September 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 our successful 2020 Virtual Annual Urology Advocacy Summit. 

I also encourage you and your section members to complete the2021 Legislative Priorities Survey. The AUA Legislative Affairs and State Advocacy Committees use the survey results to help determine the federal and state advocacy priorities for upcoming sessions of the U.S. Congress and state legislatures. Read more in our “ICYMI” section of this update.

AUA Summit 2020: Annual “Fly-In” Surpasses 300 Attendees, 160 Congressional Meetings 

More than 300 registered attendees joined us for the Annual Urology Advocacy Summit. Not only is that the highest number of registrants to date, but many were first-time attendees and 81 were medical students, residents, fellows, and young urologists.

Highlights of the meeting included the following:

Keynote speaker Margaret Brennan‘s discussion of the upcoming election, editorial standards and the level of trust in news coverage, and her real-life experiences in covering public health issues.

AUA Urology Telehealth Task Force Chair Dr. Aaron Spitz moderated a panel on Telehealth and COVID-19.  The panel, including Drs. Jonathan Rubenstein, Chad Ellimoottil, and Kara Watts, shared AUA’s advocacy to allow audio-only visits and the importance of this advocacy given the lack of broadband access or smart phones and poverty levels in some communities. They coupled it with data showing these visits improved access to care and patients reported higher satisfaction rates than face-to-face visits.

AUA Science and Quality Council Chair Dr. David Penson, R. Frank Jones Urological Society’s Dr. Tracy Downs, and Prostate Health Education Network’s (PHEN) Dr. Keith Crawford led an impactful session on Prostate Cancer Disparities: The Pandemic’s Impact on the African American Community and the Role of Urology. The session included strategies to increase the recruitment of African Americans into institutions and educational outreach program such as PHEN’s “Know Your Doctor” webinar series.

AUA State Advocacy Committee Chair and New England Section Past President Dr. Art Tarantino moderated a panel on various hot-button state issues and was joined by the American Medical Association’s Kim Horvath, Mid-Atlantic Section Health Policy Chair Dr. Mark Fallick, California Medical Association President and Public Policy Council member Dr. Peter Bretan, and American Association of Clinical Urologists State Society Network Chair and Public Policy Council member Dr. Bill Reha. The session provided an overview of how the impact of the pandemic on requirements for licensure as well as malpractice insurance when providing telehealth visits along with immunity from civil liability for out-of-state licensed practitioners.

The impact of COVID-19 and advantages of telehealth also was highlighted in a panel on Urologic Research and COVID-19. Among other things, AUA Research Council Chair Dr. Aria Olumi and panelists Drs. Dolores Lamb (Society for Basic Urologic Research), Dirk Lange (Endourological Society), and Polina Reyblat (Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction) discussed the advantages of telehealth in assessing study subjects and bringing them into clinical trials.

On September 1, AUA members and several patient advocates representing 34 states and the District of Columbia participated in more than 160 meetings with federal lawmakers and their staff. Meetings were held with the offices of 67 senators and 102 U.S. representatives. Issues discussed included the need to continue to expand telemedicine services after the public health emergency expires and addressing the physician workforce shortages around the country – particularly in rural areas.

In addition, on September 2, there was lively and interactive networking session for those younger AUA members that were registered (e.g., residents in training).  

Registered attendees may view the sessions here until the end of the year. Once logged in, click on the “Information” tab and then click “On Demand”.

Office of the National Coordinator for Health Information Technology Meeting
As part of the AUA Summit, the AUA – represented by Drs. Jonathan Rubenstein, Matt Nielsen, and Alan Kaplan – met with the Office of the National Coordinator for Health Information Technology (ONC) to discuss burden reduction, integration of prior authorization (PA), and improving interoperability. 

The ONC is focused on making changes to better integrate formulary and PA information into the electronic medical record and has convened a task force to address this issue. In the coming months, they will be releasing recommendations to improve the integration of this information. The ONC also believes that the changes in its interoperability rule regarding application programming interfaces (APIs) will begin to the address the problem. ONC informed the AUA that CMS is considering rulemaking on PA.

Health Information Exchanges (HIEs), which are already deployed across the country, are key to supporting interoperability and the exchange of key health information. ONC is working to improve the government’s participation in these exchanges and hopes that one day they will be a community resource, like a public utility, to support data exchange. 

