november 2010 etwork news - premera blue cross · dec. 31, 2010, including: a uniform electronic...

Company Updates

ContentsCompany Updates page 1-3

Claims & Payment Policy Updates page 4

Online Services Updates page 5-6

Pharmacy Update page 7-8

BlueCard Updates page 8-9

Administrative Resources page 9

Medical Policy Updates page 10-11

An Independent Licensee of the Blue Cross Blue Shield Association

The lead organizations

selected by the OIC

will help define the

processes, guidelines

and standards for the

components in the bill.

November 2010

newsNews from Premera Blue Cross

network

November 2010 Washington Network News 1

Health Plans, Providers Work Together through Washington Healthcare Forum Collaborative Efforts Continue with Implementation of Senate Bill 5346

In the 2009 legislative session, the Washington State Legislature passed Senate Bill 5346, effective July 26, 2009. This bill was designed to reduce administrative cost and complexity by establishing standards and guidelines for administrative interactions between payers and providers.

The bill called for the Office of the Insurance Commissioner (OIC) to designate one or more lead organizations to define the processes, guidelines and standards for the administrative components identified in the bill. The requirements stipulated that the lead organization(s) shall: ◗ Be representative of payers and providers

across the state ◗ Have expertise in healthcare administration ◗ Be able to support the cost of its work

without public funding ◗ Accomplish the work, in collaboration with

the commissioner, through workgroups of providers, payers and others with healthcare administration expertise

◗ Promote widespread adoption ◗ Submit regular updates to the commissioner

on the progress The OIC selected the Washington

Healthcare Forum to serve as the lead organization. Founded in 1999, the Forum is a statewide organization made up of leaders from Premera Blue Cross, First Choice Health

Plan, Group Health Cooperative, Regence BlueShield, the Washington State Hospital Association, the Washington State Medical Association, as well as three health systems and several physicians, healthcare executives, and purchasers. The Forum has been working for a number of years on administrative simplification, making it the logical choice to lead this effort.

The Forum and its partner, OneHealthPort (OHP), have designated the WorkSMART Institute to coordinate the implementation and work with insurers, billers and providers across the state.

SB 5346 requires widespread adoption of administrative standards and guidelines by Dec. 31, 2010, including: ◗ A uniform electronic process for collecting

provider credentialing data ◗ An enhanced eligibility transaction

(eligibility with rich benefits detail) ◗ National correct coding initiative (NCCI)

edit policy by plans and providers ◗ Requirements for plans to consider

extenuating circumstances and adhere to timeliness standards in processing requests for pre-authorization

◗ Establishing guidelines for browser-based tools for plans to facilitate pre-authorization requests from providers

Continued on page 2

2 November 2010 Washington Network News

Company Updates

Health Plans, Providers Work Together through Washington Healthcare Forum

Continued from page 1

Premera and Providers Benefit from Using ProviderSource

Beginning December 1, Premera will be able to access provider credentialing data through OneHealthPort’s ProviderSource when credentialing potential network providers and re-credentialing contracted Premera providers (see August 2010 Network News for more details regarding ProviderSource).

When a new provider submits their credentialing data through ProviderSource, Premera will still request some initial information so we can access the provider’s data in ProviderSource, process the credentialing request and add the provider to Premera’s payment system.

Although Premera will still accept hardcopy credentialing applications, we encourage providers to consider the benefits of using ProviderSource as a single online method to submit credentialing information.

These are some benefits of ProviderSource for your practice: ◗ Eliminates the need to complete and submit a separate

credentialing application to each health plan during your credentialing cycle.

◗ Continuously reviews and verifies pre-populated provider data available through public databases.

◗ Provides a place to enter your practice credentialing information and upload documents to a single, secure database.

◗ Sends reminders when your practice needs to re-credential, or renew malpractice insurance or licenses.

◗ Makes your data available to hospitals and health plans when they need it.

◗ No fee for you to input data, attest or print records. For more information including Frequently Asked

Questions about the ProviderSource application visit onehealthport.com/services/providersource.

New on the Provider Portal: Utilization Review Section

Premera’s provider portal now includes a Utilization Review section. We have grouped together information and tools for prospective review, admission notification and advanced imaging in this section to provide easier access for you. Using these tools will help streamline your processes: ◗ Prospective Review Tool: Check procedure codes to

determine if a benefit advisory is recommended or prior authorization is required.

