June 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 the dozens of virtual meetings with members of Congress and their staff on important issues such as passing medical liability reform legislation. I also share news on additional joint advocacy to urge governors, insurance commissioners, and the National Governors Association to continue telemedicine coverage after the public health emergency ends.
Congressional Outreach: AUA Continues Virtual Meetings on COVID-19 Relief with Federal Lawmakers
The AUA continued a series of meetings with members of Congress and their staff to discuss numerous pressing issues impacting physicians and our health care delivery system around the country. A wide-range of topics were mentioned, including top AUA legislative priorities like the need to expand additional medical liability protections for physicians and to better address physician workforce shortages. Other key areas involved telemedicine and the importance of streamlining both audio-only and visual services and improving the terms of the Medicare Accelerated and Advance Payment Programs that were enacted in March via the CARES Act (COVID III). These conversations remain timely, as congressional efforts to pass a fourth COVID-19 relief package are ramping up.
A strategic focus was placed on mainly educating lawmakers that sit on the committees overseeing U.S. health policy, which include the House Energy & Commerce and Ways & Means Committees and the Senate Finance and Health, Education, Labor & Pensions Committees, as well as others in a leadership position or with a medical background. Those members included the following: House Minority Leader Rep. Kevin McCarthy (R-CA-23); Reps. Ami Bera, MD (D-CA-07); Jim McGovern (D-MA-03); Cathy McMorris Rodgers (R-WA-05); Elise Stefanik (R-NY-21); Drew Ferguson, DMD (R-GA-03); Bob Latta (R-OH-05); Mark Takano (D-CA-41); Fred Upton (R-MI-06); Sens. Rand Paul (R-KY); Sherrod Brown (D-OH); Bob Menendez (D-NJ); as well as with professional staff from the House Energy & Commerce Committee.
AUAPAC: AUA Hosts Two Virtual Meetings with House Members
AUAPAC hosted a virtual meeting for Rep. Ann McLane Kuster (D-NH-02) that was attended by Drs. Ann Gormley and David Green, who sit on both the AUA Board and the AUAPAC Board. Congresswoman Kuster is a member of the House Energy & Commerce Subcommittee on Health, which is one of two main committees that oversee health policy in the House. She strongly supports increasing federal biomedical research funding for the National Institutes of Health, addressing the physician workforce shortage, and continuing to expand access to telemedicine whenever possible.
In addition, AUAPAC hosted a virtual meeting for Rep. Greg Murphy, MD (R-NC-03) that was attended by 14 other healthcare organizations. These groups were all part of MaDPAC, which is a large coalition of other medical and dental PACs in the Washington, DC metropolitan area. Dr. Murphy is an AUA member and practicing urologist who won a 2019 special election to represent North Carolina’s 3rd Congressional District. Dr. Murphy also is a supporter of the USPSTF Transparency and Accountability Act (H.R. 3534) and the Improving Seniors’ Timely Access to Care Act (H.R. 3107) – which would streamline the Prior Authorization process within the Medicare Advantage program.
Medical Liability Reform: New Pandemic Bill Introduced; AUA Signs Multiple Letters Supporting the Initiative
Medical liability reform is one of the AUA’s advocacy priorities and we work with multiple organizations to support and advance legislation to address this key concern. Recently, Reps. Phil Roe, MD (R-TN-01) and Luis Correa (D-CA-46) introduced legislation that would provide health care professionals, and the facilities in which they work, protections from COVID-19-related lawsuits. The Coronavirus Provider Protection Act (H.R. 7059) would provide liability protections when:
- The act or omission occurred during the declared COVID-19 public health emergency or within 60 days of termination of the emergency;
- The act or omission occurred while providing or arranging care;
- The services were within the provider’s scope of licensure/certification, without regard as to whether the service fell within the usual scope of practice; and
- The services were provided in good faith.
Additional actions covered by the bill would include those taken based on direction or guidance from any federal, state, or local official/department/agency as well as those taken due to a lack of resources attributable to the declared emergency.
