August 2020 - AUA Public Policy Council Update for MAS
From the Chair
I am pleased to share updates from the AUA Public Policy Council that may benefit your Section members. Our updates include information on this month’s Virtual Annual Urology Advocacy Summit as well as our virtual meetings with Congress on issues ranging from support for the Veteran’s Prostate Cancer Research and Treatment Act and the AUA-led legislation to provide student loan forgiveness for specialty physicians that practice in rural America.
Annual Urology Advocacy Summit: Registration for Virtual Event Launched
More than 200 of your colleagues already are registered to join this month’s Virtual Annual Urology Advocacy Summit. Make plans now to join the AUA when we bring Washington, DC, to you! The evening programming will begin on August 31. Featured speakers during the week include CBS’ Face the Nation Host Margaret Brennan and AUA member/U.S. Representative Greg Murphy, MD (R-NC-03). A special session for AUAPAC members will be held with Charlie Cook, the editor and publisher of the Cook Political Report. The Summit also will feature a virtual Hill Day of meetings with lawmakers and Congressional staff that will take place on September 1. CME credits are available to attendees. We also are proud to welcome almost 50 medical students, residents, fellows, and young urologists and will feature a dedicated evening networking event for them on September 2nd. Register today!
NIDDK Strategic Plan: Research Advocacy Committee Provides Feedback
Members of the AUA’s Research Advocacy Committee (RAC) orchestrated efforts to respond to the National Institute of Diabetes and Digestive and Kidney Diseases’ (NIDDK) call for strategic plan input. The AUA’s response aimed to recognize that non-oncologic urological diseases are extraordinarily prevalent; widely underdiagnosed due to access issues and patient unawareness; undervalued as they are not immediately life threatening; underrepresented in regard to minorities’ participation in trials; and tremendously important to the patient’s quality of life. Additionally, the AUA urged the NIDDK to recognize urology as a central component of the strategic plan.
Congressional Outreach: AUA Continues Participation in Virtual Meetings with Federal Lawmakers and Candidates
Rep. Brian Higgins (D-NY-26)
On July 20, the AUA, along with its colleagues in a coalition of medical and dental political action committees (MaDPAC), participated in a virtual meeting with Rep. Brian Higgins of New York. He serves on the House Ways & Means Committee and, subsequently, on its Health and Trade Subcommittees. During the meeting, Rep. Higgins mentioned the United States’ global standing and ongoing response to COVID-19. In addition, the AUA was able to share information on H.R. 6092, the Veteran’s Prostate Cancer Research and Treatment Act that directs the Secretary of the VA to establish a national clinical pathway for prostate cancer within the VA’s National Surgery Office for all stages of prostate cancer.
The AUA will continue to work with Congress to get as many cosponsors of the legislation as possible. Please ask your lawmakers to support prostate cancer care for America’s veterans. For more information or to contact your elected officials, visit our Action Center.
Rep. Donald Payne, Jr. (D-NJ-10)
On August 5, the AUA met with Rep. Donald Payne, Jr., co-chair of the Men’s Health Caucus regarding the Veteran’s Prostate Cancer Research and Treatment Act (H.R. 6092). There also was conversation on the once proposed legislation establishing a federal Office of Men’s Health. Rep. Payne is still interested in such a bill and is working with Men’s Health Network on this important initiative. Unfortunately, given the COVID-19 pandemic crisis, the bill is not expected to be a priority in 2020.
Rep. Phil Roe, MD (R-TN-01)
On July 31, the AUA attended a virtual meeting with Rep. Phil Roe, MD, which was hosted by the AUA’s contract lobbyists, Jim Twaddell and former Congressman Phil Gingrey, MD. During the meeting, Dr. Roe – who is not seeking re-election – discussed his desire to see the surprise medical billing issue addressed by the end of this Congress. Dr. Roe and Rep. Raul Ruiz, MD (D-CA-36) have introduced legislation on this issue, which is supported by the AUA and the broader physician community.
Dr. Roe also talked about the importance of addressing the physician workforce shortage, especially in rural and underserved communities. When informed by Dr. Gingrey of AUA-led legislation to provide student loan forgiveness for specialty physicians that practice in rural America, Dr. Roe stated that those are the exact types of programs that Congress should be moving to address this issue. He expressed an interest in having further conversations on this particular bill.
Sen. Debbie Stabenow (D-MI)
On August 5, the AUA was joined by Juan Andino, MD, a member of the AUA’s Telehealth Task Force and Michigan constituent, in meeting with staff from Sen. Debbie Stabenow’s office regarding the Telehealth Modernization Act, a draft bill proposed by Sen. Lamar Alexander (R-TN). The bill would permanently remove Medicare’s geographic and originating site restrictions, thus expanding access to telehealth anywhere and protecting access to telehealth for patients who live in rural areas by ensuring that telehealth services at federally qualified health centers and rural health clinics are covered by Medicare.