ONC is working with CMS to move the quality reporting system towards broader measures of quality that include a condition’s severity, which will reduce the health system’s dependence on having everything included in the visit note.

The AUA will continue to update members on progress on these important issues. For more information about this agency meeting, contact PublicPolicy@AUAnet.org

Agency Meeting:  AUA Leadership Discusses Telehealth, E/M Services with CMS 

On September 17, AUA leadership met virtually with the Centers for Medicare & Medicaid Services’ Hospital and Ambulatory Policy Group Division of Practitioner Services in advance of submitting final comments on the proposed Calendar Year 2021 Medicare Physician Fee schedule. The discussion focused on proposed policies for telehealth, evaluation and management (E/M) services, burden reduction, and valuation of specific urology services.

Urology Telehealth Taskforce Chair Aaron Spitz, MD, opened the meeting by thanking the agency for the flexibilities that have been made in response to the COVID-19 pandemic and for proposing to make additional changes to Medicare’s telehealth and communications technology-based services policies. He stressed AUA’s support for the creation of a code for a longer virtual check-in that covers interactions with patients of 11-20 minutes. 

In addition, Dr. Spitz, AUA President Scott Swanson, MD, and Board member Barry Kogan, MD noted that AUA recognizes that CMS regulations do not allow audio visits to be covered as telehealth services post-pandemic. AUA stated that these services play such an important role in delivering care that CMS should revise its regulations to allow for these services to be provided once the public health emergency concludes. 

In the Medicare population, there are significant barriers to delivering care with a simultaneous audio/visual connection: patients’ lack of access to the appropriate devices and broadband as well as lack of ability to use the technology. To illustrate this point, Dr. Kogan discussed the example of telehealth care delivered with a simultaneous audio/visual connection does not allow for necessary translation services for patients or for a patient’s family member or caregiver to participate in the visit. 

AUA Coding and Reimbursement Committee Chair Jonathan Rubenstein, MD, discussed the add-on code GPC1X for outpatient E/M visit complexity. The “AUA wants to work with CMS to better define this service as we believe it will be useful for our members who treat patients with diseases processes that last a year or longer or will lead to the death of the patient; or a condition that requires active monitoring by the urologist,” he said. The AUA pledged to educate physicians on the proper use of the code through its vast resources such as educational courses and informational articles.

In addition to Drs. Kogan, Rubenstein, Spitz, and Swanson, AUA Public Policy Council chair Eugene Rhee, MD, Treasurer elect Tom Stringer, MD, and Past President William Gee, MD, participated in the call.  AUA will submit formal comments on the Medicare Physician Fee Schedule later this month. 

Patient Advocacy Connections Program: More than 35 Patient Advocacy Organizations Convene for Roundtable Discussions and Networking

On August 31 – September 2, the AUA hosted the 2020 Patient Advocacy Connections Program (PACP). This year’s virtual event successfully connected more than 50 participants from 35 urology-focused patient advocacy organizations throughout the three-day Lunch & Learn series. The program included two engaging roundtable discussions. The first roundtable addressed health literacy and health equity challenges where conversations addressed key challenges, including prevention, access, and partnerships. The second roundtable discussion focused on effective advocacy communication strategies that included panelists representing the patient, physician, and research perspective. This panel discussed an array of strategies to elevate advocacy engagement among urology advocates including social media tactics and policy resources that keep stakeholders engaged and educated about legislative issues impacting the urology community.

The final component of the program was “Advocacy Rounds,” a virtual networking event.  This interactive event utilized breakout rooms to connect PACP participants with key members of the AUA/UCF’s leadership including members of the Board, the PPC, Legislative Affairs Committee, Research Advocacy Committee and more. The event provided an opportunity for AUA members to learn about the AUA’s advocacy partners and their advocacy areas of interest. Our partners noted this networking event as a highlight of the overall program experience. 

Prostate Cancer Treatment: Veterans’ Committee Holds Legislative Hearing, Includes Clinical Pathway Bill
On September 10, the House Veterans’ Affairs Committee held a legislative hearing on a number of health-related bills, including the Veteran’s Prostate Cancer Treatment and Research Act (H.R. 6092). If passed, the bill would direct the Secretary of Veterans Affairs (VA) to establish a national clinical pathway for prostate cancer within the National Surgery Office of the VA for all stages of prostate cancer.