The AUA was actively engaged with other groups – including the Health Coalition on Liability and Access (HCLA), the Alliance of Specialty Medicine, and the American Medical Association to send letters of support for this bill. Liability protections also have been a part of the virtual conversations the AUA has had with congressional offices leading up to and after introduction of this bill.
National Insurance Updates
Aetna
Aetna updated its Urinary Incontinence Policy:
- Added that the adjustable transobturator male system for the treatment of stress urinary incontinence (SUI) is considered experimental and investigational because its effectiveness has not been established.
- Added that magnetic stimulation for the treatment of women with SUI is considered experimental and investigational because the effectiveness of this approach has not been established.
- Added that genetic testing for stress urinary incontinence is considered experimental and investigational because its clinical value for this indication has not been established.
Aetna reviewed its Urinary Incontinence Policy adding the following covered CPT codes:
- 0587T — Percutaneous implantation or replacement of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
- 0588T — Revision or removal of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
- 0589T — Electronic analysis with simple programming of implanted integrated neurostimulation system (e.g., electrode array and receiver), including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient-selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, when performed by physician or other qualified health care professional, posterior tibial nerve, 1-3 parameters
- 0590T — 4 or more parameters
Aetna added the following CPT codes to its Complementary and Alternative Medicine Policy:
- 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
- 90913 — Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure)
Removed the following CPT code:
- 90911 — Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry
Aetna added the following CPT codes to its Tumor Markers Policy:
- 81542 — Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score
AmeriHealth, Independence Blue Cross
AmeriHealth, Independence Blue Cross reviewed its eviCore Lab Management Program, Genetic Testing, and Molecular Diagnostics Policies indicating the following CPT code description has been revised:
- 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
Read the lab update here, the genetic testing update here, and the molecular diagnostics update here.
AmeriHealth, Independence Blue Cross revised its Multiple Surgical Payment Reduction Policy coding in the following way:
Added CPT codes, including, but not limited to, the following:
- 0549T — Transperineal periurethral balloon continence device; bilateral placement, unilateral placement, including cystoscopy and fluoroscopy
- 0550T — Transperineal periurethral balloon continence device; removal, each balloon
- 0551T — Transperineal periurethral balloon continence device; adjustment of balloon(s) fluid volume
- 53854 — Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy
- 55874 — Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed
Removed CPT codes, including but not limited to, the following:
- 55450 — Ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure)
Revised policy title to “Multiple Surgery Payment Reduction.”
BCBS Federal Employee Plan
BCBS Federal Employee Plan reviewed its Xtandi Policy adding the diagnosis of metastatic castration-sensitive prostate cancer, and revised the medically necessary policy statement for Xtandi to reflect this change.
Capital Blue Cross
Capital Blue Cross reviewed its Zometa, Reclast Policy with the following changes to criteria:
Added note to policy section stating that for members with late stage metastatic disease (Stage IV), please refer to MP 2.373 Step Therapy Treatment in Cancer, Including Treatments for Stage Four, Advanced Metastatic Cancer and Severe Related Health Conditions for additional guidance.
Capital Blue Cross reviewed its Jevtana Policy with the following changes to criteria and supporting information:
Added note to policy section stating that for members with late stage metastatic disease (Stage IV), please refer to MP 2.373 Step Therapy Treatment in Cancer, Including Treatments for Stage Four, Advanced Metastatic Cancer and Severe Related Health Conditions for additional guidance.
Centene Corporation
Centene reviewed its Lab Tests in a Physician’s Office Policy adding the following CPT/HCPCS codes:
- 86328 — Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
- 86769 — Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
- 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.
- U0001 — CDC 2019 novel coronavirus (2019-nCoV) real-time rt-pcr diagnostic panel.
- U0002 — Non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19)
Cigna
Cigna revised its Radiation Oncology Clinical Guidelines including:
- Bladder Cancer
- Proton Beam Therapy
- Xofigo
Cigna announced a new reimbursement policy regarding COVID-19 Interim Billing Guidelines
CGS Administrators
CGS Administrators released its Decipher Biopsy Prostate Cancer Classifier Assay for Men with Favorable Intermediate Risk Disease (MoIDX) LCD (L38077) that became effective on April 6.
