March 2021 - 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 advocacy to address prior authorization, support Prostate and Kidney Cancer Research funded through Department of Defense, and minimize the impact of Medicare pay cuts during the pandemic.
AUA, Surgical Coalition Discuss Surprises Billing, Prior Authorization, Payment Policy
On March 12, AUA Public Policy Council Chair Eugene Rhee, MD, and Gallagher Scholar Robert Bass, MD, joined our colleagues in the American College of Surgeons Surgical Coalition to discuss a range of health policy issues impacting the surgical community. Among them:
- Expectation of a 9.7 percent cut in overall reimbursement to surgical specialties due to budget neutrality for the Fiscal Year 2022 (FY22) Medicare Physician Fee Schedule.
- Implementation of a Surprise Billing Law called the No Surprises Act.
- Addressing workforce shortages, physician wellness and scope of practice issues, particularly at the U.S. Department of Veterans Affairs.
The AUA presented on ways to reduce practice burdens such as the need to address repeated prior authorization requests for chronic conditions. We noted that four out of five Medicare Advantage enrollees are in plans requiring prior authorization for some services. We pointed to an American Medical Association study in which 86 percent of providers said the burden of prior authorization has increased over the past five years. “Care delays can result in some patients discontinuing treatment and lead to serious adverse advents,” we stated.
The AUA meets weekly with Surgical Coalition members to strategize and gather support for our advocacy asks. The AUA has addressed many of the issues above including:
- Working with other provider groups to urge lawmakers to ensure any legislative solution aimed at addressing unanticipated medical bills includes an accessible, fair independent dispute resolution (IDR) and payment criteria that does not tie physician reimbursement to the median in-network rate.
- Supporting the full continuum of care team model for patients led by a physician.
- Supporting the Improving Seniors’ Timely Access to Care Act (H.R. 3107) in the 116th Congress, a bill to reduce prior authorization usage in Medicare Advantage plans and require more transparency when used.
- Working with Representatives David McKinley (R-WV-01) and Peter Welch (D-VT-At Large) to introduce H.R. 944, a bill to create a student loan forgiveness program for specialty physicians that practice in designated rural areas around the country.
AUA Hosts Congressional Briefing on Prostate and Kidney Cancer Research Funded Through Department of Defense (DOD)
The AUA, KidneyCAN, and ZERO: The End of Prostate Cancer jointly hosted a congressional briefing to educate and raise awareness about the Kidney Cancer Research Program (KCRP) and Prostate Cancer Research Program (PCRP) and ensure robust and sustained funding for these urologic programs. The briefing held on March 16 targeted members of congress and congressional staffers.
As part of the briefing, the following panel of experts shared their experiences and the important work conducted through the Congressionally Directed Medical Research Programs (CDMRP):
- Dr. Scott K. Swanson, President, AUA Board of Directors and urologist at Mayo Clinic
- Representative Rosa DeLauro (D-CT-03), Chair, House Committee on Appropriations
- Dr. Carolyn Best, Director of Research, AUA
- Mr. Anthony Minter, prostate cancer patient and Consumer Reviewer for PCRP
- Dr. Hyung Kim, Director of the Cedars-Sinai Academic Urology Program, Associate Director of Surgical Research in the Samuel Oschin Comprehensive Cancer Center and KCRP peer reviewer
- Dr. Brandon Manley, Genitourinary Oncologist at Moffitt Cancer Center, and recipient of multiple KCRP awards.
As background, the CDMRP originated in 1992 via a Congressional appropriation through the Department of Defense to foster novel approaches to biomedical research. These programs focus on military medical research, cancer research, and other disease- and injury-specific research. All the programs managed by CDMRP share the common goal of filling gaps in research by funding high impact, high risk and high gains projects that lead to improvements in patient care, breakthrough technologies and resources for clinical benefit.
A recording of the briefing can be found here.
ICYMI: Updates from the AUA Policy & Advocacy Brief blog
AUA Meets Virtually with Three Incumbent Members of Congress
The AUA, through the Alliance of Specialty Medicine, met with Representative Lloyd Smucker (R-PA-11), a new member of the House Ways & Means Committee (one of two House committees with healthcare jurisdiction). He was a past co-sponsor of the Improving Seniors’ Timely Access to Care Act (H.R. 3107), which attempted to streamline prior authorization requirements under Medicare Advantage. Representative Smucker mentioned drug pricing being a crucial priority during the 117th Congress and believes COVID-19 has provided an opportunity for healthcare innovation and telemedicine expansion, which the AUA has particularly focused on this past year. The AUA also highlighted its work on H.R. 944, legislation recently introduced to create a student loan forgiveness program for specialty physicians opting to practice in rural America.
