of the following compendia: The American Hospital Formulary Service Drug Information

(AHFS-DI) under the Therapeutic Uses section The Elsevier Gold Standard’s Clinical Pharmacology under the

Indications section DRUGDEX System by Micromedex® has a Strength of

Recommendation rating of Class I, Class IIa, or Class IIb under the Therapeutic Uses section

or o MCG™ Ambulatory Care Guideline; or

o Two (2) articles from major peer reviewed medical journals that present data supporting the proposed off-label use or uses as

generally safe and effective unless there is validated and uncontested contradictory evidence presented in a major peer-reviewed medical journal.

[Examples of accepted journals include, but are not limited to, Journal of

American Medical Association, New England Journal of Medicine, and Lancet. Accepted study designs may include, but are not limited to, randomized, double blind, placebo controlled clinical trials.]

Outpatient Physical & Occupational Therapy for Self-

Funded Groups

Jan. 1, 2017


Updated benefit considerations: o Removed/replaced language

indicating all products have specific benefit limitations/benefit

maximums determined by group and individual products; refer to the member's certificate of coverage for specific

All Citigroup (CI3198) or Brooks Brothers (BB1627) Products

Oxford covers medically necessary Physical and Occupational Therapy services. Coverage is for acute conditions only whereby services must begin

within six months of the later to occur: The date of the injury or illness that caused the need for therapy The date the Member is discharged from a hospital where surgical

treatment is rendered, or The date outpatient surgical care was rendered In no event will the therapy continue beyond 365 days after such event.* (*Long-term rider may alter coverage criteria)



Oxford


UPDATED


Funded Groups (continued)

Jan. 1, 2017

limitations/ maximums o Added instruction to check

the member specific benefit

plan document and any federal or state mandates, if applicable, before using this

policy o Added language for Essential

Health Benefits for Individual and Small Group plans to

indicate: For plan years beginning

on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured

non-grandfathered individual and small

group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”)

Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer

coverage for EHBs;

however, if such plans choose to provide coverage for benefits which are deemed EHBs (such as maternity benefits), the ACA

requires all dollar limits on those benefits to be removed on all

Services must be performed by a duly licensed and certified provider. All services must be within the scope of the provider's license in order to be eligible for reimbursement.

Up to three (3) modalities/therapeutic procedures will be accepted, without additional documentation, per date of service. Services in excess of three (3)

modalities/therapeutic procedures will be reviewed upon receipt of clinical documentation. Referral Requirements

Oxford Members enrolled on gated self-funded groups are required to have a referral for all in-network physical or occupational therapy

services. Members enrolled in non-gated products are not required to have a referral.

Referrals can be issued by the following: Member's PCP, General Surgeon, Gynecological Oncologist, Hematologist-Oncologist, Neurologist, Oncologist, Orthopedists, Pain Management Specialist, Physiatrist,

Neurosurgeon, Rheumatologist. Exception: In the case of long-term physical therapy (long-term physical

therapy rider required), the referral must come from the Member's PCP. For All Oxford Self-Funded Products

Reminder: The following guidelines do not apply to Citigroup (CI3198) or Brooks Brothers (BB1627). Oxford has delegated certain administrative services related to Physical and Occupational Therapy services to OptumHealth Care Solutions. OptumHealth

Care Solutions, a UnitedHealth Group company, will administer the physical and occupational therapy benefit for Oxford products. OptumHealth Care

Solutions is a leading physical medicine company that has significant experience working with physical and occupational therapists and physicians, in promoting high quality, affordable physical medicine and rehabilitation services.

You may access OptumHealth Care Solutions clinical policies at the following website: https://www.myoptumhealthphysicalhealth.com. Services managed by OptumHealth Care Solutions include: Utilization Review functions for a designated list of CPT and HCPCS codes

https://www.myoptumhealthphysicalhealth.com/



Oxford


UPDATED



Jan. 1, 2017

Grandfathered and Non-Grandfathered plans

The determination of

which benefits constitute EHBs is made on a state by state basis; as such,

when using this guideline, it is important to refer to the member specific benefit plan

document to determine benefit coverage

Updated list of applicable CPT/HCPCS codes: o Updated list of CPT codes

requiring utilization review to

reflect annual code edits: Added 97161, 97162,

97163, 97164, 97165, 97166, 97167, and 97168

Removed 97001, 97002, 97003, and 97004

o Updated list of non-reimbursable CPT codes to reflect annual code edits: Added 97169, 97170,

97171, and 97172 Removed 97005 and

97006

for outpatient physical and occupational therapy for fully insured commercial products, excluding self-funded Members.

First level administrative, Utilization Management Member and provider

appeals, Member appeals, and external appeals where applicable. Note: Oxford has not delegated 2nd level Member internal appeals, external

Member appeals, and regulatory inquiries to OptumHealth Care Solutions. This policy applies to a specific list of CPT and HCPCS codes, regardless of the specialty of the treating provider. Refer to the Applicable Codes section below

for a list of the CPT and HCPCS codes. Exception: If a chiropractor provides any of the services specified by the CPT or HCPCS codes in this policy, those services will continue to accrue separately towards the chiropractic benefit, if available. For chiropractic services refer to Manipulative Therapy policy for additional information.

This policy applies in the outpatient setting only. The outpatient setting for

physical therapy and occupational therapy includes hospital outpatient treatment facilities, outpatient facilities at or affiliated with rehabilitation hospitals. Physical and occupational therapy provided in the home will be managed

under the home care benefit (per the Member's certificate). All home care services require precertification. Refer to the Home Health Care policy for additional information. In the case of occupational therapy, the referral must come from one of the following:

The Member's primary care provider (PCP)

General surgeon Gynecological oncologist Hematologist oncologist Neurologist Oncologist Orthopedist

Physiatrist Neurosurgeon Pain management specialist or rheumatologist



Oxford


UPDATED



Jan. 1, 2017

Refer to the Referrals policy for additional information. In-Network Subsequent Physical and Occupational Therapy

In-Network subsequent physical and occupational therapy (not rendered by a chiropractor) requires utilization review by OptumHealth Care Solutions to

determine medical necessity. An initial evaluation report must be submitted to OptumHealth Care Solutions within ten calendar days of the initial visit or prior to the second visit, whichever occurs first. All services rendered by UnitedHealthcare Choice Plus providers in the service area will be subject to retrospective review. Out-Of-Network Physical and Occupational Therapy

OptumHealth Care Solutions will review out-of-network physical and

occupational therapy services for medical necessity after the services have been received and the claims are submitted.

Members also have the option through a Voluntary Prior Approval Process to submit a treatment plan. The prior approval process is completely voluntary. Out-of-Network providers are not required to pre-authorize services. All initial evaluations and subsequent visits must be authorized when using the

Voluntary Prior Approval Process. Members are financially responsible for all out-of-network services determined to be not medically necessary. Note:

For chiropractic services, refer to the policy titled Manipulative Therapy for additional information.

For services provided by complementary and alternative medicine (CAM) providers, refer to policy titled Complementary and Alternative Medicine (CAM) Contracted Rate Program. CAM providers include: o Acupuncturists o Dieticians and nutritional counselors o Massage therapists o Naturopathic physicians (CT only - due to state licensing statutes) o Yoga instructors

For rehabilitation services for the treatment of autism, refer to the policy titled Autism.



Oxford


UPDATED



Jan. 1, 2017 Utilization management and prior approval will continue to be subject to Member's certificate of coverage.

Services must be performed by a duly licensed and certified provider. All

services must be within the scope of the provider's license in order to be eligible for reimbursement.

Physical, Occupational (OptumHealth Care Solutions

Arrangement) and Speech Therapy Including Cognitive/ Neuropsycholog-ical Rehabilitation

for New Jersey Small Group and

New Jersey Individual Members

Jan. 1, 2017


Added benefit consideration

language to indicate: o Check the member specific

benefit plan document and any federal or state

mandates, if applicable, before using this policy

o For Essential Health Benefits for Individual and Small

Group plans: For plan years beginning

on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and

outside of Exchanges) to provide coverage for ten categories of Essential

Health Benefits (“EHBs”) Large group plans (both

self-funded and fully insured), and small

group ASO plans, are not subject to the requirement to offer coverage for EHBs; however, if such plans choose to provide

Therapy and Rehabilitation will be covered by Oxford for any illness or injury that is acute or chronic, including Developmental Delays. Wellness care related to conditioning, strength training, fitness, workplace

ergonomics or injury prevention is not covered by Oxford. Small Group Plans

Services are covered when ordered by a physician for any illness or injury that is acute or chronic. Physical and Occupational Rehabilitation Therapy

There is no limit to the amount of modalities that can be reimbursed per visit.

Coverage is limited to a combined total of 30 visits per Member per year for physical and occupational rehabilitation therapy. Speech and Cognitive Rehabilitation Therapy

There is no limit to the amount of modalities that can be reimbursed per visit.

Coverage is limited to a combined total of 30 visits per Member per year for speech and cognitive rehabilitation therapy. Therapeutic Manipulation

Not a covered benefit for Plan A. For all other small group plans, coverage is limited to 30 visits per Member per year with no more than two modalities

per visit. (CPT code 97140. For CPT codes 98940 - 98943, please refer to the policy titled Manipulative Therapy). Individual Basic and Essential Plan

Physical Therapy

Services are covered following illness, injury of loss of limb or for treatment related to a biologically-based mental illness to develop a physical function.

Coverage is limited to 30 visits per Member per year. There are no modality limits per visit, but services may be subject to medical necessity review.



Oxford


UPDATED

Physical, Occupational (Optumhealth Care

Solutions Arrangement) and Speech Therapy

Including Cognitive/ Neuropsycholog-ical Rehabilitation

for New Jersey Small Group and New Jersey Individual Members (continued)

Jan. 1, 2017 coverage for benefits which are deemed EHBs (such as maternity

benefits), the ACA requires all dollar limits on those benefits to be

removed on all Grandfathered and Non-Grandfathered plans

The determination of

which benefits constitute EHBs is made on a state by state basis; as such, when using this guideline, it is important to refer to the member

specific benefit plan document to determine

benefit coverage Updated list of applicable CPT

codes to reflect annual code

edits: o Added 97161, 97162,

97163, 97164, 97165, 97166, 97167, and 97168

o Removed 97001, 97002, 97003, and 97004

Occupational, Speech or Cognitive Rehabilitation Therapy

There is no coverage for occupational, speech or cognitive rehabilitation therapy. Therapeutic Manipulation

There is no coverage for therapeutic manipulation. All Other Individual Plans

Services are covered when ordered by a physician for any illness or injury that is acute or chronic.

Physical, Occupational, Speech and Cognitive Rehabilitation Therapy

Coverage for each therapy is limited to 30 visits per Member per year. There are no modality limits per visit, but services may be subject to medical necessity review. Therapeutic Manipulation

Coverage is limited to 30 visits per Member per year. There is a modality limit of two per visit, and services may be subject to medical necessity review. (CPT code 97140. For CPT codes 98940 - 98943, please refer to the policy titled Manipulative Therapy).

Refer to the policy titled Manipulative Therapy for coverage guidelines for chiropractic services.

Radiopharmaceut-icals and Contrast

Media

Jan. 1, 2017


new template Updated benefit considerations;

added instruction to check the member specific benefit plan


Updated list of applicable HCPCS codes to reflect annual code edits:

Refer to the policy for complete details on the coverage guidelines for Radiopharmaceuticals and Contrast Media.



Oxford


UPDATED

Radiopharmaceut-icals and Contrast Media

(continued)

Jan. 1, 2017 o Added A9515, A9587, A9588, A9597 and A9598

o Removed A9544

Surgical Treatment

for Spine Pain

Jan. 1, 2017




member specific benefit plan document and any federal or state mandates, if applicable, before using this policy

Updated coverage rationale; added language to indicate

Coflex-F® is an example of an interlaminar lumbar

instrumented fusion (ILIF) method

Updated list of applicable CPT codes to reflect annual code edits:

o Added 22853, 22854, 22859, 22867, 22868, 22869 and 22870

o Removed 22851, 0171T and 0172T

o Revised description for 0274T and 0275T

o Modified table heading; removed descriptor classifying codes as “proven/medically necessary” and “unproven/not medically

necessary” Updated supporting information

to reflect the most current description of services, clinical

Spinal fusion using extreme lateral interbody fusion (XLIF) or direct

lateral interbody fusion (DLIF) is proven and medically necessary. For information regarding medical necessity review, see the following MCG™ Care Guidelines, 20th edition, 2016:

Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy, S-310 (ISC)

Lumbar Diskectomy, Foraminotomy, or Laminotomy S-810 (ISC) Cervical Laminectomy S-340 (ISC) Lumbar Laminectomy S-830 (ISC) Cervical Fusion, Anterior S-320 (ISC)

Cervical Fusion, Posterior S-330 (ISC) Lumbar Fusion S-820 (ISC)

The following spinal procedures are unproven and not medically necessary: Spinal fusion when performed via the following methods:

o Laparoscopic anterior lumbar interbody fusion (LALIF) o Transforaminal lumbar interbody fusion (TLIF) which utilizes

only endoscopy visualization (such as a percutaneous incision with video visualization)

o Axial lumbar interbody fusion (AxiaLIF™) o Interlaminar lumbar instrumented fusion ( ILIF) (e.g., Coflex-

F®)

This includes interbody cages, screws and pedicle screw fixation devices with any of the above procedures. Clinical evidence is limited primarily to retrospective studies and case series. Randomized, controlled trials comparing these procedures to standard procedures are needed to determine impact on health outcomes and long-term efficacy.

Spinal Decompression and Interspinous Process Decompression

Systems o Interspinous process decompression (IPD) systems for the



Oxford


UPDATED

Surgical Treatment for Spine Pain (continued)

Jan. 1, 2017

evidence, FDA information, and references

treatment of spinal stenosis o Minimally invasive lumbar decompression (MILD®)

Current clinical evidence is insufficient to permit conclusions about

whether any beneficial effect from minimally invasive lumbar decompression provides a significant advantage over surgical decompression. In addition, the complication rates and reoperation

rates for this procedure compared with those of decompression surgery is unknown.

Spinal Stabilization

o Stabilization systems for the treatment of degenerative spondylolisthesis

o Total facet joint arthroplasty, including facetectomy, laminectomy, foraminotomy, vertebral column fixation The current published evidence is insufficient to determine whether facet arthroplasty is as effective or as safe as spinal fusion, the

current standard for surgical treatment of degenerative disc disease. In addition, no devices have received approval from the U.S. Food

and Drug Administration for use outside the clinical trial setting. o Percutaneous sacral augmentation (sacroplasty) with or

without a balloon or bone cement for the treatment of back pain The available clinical evidence shows that percutaneous sacroplasty,

may alleviate the pain and functional impairment of sacral insufficiency fractures (SIF) in most patients with few and predominantly minor adverse effects, suggesting that this procedure may be relatively safe and efficacious for treatment of SIF. Despite these promising findings, the overall quality of the body of evidence is low given that the available studies were limited by methodological

flaws (e.g., retrospective design, small sample size, subjective

outcome measures, lack of a control group, and inadequate follow-up). Before reliable recommendations may be made, higher-quality studies are required that entail large populations with sufficient statistical power.