CGS Administrators released its Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia LCD (J15) (A57926) that became effective April 1.
CGS Administrators released its Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia – Response to Comments LCA (J15) (A57927) in effect, beginning April 1.
CGS Administrators reviewed its Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia – LCD (L38378) revising the notice period end date for policy from May 31 to August 31 and start date from March 26 to April 15, and specifying that that the policy will not be effective until September 1.
CGS Administrators posted the following new meeting information:
Announced a new meeting for Kentucky & Ohio Joint Open Public Draft/Revised LCD Discussion Meeting: Draft Local Coverage Determinations on June 23 from 4:00 p.m. to 5:00 p.m. ET, which will be held entirely via teleconference. The following LCDs will be discussed:
- MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer
- MolDX: Liquid biopsies for solid organ transplantation
- MolDX: Phenotypic Biomarker Detection in Circulating Tumor Cells
- Urine Drug Screen
Independence Blue Cross
Independence Blue Cross reviewed and updated its Modifier 25 Policy.
Independence Blue Cross removed the notification status as this policy became effective on May 18 and added a hyperlink to a news article on the topic of a waiver of certain requirements during the COVID-19 outbreak.
Medica Health Plans
Medica Health Plans added the following codes to its Emergency Telemedicine Services Code List:
- G2025 — Services that were furnished via telehealth
Medica Health Plans published its Provider Newsletter announcing several changes made to respond to the COVID-19 pandemic, including expanded coverage and payment for telehealth services, a new reimbursement policy for COVID-19 lab testing, waived PA requirements for post-acute care settings, and waived member cost-sharing for COVID-19 lab testing, office visits and hospital stays.
National Government Services (NGS)
NGS released its Salvage High-intensity Focused Ultrasound (HIFU) Treatment in Prostate Cancer – Response to Comments LCA (J06, JK) (A57835) that became effective April 1.
NGS released its Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) Response to Comments LCA (J06, JK) (A57921) that became effective April 1.
NGS released its Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) – LCD (J06, JK) (L35076) that became effective April 1.
NGS released its Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) – LCA (J06, JK) (A56874) that became effective April 1.
Noridian
Noridian released its Comment/response article published for DL38119 — Next Generation Sequencing for Solid Tumors (MolDX) – Response to Comments LCA (JE) (A57904), that became effective May 17. Collected comments are from May 30 to July 15, 2019.
Noridian released its proposed/draft Next Generation Sequencing for Solid Tumors (MoIDX) policy into future effective policy that became effective May 17. The associated response to comments article can be found here.
Noridian released its Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies (MoIDX) LCD (JF) (L38125) proposed/draft policy into future effective policy. The associated response to comments article can be found here.
Noridian released its Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies (MoIDX) LCD (JE) L38123) proposed/draft policy into future effective policy effective May 17. The associated response to comments article can be found here.
Noridian released its Next Generation Sequencing for Solid Tumors (MoIDX) – LCA, which became effective May 17.
Noridian released its Next Generation Sequencing Lab Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies (MolDX) – LCA, which became effective May 17.
Noridian released its Next-Generation Sequencing for Solid Tumors (MolDX) – LCD, which became effective May 17.
Noridian released its Next—Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies (MolDX) – LCD, that became effective May 17.
Noridian released its draft Liquid Biopsies for Solid Organ Transplantation (MoIDX) LCD on May 21. The comment period begins May 28 and ends July 12.
Noridian (JF and JE) released its draft Prognostic and Predictive Molecular Classifiers for Bladder Cancer (MoIDX) Draft LCD on May 21. A synopsis of the draft is as follows:
- Molecular diagnostic tests for use in a beneficiary with bladder cancer are covered when criteria are met. Criteria include, but are not limited to, the following:
- The beneficiary is being actively managed for bladder cancer.
- The beneficiary is within the population and has the indication for which the test was developed and is covered. The lab providing the test is responsible for clearly indicating to treating clinicians the population and indication for test use.