In addition, the AUA attended a physician coalition meeting with Representative Bill Johnson (R-OH-06) who serves on the House Energy & Commerce Committee. During the meeting, he discussed the reintroduction of the Protecting Access to Post COVID-19 Telehealth Act (H.R. 366), a bill drafted by the Telehealth Caucus – of which he is a co-chair – that would do away with certain restrictions on providing telehealth services, and permanently expand coverage for telehealth services both during and beyond the COVID-19 pandemic. Representative Johnson also talked about his efforts to ensure broadband access/expansion be included in the next infrastructure bill. He ended the conversation talking about the need to protect physicians from additional reimbursement cuts, particularly during the current public health emergency. Protecting and ensuring fair Medicare physician reimbursement levels remain a top advocacy priority for the AUA.
Finally, the AUA participated in a physician coalition meeting with Representative Kelly Armstrong (R-ND-At Large), who is one of several new members of the House Energy & Commerce Committee. Representing a large, rural state, Representative Armstrong is a strong advocate for expanding access to telehealth services, as well as protecting physicians and hospitals from further reimbursement cuts. He also showed great interest in the AUA’s aforementioned legislation (H.R. 944) to create a student loan forgiveness program for specialty physicians who practice in a rural area. While serving as a state Senator, Representative Armstrong helped to pass similar legislation for the state of North Dakota. Additional conversations on the legislation will be held with his staff over the next few weeks.
AUA Begins Outreach to Freshmen Lawmakers
The AUA attended a policy webinar hosted by Representative Carolyn Bourdeaux (D-GA-07), a freshman member of Congress who is passionate about healthcare and hopes to serve on either the House Energy & Commerce Committee or House Ways & Means Committee during her congressional tenure. She addressed COVID-19 and subsequent vaccination disparities. Representative Bourdeaux also expressed support for the permanent expansion of the use and reimbursement of telehealth services, which the AUA has been strongly advocating for over the past twelve months. Finally, the congresswoman expressed the need for continued financial support of health care providers for the full duration of the public health emergency.
The AUA also attended a policy webinar with Representative Burgess Owens (R-UT-4), another freshman member of Congress who talked about restoring freedom of choice in American values, particularly when it comes to personal health care decisions. Representative Owens mentioned the importance of having access to COVID-19 vaccines and efforts to address all racial health disparities in light of the pandemic, which is a very important issue reflective in the AUA’s 2021 legislative priorities.
The AUA will continue meeting with first-term lawmakers in an effort to introduce urology and the AUA’s advocacy initiatives during the 117th Congress.
AUA, American Medical Association (AMA) Support Legislation to Delay Sequester Cuts to Medicare
The AUA joined the AMA and other national specialty and state medical societies in sending a support letter to Congress for the Medicare Sequester COVID Moratorium Act (H.R. 315), introduced by Representatives Brad Schneider (D-IL-10) and David McKinley (R-WV-01). The bill would delay the Medicare sequester through the duration of the public health emergency, ensuring providers can stay focused on treating and eradicating COVID-19 instead of worrying about their bottom line.
Since 2011, Medicare payments have been subject to a 2 percent reduction, known as the Medicare sequester. However, Congress delayed the Medicare sequester through April 1, 2021, as part of the Consolidated Appropriations Act of 2021. Unfortunately, the pandemic has not waned, and providers now again face revenue cuts when hospital operating margins are down an estimated 18.7 percent, according to the American Hospital Association. The AUA continues to identify ways to support physicians and their practices to minimize the impact of Medicare pay cuts during the pandemic, and will keep you updated as this issue moves forward.
For a copy of the letter, please contact AUA Legislative & Political Affairs Director Brad Stine at bstine@AUAnet.org.