Stand alone facet fusion without an accompanying decompressive

procedure This includes procedures performed with or without bone grafting and/or the use of posterior intrafacet implants such as fixation systems, facet



Oxford


UPDATED

Surgical Treatment for Spine Pain (continued)

Jan. 1, 2017 screw systems or anti-migration dowels. Clinical evidence is limited primarily to case series and nonrandomized studies. Randomized, controlled trials comparing facet fusion to standard procedures are

needed to determine impact on health outcomes and long-term efficacy.

Temporomandib-

ular Joint Disorders

Jan. 1, 2017



Updated benefit considerations: o Added instruction to check

the member specific benefit plan document and any federal or state mandates, if applicable, before using this policy

o Replaced references to

“alloplastic implants/TMJ implants” with “prosthetic

replacement” Updated lists of applicable

CPT/HCPCS codes: o Modified table headings;

removed descriptor

classifying codes as “proven/medically necessary” or “unproven/not medically necessary”

Updated supporting information to reflect the most current clinical evidence, FDA

information, and references

The following services are proven and medically necessary for

treating disorders of the temporomandibular joint (TMJ): Arthrocentesis Arthroplasty [For information regarding medical necessity review, when

applicable, see MCG™ Care Guidelines, 20th edition, 2016,

Temporomandibular Joint Arthroplasty, ACG: A-0523 (AC)] Arthroscopy (with or without FDA approved bone anchor devices) Arthrotomy/open joint surgery (with or without FDA approved bone

anchor devices) Injections of corticosteroids for rheumatoid arthritis-related TMJ disorders Physical therapy

Stabilization and repositioning splint therapy (This does not include low-load prolonged-duration stretch (LLPS) devices discussed below)

Partial or total joint replacement with an artificial prosthesis is proven and medically necessary for treating disorders of the temporomandibular joint (TMJ) when all other treatments have failed.

Not all services treat all TMJ disorders; specific treatments are based upon the specific diagnosis. The following services are unproven and not medically necessary for treating disorders of the temporomandibular joint (TMJ): Biofeedback Craniosacral manipulation

Passive rehabilitation therapy Low-load prolonged-duration stretch (LLPS) devices There are limited studies evaluating biofeedback for the treatment of musculoskeletal pain, including TMJ pain. One small uncontrolled study reported positive effects, while a larger randomized controlled study failed to

demonstrate any treatment effect. Well-designed randomized, blinded and placebo-controlled outcome studies published on craniosacral manipulation for TMJ are not available. For



Oxford


UPDATED

Temporomandib-ular Joint Disorders (continued)

Jan. 1, 2017 additional information regarding manipulation under anesthesia for TMJ disorders, refer to the policy titled Manipulation Under Anesthesia.

While there are some data from several randomized trials and case series studies that certain types of passive rehabilitation techniques may improve jaw mobility early in recovery in patients who have undergone TMJ surgery,

or have lost jaw mobility due to TMJ derangement or to contracture following radiation therapy, these studies all included very small numbers of patients, and did not provide blinded assessment of outcomes, long-term follow-up, or information on optimal treatment protocols.

Further prospective controlled clinical trials that directly compare LLPS devices to other treatment modalities are needed.


REVISED

Blepharoplasty,

Blepharoptosis, and Brow Ptosis Repair

Feb. 1, 2017

Revised coverage rationale for

brow ptosis: o Modified coverage criterion

addressing documentation requirements to clarify documentation indicating the specific brow lift procedure

(e.g., supra-ciliary, mid-brow or coronal direct brow lift vs browpexy) is required

Revised coverage limitations and exclusions: o Added language to indicate

browpexy/internal brow lift is

not designed to improve function; it is considered a cosmetic procedure and is not a covered service


references

Refer to the policy for complete details on the coverage guidelines for

Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair.



Oxford


REVISED

Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair

(continued)

Feb. 1, 2017

Drug Coverage

Criteria - New and Therapeutic Equivalent Medications

Feb. 1, 2017 Revised list of medications

requiring precertification through the pharmacy benefit manager (PBM): o Added Hydrocortisone 1%

Ointment in Absorbase, Rayaldee, and Vemlidy

o Removed Qbrelis and Xiidra

Refer to the policy for complete details on Drug Coverage Criteria - New and

Therapeutic Equivalent Medications.

Policy Title Effective Date Drug/Medication Status Summary of Changes

REVISED

Drug Coverage

Guidelines

Jan. 1, 2017 Restasis (Cyclosporine

Ophthalmic Emulsion)

Revised Revised coverage criteria/precertification requirements:

o Added prior authorization/medical necessity guidelines; refer to Prior

Authorization/Medical Necessity Guidelines: Restasis (Cyclosporine Ophthalmic Emulsion) for complete details

o Removed prior authorization/notification guidelines and corresponding reference link to policy titled Prior Authorization/ Notification Guidelines: Restasis (Cyclosporine Ophthalmic Emulsion)

Xiidra (Lifitegrast) Revised Revised coverage criteria/precertification requirements:

o Added prior authorization/medical necessity guidelines; refer to Prior

Authorization/Medical Necessity Guidelines: Xiidra for complete

details

Drug Coverage Guidelines

Feb. 1, 2017 Aptiom (Eslicarbazepine Acetate)

Updated Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Aptiom (Eslicarbazepine Acetate)

for complete details

Banzel (Rufinamide) Updated Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Banzel (Rufinamide) for complete details

Bunavail Film

(Buprenorphine and Naloxone)

Revised Revised prior authorization/medical necessity guidelines; refer to Prior

Authorization/Medical Necessity Guidelines: Buprenorphine/Naloxone Products for complete details

Buprenorphine HCl

Revised

Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Buprenorphine/Naloxone



Oxford


REVISED

Drug Coverage Guidelines (continued)

Feb. 1, 2017 Buprenorphine HCl (continued)

Revised Products for complete details

Buprenorphine/ Naloxone (Generic Suboxone)

Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Buprenorphine/Naloxone Products for complete details

Bupropion (Generic

Zyban)


Authorization/Medical Necessity Guidelines: Bupropion for complete

details

Chantix (Varenicline Tartrate)

Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Chantix for complete details

Colchicine Tablet (Manufacturer: Prasco)

Revised Revised coverage criteria/precertification requirements; added prior authorization/notification guidelines; refer to Prior

Authorization/Notification Guidelines: Colchicine Tablet for complete details

Cuvitru [Immune Globulin Subcutaneous (Human)]

New Added coverage criteria/precertification requirements: o Added language to indicate precertification is required through

Oxford’s Medical Management

o Added precertification guidelines; refer to the following policies for complete details: Precertification Guidelines: Immune Globulin (IVIG & SCIG) Precertification Guidelines: Immune Globulin Site of Care Review

Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion

Daliresp (Roflumilast) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Daliresp for complete details

Daraprim (Pyrimethamine)

Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Daraprim for complete details

Embeda (Morphine

Sulphate and Naltrexone HCl)


Authorization/Medical Necessity Guidelines: Embeda for complete details

Exalgo (Hydromorphone) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Exalgo for complete details

Exondys 51 (Eteplirsen)

New

Added coverage criteria/precertification requirements: o Added language to indicate precertification is required through

Oxford’s Medical Management o Added precertification guidelines; refer to the following policies for

complete details: Precertification Guidelines: Exondys 51



Oxford


REVISED


Feb. 1, 2017 Exondys 51 (Eteplirsen) (continued)

New Precertification Guidelines: Specialty Medication Administration - Site of Care Review Guidelines

Farxiga (Depagliflozin)

Revised

Revised coverage criteria/precertification requirements: o Removed/replaced precertification guidelines and corresponding

reference link to policy titled Precertification Guidelines: Diabetes Medications [for Connecticut (CT) and New York (NY) plan members]

o Added prior authorization/notification guidelines for CT and NY plan members; refer to Prior Authorization/Notification Guidelines: Diabetes Medications SGLT2 Inhibitors (CT/NY) for complete details

o Revised step therapy guidelines for NJ plan members; refer to Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) for complete details

Fycompa (Perampanel) Updated Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Fycompa for complete details

Glyxambi (Empagliflozin/ Linagliptin)

Revised Revised coverage criteria/precertification requirements: o Removed/replaced precertification guidelines and corresponding

reference link to policy titled Precertification Guidelines: Diabetes

Medications [for Connecticut (CT) and New York (NY) plan members] o Added prior authorization/notification guidelines for CT and NY plan

members; refer to Prior Authorization/Notification Guidelines:

Diabetes Medications SGLT2 Inhibitors (CT/NY) for complete details o Revised step therapy guidelines for NJ plan members; refer to Step

Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) for complete details

Hydrocortisone 1%

Ointment in Absorbase

New Added coverage criteria/precertification requirements:

o Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)

o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic

Equivalent Medications for complete details

Hysingla ER

(Hydrocodone Bitartrate)


Authorization/Medical Necessity Guidelines: Hysingla ER for complete details

Impavido (Miltefosine) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Impavido for complete details

Inflectra (Infliximab) Revised Revised coverage criteria/precertification requirements: o Added precertification guidelines; refer to Precertification Guidelines:

Maximum Dosage Policy for complete details



Oxford


REVISED


Feb. 1, 2017 Insulins (Novolin 70/30, Novolog Pens and Vials, Novolog Mix 70/30 Pens

and Vials, Apidra, Apidra Solostar, Novolin N, Novolin R)

Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Insulins for complete details

Invokana (Canagliflozin) Revised Revised coverage criteria/precertification requirements: o Removed/replaced precertification guidelines and corresponding



members; refer to Prior Authorization/Notification Guidelines: Diabetes Medications SGLT2 Inhibitors (CT/NY) for complete details

o Revised step therapy guidelines for NJ plan members; refer to Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) for

complete details

Intron-A (Interferon

Alfa-2b)

Revised Revised prior authorization/notification guidelines; refer to Prior

Authorization/Notification Guidelines: Intron-A (Interferon Alfa-2b) for complete details

Janumet (Sitagliptin and

Metformin Hydrochloride)

Revised Revised coverage criteria/precertification requirements:

o Removed/replaced precertification guidelines and corresponding reference link to policy titled Precertification Guidelines: Diabetes Medications [for Connecticut (CT) and New York (NY) plan members]

o Added prior authorization/notification guidelines for CT and NY plan members; refer to Prior Authorization/Notification Guidelines: Diabetes Medications DPP4 Inhibitors (CT/NY) for complete details

o Revised step therapy guidelines for NJ plan members; refer to Step Therapy Guidelines: Diabetes Medications DPP4 Inhibitors (NJ) for complete details

Janumet XR (Sitagliptin and Metformin Hydrochloride, Extended

Release)




members; refer to Prior Authorization/Notification Guidelines: Diabetes Medications DPP4 Inhibitors (CT/NY) for complete details

o Revised step therapy guidelines for NJ plan members; refer to Step Therapy Guidelines: Diabetes Medications DPP4 Inhibitors (NJ) for complete details



Oxford


REVISED


Feb. 1, 2017

Januvia (Sitagliptin)

Revised

Revised coverage criteria/precertification requirements: o Removed/replaced precertification guidelines and corresponding



members; refer to Prior Authorization/Notification Guidelines:

Diabetes Medications DPP4 Inhibitors (CT/NY) for complete details o Revised step therapy guidelines for NJ plan members; refer to Step

Therapy Guidelines: Diabetes Medications DPP4 Inhibitors (NJ) for complete details

Jardiance (Empagliflozin) Revised Revised coverage criteria/precertification requirements: o Removed/replaced precertification guidelines and corresponding


o Added prior authorization/notification guidelines for CT and NY plan

members; refer to Prior Authorization/Notification Guidelines: Diabetes Medications SGLT2 Inhibitors (CT/NY) for complete details


Kadian (Morphine

Sulfate Extended Release)


Authorization/Medical Necessity Guidelines: Kadian for complete details

Kalydeco (Ivacaftor) Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Kalydeco for complete details

Lyrica (Pregabalin) Revised Revised step therapy guidelines; refer to Step Therapy Guidelines: Lyrica for complete details

MS Contin Revised Revised prior authorization/medical necessity guidelines; refer to Prior

Authorization/Medical Necessity Guidelines: MS Contin for complete details



Oxford


REVISED


Feb. 1, 2017 Nicotine OTC Products: Nicotine Gum (e.g. Nicorette, Thrive),

Nicotine Lozenge (e.g. Commit, Nicorette), Nicotine Patch (e.g.

Nicoderm CQ), Nicotrol Inhaler (Nicotine Inhalation System), Nicotrol NS (Nicotine

Nasal Spray)

Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Tobacco Cessation for Health Care Reform for complete details

Nicotrol Inhaler (Nicotine)

Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Tobacco Cessation for Health Care Reform for complete details

Nicotrol NS (Nicotine) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Tobacco Cessation for Health Care Reform for complete details

Nucynta ER (Tapentadol Extended Release)

Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Nucynta ER for complete details

Onfi (Clobazam) Updated Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Onfi for complete details

Opana ER (Oxymorphone Extended

Release)

Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Opana ER for complete

details

Orkambi™ (Lumacaftor/ Ivacaftor)

Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Orkambi for complete details

Oxycontin (Oxycodone Extended Release)

Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Oxycontin for complete

details

Oxycodone ER 12hr Tablet

Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Oxycodone ER for complete details

Oxymorphone Extended Release

Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Oxymorphone for complete details

Pegasys (Peginterferon Alfa-2a)

Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Pegasys (Peginterferon Alfa-2a) for complete details



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REVISED


Feb. 1, 2017 Peg-Intron (Peginterferon Alfa-2b)

Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Peg-Intron (Peginterferon Alfa-2b) for complete details

Potiga (Ezogabine) Updated Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Potiga (Ezogabine) for complete details

Pulmicort Flexhaler

(Budesonide)

New Added coverage criteria/precertification requirements:


o Added step therapy guidelines; refer to Step Therapy Guidelines: Pulmicort for complete details

Qbrelis (Lisinopril)

Revised

Revised coverage criteria/precertification requirements: o Added prior authorization/medical necessity guidelines; refer to Prior

Authorization/Medical Necessity Guidelines: Qbrelis for complete details

o Removed therapeutic equivalent guidelines and corresponding reference link to policy titled Drug Coverage Criteria - New and

Therapeutic Equivalent Medications

Rayaldee (Calcifediol) New Added coverage criteria/precertification requirements:


o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details

Rexulti (Brexpiprazole) Updated Updated step therapy guidelines; refer to Step Therapy Guidelines: Rexulti (brexpiprazole) for complete details

Sylatron (Peginterferon Alfa-2b)

Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Sylatron (Peginterferon Alfa-2b) for complete details

Stelara (Ustekinumab): Subcutaneous Injection

Updated Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Stelara (Ustekinumab): Subcutaneous Injection for complete details

Stelara (Ustekinumab): Intravenous Infusion

Revised Revised coverage criteria/precertification requirements: o Changed precertification routing designation from “PBM” to “Oxford’s

Medical Management” o Added precertification guidelines; refer to Precertification Guidelines:

Maximum Dosage Policy for complete details Updated list of applicable HCPCS codes; replaced J3490 with J3590



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REVISED


Feb. 1, 2017 Suboxone (Buprenorphine)

Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Buprenorphine/Naloxone Products for complete details

Test Strips and Meters (Diabetic)

Updated Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Test Strips for complete details

Trulicity (Dulaglutide) Revised Revised coverage criteria/precertification requirements:

o Removed/replaced precertification guidelines and corresponding


o Added prior authorization/notification guidelines for CT and NY plan members; refer to Prior Authorization/Notification Guidelines: Diabetes Medications GLP1 Inhibitors (CT/NY) for complete details

o Revised step therapy guidelines for NJ plan members; refer to Step Therapy Guidelines: Diabetes Medications GLP1 Inhibitors (NJ) for

complete details

Vemlidy (Tenofovir Alafenamide)

New Added coverage criteria/precertification requirements: o Added language to indicate precertification is required through the

Pharmacy Benefit Manager (PBM) o Added therapeutic equivalent guidelines; refer to Therapeutic

Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic

Equivalent Medications for complete details

Vimpat (Lacosamide): Tablet

Updated Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Vimpat (Lacosamide) for complete details

Xifaxan (Rifaximin) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Xifaxan for complete details

Xigduo XR (Dapagliflozin and Metformin HCl)



Medications [for Connecticut (CT) and New York (NY) plan members]

o Added prior authorization/notification guidelines for CT and NY plan members; refer to Prior Authorization/Notification Guidelines: Diabetes Medications SGLT2 Inhibitors (CT/NY) for complete details


Xiidra (Lifitegrast)

Revised

Revised coverage criteria/precertification requirements: o Removed therapeutic equivalent guidelines and corresponding

reference link to policy titled Drug Coverage Criteria - New and



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REVISED


Feb. 1, 2017

Xiidra (Lifitegrast) (continued)

Revised Therapeutic Equivalent Medications

Xtampza ER (Oxycodone)

Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Xtampza ER for complete details

Zohydro ER (Hydrocodone Bitartrate

Extended Release)

Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Zohydro ER for complete

details

Zyban (Bupropion) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Tobacco Cessation for Health Care Reform for complete details


REVISED


and Muscle Rehabilitation

Feb. 1, 2017

Revised coverage rationale: o Added language to clarify

when used for walking,

functional electrical stimulation (FES) is proven

and medically necessary when used as one component of a comprehensive rehabilitation program in persons with paralyzed lower limbs due to spinal cord injury with

characteristics listed in the policy

o Modified language pertaining

to unproven/not medically necessary indications for functional electrical stimulation (FES) to

indicate: Functional electrical

stimulation (FES) is unproven and not medically necessary for any other indication not

When used for walking, functional electrical stimulation (FES), a form of neuromuscular electrical stimulation (NMES) is proven and medically necessary when used as one component of a

comprehensive rehabilitation program in persons with paralyzed lower limbs due to spinal cord injury (SCI) with ALL of the following

characteristics: Intact lower motor units (L1 and below) (both muscle and peripheral

nerves); Muscle and joint stability for weight bearing at upper and lower

extremities that can demonstrate balance and control to maintain an upright support posture independently;

Demonstrate brisk muscle contraction to NMES and have sensory

perception of electrical stimulation sufficient for muscle contraction; Possess high motivation, commitment and cognitive ability to use such

devices for walking;

Able to transfer independently and can demonstrate independent standing tolerance for at least 3 minutes;

Demonstrate hand and finger function to manipulate controls; Post recovery from SCI and restorative surgery of at least 6 months;

No hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis.

Functional electrical stimulation (FES) is unproven and not medically necessary for ANY other indication not listed above as proven and medically necessary, including but not limited to:



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REVISED



Feb. 1, 2017

listed in the policy as proven and medically necessary, including but

not limited to: - Disuse muscle

atrophy in persons

with spinal cord injury (SCI)

- Disuse muscle atrophy in persons

with multiple sclerosis (MS)

- Gait disorders (e.g., foot drop) of central neurologic origin, including but not

limited to stroke or MS

Further studies are needed to confirm that FES promotes bone remineralization and prevents or reverses

muscle atrophy Only a few studies have

looked at FES as a modality of treatment of MS, and the results are limited and conflicting

regarding whether FES

improves treatment outcomes in MS when offered in addition to other rehabilitative treatment modalities

There is insufficient

evidence in the peer reviewed literature that use of FES will improve

Disuse muscle atrophy in persons with spinal cord injury (SCI) Disuse muscle atrophy in persons with multiple sclerosis (MS) Gait disorders (e.g., foot drop) of central neurologic origin, including but

not limited to stroke or MS Further studies are needed to confirm that FES promotes bone

remineralization and prevents or reverses muscle atrophy. Only a few studies have looked at FES as a modality of treatment of MS, and the results are limited and conflicting regarding whether FES improves treatment outcomes in MS when offered in addition to other rehabilitative treatment modalities.

There is insufficient evidence in the peer reviewed literature that use of FES will improve health outcomes in patients with gait disorders. Published studies have included small heterogeneous patient populations, short-term follow-ups, and various treatment protocols, outcome measures, and FES devices.

Neuromuscular electrical stimulation (NMES) is proven and medically necessary for:

Treatment of disuse muscle atrophy if: The nerve supply to the muscle is intact; and The disuse muscle atrophy is not of neurological origin but originates

from conditions such as casting, splinting or contractures; or Treatment to improve wrist and finger function and prevent or correct

shoulder subluxation in persons with partial paralysis following stroke. Neuromuscular electrical stimulation (NMES) is unproven and not medically necessary for ANY other indication not listed above as proven and medically necessary. There is insufficient evidence in the peer reviewed literature that use of

electrical stimulation will improve health outcomes for the treatment of

multiple conditions other than those identified above as proven. Overall, studies in the form of randomized controlled trials and case series included small, heterogeneous patient populations and short-term follow-ups. Some systematic reviews have reported that no improvement was seen with NMES, outcomes were conflicting and/or in some cases, when improvement was noted, the effects did not last. Heterogeneity of treatment regimens and

outcome measures make it difficult to establish that NMES resulted in meaningful clinical outcomes (e.g., decrease pain, functional improvement, improvement in quality of life and ability to carry out activities of daily living)



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REVISED



Feb. 1, 2017 health outcomes in patients with gait disorders

Published studies have included small heterogeneous patient

populations, short-term follow-ups, and various treatment protocols, outcome measures, and

FES devices Updated supporting information

to reflect the most current description of services, clinical evidence, FDA information, and references

for these other conditions and indications. Interferential therapy (IFT) is unproven and not medically necessary for the following indications:

For the treatment of musculoskeletal disorders or injuries For stimulating healing of nonsurgical soft tissue injuries To facilitate the healing of bone fractures

There is limited evidence from the available studies to conclude that IFT reduces the pain or promotes healing of bone fractures, musculoskeletal or nonsurgical soft tissue injuries. Although a few studies reported some

improvement in pain or disability following IFT for these conditions, none of the double-blind, randomized, placebo-controlled studies reported a positive treatment effect of IFT for nonsurgical soft tissue injuries or bone fractures. Pulsed electrical stimulation (PES) is unproven and not medically necessary for the treatment of osteoarthritis.

There is insufficient evidence to conclude that PES provides health benefits to patients with osteoarthritis. Randomized, controlled trials are necessary to

assess the durability of this procedure in comparison to other types of treatment.

Peripheral subcutaneous field stimulation (PSFS) or peripheral nerve

field stimulation (PNFS) is unproven and not medically necessary for the treatment of pain. Evidence for the effectiveness of PSFS or PNFS based on controlled studies is lacking. Randomized controlled trials are needed to evaluate the efficacy of this treatment.

Hearing Aids and

Devices Including Wearable, Bone-Anchored and Semi-Implantable

Feb. 1, 2017

Updated benefit considerations;

expanded list of hearing aids that may not be covered for certain benefit plans to include laser or light based hearing aids

Revised coverage rationale:

o Replaced references to “U.S. Food and Drug Administration (FDA) approved indications” with “U.S. Food and Drug

Wearable Hearing Aids (Including Non-Implantable Bone Conduction Hearing Aids Utilizing a Headband)

Hearing aids required for the correction of a hearing impairment (a reduction in the ability to perceive sound which may range from slight to complete deafness) are proven and medically necessary. Bilateral or unilateral bone-anchored hearing aids utilizing a headband (without osseointegration) are proven and medically necessary for hearing loss in a patient who is not a candidate for an air-conduction hearing aid and

when used according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings and precautions. See the FDA section of the policy for more information.



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REVISED

Hearing Aids and Devices Including Wearable, Bone-

Anchored and Semi-Implantable (continued)

Feb. 1, 2017

Administration (FDA) labeled indications, contraindications, warnings,

and precautions” o Added language to indicate:

Laser or light based

hearing aids (e.g., Earlens Contact Hearing Device) are unproven and not medically

necessary for treating hearing loss

The evidence assessing the effectiveness of this device is limited; additional studies with

larger populations and long-term follow-up are

needed to evaluate improvement of hearing with hearing aids that use light to transmit sound

Updated definitions: o Added definition of:

Conductive hearing loss Degree of hearing loss Frequency modulation

systems (auditory

trainers)

Mixed hearing loss Sensorineural hearing

loss (SNHL) o Revised definition of

“hearing aids” Updated list of applicable HCPCS

codes; revised description for L8693


Semi-Implantable Electromagnetic Hearing Aids (SEHA)

A semi-implantable electromagnetic hearing aid is proven and medically necessary for sensorineural hearing loss in a patient who is not a candidate for an air-conduction hearing aid and when used

according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings and precautions. See the FDA section of the policy for more information. Bone Anchored Hearing Aids

Implantable Bone-Anchored Hearing Aid (BAHA) for Sensorineural Hearing Loss: A unilateral implantable bone-anchored hearing aid is proven and medically necessary for sensorineural hearing loss in one ear in a

patient who is not a candidate for an air-conduction hearing aid and when used according to U.S. Food and Drug Administration (FDA) labeled indications, contraindications, warnings and precautions. See

the FDA section of the policy for more information. Unilateral or bilateral implantable bone-anchored hearing aids are proven and medically necessary for sensorineural hearing loss in

both ears when both of the following criteria are present: The poorer ear is not a candidate for an air-conduction hearing aid due to

a speech reception threshold of 70 dB or more OR a word discrimination score of less than 60%; and

The better hearing ear has a speech reception threshold of 35 dB or less and a speech discrimination score of 60% or more.

Implantable Bone-Anchored Hearing Aid (BAHA) for Conductive or

Mixed Hearing Loss: A unilateral implantable bone-anchored hearing aid is proven and medically necessary for conductive or mixed hearing loss in one or both ears in a patient who is not a candidate for an air-conduction hearing aid and when used according to U.S. Food and Drug

Administration (FDA) labeled indications, contraindications, warnings and precautions. See the FDA section of the policy for more information. Bilateral implantable bone-anchored hearing aids are proven and



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REVISED



Feb. 1, 2017

to reflect the most current description of services, clinical evidence, FDA information and

references

medically necessary for conductive or mixed hearing loss in both ears in a patient who is not a candidate for an air-conduction hearing aid and when used according to U.S. Food and Drug Administration

(FDA) labeled indications, contraindications, warnings and precautions. See the FDA section of the policy for more information. Totally Implanted Hearing Systems

Totally implanted hearing systems are unproven and not medically necessary for hearing loss. There is inadequate evidence demonstrating the efficacy of totally implanted hearing systems for treating hearing loss or deafness. Well-designed studies with larger patient populations and longer follow-up are required to

demonstrate the safety and benefits of these devices. Partially Implantable Bone Conduction Hearing Aid With Magnetic Coupling

Partially implantable magnetic bone conduction hearing devices are

unproven and not medically necessary for hearing loss. There is limited evidence to support the use of partially implantable magnetic bone conduction hearing devices to treat hearing loss. The evidence assessing the effectiveness of this device is limited to preliminary

uncontrolled studies with small populations. Additional studies with larger populations and long-term follow-up are needed to evaluate improvement of hearing with this device. See the Description of Services section of the policy for more information. Intraoral Bone Conduction Hearing Aids

An intraoral bone conduction hearing aid is unproven and not medically necessary for treating hearing loss.

There is insufficient evidence to support the use of an intraoral bone

conduction hearing aid to treat hearing loss. The quality of the studies was low due to small study populations, short follow-up, and lack of randomization and appropriate control groups. Future studies with larger populations of patients wearing the device for longer periods are needed to evaluate hearing benefits and device safety. Laser or Light Based Hearing Aids

Laser or light based hearing aids (e.g., Earlens Contact Hearing



Oxford


REVISED



Feb. 1, 2017 Device) are unproven and not medically necessary for treating hearing loss. The evidence assessing the effectiveness of this device is limited. Additional

studies with larger populations and long-term follow-up are needed to evaluate improvement of hearing with hearing aids that use light to transmit sound.

Immune Globulin (IVIG and SCIG)

Feb. 1, 2017

Revised coverage rationale: o Updated list of intravenous

(IV) and subcutaneous (SC)

immune globulin (IG) products addressed in the policy; added Cuvitru™ (SC)

o Updated medical necessity criteria for the initial treatment of chronic

inflammatory demyelinating

polyneuropathy; removed criterion requiring the below findings following lumbar puncture: White blood cell count

<10/mm3 Elevated CSF protein

o Updated medical necessity criteria for the initial treatment of multiple sclerosis, relapsing remitting (RRMS);

expanded list of agents to which the patient must demonstrate history of failure, contraindication, or intolerance to include: Glatopa (glatiramer

acetate) Lemtrada

(alemtuzumab) Ocrevus (ocrelizumab)

Refer to the policy for complete details on the coverage guidelines for Immune Globulin (IVIG and SCIG).



Oxford


REVISED

Immune Globulin (IVIG and SCIG) (continued)

Feb. 1, 2017 Plegridy (peginterferon beta-1a)


to reflect the most current clinical evidence and references


Feb. 1, 2017

Revised coverage rationale: o Updated list of drug products

addressed in the policy; added infliximab-dyyb

(Inflectra™) and ustekinumab (Stelara®)

o Added maximum dosage and National Drug Code (NDC) billing guidelines for infliximab-dyyb (Inflectra™)

and ustekinumab (Stelara®) Updated list of applicable HCPCS

codes; added J3357 and Q5102 Updated list of applicable NDCs;

added 32228-0001-01, 57894-0060-02, 57894-0060-03, and 57894-0061-03

Updated supporting information to reflect the most current CMS information and references

This policy provides information about the maximum dosage per administration for certain medications administered by a medical professional.