◗ Admission Notification Tool: Notify Premera of inpatient admissions, allowing us to verify benefits, link your patients to other programs, and assess your patients’ need for case management.

◗ Advanced Imaging: Review the list of services that require prospective review and an order number from Advanced Imaging Management (AIM).

These tools also enable Premera to meet the requirements of Washington’s Senate Bill 5346, which requires health plans to: ◗ Consider extenuating circumstances and adhere to

timeliness standards in processing requests for pre-authorization; and,

◗ Establish browser-based tools to facilitate pre-authorization requests from providers.


Company Updates

On March 23, 2010, President Barack Obama signed the Patient Protection and

Affordable Care Act of 2010 (PPACA). Since the law was signed, Premera has been analyzing the provisions and monitoring ongoing regulatory guidance to direct our work and provide our customers the information they need to make educated decisions.

Premera’s Response

Premera is actively engaged in how the law is being implemented by federal and state regulators, coordinating directly with state insurance departments and working with key stakeholders. But, we aren’t waiting for legislation to drive real change.

Premera is committed to controlling costs and creating a sustainable health system: ◗ Working with our members to

promote wellness and prevention. ◗ Working with providers to control

costs and make medical care more cost-effective.

◗ Doing our part to be administratively efficient and deliver only what our customers value.

PremeraReformUpdate.com contains the most recent information about healthcare reform and how we are responding and communicating with our members. Go to this site to learn more and watch premera.com/provider and future issues of Network News for updates relevant to providers.

Premera Engaged in Healthcare Reform and Readiness

Providers and Premera Team Up to Improve Medical Records Requests

Premera sponsored its third collaborative Lean event in September, teaming up with multiple provider organizations to improve administrative processes.

Premera would like to thank the representatives from the University of Washington Physicians, UW Medicine, and The Everett Clinic, who joined us for a Lean Rapid Process Improvement Workshop (RPIW) September 13-17. We would also like to thank Wenatchee Valley Clinic and Virginia Mason for allowing us to observe their processes and for providing valuable feedback during the planning phase of this event.

The goal of the workshop was to eliminate waste and defects in both the payer and provider processes for handling medical records requests. Premera associates and providers spent the week observing their end-to-end processes and identifying areas for improvement.

Workshop participants focused on streamlining each step of the overall workflow. This included: Premera’s initial request of the records; the receipt and processing of the request by the provider; the return of the records to Premera; the review of the records by our clinical staff; and the final processing of the claim.

This collaborative undertaking resulted in multiple improvements to the medical records request processes. During the RPIW, the participants: ◗ Created standardized language to help providers understand what documentation

is needed. ◗ Reviewed and/or revised Top 50 codes associated with records requests. ◗ Reduced the number of request forms Premera processors use, thereby simplifying

the process and eliminating multiple versions. ◗ Created a form for second requests, when additional medical records are needed for

the same claim. ◗ Revised Premera’s internal procedures to assist processors when they receive medical

records without the original request letter. (Note: We highly recommend including the original request letter).

◗ Improved the imaging of the medical records received by Premera to facilitate quicker processing.

◗ Made changes to enhance transparency:• Customer Service Representatives can find and view medical records when they

are received internally. • Premera will post the most current list of procedure codes that require review for

medical necessity (RMN list) on the provider portal (watch the provider landing page for updates).


Claims & payment poliCy Updates

Premera Prepares for HIPAA 5010

The U.S. Department of Health and Human Services has ruled to adopt the 5010 version as the standard format for electronic health claim transactions.

Please note the following key dates for the transition from version 4010A1 to version 5010: ◗ Jan. 1, 2011: Payers must be ready to

begin Trading Partner testing ◗ Dec. 31, 2011: Compliance testing

completed ◗ Jan. 1, 2012: Full transition

compliance for all parties expected

For more information about this mandate, the requirements, and how Premera is preparing, visit the HIPAA 5010 section, located under Popular Topics at premera.com/provider (see Figure 1 at right). Watch for updates and reminders on the provider page and in future issues of EDI News and Network News.

Physical Therapy Payment Policy Reminder

Our payment policy limits physical therapy based upon the modality provided. Constant attendance modalities (97032-97039) are limited to a maximum of 30 minutes on a single date of service. Therapeutic procedures (97110-97140; 97530, 97760-97762) are limited to a maximum of 60 minutes on a single date of service, regardless of the combination of modality and therapeutic procedure codes submitted.