- The patient has not had a cystectomy.
The comment period begins May 28 and ends July 12.
Read the update for JF here and JE here.
Palmetto
Palmetto released its Fluid Jet System in the Treatment of Benign Prostatic Hypertrophy (BPH) (MoIDX) – Draft LCD (DL38549), on April 23. This policy will be presented at the open meeting for South Carolina on June 1. Comment period begins on April 23 and ends on June 6. A synopsis of the draft is as follows:
- One treatment for LUTS, or a BPH treatment performed once, is covered when all criteria are met. Criteria include, but are not limited to, the following:
- Age is less than or equal to 80 years
- Prostate volume of 30-80 cc by TRUS
- Persistent moderate to severe symptoms despite maximal medical management
Palmetto reviewed its Molecular Diagnostic Tests (MoIDX) – LCA (A56853) revising descriptions for the following CPT code due to quarterly coding update:
- 0154U — Onc urthl ca rna fgfr3 gene
Palmetto states that its Minimally Invasive Treatment for BPH Involving PUL article, is retired effective May 1 due to new Food and Drug Administration indications that no longer require a restrictive article, other than the medical necessity requirements.
Paramount
Paramount reviewed its Telehealth Services COVID-19 Policy with the following changes to criteria and coding:
- Removed a statement indicating that only established patients can be provided services through telehealth under this policy.
Regence
Regence published a Provider Bulletin announcing:
- Due to COVID-19, Regence is working to expedite claims payments.
- Expansions to telehealth services.
- COVID-19 testing does not require prior authorization and testing and associated office visits are covered.
- Changes for pharmacy prior authorization and medication refills to extend PAs and adjust refill time for all medication except opioids.
Regence reviewed its Uniform Medical Plan PA List (Idaho) adding the following note to the service category Noninvasive Ventilators in the Home Setting:
- Due to the COVID-19 pandemic, pre-authorization requirements for noninvasive ventilators will be suspended until August 1.
Security Health Plan
Security Health Plan updated its Provider Bulletin to announce members who need care from an out-of-network provider during the COVID-19 health emergency should contact a Security Health Plan nurse navigator.
Tufts Health Plan
Tufts Health Plan updated its Provider Bulletin removing an announcement that COVID-19 CDC and non-CDC testing services applies to diagnostic testing at drive through sites.
UHC Community Plan
UHC Community Plan reviewed its Maximum Frequency Per Day Policy adding the following state exception to Washington:
- The following COVID-19 codes does not impose a daily limit: 98966, 98967, 98968, 99001, 99422, 99423, 99441, 99442, 99443, 99451, G2012.
UHC Community Plan reviewed its Medically Unlikely Edits (MUE), Facility and Professional – Reimbursement Policy adding the following state exception to Washington:
- The following COVID-19 codes do not impose a daily limit: 99001 & 99451.
UHC Community Plan reviewed its Genetic Testing for Hereditary Cancer Policy with the following changes to criteria, coding, and supporting information:
Revised medically necessary indications for BRCA1/BRCA2 testing in the following populations:
- Men with a personal history of prostate cancer;
- Women with a personal history of breast cancer;
- Individuals without a personal history of a related cancer.
Added the following CPT codes:
- 0133U — Hereditary prostate cancer–related disorders, targeted mRNA sequence analysis panel (11 genes) (List separately in addition to code for primary procedure)
UHC Community Plan reviewed its Oncology Medication Clinical Coverage Policy with the following changes to coding, medications, and supporting information:
Added applicable codes section with the following denied HCPCS code:
- J9219 — Leuprolide acetate implant, 65 mg.
Added the following preferred/non-preferred oncology products:
- Gemcitabine / Infugem (gemcitabine in sodium chloride injection).