In advance of the hearing, the AUA submitted public comments supporting this legislation. This measure is sponsored by AUA-member and U.S. Congressman Neal Dunn, MD (R-FL-02), and was drafted with assistance from the AUA. For a copy of the AUA’s comments, please contact AUA Legislative & Political Affairs Manager Quardricos Driskell at QDriskell@AUAnet.org

In an effort to help this important legislation continue to move forward, please log onto the AUA’s grassroots alert systemand urge your lawmaker to cosponsor H.R. 6092. 

Below are insurance updates from national insurance carriers.

Aetna

Aetna reviewed its Urinary Incontinence Policy revising approval criteria for InterStim Continence Control Therapy/Sacral Nerve Stimulation. Updated medically necessary criteria regarding sequential test stimulation to state that leads placed bilaterally and each side tested sequentially during a single visit, is acceptable.

Read the update.

Anthem

Anthem reviewed its Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling Policy with the following changes: 

  • Added medically necessary indication for molecular profiling for unresectable or metastatic solid tumors; added requirements that the individual has progressed following prior treatment and the individual has no satisfactory alternative treatment options.
  • Added the following CPT codes:

o   81448, 0211U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U

Read the update.

BCBS Federal Employee Plan

BCBS Federal Employee Plan released a new Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hypertrophy policy, stating transurethral water vapor thermal therapy is considered experimental, investigational, or unproven.

Read the update.

Cap Blue Cross

Cap Blue Cross reviewed its Urinary Tumor Markers for Bladder Cancer Policy with the following changes:

  • Revised policy position from “considered experimental and investigational” to “does not meet coverage criteria” in statements addressing urinary biomarkers (bladder tumor antigen (BTA) test, nuclear matrix protein (NMP22) test, or fluorescence in situ hybridization (FISH) UroVysion bladder cancer test); and fluorescence immunocytology (ImmunoCyt/uCyt) in the evaluation of hematuria, diagnosing bladder cancer, or for screening for bladder cancer in asymptomatic individuals, and all other indications.
  • Added policy statement specifying that any other urinary tumor markers for bladder cancer not mentioned above do not meet coverage criteria.

Read the update.

Centers for Medicare & Medicaid Services (CMS)

CMS released its MLN Connects newsletter. Topics included Trump Administration Proposes to Expand Telehealth Benefits Permanently for Medicare Beneficiaries beyond the COVID-19 Public Health Emergency (PHE) and Advances Access to Care in Rural Areas.

Read the update.

CGS Administrators

CGS Administrators reviewed its Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia LCA and LCD with the following changes to date information:  

  • The related policy has had the notice period extended to October 31, to review additional information and comments received prior to finalization. This article will now be effective November 1, to be in align with its related policy.

Read the update (J15 – A57926)

Read the update (J15 – L38378)

CGS Administrators announced a new collaborative webinar for Oxygen Coverage & Documentation Requirements, which will take place September 29. Topics include the effects from COVID-19 Public Health Emergency.

Read the update.

Cigna

Cigna reviewed its Male Sexual Dysfunction Treatment Policy with the following changes:

  • Added medically necessary policy statement for a vacuum erection device for the treatment of erectile dysfunction.
  • Added additional medically necessary criterion option for surgical implantation of a penile prosthesis stating there is failure, contraindication or intolerance to vacuum erection device.
  • Removed medically necessary policy statement for a vacuum constriction device for the treatment of erectile dysfunction when there is failure, contraindication or intolerance to FDA approved pharmacological therapy (e.g., oral PDE5 inhibitors, intracavernosal injection, intraurethral medication).
  • Removed not medically necessary policy statement for a vacuum constriction device for any other indication. 
  • Revised medically necessary criterion for surgical implantation of a penile prosthesis when there is failure, contraindication or intolerance to FDA pharmacological therapy, to specify that FDA pharmacological therapy is one example of conservative medical management that can be failed, contraindicated, or not tolerated.

Read the update.

Cigna reviewed its Oncology Medications Policy adding Xtandi to criteria section (for Standard, Performance, Value, Advantage, Legacy, and Individual and Family Plans) stating where coverage requires the use of preferred products eligible for pharmacy benefit coverage: for castration-recurrent metastatic prostate cancer only both of the following are met: one of the following:  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.

Read the update.

First Coast Service Options

First Coast Service Options retired its Sacral Neuromodulation (JN) (A56508) Local Coverage Article (LCA) effective August 13, stating based on review of the LCD for Sacral Neuromodulation, it was determined that the LCD is no longer required and is being retired, and therefore, this related billing and coding article is also being retired. The effective date of this billing and coding article retirement is based on date of service.