Final payment is subject to the plan’s fee schedule, payment policies, and the member’s eligibility and coverage benefit limits at the time of service. If you have questions about this article, please call Physician and Provider Relations at 877-342-5258, option 4. Select option 2 for claims related questions.

Figure 1: Provider page link to HIPAA 5010 information and resources:

Clarification to May Edition: Changes to Maintenance Code S8990

In May of 2010, we notified you that CPT Code S8990 Physical or manipulative therapy performed for maintenance rather than restoration would begin to deny as member liability, as it is not medically necessary.

While it is true that CPT code S8990 will deny as member liability, it is not accurate to state that it will deny because it is not medically necessary. Code S8990 indicates that you are billing for maintenance. Maintenance is a member benefit exclusion and not a question of medical necessity. When billed, the code will deny and denote as member liability on the Explanation of Payment (EOP) and you may collect payment directly from the member.

If you have questions about this article, please call Physician and Provider Relations at 877-342-5258, option 4. Select option 2 for claims related questions.


We Want to Hear From You!

A survey is now available on the main provider page to gather user feedback and to

help us consider future improvements to the provider portal. This short online survey is intended to gather input to determine how you are using provider tools, and how we can continue to enhance the site to serve your needs.

You can find the link on the landing page (see Figure 1 at right) and it is also available on the secure “My Premera” page.

online serviCes Updates

4Use for Premera Dimensions members

4Set your Internet browser to allow pop-ups

4Create templates for common services to save keying time

4Organize your templates by categories for quick retrieval

4Maximize the screen and reduce scrolling by clicking on the small black arrow located on the left navigation menu

4Use the help file for detailed, step-by-step instructions and more tips

TIPSHelpful

Figure 1: Provider portal online survey

1,000 Providers See the Benefits of Real-Time EstimatesProviders can access the tool on premera.com/provider by

selecting Submit Estimate/Claim from the left navigation menu under Tools. Our network providers already have immediate access to use the tool to generate estimates. Providers who submit claims on paper also have the option of using the tool to submit real-time claims.

To learn more about navigation and functionality of the tool, watch our video tours at onehealthport.com. We have a link to OneHealthPort’s Training Center from our landing page at premera.com/provider. It is located under Resources and Tools.

More than 1,000 providers have used the Real-Time Estimate/Claims tool since we delivered this new user-friendly, web-based technology to professional providers last year.

The Real-Time Estimate/Claims tool calculates the patient’s share of cost at the point of service for most services. Providers simply enter patient information and service details. Estimates are calculated in real time and delivered within seconds based on: ◗ Contract pricing for each specific provider ◗ Patient eligibility and benefit plan ◗ Patient current deductible, coinsurance or copay ◗ All accumulators met to date and out of pocket maximum

The tool enables providers and office personnel to print copies of the estimates for patients, which clearly show how their cost was calculated. Patients are served by better understanding their share of the cost at the time of service. The estimates may also reduce confusion and facilitate pre-service financial discussions.


online serviCes Updates

Enhanced Drug Search Tool Helps Patients Understand Costs

The provider and member portals have an enhanced pharmacy drug-search tool that expands

access to drug list information. The tool provides a quick way to

search for specific drugs and determine the drugs’ tier and prior authorization requirements before filling prescriptions (the tool does not provide pricing information). See Figure 1 for an example of the drug information available with the enhanced capabilities.

The new tool is accessible on the Premera provider landing page under

Pharmacy. Click Drug Search under Popular Topics.

Having initial access to this information reduces the possibility of “sticker shock,” non-adherence, or denial of the prescription. By understanding the cost share of their drugs, users are empowered to reduce their out-of-pocket cost by choosing economically and clinically effective medications, leading to increased patient satisfaction, improved health outcomes and reduced costs for both member and health plan/employer.

Figure 1: Enbrel search results with enhanced drug information.

Optimizing Your Online Experience

To optimize your online experience, we have provided some tips, additional resources and contact information to assist you when using the premera.com website.

Use the recommended web browsers and screen resolution

Our website is best viewed using a Windows-based computer system and either Internet Explorer 7.0 or higher or Firefox/Mozilla 3.0 or higher. The site may not function well with either Opera or Safari. This site is best viewed at resolutions of 800x600 or higher and some secured functions require a minimum resolution of 1024x768.