AUA Supports Fiscal Year 2022 NIDDK Research Funding and Emergency Supplemental Funding for NIH
On March 3, the AUA collaborated with Friends of the National Institute of Diabetes, Digestive and Kidney Diseases (FNIDDK) in the submission of a letter to congressional leadership supporting the research community’s overall Fiscal Year 2022 (FY22) funding request for the National Institutes of Health (NIH), $46.1 billion, and a proportionate increase for the NIDDK, a total of at least $2.2 billion. The letter also includes a request for $10 billion for the NIH in emergency supplemental funding to support COVID-19 research and research recovery.
The AUA continues to play a role on the Advisory Board of the FNIDDK coalition. AUA’s Research Advocacy Committee will continue working proactively with the NIDDK to ensure funding of functional urologic research.
AUA Facilitates Appropriations Meetings with House Staff to Secure Funding for Bladder Cancer
The AUA is working to procure a $10 million dedicated research program, or line item, for bladder cancer within the Congressionally Directed Medical Research Programs (CDMRP). Last week, the AUA, in collaboration with the Bladder Cancer Advocacy Network, met with the offices of Representative Julia Brownley (D-CA-26), Representative Cheri Bustos (D-IL-17), Representative Gregory F. Murphy (R-NC-3), Representative John Rutherford (R-FL-4), and Representative Neal Dunn (R-FL-2) to discuss the AUA’s Fiscal Year (FY) 2022 research appropriation funding priorities around the creation of a bladder cancer research program within CDMRP. CDMRP is a major funder of scientific research administered by the Department of Defense. CDMRP is known for funding high risk, high reward projects and for allowing patients to play a role in deciding what research will be funded.
Both prostate cancer and kidney cancer have their own line items with dedicated funding Congress votes to approve yearly. Bladder cancer currently is funded under a larger umbrella program called the Peer Reviewed Cancer Research Program. The AUA’s goal is to ensure in fiscal year 2022, bladder cancer receives its own line item at $10 million. While this is a significant request, congressional offices have given us positive feedback and we are hopeful the need for bladder cancer funding will be recognized this year.
Below are insurance updates from national insurance carriers. If you have questions about insurer issues, contact Ray Wezik at rwezik@auanet.org.
BCBS Federal Employee Plan
BCBS Federal Employee Plan reviewed its Prostatic Urethral Lift Policy revising investigational policy statement to include repeat procedures.
CGS Administrators
CGS Administrators published its JC DME MAC POE Calendar of Events announcing a Urological Supplies meeting on April 6. Register here.
CGS Administrators reviewed its Molecular Diagnostic Tests (MolDX) (J15) (A56973) Local Coverage Article (LCA) with the following changes to coding due to the Q1 2021 CPT/HCPCS code update and MoIDX program.
Added CPT code:
- 0133U – Hereditary prostate cancer–related disorders, targeted mRNA sequence analysis panel (11 genes) (List separately in addition to code for primary procedure)
Removed CPT code:
- 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
- 0053U – Oncology (prostate cancer), FISH analysis of 4 genes (ASAP1, HDAC9, CHD1 and PTEN), needle biopsy specimen, algorithm reported as probability of higher tumor grade
CGS Administrators reviewed its Bladder/Urothelial Tumor Markers (J15) (A56471) Local Coverage Article (LCA) updating ICD-10 coding information and adding billing instructions for the following codes, in order to specify instructions for UroVysion that are differentiated from other services:
- 88120 – Cytopathology, in situ hybridization (e.g., fish), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual
- 88121 – Cytopathology, in situ hybridization (e.g., fish), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; using computer-assisted technology
Cigna
Cigna reviewed its Sacral Nerve and Tibial Nerve Stimulation for Urinary Voiding Dysfunction, Fecal Incontinence and Constipation Policy adding the following HCPCS code:
- C1820 – Generator, neurostimulator (implantable), with rechargeable battery and charging system
Cigna released its new Oncology Injectable (Gonadotropin-Releasing Hormone Analogs) (CA Commercial) Policy.
Cigna reviewed its Infertility Services Policy adding the following CPT codes:
- 89322 – Semen analysis; volume, count, motility, and differential using strict morphologic criteria (e.g., kruger)
- 89300 – Semen analysis; presence and/or motility of sperm including huhner test (post coital)
Centers for Medicare & Medicaid Services (CMS)
CMS reviewed its Prostate Specific Antigen (190.31) National Coverage Determination (NCD) updating the revision history, adding a link to January 2021 ICD-10 covered code list, and adding January, April, and October 2020 editions of changes to Lab NCD Edit Software.