As a reminder, the AUA has been extremely active in identifying needed key telehealth flexibilities – particularly as the current Public Health Emergency (PHE) was extended to October 22 – and communicating these issues with lawmakers and agency officials alike. Flexibilities include maintaining the expanded Telehealth Services List Medicare implemented during the PHE, continuing coverage and enhance payment for telephone visits, and continuing the relaxation of telehealth originating site requirements to allow patients to receive telehealth services in their homes.
Rep. Mark Takano (D-CA-11)
On July 13, the AUA met with the office of Rep. Mark Takano, who chairs the House Veterans’ Affairs Committee. The conversation centered on a potential hearing on the aforementioned H.R. 6092, the Veteran’s Prostate Cancer Treatment and Research Act.
Congressional Candidate Cameron Webb, MD
On July 21, the AUA participated in a meet and greet with Dr. Cameron Webb, who is running for Congress in Virginia’s 5th Congressional District. An internist and husband to an emergency physician, Dr. Webb served in the Obama administration as part of the MY Brother’s Keeper Initiative, where he helped tackle issues in education, workforce development and criminal justice reform. If elected, Dr. Webb hopes to champion various health care issues related to access to care in rural, low-income, and underserved communities, and reducing the cost of prescription drugs.
Telehealth: AUA Task Force Chair’s Report on American Telehealth Association Annual Meeting
On June 29, AUA Telehealth Urology Task Force Chair Dr. Aaron Spitz, attended the American Telehealth Association (ATA) Annual Meeting. His report points to the most relevant topics for urology including the use of artificial intelligence (AI), and direct-to-consumer (DTC) virtual care.
Artificial Intelligence (AI)
The ATA meeting outlined specific information about the use of artificial intelligence, specifically the use of “chat bots.” This current iteration of technology can be sophisticated and nuanced and has the potential for a high level of engagement with patients. Speakers highlighted the following:
- Chat bots are revolutionizing the intake of patient information and the presentation of data to caretakers.
- Patients like asynchronous (not simultaneous or concurrent in time) chat bots because they can take the time to provide answers and have information repeated to them without the pressure of an in-person encounter with a physician.
- Chat bots “nudge” patient into compliance or reporting information with text reminders.
- Chat bots can be used to triage patients to determine the urgency of a patients need for care.
- Chat bots work best when questions are closed ended and interactions with bots are short.
The American Medical Association’s (AMA) position on AI is that the technology is complementary to medical doctors, and not a means to replace them.
Direct-To-Consumer (DTC) and Digital Therapeutics Evolution
- There was significant attention placed on DTC telemedicine including services such as HIMS and Roman which provide urological DTC services.
- DTC virtual care has paved the way for telemedicine encounters. There is rapidly growing engagement by patients with these services.
- Patients with large deductibles are attracted to transparent pricing of DTC virtual care.
- DTC virtual care has traditionally been a service paid by the patient, but with the widespread adoption of telemedicine due to the COVID-19 public health emergency, providers will increasingly bill payers and strike collaborative ventures with payers.
- Studies have shown that DTC virtual care demonstrates greater adherence to clinical guidelines than in-person encounters.
- DTC virtual care companies utilize sophisticated software that streamlines the information for medical decision-making for both the provider and the patient.
The information is also available here.
Telemedicine: AUA Provides Valuable Insight to National Cancer Institute’s Request for Information Regarding Patient Care and Telehealth
The AUA’s Urology Telehealth Taskforce and Research Advocacy Committee joined efforts in responding to the National Cancer Institute’s Request for Information (RFI) seeking “Stakeholder Input on Scientific Gaps and Research Needs Related to Delivery of Cancer-related Care via Telehealth.” The response focused on the need to deliver care by telehealth that is both high quality and arguably even better than in-person care. Research gaps identified in the response include quantifying the added value of face-to-face video interactions and use of visual aids to a urologic consultation; analysis of cost-effective technology that can be deployed to patients without access to high-speed internet; and urology-specific apps that can capture patient reported outcomes in real-time and automatically import them to electronic medical records.
Below are insurance updates from national insurance carriers.
Aetna
Aetna reviewed its Ablative Procedures for Prostate Cancer Policy adding:
- Water vapor thermotherapy to the list of ablative procedures considered experimental and investigational for the treatment (primary or salvage therapy) of prostate cancer.