Drug Products bevacizumab (Avastin®) infliximab (Remicade®) infliximab-dyyb (Inflectra™) pegfilgrastim (Neulasta®) rituximab (Rituxan®)

trastuzumab (Herceptin®) ustekinumab (Stelara®)

zoledronic acid (zoledronic acid, Reclast® and Zometa®) Most medications have a maximum dosage based upon body surface area or patient weight or a set maximal dosage independent of patient body size, and are proven when used according to labeled indications or when

otherwise supported by published clinical evidence. The medications included in this policy when given beyond maximum dosages based upon body surface area or patient weight or a set maximal dosage independent of patient body size are not supported by package labeling or published clinical evidence and are not medically necessary. This policy creates an upper dose limit based on the clinical evidence and the

95th percentile for adult body weight (119 kg) and body surface area (2.45 meters2) in the U.S. (Fryar, 2012). In some cases, the maximum allowed units and/or vials may exceed the upper level limit as defined within this policy due to an individual patient body weight > 119 kg or body surface area > 2.45 meters2.

HCPCS Code Based Maximum Dosage Information



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REVISED

Maximum Dosage Policy (continued)

Feb. 1, 2017

Medication Name Maximum

Dosage Per Administratio

n

HCPCS Code

Maximum Allowed Brand Generic

Avastin bevacizumab 15 mg/kg J9035 179 HCPCS units

(10 mg per unit)

Herceptin trastuzumab 8 mg/kg J9355 95 HCPCS units (10 mg per unit)

Inflectra infliximab-dyyb

10 mg/kg Q5102 119 HCPCS units (10 mg per unit)

Neulasta pegfilgrastim 6 mg total

dose J2505

1 HCPCS unit (6 mg per unit)

Reclast zoledronic

acid 5 mg total

dose J3489

5 HCPCS units (1 mg per unit)

Remicade infliximab 10 mg/kg J1745 119 HCPCS units (10 mg per unit)

Rituxan rituximab 1,225 mg total dose

J9310 13 HCPCS units (100 mg per unit)

Stelara ustekinumab 90 mg J3357 90 HCPCS units (1 mg per unit)

Zoledronic Acid

zoledronic acid

5 mg total dose


Zoledronic Acid

zoledronic acid

4 mg total dose


Zometa zoledronic

acid 4 mg total

dose J3489

5 HCPCS units (1 mg per unit)

Maximum Allowed Quantities for National Drug Code (NDC) Billing

This information only applies to select providers billing medical claims by National Drug Code (NDC). The allowed quantities in this section are

calculated based upon both the maximum dosage information supplied within this policy as well as the process by which NDC claims are billed. This list may not be inclusive of all available NDC’s for each drug product and is subject to change.



Oxford


REVISED


Feb. 1, 2017

Medication Name How Supplied

National Drug Code

Maximum Allowed Brand Generic

Avastin Bevacizumab

100 mg/4mL

solution in vials 50242-0060-01

50242-0061-01 72 mL

400 mg/16 mL solution in

vials

Herceptin trastuzumab 440 mg

powder for reconstitution

50242-0056-56

50242-0134-68 3 vials

Inflectra infliximab-

dyyb

100 mg powder for

reconstitution 32228-0001-01 12 vials

Neulasta pegfilgrastim

6 mg/0.6 mL

prefilled syringe

54868-5229-00

55513-0190-01

0.6 mL 6 mg/0.6 mL

prefilled syringe with

on-body Injector

55513-0190-01

Reclast zoledronic

acid


vials

00078-0435-61

35356-0351-01 100 mL

Remicade infliximab 100 mg

powder for reconstitution

57894-0030-01 12 vials

Rituxan rituximab 100 mg/10

mL solution in vials

50242-0051-21 130 mL

Rituxan rituximab 500 mg/50

mL solution in vials

50242-0053-06 130 mL



Oxford


REVISED


Feb. 1, 2017

Stelara ustekinumab

45 mg/0.5 mL

prefilled syringe

57894-0060-03 0.5 mL

45 mg/0.5 mL solution in

vials

57894-0060-02 0.5 mL

90 mg/1 mL

prefilled syringe

57894-0061-03 1 mL

zoledronic acid

zoledronic acid

5 mg/100 mL

solution in vials

25021-0830-82 42023-0163-01

43598-0331-11 23155-0186-31 55111-0688-52

100 mL


vials

00143-9642-01 47335-0035-40

25021-0801-66

42023-0151-01 43598-0330-11 53150-0871-01 23155-0170-31 55111-0685-07 60505-6110-00 45963-0440-55

5 mL

4 mg/5 ml

lyophilisate for solution

for injection in vials

47335-0962-41 5 mL

4 mg/100 mL

solution in vials

25021-0826-82 100 mL

Zometa zoledronic

acid


vials 00078-0387-25 5 mL



Oxford


REVISED


Feb. 1, 2017 4 mg/100 mL

solution in vials

00078-0590-61 100 mL

Omnibus Codes

Jan. 1, 2017

Revised coverage rationale to reflect annual code edits:

o Removed language indicating the following procedures are unproven and not medically necessary:

Near-infrared spectroscopy (NIRS) for assessing tissue oxygenation in lower extremity wounds (CPT code 0286T)

Near-infrared vascular

imaging systems (e.g.,

AccuVein® AV300 or VeinViewer™) for guiding vascular access (CPT code 0287T)

Anoscopy with delivery

of thermal energy such as radio-frequency for treating fecal incontinence (CPT code 0288T)

Optical coherence

tomography (OCT),

using near-infrared light, is unproven and not medically necessary for evaluating coronary arteries (CPT codes 0291T and 0292T)

o Updated list of applicable

CPT/HCPCS codes for: Implantable cardiac

Refer to the policy for complete details on the coverage guidelines for Omnibus Codes.



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REVISED

Omnibus Codes (continued)

Jan. 1, 2017

devices for percutaneous closure (occlusion) of the left atrial appendage

(LAA) Added 33340 Removed 0281T

Cardiac contractility modulation, using an implantable device Revised description for

0418T Real time spectral analysis of prostate tissue by fluorescence spectroscopy Revised description for

0443T Dermal/skin substitutes:

PuraPly™ or PuraPly™ Antimicrobial Added Q4172 Removed C9349

o Added language to indicate

the use of suprachoroidal delivery of pharmacologic agents (CPT code 0465T) is unproven and not medically necessary


to reflect the most current

clinical evidence and references

Oxford's Outpatient Imaging Self-Referral Policy

Jan. 1, 2017

Updated list of reimbursable CPT codes: o Nephrologists:

Removed 75791 and

75978 (discontinued Jan. 1, 2017)

o Reproductive Endocrinologists,

Refer to the policy for complete details on Oxford's Outpatient Imaging Self-Referral Policy.



Oxford


REVISED

Oxford's Outpatient Imaging Self-Referral Policy

(continued)

Jan. 1, 2017 Infertility Specialists practicing within an Infertility Clinic:

Removed 77052 (discontinued Jan. 1, 2017)

o OB/GYNs: Removed 77052

(discontinued Jan. 1, 2017)

o Maternal and Fetal Medicine, Neonatal/Perinatal Medicine: Removed 77052

(discontinued Jan. 1,

2017) o Pain Management

Specialists (Physiatrists, Physical Rehabilitation Medicine, Anesthesiologists, Neurologists, and

Neurosurgeons): Revised description for

77002 and 77003 o Cardiologists - Nuclear

Medicine: Added 78492

o Cardiologists - Pediatric

only: Added 78492

o Rheumatologists: Corrected typographical

error; replaced 73502 with 73052



Oxford


REVISED


Jan. 1, 2017

Notice of Revision: The following summary of changes has been modified. Revisions to the policy

update announcement previously appearing in the Policy Update Bulletin are outlined in red below.

Please take note of the additional updates to be implemented on Jan. 1, 2017.

Revised coverage rationale/indications for coverage for Preventive vs. Diagnostic Services: o Expanded list of reasons

diagnostic services are done

to include “a person who does not fall within the

applicable population for a recommendation or guideline (e.g., someone who has a colorectal cancer screening due to a family history)”

Revised list of applicable procedure and diagnosis codes: o Removed language

addressing requirement for use of ICD-10-CM (diagnoses) and ICD-10-PCS

(inpatient procedures)

beginning October 1, 2015


Abdominal Aortic Aneurysm

Screening o Updated list of applicable

procedure codes for ultrasound screening study for abdominal aortic aneurysm:

Refer to the policy for complete details on the coverage guidelines for Preventive Care Services.



Oxford


REVISED


Jan. 1, 2017

- Added CPT code 76706 (new code effective Jan. 1, 2017)

- Removed CPT codes 76700, 76705, 76770, and 76775

- Removed HCPCS code G0389 (discontinued Jan. 1, 2017)

Chlamydia Infection Screening

o Updated list of applicable ICD-10 diagnosis codes; added Z00.121 and Z00.129

Gonorrhea Screening


Hepatitis B Virus Infection

Screening o Updated list of applicable

procedure codes for hepatitis B virus infection screening to reflect annual code edits;

added HCPCS code G0499 (new code effective Jan. 1, 2017)

HIV – Human Immunodeficiency

Virus – Screening for Adolescents and Adults

o Updated list of applicable procedure codes for HIV – human immunodeficiency virus – screening; added CPT codes 87389 and 87390


Syphilis Screening o Revised service description:



Oxford


REVISED


Jan. 1, 2017

Removed July 2004 USPSTF ‘A’ rating

Added June 2016

USPSTF ‘A’ rating: The USPSTF recommends screening for syphilis

infection in persons who are at increased risk for infection (asymptomatic, nonpregnant adults and

adolescents who are at increased risk for syphilis infection)

Added May 2009 USPSTF ‘A’ rating: The USPSTF recommends that

clinicians screen all pregnant women for

syphilis infection o Updated list of applicable

ICD-10 diagnosis codes; added Z00.121 and Z00.129

Diabetes Screening

o Updated claims edit criteria to clarify when the preventive benefit does not apply; replaced language

indicating “if a Diabetes Diagnosis Code is present in

any position, the preventive benefit will not be applied” with “if a Diabetes Diagnosis Code is present in any position, the preventive

benefit does not apply”

Screening Mammography o Updated list of applicable

procedure codes to reflect annual code edits:



Oxford


REVISED


Jan. 1, 2017

Added CPT code 77067 (new code effective Jan. 1, 2017)

Removed CPT codes 77052 and 77057 (discontinued Jan. 1,

2017)

Cholesterol Screening (Lipid

Disorders Screening) o Updated list of applicable

ICD-10 diagnosis codes for Diabetes; reformatted content/retitled sub-headers for clarity

o Updated claims edit criteria to clarify when the preventive benefit does not

apply; replaced language indicating “if any of the [listed] lipid disorders diagnosis codes are present

in any position, the preventive benefit will not be applied” with “for all ages [listed in the policy for cholesterol screening], if any of the [listed] lipid disorders

diagnosis codes are present in any position, the

preventive benefit does not apply”

Screening for Depression in

Adults o Updated list of applicable

procedure codes: Added CPT code 96127 Removed CPT code

99420 (discontinued Jan. 1, 2017)



Oxford


REVISED


Jan. 1, 2017

Depression in Children and

Adolescents (Screening) o Updated list of applicable

procedure codes: Added CPT code 96127 Removed CPT code

99420 (discontinued Jan.

1, 2017)

Behavioral Counseling in Primary Care to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease

Prevention in Adults with Cardiovascular Risk Factors o Updated list of applicable

ICD-10 diagnosis codes for Diabetes; reformatted

content/retitled sub-headers for clarity

Formal Developmental/Autism Screening (Bright Futures) o Revised service description;

replaced language indicating

“a formal, standardized autism screen is recommended during the 9 month visit” with “a formal, standardized developmental screen is recommended

during the 9 month visit”

Preventive Immunizations

Meningococcal

o Updated list of applicable procedure codes to reflect annual code edits; revised description for CPT code 90734

Seasonal Influenza (‘Flu’)

o Updated list of applicable



Oxford


REVISED


Jan. 1, 2017

procedure codes to reflect annual code edits: Added CPT code 90682

(new code effective Jan. 1, 2017)

Revised description for

CPT codes 90655, 90656, 90657, 90658, 90661, 90685, 90686, 90687, and 90688

Revised description for HCPCS code Q2039; removed benefit age limit of 3 years of age and older

o Revised benefit guidelines

for CPT codes 90686 and 90688 to reflect Nov. 2016

FDA update: Changed trade name

from “Flulaval®” to “FluLaval Quadrivalent®”

Changed benefit age

limit from “3 years and up” to “6 months and up”

Diphtheria, tetanus toxoids,

acellular pertussis, haemophilus influenza B, and polio inactive

(DTap-IPV/Hib) o Updated list of applicable

procedure codes to reflect annual code edits; revised description for CPT code

90698

Expanded Women’s Preventive Health

Contraceptive Methods (Including Sterilizations)



Oxford


REVISED


Jan. 1, 2017

o Updated list of applicable procedure codes to reflect annual code edits:

Code Group 1/Contraceptive Methods: Revised

description for HCPCS code J7297; replaced “IUD (other)” with “IUD (Liletta®)”

Code Group 2/IUDs: Added description to identify J7298 as “Mirena®”

Updated list of applicable ICD-10 diagnosis codes for Code Group

2/ Contraceptive Management; removed Z30.011 and Z30.41

(pharmacy items)

Probuphine® (Buprenorphine)

Feb. 1, 2017

Revised coverage rationale; updated coverage criteria for maintenance treatment of opioid

dependence: o Expanded documentation

submission requirements for continuation therapy with Probuphine; added criterion requiring “patient is participating in behavioral

therapy/peer support program”

Probuphine (buprenorphine) subdermal implant is proven and medically necessary for:

The maintenance treatment of opioid dependence in patients who meet all of the following criteria:

Patient has achieved and sustained prolonged clinical stability on transmucosal buprenorphine; and

Patient is currently maintained on a dose of 8mg per day or less of sublingual or transmucosal buprenorphine product equivalent [e.g., Subutex 8 mg or less, Suboxone (or generic equivalent) 8 mg/2 mg or

less, Bunavail 4.2 mg/0.7 mg or less, or Zubsolv 5.7 mg/1.4 mg or less]; and

Patient has been on a stable sublingual or transmucosal buprenorphine dose for six months or longer without any need for supplemental dosing or adjustments; and

Prescriber meets DATA 2000 requirements and has been assigned a

unique identification number specific to the prescription of medication assisted therapy (DEA-X); and

Prescriber and/or the healthcare provider performing insertion has successfully completed a live training program specific to Probuphine



Oxford


REVISED

Probuphine® (Buprenorphine) (continued)

Feb. 1, 2017

insertion; and Submission of medical records (e.g., chart notes, laboratory values)

documenting one of the following:

o Initial therapy with Probuphine when meeting all of the following:

Patient has a viable site for implant on the upper arm (inner side

of the upper arm about 8-10 cm (3-4 inches) above the medial epicondyle of the humerus in the sulcus between the biceps and triceps muscle).

Patient is participating in behavioral therapy/peer support

program. Patient will not be receiving supplemental sublingual or

transmucosal buprenorphine. Patient has not had an opioid-positive urine drug screen within

the previous ninety days prior to insertion.* or

o Continuation therapy with Probuphine when meeting all of the following:

Patient has only had one Probuphine implant and has a viable, unused site in the contralateral arm.

Patient is participating in behavioral therapy/peer support program.