United Healthcare
United Healthcare reviewed its Xtandi – Step Therapy Policy with the following changes to criteria and supporting information:
- Replaced Prostate Cancer criterion “History of failure, contraindication, or intolerance to Erleada (apalutamide)” with “History of failure, contraindication, or intolerance to both of the following:
- Erleada (apalutamide)
- Nubeqa (darolutamide)”
United Healthcare reviewed its Laboratory Tests and Services Coverage Summary adding prostate specific antigen to guideline 2 (clinical diagnostic laboratory tests and services).
United Healthcare reviewed its Molecular Pathology/Molecular Diagnostics/Genetic Testing Policy with the following changes:
Revised criteria for molecular assays for prostate cancer; removed ProMark risk score from examples of molecular assays with proven efficacy.
Removed CPT code:
- 0133U—Hereditary prostate cancer–related disorders, targeted mRNA sequence analysis panel (11 genes) (List separately in addition to code for primary procedure)
United Healthcare reviewed its Clinical Diagnostic Laboratory Services Policy revising coding to the following:
Added the following HCPCS codes:
- U0001 — CDC 2019 novel coronavirus (2019-ncov) real-time rt-pcr diagnostic panel
- U0002 — Non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19)
Added the following CPT codes:
- 81542 — Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as metastasis risk score
- 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
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 reviewed its Miscellaneous Services Policy with the following changes to criteria and coding:
Removed prolonged physician services without direct (face-to-face) contact and telephone calls from the list of services that are considered no professional service rendered and therefore non-covered.
Removed the following procedure codes:
- Telephone assessment and management service provided by a qualified non-physician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment;
- 98966 — 5-10 minutes of medical discussion
- 98967 — 11-20 minutes of medical discussion
- 98968 — 21-30 minutes of medical discussion
- Prolonged evaluation and management service before and/or after direct patient care;
- 99358 — first hour
- 99359 — each additional 30 minutes (list separately in addition to code for prolonged service)
- Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment;
- 99441 — 5-10 minutes of medical discussion
- 99442 — 11-20 minutes of medical discussion
- 99443 — 21-30 minutes of medical discussion
- Interprofessional telephone/internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional;
- 99446 — 5-10 minutes of medical consultative discussion and review
- 99447 — 11-20 minutes of medical consultative discussion and review
- 99448 — 21-30 minutes of medical consultative discussion and review
- 99449 — 31 minutes or more of medical consultative discussion and review
Highmark BCBS Delaware published its COVID-19 News bulletin announcing:
- Early refills will be available for all medications that became effective March 25.
- Effective March 25, copays for prescriptions are waived.
- 30 day early refills will be provided for certain DME supplies effective March 18.
West Virginia
Highmark West Virginia reviewed its Miscellaneous Services Policy with the following changes to criteria and coding.
Removed prolonged physician services without direct (face-to-face) contact and telephone calls from the list of services that are considered no professional service rendered and therefore non-covered.
Removed the following procedure codes:
- Telephone assessment and management service provided by a qualified non-physician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment;
- 98966 — 5-10 minutes of medical discussion
- 98967 — 11-20 minutes of medical discussion
- 98968 — 21-30 minutes of medical discussion
- Prolonged evaluation and management service before and/or after direct patient care;
- 99358 — first hour
- 99359 — each additional 30 minutes (list separately in addition to code for prolonged service)
- Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment;
- 99441 — 5-10 minutes of medical discussion
- 99442 — 11-20 minutes of medical discussion
- 99443 — 21-30 minutes of medical discussion
- Interprofessional telephone/internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional;
- 99446 — 5-10 minutes of medical consultative discussion and review
- 99447 — 11-20 minutes of medical consultative discussion and review
- 99448 — 21-30 minutes of medical consultative discussion and review
- 99449 — 31 minutes or more of medical consultative discussion and review
New Jersey
Horizon BCBS New Jersey published its Medical Policy Updates Provider Bulletin announcing that effective April 24, Magellan Rx Management will no longer conduct medical necessity reviews for Dysport.