- The following not covered CPT codes:
- 0582T – Transurethral ablation of malignant prostate tissue by high-energy water vapor thermotherapy, including intraoperative imaging and needle guidance
- 53854 – Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy
Aetna reviewed its Radiation Therapy Clinical Guidelines with the following changes:
- Added Xofigo guidelines
- Revised Image-Guided Radiation Therapy (IGRT) guidelines
Aetna reviewed its Erectile Dysfunction Policy with the following changes:
- Added measurement of serum vitamin D levels to the list of tests considered experimental and investigational for the diagnosis of sexual dysfunction
- Added endovascular treatment and pelvic floor muscle training to the list of treatments considered experimental and investigational for sexual dysfunction
- Added the following not covered CPT codes:
- 0038U – Vitamin D, 25 hydroxy D2 and D3, by LC-MS/MS, serum microsample, quantitative
- 82306 – Vitamin D; 25 hydroxy, includes fraction(s), if performed
- 82306 – Vitamin D; 25 hydroxy, includes fraction(s), if performed
- Removed the following not covered HCPCS codes:
- J0900 – Injection, testosterone enanthate and estradiol valerate, up to 1 cc
- J1060 – Injection, testosterone cypionate and estradiol cypionate, up to 1 ml
- J1070 – Injection, testosterone cypionate, up to 100 mg
- J1080 – Injection, testosterone cypionate, 1cc, 200 mg
- J3120 – Injection, testosterone enanthate, up to 100 mg
- J3130 – Injection, testosterone enanthate, up to 200 mg
- J3140 – Injection, testosterone suspension, up to 50 mg
- J3150 – Injection, testosterone propionate, up to 100 mg
Anthem
Anthem reviewed its Gene Mutation Testing for Solid Tumor cancer Susceptibility and Management Policy adding the following CPT Code:
- 0154U – Oncology (urothelial cancer), RNA, analysis by real-time RT-PCR of the FGFR3 (fibroblast growth factor receptor 3) gene analysis (i.e., p.R248C [c.742C>T], p.S249C [c.746C>G], p.G370C [c.1108G>T], p.Y373C [c.1118A>G], FGFR3-TACC3v1, and FGFR3-TACC3v3), utilizing formalin-fixed paraffin-embedded urothelial cancer tumor tissue, reported as FGFR gene alteration status
Anthem reviewed its Irreversible Electroporation Policy removing the following code:
- 53899 – Unlisted procedure, urinary system
Anthem reviewed its Surgical and Minimally Invasive Treatments BPH Policy with the following changes:
- Updated the list of medically necessary procedures; added Urolift as an example of prostatic urethral lift; added Rezūm as an example of transurethral convective water vapor thermal ablation; added Aquablation as an example of waterjet tissue ablation; revised requirement of image-confirmed absence of an obstructing middle lobe for prostatic urethral lift to remove the descriptor “image-confirmed.”
- Added not medically necessary policy statement for prostatic urethral lift when the intent is to treat symptoms of conditions other than benign prostatic hyperplasia.
Anthem reviewed its Treatments for Urinary Incontinence Policy adding the following investigational and not medically necessary CPT codes:
- 0596T – Temporary female intraurethral valve-pump (i.e., voiding prosthesis); initial insertion, including urethral measurement [inFlow system]
- 0597T – Temporary female intraurethral valve-pump (i.e., voiding prosthesis); replacement [inFlow system]
Centers for Medicare & Medicaid Services (CMS)
CMS released its COVID-19 Updates Newsletter for July 2 and July 6. Topics addressed include:
- COVID-19: New and Expanded Flexibilities for Rural Health Centers & Federally Qualified Health Centers during the Public Health Emergency
- Trump Administration Issues Call to Action Based on New Data Detailing COVID-19 Impacts on Medicare Beneficiaries
- Hospital Outpatient Departments: Prior Authorization Begins July 1
- A new MLN Matters Article MM11842 on July 2020 Update of the Ambulatory Surgical Center (ASC) Payment System is available. Learn about billing instructions and updates to HCPCS codes.
Read the updates here and here.
Cigna
Cigna reviewed its Genetic Testing for Hereditary Cancer Susceptibility Syndromes Policy with the following changes to criteria, coding, and supporting information:
- Added prostate cancer to hereditary cancer susceptibility syndromes for which genetic testing may be considered medically necessary when the individual meets the general criteria for hereditary cancer genetic testing as above and current National Comprehensive Cancer Network (NCCN) Guidelines (category 1, 2A or 2B) for the testing requested.
- Removed policy statement previously specifying that germline genetic testing is considered medically necessary for early stage, non-metastatic prostate cancer when the individual meets the general criteria for hereditary cancer genetic testing as described above.
- Removed policy statement previously specifying that germline testing for pathogenic or likely pathogenic variants in MLH1, MSH2, MS6, PMS2, BRCA1, BRCA2, ATM, PALB2, CHEK2 and RAD51D genes is considered medically necessary for localized stage III (i.e., NCCN high-risk and very high-risk group), regional or metastatic prostate cancer.
- Removed policy statement previously indicating that genetic testing for CHEK2 is considered medically necessary when the individual meets general criteria for hereditary cancer as above and any of the listed criteria are met; removed all criteria for CHEK2.