Probuphine is not being inserted into a previously used arm or

insertion site. Probuphine is only to be used in a maximum of 2 insertions (once

in each arm). Patient shows no evidence of tampering, extraction, or attempted

removal of the previous Probuphine implant. Patient has not had an opioid-positive urine drug screen since

starting Probuphine therapy.*

*Note: Patients screening positive for opioid use outside of an opioid

dependence treatment regimen is evidence that the patient has not achieved or is no longer in sustained, prolonged, clinical stability with their treatment program. Use of Probuphine is not indicated in this population. Patients should use sublingual or transmucosal buprenorphine until the patient can achieve sustained, prolonged, clinical stability on a low-to-moderate dose (i.e., doses of no more

than 8 mg per day of Subutex or Suboxone sublingual tablet or generic equivalent).



Oxford


REVISED

Probuphine® (Buprenorphine) (continued)

Feb. 1, 2017

Probuphine is unproven and not medically necessary for: Pain management Patients who have not achieved and sustained prolonged clinical stability

and tolerance to opioids for at least six months Patients who are maintained on sublinqual or transmucosal

buprenorphine at doses greater than 8 mg per day Patients who are not participating in a treatment program that includes

counseling and psychosocial support Patients who are recently tapered to a lower dose of sublingual or

transmucosal buprenorphine for the sole purpose of transitioning to Probuphine

Patients who are new entrants to opioid dependence treatment Patients who have already had one insertion in each arm Patient who do not have viable sites for insertion in the upper arm

Patients who have an opioid-positive urine drug screen within the previous ninety days

Patient is currently being treated for chronic pain requiring opioids

Prosthetic Devices, Wigs, Specialized,

Microprocessor or Myoelectric Limbs

Feb. 1, 2017

Revised coverage rationale/indications for

coverage: o Updated coverage guidelines

for Prosthetic Devices and Wigs: Reorganized language

pertaining to breast prosthesis covered by

the Women’s Health and Cancer Act of 1998

Added language to clarify manufactured prosthetic devices must be approved by the Food and Drug Administration

(FDA) and otherwise generally considered to be safe and effective for the purposes intended and the item must be

Prosthetic Devices and Wigs

A determination of coverage for the prosthesis is based on the member’s potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, and treating physician, considering factors including, but not limited to:

o The member’s past history (including prior prosthetic use if applicable); and

o The member’s current condition including the status of the residual limb and the nature of other medical problems.

Prosthetic device coverage is limited to those prosthetic devices that replace a limb or external body part that are listed below:

o Artificial arms, legs, feet and hands. o Artificial eyes, ears and nose. o Benefits include breast prosthesis, mastectomy bras and

lymphedema stockings for the arm. These items are always covered on an unlimited basis as to number of items and dollar amounts covered as required by the Women’s Health and Cancer Act of 1998.

o Speech aid prosthetics and tracheo-esophageal voice prosthesis.

Although these are typically external devices replacing the vocal cords, there may be an intra-oral component. These devices are covered as either DME or Prosthetics. Please check the member



Oxford


REVISED

Prosthetic Devices, Wigs, Specialized, Microprocessor or

Myoelectric Limbs (continued)

Feb. 1, 2017

reasonable and necessary for the individual member

Replaced language indicating “coverage is available for repair and

replacement, when it is not due to misuse, malicious damage, or gross neglect” with

“coverage is available for repair and replacement, when it is not due to theft, loss, misuse, malicious damage or gross neglect”

o Updated coverage criteria for Specialized,

Microprocessor or Myoelectric Limbs: Added language to

indicate: - Lower extremity

specialized computerized or microprocessor limbs are based on a patient’s current functional

capabilities and

his/her expected functional rehabilitation potential

- Microprocessor-controlled prosthesis

in limited community ambulators (K2) and next-generation

specific benefit plan document for coverage. Prosthetic devices when covered, regardless of the setting or vendor

from whom the prosthetic device is dispensed, are covered under the

Prosthetic Devices section of the benefit document. Prosthetic devices must be ordered by or under the direction of a

physician.

Manufactured prosthetic devices must be approved by the Food and Drug Administration (FDA) and otherwise generally considered to be safe and effective for the purposes intended and the item must be reasonable and necessary for the individual patient.

Implantable devices/prostheses, such as artificial heart valves, are not prosthetics. If covered, these devices would be covered as a surgical service.

Coverage is available for repair and replacement, when it is not due to theft, loss, misuse, malicious damage or gross neglect.

Several states mandate coverage for prosthetics. Please check the

member specific benefit plan document for coverage.

Specialized, Microprocessor or Myoelectric Limbs

Computerized, bionic, microprocessor or myoelectric terms are considered the same for the purpose of this policy. Some states may require coverage of prosthetics that Oxford may not otherwise consider covered. Lower Extremity Specialized, computerized or microprocessor limbs are based on a patient’s current functional capabilities and his/her expected

functional rehabilitation potential. If more than one prosthetic limb meets a patient’s prosthetic rehabilitation needs, the least costly prosthetic will be approved.

Evidence is insufficient to permit conclusions regarding the effect of a microprocessor-controlled prosthesis on health outcomes in limited community ambulators (K2). Evidence is also insufficient to permit

conclusions regarding the effect of a next-generation microprocessor-controlled prosthesis on health outcomes. Therefore, these are considered investigational and not covered.

Prosthetic limbs are a covered health service when criteria are met: Ordered by a physician; and Patient is evaluated for his/her individual needs by a healthcare



Oxford


REVISED



Feb. 1, 2017

microprocessor-controlled prosthesis are considered

investigational and not covered due to insufficient evidence

regarding the effect on health outcomes

Replaced language indicating “computerized

prosthetic limbs are a covered health service when criteria are met” with “prosthetic limbs are a covered health service when criteria are

met” Modified language

pertaining to maximum prosthetic function level of the member for coverage of computerized and

specialized lower limb prostheses; replaced criterion requiring “Lower Limb Rehabilitation Classification Levels 3-4

for prosthetic

ambulation” with “Lower Limb Rehabilitation Classification Levels 2-4 for prosthetic ambulation”

o Updated and reformatted

coverage criteria/list of applicable HCPCS codes for prosthetic limbs:

professional with the qualifications and training and under the supervision of the ordering physician to make an evaluation (documentation should accompany the order); and

Ordering physician signs the final prosthetic proposal; and The records must document the member’s current functional capabilities

and his/her expected functional rehabilitation potential, including an

explanation for the difference, if that is the case. (It is recognized within the functional classification hierarchy that bilateral amputees often cannot be strictly bound by functional level classifications); and

Prosthetic replaces all or part of a missing limb; and

Prosthetic will help the patient regain or maintain function; and Member is willing and able to participate in the training for the use of the

prosthetic (especially important in use of a computerized upper limb); and

Member is able to physically function at a level necessary for a computerized prosthetic or microprocessor, e.g., hand, leg or foot.

Coverage of computerized and specialized lower limb prostheses is based on

maximum prosthetic function level of the patient (see Lower Limb Rehabilitation Classification Levels 1-4 in the Definitions section of the policy).

Member meets criteria for prosthetic limbs above; and Member has or is able to gain Lower Limb Rehabilitation Classification

Levels 2 - 4 for prosthetic ambulation (see the Definitions section of the policy).

HCPCS Code Functional Level Criteria

Ankles

L5982 Lower Limb Rehabilitation Classification is 2 or above




Knees

Note: Basic lower extremity prostheses include a single axis, constant friction knee. Other prosthetic knees are indicated based upon functional classification.

L5610 Functional level is 3 or above



Oxford


REVISED



Feb. 1, 2017

Changed functional level for L5978 (microprocessor or

specialized foot or feet) from “3 or above” to “2 or above”

Removed functional level listing for L5973, L5976, L5979, L5980, L5981, and L5987 (ankles)

Removed reference to specific product name (i Ottobock C-Leg®) for L5930 (knees)

Itemized code ranges; replaced:

- “L5722-L5780” with “L5722, L5724,

L5726, L5728, and L5780” (knees)

- “L5822-L5840” with “L5822, L5824, L5826, L5828,

L5830, and L5840” (knees)

- “L5982-L5986” with “L5982, L5984, L5985, and L5986” (ankles)

- “L5618-L5628” with

“L5618, L5620, L5622, L5624, L5626, and L5628” (sockets)

- “L5654-L5665” with “L5654, L5655,

L5656, L5658, L5661, and L5665” (sockets)



















L5859

Meets all of the criteria below:

Has a microprocessor [swing and stance phase type (L5856)] controlled (electronic) knee

K3 functional level only

Weight greater than 110 lbs. and less than 275 lbs

Has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps function that impairs K-3 level function with the use of a microprocessor-controlled knee alone

Is able to make use of a product that requires daily charging

Is able to understand and respond to error alerts and alarms indicating problems with the function of



Oxford


REVISED



Feb. 1, 2017

o Replaced language indicating myoelectric upper limbs (arms, joints and hands) are

covered when: “The remaining

musculature of the

arm(s) contains the minimum microvolt threshold to allow operation of a

myoelectric prosthetic device (usually 3-5 muscle groups must be activated to use a computerized arm/hand)” with “the

remaining musculature of the arm(s) contains

the minimum microvolt threshold to allow operation of a myoelectric prosthetic device (usually 3-5

muscle groups must be activated to use a computerized arm/hand), no external switch”

“A standard body-

powered prosthetic

device cannot be used or is insufficient to meet the functional needs of the individual in performing activities of daily living” with “A

standard passive or body-powered prosthetic device cannot be used or

the unit

L5930 Functional level is 4

Microprocessor or Specialized Foot or Feet

Note: A user adjustable heel height feature (L5990) will be denied as not meeting criteria for coverage.








Sockets

Note:

Exception: A test socket is not indicated for an immediate prosthesis

(L5400-L5460). Socket replacements are indicated if there is adequate

documentation of functional and/or physiological need. It is recognized that there are situations where the explanation includes but is not limited to: o Changes in the residual limb;

o Functional need changes; o Or irreparable damage or wear/tear due to excessive member

weight or prosthetic demands of very active amputees.

L5618

More than 2 test (diagnostic) sockets for an individual

prosthesis are not indicated unless there is documentation in the medical record which justifies the need

L5620



L5622 More than 2 test (diagnostic) sockets for an individual prosthesis are not indicated unless there is documentation in the medical record which justifies the



Oxford


REVISED



Feb. 1, 2017

is insufficient to meet the functional needs of the individual in

performing activities of daily living (ALD’s)”

Updated definitions; revised

definition of “microprocessor controlled lower limb prostheses”

and “upper limb prosthetic categories”

Updated list of applicable HCPCS codes; revised description for L5312, L6696, L6697, L6715, L6880, L8015, L8030, L8032, L9900, S8420, S8421, and V2628


references

need

L5624



L5626



L5628

More than 2 test (diagnostic) sockets for an individual prosthesis are not indicated unless there is documentation in the medical record which justifies the need

L5654 No more than two of the same socket inserts are allowed per individual prosthesis at the same time

L5655 No more than two of the same socket inserts are

allowed per individual prosthesis at the same time





L5673 No more than two of the same socket inserts are

allowed per individual prosthesis at the same time




Myoelectric Upper Limbs (arms, joints and hands) are covered when criteria



Oxford


REVISED



Feb. 1, 2017

are met: Member meets all the criteria for prosthetic limbs above; and Member has a congenital missing or dysfunctional arm and/or hand; or

Member has a traumatic or surgical amputation of the arm (above or below the elbow); and

The remaining musculature of the arm(s) contains the minimum

microvolt threshold to allow operation of a myoelectric prosthetic device (usually 3-5 muscle groups must be activated to use a computerized arm/hand), no external switch; and

A standard passive or body-powered prosthetic device cannot be used or

is insufficient to meet the functional needs of the individual in performing activities of daily living (ADLs).

Coverage Limitations and Exclusions

Coverage for wigs/scalp hair prosthesis is excluded unless specifically listed as a covered health service. Some states mandate coverage. Check the member specific benefit document for coverage. When wigs are

covered, the benefit does not include coverage for hair implants or hair plugs.

Coverage is not available for prosthetics if the patient is eligible through a governmental program for a prosthetic due to military service related injuries and/or primary insurance coverage, e.g., VA, Medicare or TriCare.

Replacement of prosthetic devices due to misuse, malicious damage or gross neglect or to replace lost or stolen items (check the member

specific benefit document). Repairs to prosthetic devices due to misuse, malicious damage or gross

neglect (check the member specific benefit plan document). If more than one prosthetic device can meet the member’s functional

needs, benefits are only available for the prosthetic device that meets the minimum specifications for the member’s needs (check the member specific benefit plan document).

Coverage beyond any dollar or frequency limits specified in the member’s specific benefit documents (check the member specific benefit plan document).



Oxford


REVISED

Repository Corticotropin Injection (H.P.

Acthar Gel®)

Feb. 1, 2017

Revised conditions of coverage/precertification requirements to indicate

precertification with medical director review is required

Updated benefit considerations:

o Added language to indicate the member specific benefit plan document must be consulted to make coverage

decisions for experimental/investigational treatments for life-threatening illnesses when certain conditions are met

o Replaced language

indicating: “Some states mandate

benefit coverage for off-label use of medications for some diagnoses or under some circumstances” with

“some states mandate benefit coverage for off-label use of medications for some diagnoses or under some circumstances when

certain conditions are

met” “Some states also

mandate usage of other Compendium references; where such mandates apply, they supersede

language in the benefit document or in the coverage criteria” with

H.P. Acthar Gel (repository corticotropin injection is proven and medically necessary for the treatment of:

Infantile spasm (i.e., West Syndrome) for up to 4 weeks when all

of the following criteria are met: o Diagnosis of infantile spasms (i.e., West Syndrome); and

o Patient is less than 2 years old; and o H.P Acthar Gel dosing for infantile spasm is as follows:

Initial dose: 75 U/m2 intramuscular (IM) twice daily for 2 weeks After 2 weeks, dose should be tapered according to the following

schedule: 30 U/m2 IM in the morning for 3 days; 15 U/m2 IM in the morning for 3 days; 10 U/m2 IM in the morning for 3 days; and 10 U/m2 IM every other morning for 6 days (3 doses)

Opsoclonus-myoclonus syndrome (i.e., OMS, Kinsbourne Syndrome)

H.P Acthar Gel is not medically necessary for treatment of acute exacerbations of multiple sclerosis. Published clinical evidence does not

demonstrate superiority of Acthar to other available corticosteroids.

Although FDA labeling suggests that H.P. Acthar may be used in the following conditions, it is not FDA indicated. H.P. Acthar Gel is unproven and not medically necessary for treatment of the following disorders and diseases: Rheumatic disorders: psoriatic arthritis, rheumatoid arthritis, including

juvenile rheumatoid arthritis, ankylosing spondylitis Collagen diseases: systemic lupus erythematosus, systemic

dermatomyositis (polymyositis) Dermatologic diseases: severe erythema multiforme, Stevens-Johnson

syndrome Allergic states: serum sickness Ophthalmic diseases: severe acute and chronic allergic and inflammatory

processes involving the eye and its adnexa such as keratitis, iritis, iridocyclitis, diffuse posterior uveitis and choroiditis, optic neuritis, chorioretinitis, anterior segment inflammation

Respiratory diseases: symptomatic sarcoidosis Edematous state: to induce a diuresis or a remission of proteinuria in the

nephrotic syndrome without uremia of the idiopathic type or that due to lupus erythematosus



Oxford


REVISED

Repository Corticotropin Injection (H.P.