To adjust your screen resolution in Microsoft Windows: ◗ Right-click the Windows desktop ◗ From the menu, choose Properties ◗ Click the Settings tab ◗ Adjust the Desktop Area slider to the

desired resolution

In addition, consider these steps

◗ If you have a pop-up blocker, consider disabling or overriding it

◗ Set your browser to display the latest version of the site

◗ Change the text size for easier reading ◗ Clear your browser’s cache if the site is

misbehaving

Login HelpForgot your password? Answer your secret questions to reset your password.

Providers: Are you registered, but still can’t log in? Call 800-973-4797

General Web HelpCall 800-722-9780Monday through Friday,6 a.m. to 6 p.m. Pacific Time.


pharmaCy Updates

Generics Help Members Save Money and Promote Medication AdherencePremera recognizes the

importance of helping members to safely reduce drug costs. Our strategy is to communicate the safety, efficacy, and the increasing availability of generic drugs. We also urge patients to

talk with his or her doctor(s). Our new My Name is Generic

brochure, flyer and poster are all part of our program. The key messages in these materials are: ◗ Your doctor is the best source of

information when it comes to your medicine

◗ There is no better time to discuss alternatives than when your doctor is writing your prescription.

◗ If your prescription is for a brand-name drug, ask your doctor if there is a generic available

◗ So chances are you’ll be able to make the switch!

1 DocAlert: How Generic Alternatives May Help Your Patients, epocrates.com.Tuesday, Nov. 24, 2009

2 “How to cut your medical costs: Do’s and don’ts.” Mayo Clinic staff. Mayoclinic.com/health/medical-costs/MY00733

3 Premera prescription claims data from January 2009-December 2009

4 Generic Pharmaceutical Association, 2010

Cost-related medication non-adherence can have serious health consequences, yet physicians may not even be aware of their patients’ dilemma. In a national survey of 660 older adults with chronic illness1:

• 67 percent of respondents never

told their doctors in advance that

they are planning to take less

medication or not fill a prescription

because of the cost

• 35 percent never discuss the issue

of cost at all

Of those who did not talk to their doctors:

• 66 percent reported that their

doctors did not ask about their

ability to pay for medication

• 58 percent did not think their

healthcare providers could help

• 46 percent were too embarrassed

to discuss this issue

Source: 1Piett JD, Heisler M, Wagner TH. Cost-related medication underuse: do patients with chronic illness tell their doctors? Arch Intern Med. 2004; 164:1749-1755.

Research shows that patients who struggle to afford their

medications are more likely to skip doses or refills in order to lower their out-of-pocket prescription drug expenses. When patients spend less on prescription drugs, they are more likely to take their medications as prescribed.1

There is a continuing increase in the availability of new generic drugs on the market, which will make it easier for patients to reduce their prescription costs. According to the Mayo Clinic, generics cost 30 percent to 80 percent less than brand-name drugs.2 Premera estimates that the average member can save up to $192 a year by using a generic drug instead of a brand-name drug based on the copay difference between brand and generic.3

Brand name drugs that have recently gone off market include Cozaar, Effexor XR and Valtrex. In the next five years, $89 billion in branded drugs will lose patent protection4 and generic equivalents will be available for many well known, major brand-name drugs. Brand name drugs going off market in 2011 include Levaquin, Lipitor, and Zyprexa.

Pharmacy-based Immunizations Billed DirectlyAs an added convenience for our members who chose to have immunizations administered at a

pharmacy, Premera has arranged for Medco to send the claims for these immunizations directly to us. In the past, members have had to pay upfront for these immunizations (e.g., seasonal flu, pneumococcal, shingles) and then submit the claims to us.

If you prefer to send your adult patients to the pharmacy for these immunizations, please let them know that the claims will now be billed directly to Premera.



pharmaCy Updates

New ID Cards for Boeing MembersEffective Jan. 1, 2011, new

Identification (ID) cards are being issued to The Boeing Company associates administered by Blue Cross and Blue Shield of Illinois (BCBSIL). BCBSIL is the new benefits administrator for The Boeing Company previously administered by Regence BlueShield of Washington.

To help ensure that your claims are processed correctly, please remember these guidelines when servicing Boeing associates after Jan. 1, 2011:

ID Cards ◗ The new alpha prefix is BHP, BCU,

BYR or BEM on the ID cards issued to all Boeing associates. (All ID cards

now have an alpha prefix as part of the member’s ID number.)

◗ Obtain a photocopy of this new card for the member’s file.