- Added CPT codes including but not limited to the following:
- 0133U – Hereditary prostate cancer-related disorders, targeted mRNA sequence analysis panel (11 genes) (List separately in addition to code for primary procedure)
Cigna reviewed its Oncology Medications Policy removing the criteria section for Xtandi for Employer Group Plans and Individual and Family Plans stating for castration-recurrent metastatic prostate cancer only and both of the following are met: either member has previously been started on, or is currently receiving Xtandi, or documented failure/inadequate response, contraindication per FDA label, intolerance or not a candidate (for example: unable to use prednisone) for Zytiga; and Xtandi will not be concomitantly administered with Zytiga.
Cigna added a statement to coverage policy section stating initial authorization is up to 12 months unless otherwise stated.
Cigna revised its Prostate Cancer Guidelines.
EnvisionRx
EnvisionRx released its Perspective on the Pipeline Report announcing information regarding COVID-19’s impact on drug shortages.
Humana
Humana reviewed its Gene Expression Profiling Policy with the following changes:
- Removed the following from gene expression profiling tests that are addressed in the policy:
- Oncotype DX Prostate
- Decipher Prostate
- Prolaris
- Progensa PCA3 Assay
- ConfirmMDx
- Removed the following CPT codes:
- 81313 – PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (e.g., prostate cancer)
- 81541 – Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score
- 81542 – Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score
- 81551 – Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a likelihood of prostate cancer detection on repeat biopsy
- 0047U – Oncology (prostate), mRNA, gene expression profiling by real- time RT-PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a risk score
- Added policy note to refer to Laboratory Analysis for Prostate Cancer medical coverage policy for information regarding gene expression profiling for prostate cancer.
Humana reviewed its Genetic Testing for Cancer Susceptibility Policy removing the following CPT code:
- 0133U – Hereditary prostate cancer-related disorders, targeted mRNA sequence analysis panel (11 genes) (List separately in addition to code for primary procedure)
Humana released its new Laboratory Analysis for Prostate Cancer policy, stating laboratory analysis procedures for prostate cancer may be considered medically necessary when criteria are met.
Humana reviewed its Multi-Analyte Assays with Algorithmic Analysis Policy with the following changes:
- Removed the following from multi-analyte assays with algorithmic analyses (MAAAs) that are addressed in the policy:
- 4Kscore test
- Apifiny
- Mi-Prostate Score (MiPS)
- ProMark
- Prostate Cancer Risk Score
- Prostate Health Index (PHI)
- Removed the following CPT codes:
- 81539 – Oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA, and human kallikrein-2 [hK2]), utilizing plasma or serum, prognostic algorithm reported as a probability score
- 86316 – Immunoassay for tumor antigen, other antigen, quantitative (e.g., CA 50, 72-4, 549), each
- 0021U – Oncology (prostate), detection of 8 autoantibodies (ARF 6, NKX3-1, 5’-UTR-BMI1, CEP 164, 3′-UTR-Ropporin, Desmocollin, AURKAIP-1, CSNK2A2), multiplexed immunoassay and flow cytometry serum, algorithm reported as risk score Oncology (prostate cancer), FISH analysis of 4 genes (ASAP1, HDAC9, CHD1 and PTEN), needle biopsy specimen, algorithm reported as probability of higher tumor grade
- 0113U – Oncology (prostate), measurement of PCA3 and TMPRSS2-ERG in urine and PSA in serum following prostatic massage, by RNA amplification and fluorescence-based detection, algorithm reported as risk score
- Added policy note to refer to Laboratory Analysis for Prostate Cancer medical coverage policy for information regarding MAAA testing for prostate cancer.
Humana reviewed its Tumor Markers for Diagnosis and Monitoring of Cancer Policy with the following changes:
- Removed the following from tumor markers that are addressed in the policy:
- Prostate-specific antigen (PSA)
- IsoPSA Assay
- Prostate specific antigen (PSA) Slope (e.g., NADiA ProsVue)
- Removed the following CPT/HCPCS codes:
- 84153 – Prostate specific antigen (PSA); total
- 84154 – Prostate specific antigen (PSA); free
- G0103 – Prostate cancer screening; prostate specific antigen test (PSA)
- Added policy note to refer to Laboratory Analysis for Prostate Cancer medical coverage policy for information regarding tumor markers for prostate cancer (IsoPSA Assay, PSA, PSA slope).
Humana released its new Irreversible Electroporation (NanoKnife) Policy. The NanoKnife is considered experimental, investigational, or unproven.
Medica Health Plans
Medica Health Plans reviewed its Add-On to Primary Code Relationship Code List adding:
- 87635 – Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique
Medica Health Plans reviewed its Emergency Telemedicine Services Code List adding CPT codes 99381-99387, 99391-99393, and 99384-99397.
Palmetto
Palmetto released its Provider Newsletter for July. Topics covered include Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19), and a summary of policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Public Health Emergency (PHE) Interim Final Rules
United Healthcare (UHC)
UHC announced through October 22, Medicare Advantage plan members must bill for telehealth services with FQHCs and RHCs with code G2025.
To provide ongoing support to members and providers, UHC is extending many of the COVID-19 temporary program, process and coverage changes through October 22. Full details, including applicable benefit plans and service information, can be found here.