Horizon BCBS New Jersey reviewed its Self-Administered Oncology Agents PA Criteria adding a requirement of past 90 days in criteria options stating that medical necessity may be indicated for Zytiga 250mg or 500 mg tablets, the member has tried and failed generic abiraterone 250mg tablets in the past 90 days, if the requested agent is Imbruvica 140mg or 280 mg tablets, the member has tried and had an inadequate response to Imbruvica 140 mg capsules in the past 90 days, or if the requested agent is a brand agent with a generic agent available and the member’s medication history indicates use of the available generic equivalent in the past 90 days.
Horizon BCBS New Jersey reviewed its Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer Policy with the following changes to criteria and supporting information:
- Revised Medicare criteria to indicate that per NGS LCD L37733: Biomarker testing (prior to initial biopsy) for prostate cancer diagnosis, ExoDx Prostate IntelliScore (EPI) is covered once for men ≥ 50 years old prior to initial biopsy, with confirmed moderately elevated PSA (>3 and <10 ng/mL; ≥4 and <10 ng/mL in men >75 years old) when %fPSA, PHI, 4Kscore or EPI biomarker test have not been performed prior and both of the following are met: no other relative indication for prostate biopsy; and no other relative contraindication for prostate biopsy.
Horizon BCBS New Jersey reviewed its Injectable Bulking Agents for the Treatment of Urinary Incontinence Policy with the following changes to coding:
Added the following HCPCS code:
- L8604—Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies
Removed the following HCPCS code:
- Q3031—Collagen skin test
Horizon BCBS New Jersey reviewed its Provenge Policy with the following changes to criteria, limitations, and supporting information:
- Added criterion stating that for medical necessity to be indicated for Provenge in the treatment of prostate cancer, the prescriber must be a specialist in the area of the member’s diagnosis (e.g., oncologist) or must have consulted with a specialist in the area of the member’s diagnosis.
- Added criterion stating that for medical necessity to be indicated for Provenge in the treatment of prostate cancer, the member must not have previously received therapy with sipuleucel-T.
- Revised criteria for off-label indications to remove diagnosis-specific criteria and add statement indicating that off-label indications that are 2A or better recommendations in the NCCN compendium may be considered medically necessary when criteria are met.
- Removed treatment of hormone-responsive prostate cancer, moderate to severe symptomatic metastatic prostate cancer, non-metastatic prostate cancer, castrate-resistance prostate cancer in conjunction with abiraterone and those with visceral (liver, lung or brain) metastases, sarcoma, and glioblastoma from list of other uses considered investigational.
SB 2465 – Medical Licensure
On May 11, Senator Stephen Sweeney (D) introduced SB 2465. This bill creates the “New Jersey Health Care Transparency Act” to require health professionals to display information about their license in advertisements and place of practice. SB 2465 also requires health care professionals to wear nametags with the professional’s: full name, licensed profession, license expiration, and recent picture. SB 2465 was referred to the Senate Health, Human Services and Senior Citizens Committee. This bill is eligible for consideration at the discretion of the chair. Read the bill.
AB 4177 – Certificate of Need
On June 1, Assemblymember Ralph Caputo (D) introduced AB 4177. This bill revises the certificate of need program and requests an increase in the Medicaid reimbursement rate for emergency medical services. AB 4177 was referred to the Assembly Health Committee and awaits further consideration. Read the bill.
AB 4179 – Telemedicine
On June 1, Assemblymember JoAnn Downey (D) introduced AB 4179. This bill requires that reimbursement for telemedicine and telehealth services be equal to the reimbursement rate for the same in-person services. Current law states that these services may be reimbursed up to the amount of in-person service reimbursement. AB 4179 was referred to the Assembly Financial Institutions and Insurance Committee. Read the bill.
Pennsylvania
Highmark Pennsylvania reviewed its Miscellaneous Services Policy with the following changes to criteria and coding:
Removed prolonged physician services without direct (face-to-face) contact and telephone calls from the list of services that are considered no professional service rendered and therefore non-covered.