To Verify Eligibility and Benefits ◗ Send an electronic inquiry to Premera

Blue Cross (ANSI 270 transaction) via your preferred online vendor portal such as Availity, etc., or call the BlueCard eligibility line at 800-676-BLUE (2583).

Pre-certification ◗ Call the newly designated telephone

number on the back of the patient’s ID card for services requiring pre-certification.

Polypharmacy Celebrates 10 Successful Years

At Premera brown bags have proved useful for more than just lunches.

The 10th anniversary of Premera’s Polypharmacy program reflects the longevity of a simple solution for a complex problem. The problem is the potential for harmful side effects or interactions for members who use multiple medications. The solution is promoting medication reviews with providers to help members adopt the most appropriate medication regimens.

Members taking multiple medications for chronic conditions receive a mailing that includes an educational brochure, a medication log, and a brown bag. ◗ The brochure explains the potential

problems associated with using multiple medications.

◗ Members are asked to list their medications by name, strength, directions, and purpose.

◗ Members are then advised to put all their medications, including over-the-counter medications and herbal supplements, in the brown bag and take them to their provider for a thorough medication review.

Since 2001, the program has educated and informed members about drug safety and helped members understand their medication therapy. Consequently, the program has helped minimize potential drug related problems, contributed to health safety, and lowered healthcare costs.

A 2009 Company survey indicated that 50 percent of members who responded to the survey agreed that the information provided is “somewhat or very valuable.”

Another 2009 survey asked providers about the program: 48 percent of those surveyed agreed the program is useful, and 44 percent agreed the program helps reduce medication-related complications and hospitalizations.

The Polypharmacy program is widely accepted by members, providers, industry associations, and government agencies. ◗ 166,000 member brochures and brown

bags have been distributed since 2001 ◗ 42,000 physician newsletters

distributed 2

◗ Partners include the Washington State Medical Association, Washington State Department of Health, and the Alaska State Medical Association

◗ The BCBSA and Harvard Medical School, Department of Healthcare Policy recognized the Polypharmacy program with a BlueWorks Award in 2004

Promoting healthy partnerships is one way Premera adds value for its members. Sometimes, even a brown bag can make a difference!1 Source for all survey statistics in article: Premera member and provider surveys in 2009.2 Source: Premera Pharmacy, 2009

BlueCard Updates

Claim Submission ◗ Continue to file all Eastern

Washington and Alaska provider claims with Premera Blue Cross, using the new alpha prefix – BHP, BCU, BYR or BEM – and member ID number.

Claim Status ◗ Claim status may be obtained

electronically via BlueExchange under Claims at premera.com/provider, or by contacting BlueCard Customer Service at 888-261-9562.



administrative Resources

Provider Reference Manual is Updated and Online

The Provider Reference Manual is updated and available online for physicians, providers, and

facilities. The new online version (08/2010; 09/2010) replaces all previous versions

The manual is designed to meet the needs of office staff and medical personnel by providing helpful, relevant information about our members, plans, online services, claims and payment policies, and much more.

We encourage you to access the manual through the provider portal. Click on Reference Info under Library to locate the online version. A OneHealthPort sign-on is required to access the secure portal. Manual content is updated periodically as policies and programs change.

If you have questions or suggestions for future improvements to the manual, please call Physician and Provider Relations at 877-342-5258, option 4.

Overpayment Notification Form Expedites Refunds — including BlueCard

BlueCard Updates

Did you know you can use the Overpayment Notification form for all Premera refunds – including BlueCard? If Premera Blue Cross is the payor and you are sending a voluntary refund, complete the Overpayment Notification Form in its entirety and select from the following options on the form:4Check attached — send the

overpayment to Calypso for processing4Requesting a voucher deduction/offset —

we will deduct the money from a future voucher

4 Please send a refund request letter — we will send you a confirmation of your request

When we are unable to determine the reason for your refund, we attempt to contact your office to obtain the information. If we are unable to obtain

the information, we return the money to you and you may have to resubmit the refund.

Completing the form, attaching the refund letter and supporting documentation, ensures that we have all the necessary information to process your refund quickly and accurately. Please be sure to include a copy of the other health insurance’s explanation of benefits (EOB) for coordination of benefits (COB) overpayments.

You can find the Overpayment Notification form online at premera.com/provider under Forms, Claims and Billing.