Implementation of these temporary changes may vary by health plan and for self-funded customers. State-specific and Medicaid rules, regulations, date limitations or exclusions may also apply.
Specifically, the temporary changes include:
- Cost share waivers for COVID-19 testing-related visits, testing (diagnostic and antibody) and treatment
- Telehealth coverage for COVID-19-related services for in- and out-of-network providers
- Telehealth coverage for non-COVID-19-related services for in- and out-of-network providers
Implementation by health plan may vary.
The Summary of COVID-19 Dates by Program summaries the temporary measures for easy reference, and, the COVID-19 Testing and Treatment Billing Guide has helpful coding guidance to assist with claim submissions. For United Healthcare COVID-19 related resources for providers, learn more at UHCprovider.com/covid19.
UHC updated its provider bulletin announcing changes to timely filing extensions to state that for commercial plans, there will be an additional 60 day extension following the last day of the national emergency period.
Local and Regional Updates
The following are updates in your Section. Please contact AUA Executive Vice President Kathleen Shanley at kshanley@AUAnet.org for more information on any of these issues.
Delaware
Highmark BCBS Delaware
Highmark BCBS Delaware reviewed its Posterior Tibial Nerve Stimulation Policy with the following changes to language:
- Added neurogenic bladder dysfunction and fecal incontinence as examples of experimental /investigational indications.
- Revised experimental/investigational language.
Highmark BCBS Delaware reviewed its Gonadotropin Releasing Hormones Analogs Policy with the following changes:
- Revised criteria for use as adjuvant androgen deprivation therapy (ADT) as a single agent or with a first-generation antiandrogen with or without external beam radiation (EBRT) if lymph node metastasis found during pelvic lymph node dissection (PLND), removing use in individuals in the very low risk group and greater than or equal to 20 year expected survival as a medically necessary indication for Lupron.
- Added use as adjuvant ADT as a single agent or in combination with a first-generation antiandrogen with EBRT if adverse features noted after radical prostatectomy as a medically necessary indication for Lupron when criteria are met.
- Updated Lupron medically necessary treatment regimens for initial ADT as a single agent or in combination with a first-generation antiandrogen with EBRT if life expectancy greater than 5 years or symptomatic.
- Added National Comprehensive Cancer Network (NCCN) recommendations for Lupron Depot for treatment of prostate cancer and salivary gland tumors.
- Updated NCCN recommendations for Eligard for treatment of prostate cancer and salivary gland tumors.
- Updated NCCN recommendations for Trelstar and Vantas for treatment of prostate cancer.
Highmark BCBS Delaware reviewed its Experimental/Investigational Services policy with the following changes:
- Added codes include, but are not limited to, the following:
- 0596T – Temporary female intraurethral valve-pump (i.e., voiding prosthesis); initial insertion, including urethral measurement
- 0600T – Ablation, irreversible electroporation; 1 or more tumors per organ, including imaging guidance, when performed, percutaneous
- 0601T – Ablation, irreversible electroporation; 1 or more tumors, including fluoroscopic and ultrasound guidance, when performed, open
- 0602T – Glomerular filtration rate (GFR) measurement(s), transdermal, including sensor placement and administration of a single dose of fluorescent pyrazine agent
- 0603T – Glomerular filtration rate (GFR) monitoring, transdermal, including sensor placement and administration of more than one dose of fluorescent pyrazine agent, each 24 hours
- Removed codes, including, but not limited, to the following:
- 0012U – Germline disorders, gene rearrangement detection by whole genome next generation sequencing, DNA, whole blood, report of specific gene rearrangement(s)
- 0016U – Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitation
- 0017U – Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected
- 0019U – Oncology, RNA, gene expression by whole transcriptome sequencing, formalin-fixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential targets for therapeutic agents
- 0021U – Oncology (prostate), detection of 8 autoantibodies (ARF 6, NKX3-1, 5’-UTRBMI1, CEP 164, 3’-UTR-Ropporin, Desmocollin, AURKAIP-1, CSNK2A2), multiplexed immunoassay and flow cytometry serum, algorithm reported as risk score
- 0024U – Glycosylated acute phase proteins (GlycA), nuclear magnetic resonance spectroscopy, quantitative
- 0025U – Tenofovir, by liquid chromatography with tandem mass spectrometry (LC-MS/MS), urine, quantitative
- 0027U – JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15
Highmark BCBS Delaware released its new Prostate Specific Antigen policy stating prostate specific antigen testing may be considered medically necessary when criteria are met.
Maryland
CareFirst BCBS
CareFirst BCBS reviewed its Erectile Dysfunction Policy adding CPT code 54400 associated with non-hydraulic penile implants.
West Virginia
Highmark West Virginia
Highmark West Virginia reviewed its Posterior Tibial Nerve Stimulation Policy with the following changes to language:
- Added neurogenic bladder dysfunction and fecal incontinence as examples of experimental /investigational indications.