Read the update.

First Coast Service Options retired its Sacral Neuromodulation (JN) (L36296) Local Coverage Determination (LCD effective August 13, stating based on review of the LCD, it was determined that the LCD is no longer required and the effective date of this LCD retirement is based on date of service.

Read the update.

National Government Services (NGS)

National Government Service (NGS) reviewed its Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH) LCD adding a note stating that new literature has been received by the payer and will be reviewed before finalizing the policy, and the notice period has been extended to October 31, now starting on August 31.

Read the update.

Noridian

Noridian retired several IMRT LCD and LCAs, effective August 1.

LCA A57013 information may be found in LCA A58236.

LCD L43217 information may be found in LCA A58236.

LCA A57231 information may be found in LCA A58245.

LCD L34080 information may be found in LCA A58245.

Novitas

Novitas retired its Sacral Nerve Stimulation (JH) (A57617) Local Coverage Article (LCA) effective for dates of service on and after August 13.

Read the update.

Novitas retired its Sacral Nerve Stimulation (L35449) Local Coverage Determination (LCD) effective for dates of service on and after August 13.

Read the update.

Palmetto

Palmetto released its Home Health & Hospice Medicare Advisory Newsletter for August. Topics covered include:

  • Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)
  • COVID-19: SNF Benefit Period Waiver
  • COVID-19: New and Expanded Flexibilities for RHCs & FQHCs during the Public Health Emergency

Read the update.

United Healthcare

United Healthcare reviewed its Prostate Services and Procedures Medicare Coverage Summary revising Prostate Rectal Spacers Placement (CPT code 55874) guideline language from “states with no LCDs/LCAs” to “states/territories with no LCDs/LCAs.”

Read the update.

United Healthcare reviewed its Cryosurgery of Prostate NCD 230.0 Policy removing Revenue Code 361 – Minor surgery.

Read the update.

United Healthcare reviewed its Urinary and Fecal Incontinence Diagnosis and Treatment Policy with the following changes:

  • Removed Radiofrequency (RF) Micro-remodeling for Stress Urinary Incontinence (CPT code 53860) section including the following guidelines:

o   Medicare does not have a National Coverage Determination (NCD) for radiofrequency micro-remodeling for stress urinary incontinence.

o   Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) exist and compliance with these policies is required where applicable. For state-specific LCDs/LCAs, see the LCD Availability Grid (Attachment A).

o   For states with no LCDs/LCAs, refer to the National Government Services. LCD for Non-covered Services (L33629) for coverage guideline.

o   Revised coverage guideline language for guidelines 11 and 13 from “states with no LCDs/LCAs” to “states/territories with no LCDs/LCAs.”

Read the update.

United Healthcare reviewed its Urinary Drainage Bags (NCD 230.17) Policy removing Modifier code GY – Item or service expected to be denied as not reasonable and necessary.

Read the update.

United Healthcare reviewed its Urological Supplies Policy adding the following guidelines:

  • The inFlow™ device (A4335) [Incontinence supply; miscellaneous (Bundled)] 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).
  • 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 re-evaluation and document that the beneficiary continues to use and is benefiting from the inFlow device.
  • If the practitioner re-evaluation does not occur until after the 91st day but the evaluation demonstrates that the beneficiary is benefiting from the inFlow device as defined in criteria 1 and 2 above, continued coverage of the inFlow device will commence with the date of that re-evaluation.
  • The inFlow Intraurethral Valve-Pump (Vesiflo, Inc.) must be billed using HCPCS code A4335. Code A4335 is billed as 1 unit of service (UOS) at initial issue, and is all inclusive (catheter, activator). Code A4335 must also be used on separate claim lines for replacement of any of the individual components of the inFlow Intraurethral Valve-Pump (catheter, activator). In addition, claims for replacement catheters, batteries, or wands must also use HCPCS code A4335.

Read the update.

United Healthcare reviewed its Xtandi Step Therapy Criteria revising coverage criterion from: 

  • “Diagnosis of metastatic, castration-resistant or recurrent prostate cancer” to “Diagnosis of metastatic, castration-resistant prostate cancer.”
  • “Diagnosis of non-metastatic, castration-resistant or recurrent prostate cancer” to “Diagnosis of non-metastatic, castration-resistant prostate cancer.”