Medical Policy and Pre-certification Requirements Online Premera recently added a new feature to our provider portal to help providers treat out-of-area Blue patients. In

one easy step you can look up medical policy applicable to out-of-area Blue patients and general pre-certification/ pre-authorization requirements, along with the contact information to initiate pre-certification/pre-authorization.

We have a link to this tool from our landing page at premera.com/provider, under Resources and Tools. This new web functionality gives providers easy access to the information they need and provides a valuable supplement to the patient’s benefits and eligibility information they currently receive.


mediCal poliCy Updates

Physicians, Providers and Office Staff

Premera medical policies are guides in used to evaluate the medical necessity of a particular service or treatment. We adopt policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, we reserve the right to review and update our policies as appropriate. When

there are differences between the member’s contract and medical policy, the member’s contract prevails. The existence of a medical policy regarding a specific service or treatment does not guarantee that the member’s contract covers that service.

Medical policies are available premera.com/provider; click on Medical Policies under Reference Info. If you would like a copy of a particular medical policy and are unable to obtain it from the website, email your request to [email protected]. If you do not have Internet access, you may call Physician and Provider Relations at 877-342-5258, option 4.

Note: All policy numbers begin with CP.MP and are listed here in numeric order.

The following policy changes are effective for dates of service of August 10, 2010 and later:

PR.1.01.511 Home Apnea Monitors This policy has been deleted and will no longer be reviewed.

PR.1.04.02 Thoracic Lumbo-Sacral Orthosis with Pneumatics This policy has been deleted and will no longer be reviewed.

BC.2.01.21 Temporomandibular Joint Dysfunction Policy statement added. Acupuncture is considered investigational in the treatment of TMJ dysfunction.

PR.2.03.503 Oncology Clinical Trials Policy updated. Alaska clinical trials mandate information has been added along with a link to the mandate which provides information that outlines covered and non-covered services, and administrative criteria.

PR.5.01.518 Bcr-Abl Kinase Inhibitors Policy statements added. Imatinib may be considered medically necessary for treatment of patients with Kit (CD117) positive, translocation positive only to Non-Melanoma Skin Cancers; and treatment of patients with Ph+NHL – Lymphoblastic lymphoma.

BC.7.01.67 Endovascular Grafts for Abdominal Aortic Aneurysms This policy has been deleted and will no longer be reviewed.

BC.7.01.69 Sacral Nerve Modulation/Stimulation for Pelvic Floor Dysfunction Policy statement added. Sacral nerve neuromodulation may be considered medically necessary for the treatment of fecal incontinence when certain criteria are met.

BC.7.01.71 Lung Volume Reduction Surgery for Severe Emphysema Policy updated. A four month time-frame requirement for tobacco abstinence has been added to the list of medically necessary criteria.

BC.8.03.05 Outpatient Pulmonary Rehabilitation This policy has been deleted and will no longer be reviewed.

BC.8.03.08 Cardiac Rehabilitation in the Outpatient Setting Policy statements added. Repeat participation in an outpatient cardiac rehabilitation program in the absence of another qualifying cardiac event is considered investigational. Outpatient cardiac rehabilitation programs may be considered medically necessary for a history of coronary stenting and heart-lung transplantation.

PR.8.01.503 Intravenous Immune Globulin Therapy Policy statements added. Intravenous immunoglobulin therapy may be considered medically necessary for the following additional conditions: prior to solid organ transplant, as a treatment of patients at high risk of antibody-mediated rejection, including highly sensitized patients and those receiving an ABO incompatible organ, and following solid-organ transplant for treatment of antibody-mediated rejection.

BC.9.03.23 Intravitreal Implant New policy A fluocinolone acetonide intravitreal implant may be considered medically necessary for the treatment of chronic noninfectious posterior uveitis, in one or both eyes. All other uses of a fluocinolone acetonide intravitreal implant are considered investigational.

PR.10.01.510 Anesthesia Services This policy has been deleted and will no longer be reviewed.


mediCal poliCy Updates

The following policy changes are effective for dates of service of September 14, 2010 and later:

BC.1.01.18 Pneumatic Compression Pumps for the Treatment of Lymphedema Policy statement added. Single-chamber or multi-chamber programmable lymphedema pumps are considered medically necessary for the treatment of lymphedema when certain indications are met.

BC.1.03.02 Knee Braces This policy has been deleted and replaced by PR.1.03.501.