- Revised experimental/investigational language.
Highmark West Virginia reviewed its Experimental/Investigational Services policy with the following changes:
- Added codes include, but are not limited to, the following:
- 0596T – Temporary female intraurethral valve-pump (i.e., voiding prosthesis); initial insertion, including urethral measurement
- 0600T – Ablation, irreversible electroporation; 1 or more tumors per organ, including imaging guidance, when performed, percutaneous
- 0601T – Ablation, irreversible electroporation; 1 or more tumors, including fluoroscopic and ultrasound guidance, when performed, open
- 0602T – Glomerular filtration rate (GFR) measurement(s), transdermal, including sensor placement and administration of a single dose of fluorescent pyrazine agent
- 0603T – Glomerular filtration rate (GFR) monitoring, transdermal, including sensor placement and administration of more than one dose of fluorescent pyrazine agent, each 24 hours
- Removed codes, including, but not limited, to the following:
- 0012U – Germline disorders, gene rearrangement detection by whole genome next generation sequencing, DNA, whole blood, report of specific gene rearrangement(s)
- 0016U – Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitation
- 0017U – Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected
- 0019U – Oncology, RNA, gene expression by whole transcriptome sequencing, formalin-fixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential targets for therapeutic agents
- 0021U – Oncology (prostate), detection of 8 autoantibodies (ARF 6, NKX3-1, 5’-UTRBMI1, CEP 164, 3’-UTR-Ropporin, Desmocollin, AURKAIP-1, CSNK2A2), multiplexed immunoassay and flow cytometry serum, algorithm reported as risk score
- 0024U – Glycosylated acute phase proteins (GlycA), nuclear magnetic resonance spectroscopy, quantitative
- 0025U – Tenofovir, by liquid chromatography with tandem mass spectrometry (LC-MS/MS), urine, quantitative
- 0027U – JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15
Highmark West Virginia released its new Prostate Specific Antigen policy. Prostate specific antigen testing may be considered medically necessary when criteria are met.
Highmark West Virginia reviewed its Gonadotropin Releasing Hormones (GnRHs) Analogs Policy with the following changes:
- Revised criteria for use as adjuvant androgen deprivation therapy (ADT) as a single agent or with a first-generation antiandrogen with or without external beam radiation (EBRT) if lymph node metastasis found during pelvic lymph node dissection (PLND), removing use in individuals in the very low risk group and greater than or equal to 20 year expected survival as a medically necessary indication for Lupron.
- Added use as adjuvant ADT as a single agent or in combination with a first-generation antiandrogen with EBRT if adverse features noted after radical prostatectomy as a medically necessary indication for Lupron when criteria are met.
- Updated Lupron medically necessary treatment regimens for initial ADT as a single agent or in combination with a first-generation antiandrogen with EBRT if life expectancy greater than 5 years or symptomatic.
- Added National Comprehensive Cancer Network (NCCN) recommendations for Lupron Depot for treatment of prostate cancer and salivary gland tumors.
- Updated NCCN recommendations for Eligard for treatment of prostate cancer and salivary gland tumors.
- Updated NCCN recommendations for Trelstar and Vantas for treatment of prostate cancer.
New Jersey
AR 149 – Workforce Shortage
On March 23, Assemblymember William Moen (D) introduced AR 149. This bill urges the President and Congress of United States to continue the federal Public Service Loan Forgiveness Program. On July 30, AR 149 passed the Assembly. This measure is a resolution and only needed to pass the Assembly. Read the bill.
SB 2750 – Medical Licensure
On July 28, Senator Joseph Cryan (D) introduced SB 2750. This bill creates New Jersey code to require communicable disease training for health care professionals. SB 2750 was introduced and referred to the Senate Health, Human Services and Senior Citizens Committee. Read the bill.
AB 4403 – Telemedicine
On July 16, Assemblymember Valerie Vainieri Huttle (D) introduced AB 4403. This bill creates New Jersey code to establish the “Telehealth and Telemedicine Improvement Task Force” within the Department of Health. On July 16, AB 4403 was referred to the Assembly Health Committee and awaits a hearing. Read the bill.
Horizon BCBS New Jersey
Horizon BCBS New Jersey reviewed its Detection of Circulating Tumor Cells Policy revising Medicare coverage section to remove statement previously indicating that per Local Coverage Article (LCA): Billing and coding: Biomarkers for oncology (A52986), CPT code 0013U is non-covered.
Horizon BCBS New Jersey reviewed its Prolia, Xgeva Policy with the following changes:
- Added that the prescriber must be a specialist in the area of the member’s diagnosis or must have consulted with a specialist in the area of the member’s diagnosis to criterion stating that for medical necessity to be indicated for Prolia and Xgeva, they must be administered by a healthcare professional and the prescriber must be a specialist in the area of the member’s diagnosis or must have consulted with a specialist in the area of the member’s diagnosis.