Removed the following procedure codes:
- Telephone assessment and management service provided by a qualified non-physician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment;
- 98966 — 5-10 minutes of medical discussion
- 98967 — 11-20 minutes of medical discussion
- 98968 — 21-30 minutes of medical discussion
- Prolonged evaluation and management service before and/or after direct patient care;
- 99358 — first hour
- 99359 — each additional 30 minutes (list separately in addition to code for prolonged service)
- Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment;
- 99441 — 5-10 minutes of medical discussion
- 99442 — 11-20 minutes of medical discussion
- 99443 — 21-30 minutes of medical discussion
- Interprofessional telephone/internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional;
- 99446 — 5-10 minutes of medical consultative discussion and review
- 99447 — 11-20 minutes of medical consultative discussion and review
- 99448 — 21-30 minutes of medical consultative discussion and review
- 99449 — 31 minutes or more of medical consultative discussion and review
HB 1947 – Medical Licensure
Earlier this year, Representative Aaron Kaufer (R) introduced HB 1947. This bill stipulates that no license without restriction may be issued to a graduate of an unaccredited medical college unless the applicant has completed successfully, as a resident, two years of approved graduate medical training, educational requirements prescribed by the board and certification by the Educational Council for Foreign Medical Graduates, or its successors. On June 9, HB 1947 passed the House Appropriations Committee. This measure awaits consideration by the full House. Read the bill.
HB 2350 – Medical Licensure
Earlier this year, Representative Aaron Kaufer (R) introduced HB 2350. This bill requires any provider that seeks to operate in the Medicaid program to use either a National Provider Identification (NPI) or register for a State Provider Identifier (SPI). The Department of Human Services would be required to establish a standardized program for any company, which lacks an NPI and must register for provider identification with the state. On June 9, HB 2350 passed the House Human Services Committee. This bill awaits further consideration by the House Rules Committee. Read the bill.
SB 1181 – Medical Malpractice
On June 4, Senator Michele Brooks (R) introduced SB 1181. This bill creates limitations on liability in civil actions during a state of disaster emergency as it relates to COVID-19. SB 1181 was referred to the Senate Judiciary Committee and awaits further consideration. Read the bill.
ICYMI: Updates from the AUA Policy & Advocacy Brief blog
American Medical Association (AMA) House of Delegates: Special Business Meeting Held
On June 7, the AUA’s Delegates – Drs. Terrence Grimm and Hans Arora, Alternate Delegates Drs. Jason Jameson and James Gilbaugh, Resident and Fellow Delegate Dr. Ruchika Talwar, and Young Physicians Section Delegate Dr. Clint Cary – joined the Urology Caucus, the American Association of Clinical Urologists, and hundreds of other physicians via webinar platform to participate in the AMA’s House of Delegates (HoD) meeting. The 2020 Special Meeting was limited to essential business only, namely, elections and reports that AMA bylaws specify be presented to the House. Drs. Grimm and Jameson also participated in a meeting of the Cancer Caucus, which preceded the special business meeting and focused largely on COVID-19 and the pandemic’s effect on cancer care around the country. In addition, the AMA sponsored a more comprehensive town hall on COVID-19 following the special meeting. Highlights from these events include the following:
Special Business Meeting
Election Results:
AMA President – Susan R. Bailey, MD
AMA President-elect – Gerald E. Harmon, MD
AMA Speaker – Bruce A. Scott, MD
AMA Vice-speaker – Lisa Bohman Egbert, MD
Board of Trustees
Willarda V. Edwards, MD, MBA (Incumbent)
David H. Aizuss, MD
Thomas Madejski, MD
Ilse Levin, MD
Council on Medical Service
Erick A. Eiting, MD, MPH, MMM
Lynn Jeffers, MD, MBA
Steve Chen, MD, FACS
Reference Committee F and Amendments to Constitution & Bylaws Actions:
- Board of Trustees Report 2 — New Specialty Organizations Representation in the House of Delegates was adopted. This measure grants the American Society of Nuclear Cardiology and the Society of Cardiovascular Computed Tomography representation in the AMA House of Delegates.
- Council on Ethical and Judicial Affairs (CEJA) Report 1 — CEJA’s Sunset Review of 2010 House Policies was adopted.