PR.1.03.501 Knee Braces New policy Policy statement added. Custom-made unloader knee braces may be considered medically necessary as a treatment of patients with painful osteoarthritis involving the medial or lateral compartment of the knee.

BC.2.02 .12 Noninvasive Measurements of Cardiac Hemodynamics in the Ambulatory Care Outpatient Setting This policy has been deleted and replaced by BC.2.02.24.

BC.2.02.24 Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting New policy In the ambulatory care and outpatient setting, cardiac hemodynamic monitoring for the management of heart failure utilizing thoracic bioimpedance, inert gas rebreathing, arterial pressure/Valsalva, and implantable direct pressure monitoring of the pulmonary artery is considered investigational.

BC.2.04.20 Apolipoprotein B in the Risk Assessment and Management of Cardiovascular Disease This was deleted and replaced by BC.2.04.65

BC.2.04.65 Novel Lipid Risk Factors in Risk Assessment and Management of Cardiovascular Disease New policy Measurement of novel lipid risk factors (i.e. Apolipoprotein B, Apolipoprotein A-I, Apolipoprotein E, LDL subclass, HDL subclass, lipoprotein [a]) is considered investigational as an adjunct to LDL cholesterol in the risk assessment and management of cardiovascular disease.

PR.5.01.517 Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and other Angiogenesis Inhibitors in Oncology Patients Policy updated. Bevacizumab may be considered medically necessary for treatment of patients

The following policy changes are effective for dates of service of February 1, 2011 and later:

BC.2.04.59 Array Comparative Genomic Hybridization (aCGH) for the Genetic Evaluation of Patients with Developmental Delay/Mental Retardation or Autism Spectrum Disorder New policy Array comparative genomic hybridization is considered investigational in the evaluation of children with cognitive developmental delay/mental retardation or autism spectrum disorder.

BC.2.04.64 Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer New policy Use of tests utilizing systems pathology that uses cellular and biologic features of a tumor is considered investigational, including use in predicting risk of recurrence in patients with prostate cancer.

PR.6.01.502 Single Photon Emission Computed Tomography (SPECT) Policy statement added. SPECT with concurrently-acquired computed tomography (SPECT/CT) is considered investigational for any indication.

with angiosarcoma or solitary fibrous tumor/hemangiopericytoma. Lenalidomide may now be considered

PR.6.01.510 MRI of the Breast and Computer Aided Detection/Evaluation of the Breast Policy statement added. MRI of the breast may be considered medically necessary to evaluate a documented abnormality of the breast prior to obtaining an MRI guided biopsy when there is documentation that other methods, such as palpation or ultrasound, are not able to localize the lesion for biopsy.

BC.7.01.40 Laser Treatment of Port Wine Stains Policy statement updated. Laser treatment of port wine stains in the presence of functional impairment may be considered medically necessary. Policy statement added. Treatment with lasers in combination with photodynamic therapy or topical angiogenesis inhibitors is considered investigational.

PR.7.01.526 Cryosurgical Ablation of Miscellaneous Solid Tumors other Than Liver, Prostate, or Dermatologic Tumors Policy statement added. Cryosurgical ablation may be considered medically necessary to treat localized renal cell carcinoma that is no more than 4 cm in size when certain criteria are met.

BC.8.01.35 Hematopoietic Stem Cell Transplantation in the Treatment of Germ Cell Tumors Policy statements updated. Single autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy for germ-cell tumors in patients with favorable or unfavorable prognostic factors under certain situations. Previously considered investigational, tandem or sequential autologous hematopoietic stem-cell transplantation may be considered medically necessary for the treatment of testicular tumors either as salvage therapy or with platinum-refractory disease.

BC.8.01.37 Inhaled Nitric Oxide as a Treatment of Hypoxic Respiratory Failure This policy has been deleted and will no longer be reviewed.


PRESORTED STANDARD

U.S. POSTAGE PAIDSEATTLE, WA

PERMIT NO. 2944

Premera Blue Cross

P.O. Box 327

Seattle, WA 98111

001399 (11-2010)DR 1440

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Network News is an online publication that can be viewed at premera.com/provider, under Communications in the Library. There you can view the current issues of the newsletter, as well as archived issues.

You can also request an email notification when a new edition is published. Simply go to “My Email Subscriptions” at the bottom of the My Premera page, check the Medical Network News Notice box, enter your email address, and click Save Subscription Changes.

november 2010 etwork news - premera blue cross · dec. 31, 2010, including: a uniform electronic...

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