- Revised limitations for Xgeva and Prolia to remove list of indications considered investigational to remove listed indications and add statement that other uses of Xgeva and Prolia are considered investigational.
Horizon BCBS New Jersey reviewed its Radiation Therapy for Prostate Cancer Policy with the following changes:
- Added treatment of pelvic lymph nodes list of situations for which medical necessity is indicated for radiation therapy for prostate cancer; Added criterion stating that medical necessity is indicated for the following in the treatment of prostate cancer when treating pelvic lymph nodes: conventional fractionation when delivering 1.8 to 2.0 Gy/fraction, 36 to 45 fractions of intensity modulated radiation therapy (IMRT), hypofractionation in 20 to 28 fractions of IMRT, low dose brachytherapy in combination with 25 to 28 fractions of three dimensional conformal radiation therapy (3DCRT) or IMRT, and high dose rate brachytherapy in combination with 25 to 28 fractions of 3DCRT or IMRT.
- Added treatment of metastatic disease to list of situations for which medical necessity is indicated for radiation therapy for prostate cancer; Added criterion applicable to low volume disease stating that in members with castration naive metastatic prostate cancer with 3 or fewer bone metastases and no visceral disease, IMRT to a dose of 55 Gy in 20 fractions to the prostate in conjunction with androgen deprivation therapy is considered medically necessary only when the use of NCCN category 1 systemic regimens are contraindicated.
- Changed ‘up to 28 fractions’ to ‘20-28 fractions’ in criterion stating medical necessity is indicated for hypofractionation in 20 to 28 fractions of 3DCRT or IMRT in the treatment of low risk prostate cancer.
- Specified dose of 64-72 Gy in criterion stating that for medical necessity is indicated for adjuvant or salvage radiation therapy in a dose of 64-72 Gy in 32 to 40 fractions of 3DCRT or IMRT.
- Specified that treatment must not be of pelvic lymph nodes in policy statement listing medically necessary treatments for high risk prostate cancer when not treating the pelvic lymph nodes.
- Added limitation applicable to metastatic disease stating that radiation to the prostate is considered not medically necessary for high volume disease.
Horizon BCBS New Jersey reviewed its Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence Policy with the following changes:
- Added the Medicaid coverage information section.
- Added Medicaid coverage information stating that the service is not covered under the Horizon NJ health contract.
Pennsylvania
Cap Blue Cross
Cap Blue Cross reviewed its Experimental and Investigational Procedures Policy adding the following CPT codes:
- 0596T – Temporary female intraurethral valve-pump (i.e., voiding prosthesis); initial insertion, including urethral measurement
- 0597T – Under Female Voiding Prosthesis Procedures
- 0619T – Cystourethroscopy with transurethral anterior prostate commissurotomy and drug delivery, including transrectal ultrasound and fluoroscopy, when performed
Independence Blue Cross
Independence Blue Cross reviewed its Experimental/Investigational Services Policy adding CPT code:
- 0596T – Temporary female intraurethral valve-pump (i.e., voiding prosthesis); initial insertion, including urethral measurement
Read the Medicare advantage update.
Independence Blue Cross reviewed its Jevtana Policy with the following changes:
- Revised the effective date to July 6.
- Revised medically necessary indications by adding castration-resistant distant metastatic (M1) prostate cancer.
- Revised medically necessary indications by removing progressive, metastatic, hormone-refractory prostate cancer (mHRPC).
Independence Blue Cross reviewed its Modifier 25 Policy with the following changes to coding:
- Added the following CPT code:
- 90912 – Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient
- Removed the following CPT codes:
- 90911 – Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry
Highmark Pennsylvania
Highmark Pennsylvania reviewed its Posterior Tibial Nerve Stimulation Policy with the following changes to language:
- Added neurogenic bladder dysfunction and fecal incontinence as examples of experimental /investigational indications.
- Revised experimental/investigational language.
Highmark Pennsylvania reviewed its Experimental/Investigational Services policy with the following changes:
- Added codes include, but are not limited to, the following:
- 0596T – Temporary female intraurethral valve-pump (i.e., voiding prosthesis); initial insertion, including urethral measurement
- 0600T – Ablation, irreversible electroporation; 1 or more tumors per organ, including imaging guidance, when performed, percutaneous
- 0601T – Ablation, irreversible electroporation; 1 or more tumors, including fluoroscopic and ultrasound guidance, when performed, open
- 0602T – Glomerular filtration rate (GFR) measurement(s), transdermal, including sensor placement and administration of a single dose of fluorescent pyrazine agent
- 0603T – Glomerular filtration rate (GFR) monitoring, transdermal, including sensor placement and administration of more than one dose of fluorescent pyrazine agent, each 24 hours
- Removed codes, including, but not limited, to the following:
- 0012U – Germline disorders, gene rearrangement detection by whole genome next generation sequencing, DNA, whole blood, report of specific gene rearrangement(s)
- 0016U – Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitation
- 0017U – Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected
- 0019U – Oncology, RNA, gene expression by whole transcriptome sequencing, formalin-fixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential targets for therapeutic agents
- 0021U – Oncology (prostate), detection of 8 autoantibodies (ARF 6, NKX3-1, 5’-UTRBMI1, CEP 164, 3’-UTR-Ropporin, Desmocollin, AURKAIP-1, CSNK2A2), multiplexed immunoassay and flow cytometry serum, algorithm reported as risk score
- 0024U – Glycosylated acute phase proteins (GlycA), nuclear magnetic resonance spectroscopy, quantitative
- 0025U – Tenofovir, by liquid chromatography with tandem mass spectrometry (LC-MS/MS), urine, quantitative
- 0027U – JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15
Highmark Pennsylvania released its new Prostate Specific Antigen policy stating prostate specific antigen testing may be considered medically necessary when criteria are met.