Acthar Gel®) (continued)

Feb. 1, 2017 “where such mandates apply, they supersede language in the benefit

document or in the medical or drug policy”

Updated coverage guidelines:

o Removed statement describing services addressed in the policy

o Added language to clarify

although FDA labeling suggests that H.P. Acthar may be used for the listed unproven/not medically necessary indications, it is not FDA indicated for these

disorders and diseases Updated supporting information

to reflect the most current references

Any indication outside of the medically necessary indications above

Specialty Medication

Administration - Site of Care Review Guidelines

Feb. 1, 2017

Updated list of related policies: o Added reference link to

policy titled Exondys 51™ (Eteplirsen)

o Removed reference link to policy titled Skilled Care and Custodial Care Services

Revised coverage rationale; expanded list of specialty

medications requiring healthcare provider administration to include eteplirsen (Exondys 51™)

Introduction

This policy addresses the criteria for consideration of allowing hospital outpatient facility specialty medication infusion services. This includes claim submission for hospital based services with the following CMS/AMA Place of

Service codes: 22 On Campus - Outpatient Hospital; and 19 Off Campus - Outpatient Hospital. Alternative sites of care, such as non-hospital outpatient infusion, physician

office, ambulatory infusion or home infusion services are well accepted places of service for medication infusion therapy. If a patient does not meet

criteria for outpatient hospital facility infusion, alternative sites of care may be used. This policy applies to these specialty medications that require healthcare provider administration: Abatacept (Orencia®)

Eculizumab (Soliris®)



Oxford


REVISED

Specialty Medication Administration -

Site of Care Review Guidelines (continued)

Feb. 1, 2017 Eteplirsen (Exondys 51™) Golimumab (Simponi® Aria™) Infliximab (Remicade® lyophilized concentrate for intravenous use)

Infliximab-dyyb (Inflectra™) Tocilizumab (Actemra® injection for intravenous use) Vedolizumab (Entyvio®)

Review Criteria for Site of Care Selection

Outpatient hospital facility-based intravenous medication infusion is medically necessary for Members who meet any of the following criteria: Medically unstable based upon submitted clinical history

Initial medication infusion of or re-initiation after more than 6 months following discontinuation of therapy

Previous experience of a severe adverse event following infusion. Examples include but are not limited to anaphylaxis, seizure, thromboembolism, myocardial infarction, renal failure.

Continuing experience of adverse events that cannot be mitigated by pre-medications; or

Physically and/or cognitively impaired and no home caregiver available Additional Information

Medical necessity criteria for administration of intravenous infusion therapy at home are addressed in MCG™ Care Guidelines, 20th edition, 2016, Home Infusion Therapy, CMT: CMT-0009(SR).

Stelara®

(Ustekinumab)

Feb. 1, 2017

Changed policy title; previously titled Stelara® (Ustekinumab) Injection for Intravenous

Infusion Updated list of related policies;

added reference link to policy titled Maximum Dosage Policy

Reformatted and revised coverage rationale: o Removed language

indicating Stelara (ustekinumab) injection is for intravenous infusion only

This policy refers to Stelara (ustekinumab) injection for intravenous infusion.

Stelara is proven and medically necessary for the treatment of: Crohn’s disease when all of the following criteria are met:

o Diagnosis of moderately to severely active Crohn’s disease; and o One of the following:

History of failure, contraindication, or intolerance to at least one tumor necrosis factor (TNF) blocker [e.g., Remicade/Inflectra (infliximab), Humira (adalimumab), Cimzia (certolizumab)]; or

Both of the following: - History of failure, contraindication, or intolerance to at least

one immunomodulator or corticosteroid (e.g.,



Oxford


REVISED

Stelara®

(Ustekinumab) (continued)

Feb. 1, 2017

o Updated coverage guidelines for treatment of Crohn’s disease:

Modified coverage criteria for initial therapy:

- Expanded list of

drugs that cannot be received in combination with Stelara; added

phosphodiesterase 4 (PDE4) inhibitor [e.g., Otezla (apremilast)]

- Removed language

indicating

maintenance doses are to be self-

administered subcutaneously and obtained under the pharmacy benefit

Added coverage criteria for continuation therapy to indicate:

- Patient is unable to self-administer subcutaneous doses;

and - Stelara is to be

subcutaneously administered 8

weeks after the initial intravenous dose; and

- Stelara continuation dosing is in accordance with the

corticosteroids, 6-mercaptopurine, azathioprine, methotrexate, etc.)

- Patient has never failed a TNF blocker [e.g.,

Remicade/Inflectra (infliximab), Humira (adalimumab), Cimzia (certolizumab)]

and

o Stelara is to be administered as an intravenous induction dose; and o Stelara induction dosing is accordance with the United States Food

and Drug Administration approved labeled dosing for Crohn’s disease:

260mg for patients weighing ≤55kg 390mg for patients weighing >55kg to ≤85kg 520mg for patients weighing >85kg

and o Patient is not receiving Stelara in combination with any of the

following:

Biologic DMARD [e.g., Remicade/Inflectra (infliximab), Humira (adalimumab), Cimzia (certolizumab), Simponi (golimumab)]

Janus kinase inhibitor [e.g., Xeljanz (tofacitinib)]

and o Authorization will be for one induction dose

Plaque psoriasis when all of the following criteria are met:

o Diagnosis of moderate to severe plaque psoriasis; and o One of the following:

Patient is a candidate for phototherapy Patient is a candidate for systemic therapy and

o Patient is unable to self-administer subcutaneous doses; and

o Stelara is initiated and titrated according to US Food and Drug

Administration labeled dosing for plaque psoriasis up to a maximum of (or equivalent dose and interval schedule): 45mg every 12 weeks for patients weighing ≤100kg

subcutaneously 90mg every 12 weeks for patients weighing >100kg

subcutaneously

and o Patient is not receiving Stelara in combination with any of the

following:



Oxford


REVISED

Stelara®

(Ustekinumab) (continued)

Feb. 1, 2017

United States Food and Drug Administration

approved labeled dosing for Crohn’s disease: 90mg every

8 weeks subcutaneously; and

- Patient is not receiving Stelara in

combination with any of the following: Biologic DMARD

[e.g., Remicade/Inflectra (infliximab),

Humira (adalimumab),

Cimzia (certolizumab), Simponi (golimumab)]

Janus kinase

inhibitor [e.g., Xeljanz (tofacitinib)]16

Phosphodiesterase 4 (PDE4) inhibitor [e.g.,

Otezla

(apremilast)]

Biologic DMARD [e.g., Enbrel (etanercept), Humira (adalimumab), Cimzia (certolizumab), Simponi (golimumab)]

Janus kinase inhibitor [e.g., Xeljanz (tofacitinib)]

Phosphodiesterase 4 (PDE4) inhibitor [e.g., Otezla (apremilast)] Psoriatic arthritis when all of the following criteria are met:

o Diagnosis of psoriatic arthritis; and

o Stelara is initiated and titrated according to US Food and Drug Administration labeled dosing for psoriatic arthritis up to a maximum of 90mg every 12 weeks subcutaneously (or equivalent dose and interval schedule); and

o Patient is unable to self-administer subcutaneous doses; and o Patient is not receiving Stelara in combination with any of the

following: Biologic DMARD [e.g., Enbrel (etanercept), Humira

(adalimumab), Cimzia (certolizumab), Simponi (golimumab)] Janus kinase inhibitor [e.g., Xeljanz (tofacitinib)]

Phosphodiesterase 4 (PDE4) inhibitor [e.g., Otezla (apremilast)]

Stelara is unproven and not medically necessary for the treatment of: Multiple sclerosis In available studies, ustekinumab does not demonstrate efficacy in the

treatment of multiple sclerosis.



Oxford

Policy Title Effective Date Summary of Changes Administrative Guidelines

UPDATED

Acquired Rare Disease Drug

Therapy Exception Process

Jan. 1, 2017


new template (no change to policy guidelines)


member specific benefit plan document and any federal or state mandates, if applicable,

before using this policy

After receiving a request for experimental treatment of an acquired rare disease, an Oxford Medical Director will review the relevant clinical and

patient information. As part of that review, the Medical Director, in his/her discretion, will determine whether the disease is an acquired rare disease and whether the proposed drug therapy is clinically reasonable.

For purposes of this policy, clinically reasonable means: The drug is FDA approved and is not contraindicated for the proposed

use.

There is evidence of early success with the drug therapy and at least a small number of patients with the same acquired rare disease have responded to treatment but there is not enough information to have a peer review published study at this time.

The evidence showing early success is from a Center of Excellence which treats members with the same acquired rare disease.

The benefit likely exceeds the risk to the member in receiving the drug therapy.

The treatment results will be available for use by the medical community by establishment of a patient registry to evaluate the effectiveness of the drug therapy for patients with this acquired rare disease.

The member has not failed a previous course or trial of the drug therapy. The member does not have any other comorbidity which would preclude

the proposed drug therapy. The member has signed an informed consent. The Medical Director will consult with the specialist who has received early success with use of the proposed treatment if possible and/or an outside consultant. The specialist/consultant must have credentials in the specific discipline of medicine that treats the member's acquired rare disease. That

specialist or consultant will be asked to certify that the basis of the medical documents submitted that: The member has an acquired rare disease. There have not been, and are not likely to be in the period of time during

which the member must be treated, either clinical trials or articles published in the peer reviewed medical literature showing that the

proposed treatment is likely to benefit patients who have the specific rare disease.

The requested drug therapy protocol is clinically reasonable to treat the member's acquired rare disease, with stated rationales that support that



Oxford


UPDATED

Acquired Rare Disease Drug Therapy Exception

Process (continued)

Jan. 1, 2017

conclusion. Based on the consultant's opinion, the benefits of the treatment are likely

to outweigh the risks of treatment.

The specialist/consultant has treated patients with this condition. Precertification will be required for each course of drug therapy. If the

member does not respond to the initial prescribed course of drug therapy, Oxford will not continue to approve the therapy and the therapy will be denied as an unproven therapy. Documentation

The following documentation must be submitted to Oxford demonstrating the

criteria below have been satisfied. Without all such documentation, Oxford will deny any such request. Necessary Information

The following supporting documentation must be provided by the member

and/or the member's provider for consideration of the drug therapy: Certification from the member's attending physician* which includes:

o A statement that the member has an acquired rare disease. o A statement of the evidence relied upon to recommend the proposed

drug therapy and a statement of why any standard therapy available would not be beneficial, would be ineffective or would be inappropriate, including an assessment of the risks and benefits of the proposed treatment.

o A copy of any available medical and scientific evidence, upon which the attending physician based his recommendation for the proposed

treatment.

*The attending physician must be a board certified or board eligible physician qualified to practice in the area of practice appropriate to treat the member's condition. A written description of the proposed treatment (or protocol if available),

which must include: o Specific goals o A rationale and background for the plan o Criteria for patient selection o Specific directions for administering the therapy



Oxford


UPDATED

Acquired Rare Disease Drug Therapy Exception

Process (continued)

Jan. 1, 2017 o Specific directions for the monitoring of patients o A definition of quantitative measures for determining treatment or

intervention response

o Methods for documenting and treating adverse reactions to the treatment or intervention

A copy of the member's informed consent form. A copy of the member's medical and treatment records, including results

of tests or studies, showing the member's current condition and any treatment the member has received for the condition.

The available clinical or pre-clinical data that indicate the effectiveness of the proposed drug therapy for treatment of the member's condition and the contact information for the specialist who can discuss the evidence of early success of the drug therapy with an Oxford Medical Director.

Depending upon the nature of the proposed drug therapy and/or the member's disease, the specialist/consultant or Oxford may require

additional documentation to review the requested therapy.

Oxford will also accept and consider any additional pertinent clinical documentation, peer review publications and/or relevant data concerning the protocol that the member and/or the member's physician would like to provide in support of the request for the drug therapy.

Transportation

Services

Jan. 1, 2017


policy; transferred content to new template (no change to coverage rationale or lists of applicable codes)

Note: Refer to the Ambulance policy for additional information regarding the

reimbursement of ambulance transportation services. Emergency Transportation

Land Transportation

Coverage includes emergency ambulance transportation by a licensed

ambulance service from the location of the sudden illness or injury, to the nearest hospital where services can be performed.

Emergency transportation to an acute care hospital and/or hospital emergency facility does not require notification, precertification or certification.

Air Transportation

Precertification with review by a Medical Director or their designee is required

for all air transportation. In the event precertification is not feasible due to



Oxford


UPDATED

Transportation Services (continued)

Jan. 1, 2017

time constraints related to medical emergencies, Oxford will require review of clinical notes post service and prior to payment.

As a general guideline, when it would take a ground ambulance 30-60 minutes or more to transport an member whose medical condition at the time of pick-up required immediate and rapid transport due to the nature

and/or severity of the member’s illness/injury, air transportation may be appropriate.

Criteria

Air ambulance transportation should meet the following criteria: The patient’s destination is an acute care hospital, and

The patient’s condition is such that the ground ambulance (basic or advanced life support) would endanger the member’s life or health, or

Inaccessibility to ground ambulance transport or extended length of time required to transport the patient via ground ambulance transportation could endanger the member, or

Weather or traffic conditions make ground ambulance transportation impractical, impossible, or overly time consuming.

Non-emergency Transportation

Coverage includes non-emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance), between health care facilities when the ambulance transportation is any of the following: From a non-network hospital to a network hospital To a hospital that provides a required higher level of care that was not

available at the original hospital

To a more cost-effective acute care facility From an acute facility to a sub-acute setting

Precertification with review by a Medical Director or their designee is required for all non-emergent transportation and is covered only when the member’s specific benefit document includes coverage for non-emergent ambulance/transportation and/or coverage is required due to federal or state

mandates. Out-of-Country Transportation

When a member has traveled outside of the United States, Mexico, Canada and the U.S. Territories, emergency transportation to the nearest hospital



Oxford


UPDATED

Transportation Services (continued)

Jan. 1, 2017 and/or hospital emergency facility does not require notification, precertification or certification. However, Oxford should be notified of an admission within 48 hours or as soon as possible, consistent with the

member's certificate. All requests for any other out-of-the-country transportation, including

repatriation, require precertification and Medical Director review. Refer to the policy titled Emergency Room Visits (Including Coverage for Members Outside of the United States for additional information on coverage

for services received outside of the United States, Mexico, Canada, and the U.S. Territories.



Oxford

Policy Title Effective Date Summary of Changes Reimbursement Guidelines

UPDATED

Physician Extenders

Jan. 1, 2017


new template (no change to policy guidelines)

Oxford does not require a Primary Care Provider (PCP) referral for services rendered by a Physician Extender who is employed by or works under

supervision of the member’s PCP and/or OBGYN. Precertification is required for: Physician Extenders used as Assistant Surgeons. Refer to the Assistant

Surgeon Policy. Midwives performing home births.