- Council on Medical Education (CME) Report 1 — CME Sunset Review of 2010 House of Delegate’s Policies was adopted.
- BOT 03 AMA 2021 Dues — AMA 2021 dues was adopted as amended. This measure expands the number of years over which young physician dues rates increase to the full $420 rate.
- Board of Trustees Report 4 — Council on Legislation Sunset Review of 2008 and 2010 House Policies was adopted as amended.
- Council on Medical Service Report 1 — Council on Medical Service Sunset Review of 2010 AMA House Policies was adopted as amended.
- Council on Science and Public Health Report 1 — CSAPH Sunset Review of 2010 House of Delegates Policies was adopted as amended.
- Board of Trustees Report 1 — Annual Report was filed.
COVID-19 Town Hall Highlights
- The AMA is petitioning the Centers for Medicare & Medicaid Services to extend payment for telemedicine services
- The AMA supports maintaining ties to the World Health Organization.
- Telemedicine is going to be a significant part of the post COVID-19 era and AMA speakers stated it is important to not go backwards. Policies on telehealth have advanced five years during this pandemic by allowing remote monitoring, triaging patients, and keeping the fragile patients at home. The AMA has a quick guide available that practices can use to evaluate if they have the right technology in place to implement telemedicine
- The AMA has made efforts to speak about collecting data in meaningful ways in communities of color. They are exploring how these communities are getting sick and how they are dying at higher rates.
- The AMA expects medical liability protections related to COVID-19 to be part of the next stimulus bill.
As a reminder, since the pandemic started, the AUA has been proactive in its advocacy to extend telehealth services – providing members with telemedicine resources on its COVID-19 response center – and working with other groups to extend medical liability protections to health care providers. Learn more here.
AUA Letter Recommends CMS Address Policies Post Public Health Emergency (PHE)
The AUA Urology Telehealth Taskforce also is partnering with the Regulatory Workgroup on a strategy to retain certain waivers after the COVID-19 PHE is completed. A letter is being drafted to CMS asking the agency for the following:
- Maintain expansion of services included on the telehealth services list
- Continue to allow certain telehealth and virtual care services to be provided to new and established patients
- Continue to allow Medicare payment for certain telehealth and virtual care services when furnished by a resident under direct supervision of a teaching physician
- Provide coverage and enhanced payment for the telephone E/M services (CPT codes – 99441-99443)
- Continue to allow patients and providers to deliver and receive telehealth services from their homes.
- Preserve direct supervision revisions that allow physicians to supervise in-office clinical staff using communications technologies, when appropriate.
- Adopt the Interstate Medical Licensure Compact (IMLC) to facilitate broader physician adoption of telehealth and improve access to care across state lines
- Delay the implementation of QCDR measure testing and data collection until September of the year following the completion of the COVID-19 PHE.
The AUA plans to send this letter to CMS by the end of June.
Partnerships: AUA Supports American Geriatrics Society’s LEARNING Collaborative
The AUA is supporting the American Geriatrics Society’s (AGS) application to the National Institute on Aging (NIA) to create a curriculum for researchers to fill educational and training gaps in multiple chronic conditions (MCCs) science. The curriculum is designed to meet the educational needs of specialty investigators who are looking to include people with MCCs in their study populations. This effort will involve a partnership with The Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative and will be branded as the AGS/AGING Learning, Educating, And, Researching National INitiative in Geriatrics (LEARNING) Collaborative.
The LEARNING Collaborative’s curriculum will encompass approaches to: (1) research on the prevention and management of MCCs; (2) the development and incorporation of functional outcomes into clinical trials; (3) the recruitment of diverse populations into clinical research studies; and (4) research approaches to the study of geriatric health disparities. Focusing on early to mid-career investigators, the AGS plans to offer a self-directed online curriculum and establish a Learning Community to promote discussions of innovative solutions to challenges of conducting research focused on the prevention and management of MCCs, including those relating to recruitment of diverse populations.
We will keep you updated on the status of the AGS’ proposal to the NIA and any future collaborations.
With my warmest wishes for your good health,
Kathy