First Coast Service Options
First Coast Service Options retired its Prostate Biopsies (JN) (A52575) Local Coverage Article (LCA) effective February 4.
Humana
Humana reviewed its Benign Prostatic Hyperplasia (BPH) Treatments Policy with the following changes:
- Added CPT code 55880 (effective January 1)
- Indicated that HCPCS code C9747 was deleted December 31, 2020.
Humana reviewed its Tumor Markers for Diagnosis and Monitoring of Cancer Policy adding bladder cancer as an indication for carcinoembryonic antigen (CEA).
Humana reviewed its Urinary Incontinence Evaluation and Treatments Policy adding CPT codes A4328 and A5102.
Humana reviewed its Urinary Incontinence Evaluation and Treatments Policy revising criteria to indicate review by Medical Director applies to commercial plan members only.
National Government Services
National Government Services released its Biomarker Testing for Prostate Cancer Diagnosis (J06, JK) (DL37733) Local Coverage Determination (LCD). This policy will be presented at the open meeting for jurisdictions J06 and JK on February 24. Only the changed EPI test criteria are open for official comment.
Noridian
Noridian reviewed its Prolaris Prostate Cancer Genomic Assay (MolDX) Local Coverage Article (LCA) adding the following HCPCS code:
- 0228U – Oncology (prostate), multianalyte molecular profile by photometric detection of macromolecules adsorbed on nanosponge array slides with machine learning, utilizing first morning voided urine, algorithm reported as likelihood of prostate cancer
Read the update. (JE) (A57509)
Noridian reviewed its Prolaris Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease (MolDX) Local Coverage Article (LCA) adding the following HCPCS code:
- 0228U – Oncology (prostate), multianalyte molecular profile by photometric detection of macromolecules adsorbed on nanosponge array slides with machine learning, utilizing first morning voided urine, algorithm reported as likelihood of prostate cancer
Noridian reviewed its Prostate Cancer Genomic Classifier Assay for Men with Localized Disease Local Coverage Article (LCA) adding HCPCS code:
- 0228U – Oncology (prostate), multianalyte molecular profile by photometric detection of macromolecules adsorbed on nanosponge array slides with machine learning, utilizing first morning voided urine, algorithm reported as likelihood of prostate cancer
United Healthcare
United Healthcare reviewed its Incontinence Control Devices (Medicare Advantage) Policy to add HCPCS codes K1010, K1011, and K1012 and inFLOW™ to incontinence devices with associated criteria including:
- The inFlow device is considered to be reasonable and necessary as an alternative to intermittent catheterization for beneficiaries with Permanent Urinary Retention (PUR) due to Impaired Detrusor Contractility (IDC);
- One (1) inFlow device may be covered no more than once every 29 days. Claims for the inFlow device billed more than once every 29 days will be denied as not reasonable and necessary;
- Continued coverage of the inFlow device beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the treating practitioner must conduct a clinical reevaluation and document that the beneficiary continues to use and is benefiting from the inFlow device.
United Healthcare revised its Nerve Graft to Restore Erectile Function during Radical Prostatectomy (Value & Balance Exchange) Policy criteria statement to indicate autologous or allogenic nerve grafts to restore erectile function during or after radical prostatectomy are unproven and not medically necessary.
United Healthcare revised its Prostate Surgery (Commercial West) Policy to state that prostate surgery may be considered medically necessary when criteria are met.
United Healthcare revised its Sacral Nerve Stimulation for Urinary Incontinence (Medicare Advantage) Policy to revise its ICD-10 diagnosis code list (see policy for complete changes).
United Healthcare revised its Urological Supplies (Medicare Advantage) Policy to remove inFLOW device from products and associated guidelines (see policy for complete changes).
Local and Regional Updates
The following are updates in your section. The AUA routinely monitors state legislative, regulatory, and insurance policy trends. Please contact AUA State Advocacy Manager Catherine Hendricks at chendricks@AUAnet.org for more information on any of these issues. In addition, check out our interactive map on the AUA State Advocacy Webpage for the most updated information on bill status.
State Legislative Trends
- Six telehealth bills introduced – the AUA continues to support the full expansion of telehealth services post the current public health emergency and, on a national level, has met with the Centers for Medicare & Medicaid Services (CMS) to urge the adoption of audio-only visits;
- Pennsylvania seeks to amend insurance law with cost-sharing amendment;
- Virginia resolution highlighting prostate cancer education fails sine die; and
- West Virginia considers amendments to licensure and balance billing laws.