Oxford makes payment for Physician Assistant, Nurse Practitioner, Certified Nurse Midwife, Registered Nurse First Assistant, and Clinical Nurse Specialist services directly to the provider (Physician Extender). Oxford makes payment to the Anesthesiologist for services rendered by their Certified Registered Nurse Anesthetist or Anesthesia Assistant.

Certified Nurse Midwife (CNM)

Certified Nurse Midwives are subject to the same processing guidelines for

non-surgical services as OB/GYNs. The SB modifier: Is used to designate the Certified Nurse Midwife. Allows payment to be made at *100% of the allowable amount for

services rendered by a Certified Nurse Midwife. Exception: Drugs (including vaccines, flu shots, antibiotics, etc) and

devices are reimbursed at *100% of the allowable amount. Certified Registered Nurse Anesthetist (CRNA) and/or Anesthesia Assistant (AA)

Anesthesiologists must bill for their Certified Registered Nurse Anesthetist and/or Anesthesia Assistant.

The QX or QY modifiers: Are used to designate the Certified Registered Nurse Anesthetist or

Anesthesia Assistant. Allow payment to be made at *50% of the allowable amount for services

provided by a Certified Registered Nurse Anesthetist or Anesthesia Assistant.



Oxford


UPDATED

Physician Extenders (continued)

Jan. 1, 2017

Clinical Nurse Specialist (CNS)

Other names for Clinical Nurse Specialists: Nurse Practitioner (NP) Advanced Practice Registered Nurse (APRN)

Non-Surgical Services

The modifier NP: Is used to designate the Clinical Nurse Specialist for non-surgical

services. Allows payment for non-surgical Clinical Nurse Specialist services to be

made at: o For CT: *65% of the allowable amount o For NY and NJ: *85% of the allowable amount Exception: Drugs (including vaccines, flu shots, antibiotics, etc.) and devices are reimbursed at *100% of the allowable amount.

Surgical Services

The modifier AS: Is used to designate the Clinical Nurse Specialist as an assistant surgeon.

Exception: For Clinical Nurse Specialists associated with Columbia Advanced Practice Nurse Association (CAPNA), the modifier AL is used in place of the AS modifier.

Allows payment for surgical Clinical Nurse Specialist services to be made at *14% of the allowable amount.

All rules for Assistant Surgeons apply to Clinical Nurse Specialists. Refer

to the Assistant Surgeon Policy. Nurse Practitioner (NP)

Other names for Nurse Practitioners:

Nurse Practitioner(NP) Advanced Practice Registered Nurse (APRN) Behavioral Health Clinical Nurse Specialist (BHCNS) Note: In CT, members may designate a participating Nurse Practitioner as

their PCP. Non-Surgical Services

The modifier NP:



Oxford


UPDATED


Jan. 1, 2017

Is used to designate the Nurse Practitioner for non-surgical services. Allows payment for non-surgical Nurse Practitioner services to be made

at:

o For CT: *65% of the allowable amount o For NY and NJ: *85% of the allowable amount Exception: Drugs (including vaccines, flu shots, antibiotics, etc.) and

devices are reimbursed at *100% of the allowable amount. Surgical Services

The modifier AS: Is used to designate the Nurse Practitioner as an Assistant Surgeon. Allows payment for surgical Nurse Practitioner services to be made at

*14% of the allowable amount. All rules for Assistant Surgeons apply to Nurse Practitioners. Refer to the

Assistant Surgeon Policy. Physician Assistant (PA)

Other names for Physician Assistants: Specialist Assistant (New York only) Surgical Assistant Certified Surgical Assistant

Non-Surgical Services

The modifier PA: Is used to designate the Physician Assistant for non-surgical services. Allows payment for non-surgical Physician Assistant services to be made

at *65% of the allowable amount. Exception: Drugs (including vaccines, flu shots, antibiotics, etc.) and devices are reimbursed at *100% of the allowable amount.

Surgical Services

The modifier AS:

Is used to designate the Physician Assistant as an assistant surgeon. Allows payment for surgical Physician Assistant services to be made at

*14% of the allowable amount. All rules for Assistant Surgeons apply to Physician Assistants. Refer to

the Assistant Surgeon Policy.



Oxford


UPDATED


Jan. 1, 2017 Registered Nurse First Assistants (RNFA)

Surgical Services

The modifier AS: Is used to designate the Registered Nurse First Assistant as an Assistant

Surgeon.

Allows payment to be for surgical Registered Nurse First Assistant services to be made at *14% of the allowable amount.

All rules for Assistant Surgeons apply to Registered Nurse First Assistants. Refer to the Assistant Surgeon Policy.

*For NJ Small and Individual plans: Out of network providers will be reimbursed at the 80th percentile of PHCS (prevailing healthcare charges).

Reimbursement for Comprehensive and Component CPT

Codes

Jan. 1, 2017

Reformatted and reorganized policy; transferred content to new template (no change to

policy guidelines)

When two or more related procedures are performed on a patient during a single session or visit, Oxford will reimburse the provider for the comprehensive code and deny or adjust the component, incidental or

mutually exclusive procedure performed during the same session. The

rebundling guidelines in this policy are based on The Correct Coding Initiative administered through the Centers for Medicare & Medicaid Services (CMS), AMA Current Procedural Terminology (CPT Code) and additional general industry accepted guidelines.

To rebundle a claim, Oxford claims system utilizes a software package assembled by IntelliClaim (owned by McKesson Health Solutions). IntelliClaim's product provides a platform on which two off-the-shelf and widely used products (referenced below) are combined with a flexible environment that allows Oxford to develop, customize & update our payment guidelines as necessary. Through their product, the efficiency, accuracy and speed with which millions of edits can be applied, the detailed documentation

supporting the logic behind the rules, and the clear explanations for claim adjustments result in more automated claim processing, faster turnaround, more consistent and understandable results, and improved customer service. As part of the IntelliClaim package, IntelliClaim has incorporated two software packages to rebundle codes. These software packages are the Correct Coding Initiative Software by The National Technical Information Service (NTIS) and effective October 6, 2006, ClaimsXten™ by McKesson.

The NTIS software provides Oxford with the Correct Coding Rules used by CMS. This software is the same software product used by fiscal



Oxford


UPDATED

Reimbursement for Comprehensive and Component CPT

Codes (continued)

Jan. 1, 2017 intermediaries that process Medicare Fee for Service claims for CMS. The Correct Coding Rules can be found on CMS's website at www.cms.gov. The IntelliClaim software incorporates the quarterly updates that CMS makes to

the Correct Coding rules into Oxford's claims processing system. ClaimsXten™ contains KnowledgePacks consisting of rules that, among other things, characterizes coding relationships on provider medical bills.

ClaimsXten provides information that allows claims submitters, claims processors and adjudicators to identify potentially incorrect or inappropriate coding relationships by a single provider, for a single patient, on a single date of service. Examples of the rules include incidental, mutually exclusive,

unbundling and visit edits. Sources of the KnowledgePacks include the AMA and CPT publications, CMS, specialty societies and McKesson physician consultants. Senior Oxford Medical Directors will review certain categories of code pairs encompassed in the McKesson KnowledgePacks which are not currently

implemented in Oxford's system. In certain clinical circumstances, the Medical Directors may deem that certain code pairs should deviate from the

default rules for comprehensive procedures. The implementation of ClaimsXten is scheduled to be phased in as the review is completed. In light of the changes to Oxford's policy on Modifiers 25 and 59 (effective December 1, 2005), future updates to the NTIS and ClaimsXten software may be installed without review by Oxford's Medical Directors and will follow Oxford's

regular update schedule. Please note this Reimbursement policy is subject to Oxford's reimbursement policies and rules including, but not limited to the following Oxford policies: • Global Days Policy • Modifier Reference Policy

Site of Service Differential

Jan. 1, 2017

Updated list of related policies: o Added reference link to

policy titled Exondys 51™ (Eteplirsen)

o Removed reference link to policy titled Skilled Care and

Custodial Care Services Revised coverage rationale;

expanded list of specialty medications requiring healthcare

Introduction

This policy addresses the criteria for consideration of allowing hospital

outpatient facility specialty medication infusion services. This includes claim submission for hospital based services with the following CMS/AMA Place of Service codes: 22 On Campus - Outpatient Hospital; and 19 Off Campus - Outpatient Hospital.

Alternative sites of care, such as non-hospital outpatient infusion, physician



Oxford


UPDATED

Site of Service Differential (continued)

Jan. 1, 2017 provider administration to include eteplirsen (Exondys 51™)

office, ambulatory infusion or home infusion services are well accepted places of service for medication infusion therapy. If a patient does not meet criteria for outpatient hospital facility infusion, alternative sites of care may

be used. This policy applies to these specialty medications that require healthcare

provider administration: Abatacept (Orencia®) Eculizumab (Soliris®) Eteplirsen (Exondys 51™)

Golimumab (Simponi® Aria™) Infliximab (Remicade® lyophilized concentrate for intravenous use) Infliximab-dyyb (Inflectra™) Tocilizumab (Actemra® injection for intravenous use) Vedolizumab (Entyvio®) Review Criteria for Site of Care Selection

Outpatient hospital facility-based intravenous medication infusion is medically necessary for Members who meet any of the following

criteria: Medically unstable based upon submitted clinical history Initial medication infusion of or re-initiation after more than 6 months

following discontinuation of therapy Previous experience of a severe adverse event following infusion.

Examples include but are not limited to anaphylaxis, seizure,

thromboembolism, myocardial infarction, renal failure. Continuing experience of adverse events that cannot be mitigated by

pre-medications; or Physically and/or cognitively impaired and no home caregiver available

Additional Information

Medical necessity criteria for administration of intravenous infusion therapy at home are addressed in MCG™ Care Guidelines, 20th edition, 2016, Home Infusion Therapy, CMT: CMT-0009(SR).



Oxford


REVISED

Maximum Frequency Per Day

Feb. 1, 2017

Revised Maximum Frequency Per Day Code List (attachment file listing maximum frequency per

day value assignments for CPT and HCPCS codes): o Updated maximum frequency

per day values for 0054T, 0055T, 0076T, 0098T, 0205T, 22632, 22634, 33572, 90461, J9035, J9355,

J1745 and J9310 o Removed 97010, 97012,

97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036,

97110, 97112, 97113, 97116, 97124, 97140,

97150, 97530, 97532, 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97760, 97761, 97762 and G0283

Updated Maximum Frequency Per Day Code List (attachment file listing maximum frequency per day value assignments for CPT and HCPCS codes) to reflect annual code edits:

o Added 22853, 22854, 22859,

22867, 22868, 22869, 22870, 27197, 27198, 28291, 28295, 31551, 31552, 31553, 31554, 31572, 31573, 31574, 31591, 31592, 33340,

33390, 33391, 36456, 36473, 36474, 36901, 36902, 36903, 36904,

MFD Determination: Part I

The following criteria are first used to determine the MFD values for codes to which these criteria are applicable: The service is classified as bilateral (CMS Indicators 1 or 3) on the

Centers for Medicare & Medicaid Services (CMS) National Physician Fee

Schedule (NPFS) or the term 'bilateral' is included in the code descriptor. For the majority of these codes, the MFD value is 1. There are some codes that describe more than one anatomical site or vertebral level that can be treated bilaterally where the MFD value may be more than 1.

Where the CPT or HCPCS code description/verbiage references reporting the code once per day, the MFD value is 1.

The service is anatomically or clinically limited with regard to the number

of times it may be performed, in which case the MFD value is established at that value.

The CPT or HCPCS code description/verbiage indicates the number of times the service can be performed, in which case the MFD value is set at that value.

CMS Durable Medical Equipment Medicare Administrative Contractor (DMEMAC) Local Coverage Determination (LCD) assigns an MFD value in

which case the MFD value is set at that value. Where the criteria above have not defined an MFD value, the CMS

Medically Unlikely Edits (MUE) value, where available, will be utilized to establish an MFD value.

Where no other definitive value has been established based on the criteria above, drug HCPCS codes will have an MFD value of 999 which

indicates they are exempt from the MFD policy. Where no other definitive value has been established based on the

criteria above, unlisted CPT and HCPCS codes will have an MFD value of 999 which indicates they are exempt from the MFD policy.

Where no other definitive value has been established based on the criteria above, new CPT codes released by the American Medical Association and new HCPCS codes released by CMS since the last MFD

value update (not covered by any of the above criteria), will have an MFD value of 100.

MFD Determination: Part II

When none of the criteria listed in Part I apply to a code, data analysis is conducted to establish MFD values according to common billing patterns. When a code has 50 or more claim occurrences in a data set, the MFD



Oxford


REVISED


Feb. 1, 2017

36905, 36906, 36907, 36908, 36909, 37246, 37247, 37248, 37249,

43284, 43285, 58674, 62320, 62321, 62322, 62323, 62324, 62325,

62326, 62327, 62380, 76706, 77065, 77066, 77067, 80305, 80306, 80307, 81327, 81413,

81414, 81422, 81439, 81539, 84410, 87483, 90682, 90750, 92242, 93590, 93591, 93592, 96160, 96161, 96377, 97161, 97162, 97163,

97164, 97165, 97166, 97167, 97168, 97169,

97170, 97171, 97172, 99151, 99152, 99153, 99155, 99156, 99157, 0446T, 0447T, 0448T, 0449T, 0450T, 0451T,

0452T, 0453T, 0454T, 0455T, 0456T, 0457T, 0458T, 0459T, 0460T, 0461T, 0462T, 0463T, 0464T, 0465T, 0466T, 0467T, 0468T, A4224,

A4225, A4467, A4553,

A9285, A9286, A9515, A9587, A9588, A9597, A9598, D0414, D0600, D1575, D4346, D6081, D6085, D9311, D9991, D9992, D9993, D9994,

G0491, G0492, G0493, G0494, G0495, G0496, G0499, G0500, G0501,

values are determined through claim data analysis and are set at the 100th percentile (i.e., the highest number of units billed for that CPT or HCPCS code in the data set). If the 100th percentile exceeds the 98th

percentile by a factor of four, the MFD will be set at the 98th percentile. When a code has less than 50 claim occurrences in a data set, the MFD

values will be set at the default of 100 until the next annual analysis.

In any case where, in Oxford's judgment, the 98th percentile does not account for the clinical circumstances of the services billed, the MFD for a code may be increased so as to capture only obvious billing submission and data entry errors.

The "MFD per Day Policy List" list below contains the most current MFD values. Maximum Frequency Per Day List The MFD values apply whether a physician, hospital, ambulatory surgical

center, or other health care professional submits one CPT or HCPCS code with multiple units on a single claim line or multiple claim lines with one or

more unit(s) on each line. It is common coding practice for some CPT and HCPCS codes to be submitted with multiple units. However, when reporting the same CPT or HCPCS code on multiple and/or separate claim lines, the claim line may be classified as a duplicate service and/or may be subject to additional Oxford reimbursement policies.