Read the update.

United HealthCare Community Plan

United Health Care reviewed its Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions Policy adding 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

Read the update.

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 Tumor Markers Policy with the following changes:  

  • Removed policy statement previously indicating that prostate specific antigen (PSA) may be considered medically necessary for any of the following: staging; or monitoring response to therapy; or detecting disease recurrence; or individuals with palpable abnormal prostate gland; or individuals with lower urinary tract signs and symptoms (i.e., hematuria, slow urine stream, hesitancy, urgency, frequency, nocturia, incontinence).
  • Removed the following CPT codes:

o   84152 – Prostate specific antigen (PSA); complexed (direct measurement)

o   84153 – Prostate specific antigen (PSA); total

o   84154 – Prostate specific antigen (PSA); free

  • Removed applicable ICD-10 codes for 84152, 84153, and 84154.

o   Updated place of service section with language indicating that tumor markers are typically an outpatient procedure that is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

Read the update.

New Jersey

Horizon BCBS New Jersey

Horizon BCBS New Jersey reviewed its Proton Beam Therapy Policy with the following changes:

  • Added the Medicaid coverage section; added information indicating that for members enrolled in Medicaid and NJ Family Care plans, Horizon BCBSNJ applies the medical policy in the document. 
  • Added the FIDE-SNP coverage section; added information indicating that for members enrolled in fully integrated dual eligible special needs plan to the extent the service is covered under the Medicare portion of the member’s benefit package, Medicare coverage information in the document applies and the extent the service is not covered under the Medicare portion of the member’s benefit package, the Medicaid coverage statement in the document applies. 
  • Revised note stating for Medicare Advantage, Medicaid, and FIDE-SNP the coverage sections in the document can be referred to; added “Medicaid” and “FIDE-SNP”.

Read the update.

Horizon BCBS New Jersey reviewed its Radiation Therapy for Prostate Cancer Policy with the following changes:

  • Added the Medicaid coverage section; added information indicating that for members enrolled in Medicaid and NJ Family Care plans, Horizon BCBSNJ applies the medical policy in the document. 
  • Added the FIDE-SNP coverage section; added information indicating that for members enrolled in fully integrated dual eligible special needs plan to the extent the service is covered under the Medicare portion of the member’s benefit package, Medicare coverage information in the document applies and the extent the service is not covered under the Medicare portion of the member’s benefit package, the Medicaid coverage statement in the document applies. 
  • Revised note stating for Medicare Advantage, Medicaid, and FIDE-SNP the coverage sections in the document can be referred to; added “Medicaid” and “FIDE-SNP”.

Read the update.

Horizon BCBS New Jersey reviewed its Image Guided Radiation Therapy Policy adding limitation stating that the use of image guided radiation therapy (IGRT) is based on medical necessity for the specific diagnoses and that a requirement from the vendor does not support the medical necessity of IGRT. 

Read the update.

Horizon BCBS New Jersey reviewed its Radiation Therapy for Pancreatic Cancer Policy with the following changes: 

  • Added that radiation therapy must be given following 2 to 6 months of chemotherapy to criterion option stating medical necessity may be indicated for radiation therapy in the treatment of pancreatic cancer if it is used preoperatively when disease is borderline resectable and when given following 2 to 6 months of chemotherapy. 
  • Added that radiation therapy must be given following 4 to 6 months of chemotherapy with no evidence of systemic progression to criterion option stating that medical necessity may be indicated for radiation therapy in the treatment of pancreatic cancer if it used locally advanced/unresectable when given following 4 to 6 months of chemotherapy with no evidence of systemic progression. 
  • Removed criterion stating that intensity modulated radiation therapy may be medically necessary when documentation is submitted that a 3D plan does not met the normal tissue constraints using standard metrics published by the Radiation Therapy Oncology Group/ NCCN which describes the specific organs at risk whose tolerance have been exceeded, and that dose volume histograms are insufficient documentation. 
  • Revised criterion stating that stereotactic body radiation therapy (SBRT) using up to 5 fractions is medically necessary for postoperative treatment in which there is residual gross disease or positive microscopic margins that can be entirely compassed in the radiation treatment volume to now state that SBRT using up to 5 fractions is medically necessary for preoperative treatment in borderline resectable cases following a minimum of 2 cycles of chemotherapy and restaging in which there is no evidence of tumor progression and the disease volume can be entirely encompassed in the radiation treatment volume.
  • Added limitation stating that radiation therapy for pancreatic cancer is not medically necessary when given preoperatively for disease that is otherwise fully resectable. 