Highmark Pennsylvania reviewed its Gonadotropin Releasing Hormones (GnRHs) Analogs Policy with the following changes:
- Revised criteria for use as adjuvant androgen deprivation therapy (ADT) as a single agent or with a first-generation antiandrogen with or without external beam radiation (EBRT) if lymph node metastasis found during pelvic lymph node dissection (PLND), removing use in individuals in the very low risk group and greater than or equal to 20 year expected survival as a medically necessary indication for Lupron.
- Added use as adjuvant ADT as a single agent or in combination with a first-generation antiandrogen with EBRT if adverse features noted after radical prostatectomy as a medically necessary indication for Lupron when criteria are met.
- Updated Lupron medically necessary treatment regimens for initial ADT as a single agent or in combination with a first-generation antiandrogen with EBRT if life expectancy greater than 5 years or symptomatic.
- Added National Comprehensive Cancer Network (NCCN) recommendations for Lupron Depot for treatment of prostate cancer and salivary gland tumors.
- Updated NCCN recommendations for Eligard for treatment of prostate cancer and salivary gland tumors.
- Updated NCCN recommendations for Trelstar and Vantas for treatment of prostate cancer.
ICYMI: Updates from the AUA Policy & Advocacy Brief blog
Payment Policy: CMS Releases Proposed Rule for 2021 Medicare Physician Fee Schedule
The long-awaited 2021 Medicare Physician Fee Schedule proposed rule was released on August 3. The proposed rule from the Centers for Medicare & Medicaid Services (CMS) includes a number of key takeaways, including an increase in allowable services for urology, a decrease in the conversion factor for 2021, changes to code lists for telehealth services and the current status of planned changes to evaluation and management (E/M) coding in 2021. The AUA released an easy reference in the August 4 issue of the Policy & Advocacy Brief, and our more detailed review had been released to AUA members.
Evaluation and Management Services: AUA, Provider Coalition Call for End to Budget Neutrality
On August 4, the AUA joined more than 40 other organizations to urge Congress to end budget neutrality. The call to action in the press release was in response to the impact to payments in the Centers for Medicare & Medicaid Services (CMS) Medicare Physician Fee Schedule (see related article here). Due to Medicare’s budget neutrality requirements, physician, non-physician, and institutional providers billing under the Physician Fee Schedule will experience substantial payment reductions to offset payment increases to physicians and other providers who primarily deliver office-based services. These cuts will be devastating to a health care system that is already struggling and may lead to reduced access to care for older Americans and Americans with disabilities. Congress Must Act to Prevent Further Damage to the Health Care System.
Telehealth: Senate Unveils Latest COVID-19 Package Providing Waiver Extension
On July 27, Majority Leader Mitch McConnell (R-KY) unveiled several pieces of legislation that are expected to be rolled into the Health, Economic Assistance, Liability Protection, and Schools (HEALS) Act, which is the Senate Republican’s version of the next COVID-19 stimulus package. Included in this $1 trillion package is a provision that would grant authority to extend Medicare telehealth waivers through 2021, allowing more time so Congress can determine what provisions should be made permanent.
Negotiations with the White House and House Speaker Nancy Pelosi (D-CA-12) have since been sporadic. House Democrats passed their version of the next COVID relief bill (HEROES Act) back in May, which did not contain any similar language extending telehealth waivers.
AUAPAC Update: AUAPAC Cohosts Virtual Meeting with House Member
On July 29, AUAPAC, along with OphthPAC (American Academy of Ophthalmology) and SkinPAC (American Academy of Dermatology), hosted a virtual fundraiser for Rep. Bill Johnson (R-OH-06) that was also attended by seven other healthcare organizations. These groups are all part of MaDPAC, a large coalition of other medical and dental PACs in the Washington, DC metropolitan area. Congressman Johnson serves on the House Energy & Commerce Committee, which has jurisdiction on health care policy. He also is the co-chair of Congress’s bipartisan Telehealth Caucus. As such, he has championed legislation to expand patient access to and physician use of telehealth services, and has been one of the leading voices in ensuring that the telehealth services expanded by the COVID-19 pandemic become permanent.