Services provided are reimbursable services up to and including the MFD value for an individual CPT or HCPCS code. In some instances, a modifier may be necessary for correct coding and corresponding reimbursement purposes. See Q&A #3, 4 and 5 in the Q&A section of the policy. Modifiers LT and RT Restrictions

Bilateral payment via the use of modifiers LT or RT is inappropriate for procedures, services, and supplies where the concept of laterality does not

apply. Oxford will pay up to the maximum frequency per day value for codes with "bilateral" or "unilateral or bilateral" in description or for codes where the concept of laterality does not apply, whether submitted with or without modifiers LT and/or RT by the same individual physician, hospital, ambulatory surgical center, or other healthcare professional on the same date of service for the same member. Use of modifiers LT and/or RT on the codes identified in the "Codes Restricting Modifiers LT and RT" list will be



Oxford


REVISED


Feb. 1, 2017

G0502, G0503, G0504, G0505, G0506, G0507, G0508, G0509, G9678,

J0570, J0883, J0884, J1130, J1942, J2182, J2786, J2840, J7175, J7179, J7202, J7207,

J7209, J7320, J7322, J7342, J8670, J9034, J9145, J9176, J9205, J9295, J9325, J9352, L1851, L1852, Q4166,

Q4167, Q4168, Q4169, Q4170, Q4171, Q4172, Q4173, Q4174, Q4175, T1040 and T1041

o Removed 11752, 21495, 21805, 22305, 22851,

27193, 27194, 28290, 28293, 28294, 31582,

31588, 31620, 33400, 33401, 33403, 35450, 35452, 35458, 35460, 35471, 35472, 35475, 35476, 36147, 36148,

36870, 37202, 37250, 37251, 39400, 47136, 47500, 47505, 47510, 47511, 47525, 47530, 47560, 47561, 47630, 50392, 50393, 50394,

50398, 62310, 62311,

62318, 62319, 64412, 67112, 70373, 72010, 72069, 72090, 73500, 73510, 73520, 73530, 73540, 73550, 74305, 74320, 74327, 74475,

74480, 75791, 75896, 75945, 75946, 75962, 75964, 75966, 75968,

considered informational only. Codes Restricting Modifiers LT and RT

There may be situations where a physician, hospital, ambulatory surgical center, or other healthcare professional reports units accurately and those units exceed the established MFD value. In such cases, Oxford will consider

additional reimbursement if reported with an appropriate modifier such as modifier 59, 76, 91, XE, XS or XU. Medical records are not required to be submitted with the claim when modifiers 59, 76, 91, XE, XS or XU are appropriately reported. Documentation within the medical record should

reflect the number of units being reported and should support the use of the modifier. Medically Unlikely Edit Adjudication Indicator (MAI) 2

CMS has identified CPT/HCPCS codes where the units of service (UOS) on the same date of service in excess of the MUE value would be considered impossible because it is contrary to statute, regulation or sub-regulatory

guidance. Therefore, Oxford will not allow units in excess of the MFD value to be reimbursed for CPT/HCPCS codes assigned an MAI indicator of “2”. Per

CMS guidelines, no modifier override will be allowed nor will the MFD value be overridden by supplying documentation for adjustment requests. CMS MUE File

Modifier Description

59

Distinct Procedural Service Under certain circumstances, it may be necessary

to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to

identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session,

different procedure or surgery, different size or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established



Oxford


REVISED


Feb. 1, 2017

75978, 75980, 75982, 77051, 77052, 77055, 77056, 77057, 77776,

77777, 77785, 77786, 77787, 80300, 80301, 80302, 80303, 80304,

81280, 81281, 81282, 82486, 82487, 82488, 82489, 82491, 82492, 82541, 82543, 82544,

83788, 88347, 90645, 90646, 90669, 90692, 90693, 90703, 90704, 90705, 90706, 90708, 90712, 90719, 90720, 90721, 90725, 90727,

90735, 92140, 92543, 93965, 95973, 97001,

97002, 97003, 97004, 97005, 97006, 99143, 99144, 99145, 99148, 99149, 99150, 99420, 0019T, 0099T, 0103T,

0123T, 0169T, 0171T, 0172T, 0182T, 0223T, 0224T, 0225T, 0233T, 0240T, 0241T, 0243T, 0244T, 0262T, 0281T, 0282T, 0283T, 0284T,

0285T, 0286T, 0287T,

0288T, 0289T, 0291T, 0292T, 0311T, 0336T, 0392T, 0393T, A4466, A7011, A9544, A9545, B9000, D0290, E0450, E0460, E0461, E0463,

E0464, E0628, G0154, G0163, G0164, G0431, G0434, G0464, G0477,

modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive

modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct

E/M service performed on the same date, see modifier 25.

76

Repeat Procedure or Service by Same

Physician or Other Qualified Health Care Professional It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be

reported by adding modifier 76 to the repeated procedure or service.

Note: This modifier should not be appended to an

E/M service. To report a separate and distinct E/M service performed on the same date, see modifier 25. It is also inappropriate to use modifier 76 to indicate repeat laboratory services. Modifiers 59 or 91 should be used to indicate repeat or distinct laboratory services, as appropriate according to the AMA and CMS. Separate consideration for

reimbursement will not be given to laboratory codes reported with modifier 76.

91

Repeat Clinical Diagnostic Laboratory Test In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the

same day to obtain subsequent (multiple) test

results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91. Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any

other reason when a normal, one-time, reportable result is all that is required. This modifier may not



Oxford


REVISED


Feb. 1, 2017

G0478, G0479, G3001, G6018, G6019, G6020, G6021, G6022, G6023,

G6024, G6025, G6027, G6028, G6030, G6031, G6032, G6034, G6035,

G6036, G6037, G6038, G6039, G6040, G6041, G6042, G6043, G6044, G6045, G6046, G6047,

G6048, G6049, G6050, G6051, , Q9981, S0195, S2360, S2361, S3721, S3890, S5011 and S9015

Updated Codes Restricting Modifiers LT and RT list

(attachment file listing codes that allow up to the MFD limit

that have “bilateral” or “unilateral or bilateral” in the description or where the concept of laterality does not apply) to reflect annual code edits:

o Added 22853, 22854, 22859, 22867, 22868, 22869, 22870, 27197, 27198, 31551, 31552, 31553, 31554, 31592, 33340, 33390, 33391, 36456,

36901, 36902, 36903,

36904, 36905, 36906, 36907, 36908, 36909, 43284, 43285, 58674, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 76706,

77066, 77067, 80305, 80306, 80307, 81327, 81413, 81414, 81422,

be used when other code(s) describe a series of test results (e.g., glucose tolerance tests,

evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.

XE

Separate Encounter

A service that is distinct because it occurred during a separate encounter.

XS

Separate Structure

A service that is distinct because it was performed on a separate organ/structure.

XU

Unusual Non-Overlapping Service

The use of a service that is distinct because it does not overlap usual components of the main service.

Anatomic Modifier

E1 Upper left eyelid

E2 Lower left eyelid

E3 Upper right eyelid

E4 Lower right eyelid

F1 Left hand, second digit

F2 Left hand, third digit

F3 Left hand, fourth digit

F4 Left hand, fifth digit

F5 Right hand, thumb

F6 Right hand, second digit

F7 Right hand, third digit

F8 Right hand, fourth digit

F9 Right hand, fifth digit

FA Left hand, thumb

LC Left circumflex coronary artery

LD Left anterior descending coronary artery

LM Left main coronary artery



Oxford


REVISED


Feb. 1, 2017

81439, 81539, 84410, 87483, 90682, 90750, 92242, 93590, 93591,

93592, 96160, 96161, 96377, 97161, 97162, 97163, 97164, 97165,

97166, 97167, 97168, 97169, 97170, 97171, 97172, 99151, 99152, 99153, 99155, 99156,

99157, 0446T, 0447T, 0448T, 0449T, 0450T, 0451T, 0452T, 0453T, 0454T, 0455T, 0456T, 0457T, 0458T, 0459T, 0460T, 0461T, 0462T,

0463T, 0466T, 0467T, 0468T, A4224, A4225,

A4467, A4553, A9285, A9286, A9515, A9587, A9588, A9597, A9598, D9311, D9991, D9992, D9993, D9994, G0491,

G0492, G0493, G0494, G0495, G0496, G0499, G0500, G0502, G0503, G0504, G0505, G0506, G0507, G0508, G0509, G9678, J0570, J0883, J0884,

J1130, J1942, J2182, J2786,

J2840, J7175, J7179, J7202, J7207, J7209, J7320, J7322, J7342, J8670, J9034, J9145, J9176, J9205, J9295, J9325, J9352, Q4166, Q4167, Q4168, Q4169, Q4170,

Q4171, Q4172, Q4173, Q4174, Q4175, T1040 and T1041

LT Left side

RC Right coronary artery

RI Ramus intermedius coronary artery

RT Right side

T1 Left foot, second digit

T2 Left foot, third digit

T3 Left foot, fourth digit

T4 Left foot, fifth digit

T5 Right foot, great toe

T6 Right foot, second digit

T7 Right foot, third digit

T8 Right foot, fourth digit

T9 Right foot, fifth digit

TA Left foot, great toe



Oxford


REVISED


Feb. 1, 2017

o Removed 21495, 22305, 22851, 27193, 27194, 31582, 31588, 31620,

33400, 33401, 33403, 37202, 39400, 47136, 47500, 47505, 47510,

47530, 47560, 47561, 47630, 70373, 72010, 72069, 72090, 73520, 73540, 74305, 74320,

74327, 75896, 75945, 75946, 75962, 75964, 75968, 75978, 75980, 75982, 77056, 77057, 77776, 77777, 77785, 77786, 77787, 80300,

80301, 80302, 80303, 80304, 81280, 81281,

81282, 82486, 82487, 82488, 82489, 82491, 82492, 82541, 82543, 82544, 83788, 88347, 90645, 90646, 90669,

90692, 90693, 90703, 90704, 90705, 90706, 90708, 90712, 90719, 90720, 90721, 90725, 90727, 90735, 92543, 93965, 95973, 97001,

97002, 97003, 97004,

97005, 97006, 99143, 99144, 99145, 99148, 99149, 99150, 99420, 0103T, 0123T, 0169T, 0171T, 0172T, 0182T, 0223T, 0224T, 0225T,

0233T, 0240T, 0241T, 0243T, 0244T, 0262T, 0281T, 0284T, 0285T,



Oxford


REVISED


Feb. 1, 2017 0286T, 0287T, 0288T, 0291T, 0292T, 0311T, 0336T, 0392T, 0393T,

A7011, A9544, A9545, B9000, E0450, E0460, E0461, E0463, E0464,

E0628, G0154, G0163, G0164, G0431, G0434, G0464, G0477, G0478, G0479, G6018, G6019,

G6020, G6021, G6022, G6023, G6024, G6025, G6027, G6028, G6030, G6031, G6032, G6034, G6035, G6036, G6037, G6038, G6039, G6040,

G6041, G6042, G6043, G6044, G6045, G6046,

G6047, G6048, G6049, G6050, G6051, G6052, G6053, G6054, G6055, G6056, G6057, G6058, Q9975, Q9976, Q9977,

Q9978, Q9979, Q9980, Q9981, S2360, S2361, S3721, S3890 and S9015

Obstetrical Policy

Feb. 1, 2017

Removed references to ICD-9 procedure and diagnosis codes

Revised list of Obstetrical

Related ICD-10-CM Diagnosis

Codes (attachment file listing ICD-10-CM diagnosis codes related to obstetrics): o Added A92.5, O00.00,

O00.01, O00.10,O00.11, O00.20,O00.21, O00.80,O00.81,

O00.90,O00.91, O09.A0, O09.A1, O09.A2, O09.A3,

Refer to the Obstetrical Policy for complete details on reimbursement guidelines.



Oxford


REVISED

Obstetrical Policy (continued)

Feb. 1, 2017 O11.4, O11.5, O12.04, O12.05, O12.14, O12.15, O12.24, O12.25, O13.4,

O13.5, O14.04, O14.05, O14.24, O14.25, O14.94, O14.95, O16.4, O16.5,

O24.415, O24.425, O24.435, O28.0, O28.1, O28.2, O28.3, O28.4, O28.5, O28.8, O28.9, O33.7XX0,O33.7XX1,

O33.7XX2, O33.7XX3, O33.7XX4, O33.7XX5, O33.7XX9, O34.211, O34.212, O34.219, O44.20, O44.21, O44.22, O44.23, O44.30, O44.31, O44.32,

O44.33, O44.40, O44.41, O44.42, O44.43, O44.50,

O44.51, O44.52, O44.53, O70.20, O70.21, O70.22, O70.23, Z32.00, and Z33.3

o Removed O00.0, O00.1, O00.2, O00.8, O00.9, O33.7,

O34.21, O70.2, P01.5, and P05.9

Replacement Codes

Feb. 1, 2017

Revised list of Replacement Codes (attachment file listing procedure codes assigned a status code “I” and included in

Oxford’s Replacement Codes policy); added I status code 77387 with replacement code G6002

Per the public use file that accompanies the NPFS Relative Value File, the following is stated for status code “I”: Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services.

In certain instances CMS creates Healthcare Common Procedure Coding System (HCPCS) replacement codes for physicians and/or healthcare professionals to report in lieu of the Current Procedural Terminology (CPT®) or HCPCS codes assigned an “I” status. The replacement codes allow for additional code specificity so that the appropriate reimbursement and

beneficiary coverage can be applied for the service provided. In the example below CMS has replaced intraoperative neurophysiology CPT code 95941 with HCPCS code G0453 which is specific to a single beneficiary.



Oxford


REVISED

Replacement Codes (continued)

Feb. 1, 2017

Note: RVU values may not accurately reflect the current NPFS and are

intended for illustrative purposes only.

NPFS Status

Code Description RVU

I = Not

valid for Medicare purposes

95941

Continuous intraoperative

neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating

room, per hour (List separately in addition to code for primary procedure)

0.00

A = Active Code

G0453

Continuous intraoperative

neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention

directed exclusively to one patient)

each 15 minutes (list in addition to primary procedure)

0.93

Consistent with CMS, Oxford will not separately reimburse for specific CPT or HCPCS codes assigned a status code “I” on the NPFS Relative Value File, indicating another code (replacement code) is used to report the procedure or service and that replacement code has an assigned RVU. Codes from the NPFS with a status of “I” addressed in other Oxford reimbursement policies, codes with no identified replacement code and those where the replacement

code does not have an RVU are not included in this policy.

Policy Title Effective Date Summary of Changes

RETIRED

Moderate Sedation Jan. 1, 2017 This policy will be retired effective Jan. 1, 2017. Per the 2017 CPT book, moderate sedation codes 99143-99145 and 99148-99150 have been deleted and replaced by new CPT codes 99151-99157. Additionally, Appendix G in the 2016 CPT book, which included a list of codes that include moderate sedation, is not included in the 2017 CPT book. The new moderate sedation CPT codes may be reported separately with the codes formerly listed in Appendix G;

therefore Oxford will no longer maintain a separate reimbursement policy for moderate sedation services.

january 2017 policy update bulletin - oxhp7 oxford® policy update bulletin: january 2017 take note...

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