Read the update.

Horizon BCBS New Jersey reviewed its Radiation Treatment of Bone Metastases Policy removing:

  • Removed criterion stating that Xofigo is medically necessary for the treatment of castration resistant prostate cancer for a member with the following: skeletal bone metastases; no evidence of visceral metastases or bulky regional lymph nodes greater than 3 cm on imaging performed within the past 30 days; received and exhausted all medical or surgical ablative hormonal treatments, the member may be kept on his ablative hormonal treatment to maintain a castrate level in accordance with NCCN; medically or surgically castration resistant prostate cancer as defined by a serum testosterone level less than 50 ng/dl and either sequential rise of prostate specific antigen levels or worsening of existing bone metastases or development of new bone metastases on a bone scan performed within the past 60 days despite androgen deprivation treatment.
  • Removed dosing for Xofigo in the treatment of castration resistant prostate cancer.
  • Removed limitation stating that concurrent chemotherapy with Xofigo is investigational. 

Read the update.

Horizon BCBS New Jersey revised its Medicare coverage decision for baroreflex stimulation devices as determined by Novitas Solutions, the local Medicare carrier for jurisdiction JL stating not reasonable and necessary, and therefore not covered to now state that a determination has not been made; removed reference to Local Coverage Determination for “Services That Are Not Reasonable and Necessary” (L35094).

Read the update.

Horizon BCBS New Jersey reviewed its Intravesical Transurethral Electrical Bladder Stimulation (ITEBS) policy removing Medicare coverage information stating that per Local Coverage Determination for “Services That Are Not Reasonable and Necessary” (L35094), procedure code 53899 will be denied as not reasonable and necessary when reported for non-invasive urodynamic studies.

Read the update.

SB 2465 – Medical Licensure
Several months ago, 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 name tags with their full name, licensed profession, license expiration, and recent picture. On August 27, the full Senate passed SB 2465, which had been referred to the Assembly Regulated Professions Committee. Read the bill.

Pennsylvania

Highmark Pennsylvania

Highmark Pennsylvania reviewed its Tumor Markers Policy with the following changes:  

  • Removed policy statement previously indicating that prostate specific antigen (PSA) may be considered medically necessary for any of the following: staging; or monitoring response to therapy; or detecting disease recurrence; or individuals with palpable abnormal prostate gland; or individuals with lower urinary tract signs and symptoms (i.e., hematuria, slow urine stream, hesitancy, urgency, frequency, nocturia, incontinence).
  • Removed the following CPT codes:

o   84152 – Prostate specific antigen (PSA); complexed (direct measurement)

o   84153 – Prostate specific antigen (PSA); total

o   84154 – Prostate specific antigen (PSA); free

  • Removed applicable ICD-10 codes for 84152, 84153, and 84154.

o   Updated place of service section with language indicating that tumor markers are typically an outpatient procedure that is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

Read the update.

Independence Blue Cross

Independence Blue Cross revised its Radiation Therapy (eviCore) Guideline revising the effective date to October 1, and revising criteria for the following prostate cancer indications:

  • Low-risk prostate cancer.
  • Intermediate-risk prostate cancer.
  • High-risk prostate cancer. 
  • Adjuvant or salvage radiation therapy.
  • Metastatic disease. 

Read the update.

Independence Blue Cross reviewed its Biomarkers for Oncology Policy removing the following:

  • Administrative language previously indicating that the company makes decisions on coverage based CMS regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the company makes decisions based on company policy bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage policy bulletin is consistent with Medicare’s regulations and guidance, the company’s payment methodology may differ from Medicare.
  • Administrative language previously indicating that when services can be administered in various settings, the company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
  • Administrative language previously indicating that this policy bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This policy bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.
  • Coding language previously specifying that inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/ referral requirements, provider contracts, and company policies apply. The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates. In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the company.

Read the update.

Independence Blue Cross reviewed its Molecular Diagnostics Policy removing the following:

  • Administrative language previously indicating that the company makes decisions on coverage based CMS regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the company makes decisions based on company policy bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage policy bulletin is consistent with Medicare’s regulations and guidance, the company’s payment methodology may differ from Medicare.
  • Administrative language previously indicating that when services can be administered in various settings, the company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
  • Administrative language previously indicating that this policy bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This policy bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.
  • Coding language previously specifying that inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/ referral requirements, provider contracts, and company policies apply. The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates. In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the company.