State Session Calendar
Virginia’s legislative session ended March 4.
New Jersey
Horizon BCBS New Jersey
Horizon BCBS New Jersey reviewed its Lab Management Codes (eviCore) Coding Document adding the following CPT code:
- 0228U – Oncology (prostate), multianalyte molecular profile by photometric detection of macromolecules adsorbed on nanosponge array slides with machine learning, utilizing first morning voided urine, algorithm reported as likelihood of prostate cancer
5362 – Telehealth
Introduced by Assemblymember Joann Downey (D), A. 5362 seeks to allow a health care provider located outside of the state to provide health care services to residents in the state, using telemedicine and telehealth. The health care provider will need to be licensed or certified as a health care professional in New Jersey as a condition of providing health care services using telemedicine and telehealth, as is required under current law. The bill was referred to the Assembly Health Committee. Read the bill.
Pennsylvania
H.B. 642 – Telehealth
Introduced by Representative Chris Sappey (D), H.B. 642 seeks to create a telehealth law to allow the state licensure boards to regulate telehealth; allow a health care provider to provide telehealth services within the scope of their license and subject the provider to the state standards of care; establish a provider-patient relationship; obtain informed consent; establish a diagnosis and treatment plan; create and maintain an electronic medical record; and require health insurance plans to cover telemedicine services and reimburse the same as in-person services. The bill was referred to the House Insurance Committee. Read the bill.
S.B. 196 – Cost-Sharing
Introduced by Senator Judy Ward (R), S.B. 196 seeks to amend state health insurance law to include any cost-sharing amounts paid by the insured or a third party. The bill was referred to the Senate Banking and Insurance Committee. Read the bill.
Virginia
H.R. 569 – Prostate Cancer (FAILED SINE DIE)
Introduced by Cia Price (D), H.R. 569 seeks to honor the 100 Black Men of the Virginia Peninsula who through various educational programs helped to address the issues stemming from the high rates of prostate cancer suffered by African Americans. The Resolution failed sine die. Read the bill.
West Virginia
H.B. 2004 – Telemedicine
Introduced by Representative Amy Summers (R), H.B. 2004 seeks to permit a licensed health care professional from another state to practice in West Virginia through telehealth when registered with the appropriate West Virginia board. The bill was referred to the House Health and Human Resources Committee. Read the bill.
H.B. 2007 – Medical Licensure
Introduced by Representative Paul Espinosa (R), H.B. 2007 seeks to amend state licensure law to provide for an application method for persons with a valid medical license in another state, providing their license is in good standing. The bill passed the House and has been referred to the Senate Government Organization Committee. Read the bill.
H.B. 2024 – Telemedicine
Introduced by Representative Roger Hanshaw (R), H.B. 2024 seeks to allow all licensed medical personnel to use telemedicine, allow for audio-only telemedicine services, limit the ability of professional licensure boards to restrict telemedicine, and to require reimbursement for telemedicine to be the same as an in-person service. The bill passed the House and has been referred to the Senate Health and Human Resources Committee. Read the bill.
H.B. 2226 – Balance Billing
Introduced by Representative Barbara Fleischauer (D), H.B. 2226 seeks to amend state law to define surprise billing; add new disclosure requirements for health care providers, hospitals and health insurance providers; and establish how surprise bills are to be handled in certain circumstances. The bill was referred to the House Banking and Insurance Committee. Read the bill.
S.B. 1 – Telemedicine
Introduced by Senator Tom Takubo (R), S.B. 1 seeks to amend state telemedicine law to require reimbursement for telemedicine services at the same rate as in-person services and allow for audio-only telemedicine. The bill also requires a patient have no more than three telemedicine consultations without an in-person primary care visit and an in-person visit is required before controlled substances can be prescribed. The bill was passed by the Senate and is now in the House Health and Human Services Committee. Read the bill.
S.B. 273 – Telemedicine
Introduced by Senator Craig Blair (R), S.B. 273 seeks to allow all licensed medical personnel to use telemedicine, allow for audio-only telemedicine services, limit the ability of professional licensure boards to restrict telemedicine, and require reimbursement for telemedicine to be the same as an in-person service. The bill was referred to the Senate Health and Human Services Committee. Read the bill.