Read the update.

Independence Blue Cross reviewed its Ostomy Supplies policy with the following changes:

  • Revised the effective date to August 3.
  • Updated billing requirements by adding requirements for modifier AU, including the following: 

o   HCPCS codes A4450, A4452, and A5120, when used with ostomy supplies must be billed with modifier AU. 

  • For this policy, HCPCS codes A4450, A4452, and A5120, are the only codes for which modifier AU may be used. 
  • Inclusion of a code does not imply reimbursement and other restrictions may apply. 
  • Revised policy language by changing “prescription” to “standard written order.”
  • Removed a legal statement regarding cost-effective reimbursement.

Read the update.

Independence Blue Cross reviewed its Radiation Therapy Services Policy revising the effective date to October 1, and adding a notification statement that eviCore healthcare has revised their Radiation Therapy Clinical Guideline that become effective October 1.

Read the update. (Commercial)

Read the update. (Medicare Advantage)

Geisinger

Geisinger published its Medical Policy Updates News & Announcements provider bulletin, announcing effective September 15 (unless otherwise specified) a new COVID-19 Antibody Testing Policy.

Read the update.

Highmark Pennsylvania

Highmark Pennsylvania reviewed its Prolia, Xgeva policy adding the following:

  • A note that National Comprehensive Cancer Network (NCCN) recognizes that the use of a bisphosphonate (oral/IV) or denosumab as acceptable to maintain or improve bone mineral density and reduce risk of fractures in postmenopausal (natural or induced) individuals receiving adjuvant endocrine therapy. 
  • A note that therapy with denosumab (Prolia, Xgeva) is appropriate for continuation when an individual shows stability or improvement in their condition. 

Read the update.

HM 32413 – Medical Licensure

On September 10, Representative Mark Rozzi (D) published HM 32413. This co-sponsorship memorandum requires all public employees, public and private school teachers, higher education professors and employees, and licensed health care professionals to complete implicit bias training. The training will be developed and completed through the Pennsylvania Human Relations Commission as an online course. Professions for which continuing education is required will be able to receive credit for the training, which will be required every two years. This memorandum was released by Rep. Rozzi in an attempt to garner support for the general issue and is eligible for consideration during the 2019-2020 sessions. Read the memorandum.

SM 32402 – Medical Licensure
On September 9, Senator Katie Muth (D) published SM 32402. This co-sponsorship memorandum – applicable to physicians as well as surgeons, osteopaths, naturopathic doctors, chiropractors, podiatrists, and acupuncturists – requires the professionals to disclose if they have been disciplined by their regulatory board due to sexual misconduct with a patient, drug abuse, a criminal conviction, or inappropriate prescribing. Sen. Muth released this memorandum in an attempt to garner support for the general issue and is eligible for consideration during the 2019-2020 sessions. Read the memorandum.

Virginia

Optima Health

Optima Health published its provider bulletin announcing information regarding COVID-19 coverage extensions. Optima Health policy changes have been extended through September 30.

Read the update.

West Virginia

Highmark West Virginia

Highmark West Virginia reviewed its Tumor Markers Policy with the following changes:  

  • Removed policy statement previously indicating that prostate specific antigen (PSA) may be considered medically necessary for any of the following: staging; or monitoring response to therapy; or detecting disease recurrence; or individuals with palpable abnormal prostate gland; or individuals with lower urinary tract signs and symptoms (i.e., hematuria, slow urine stream, hesitancy, urgency, frequency, nocturia, incontinence).
  • Removed the following CPT codes:

o   84152 – Prostate specific antigen (PSA); complexed (direct measurement)

o   84153 – Prostate specific antigen (PSA); total

o   84154 – Prostate specific antigen (PSA); free

  • Removed applicable ICD-10 codes for 84152, 84153, and 84154.

o   Updated place of service section with language indicating that tumor markers are typically an outpatient procedure that is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

Read the update.

Highmark West Virginia reviewed its Prolia, Xgeva policy adding the following:

  • A note that National Comprehensive Cancer Network (NCCN) recognizes that the use of a bisphosphonate (oral/IV) or denosumab as acceptable to maintain or improve bone mineral density and reduce risk of fractures in postmenopausal (natural or induced) individuals receiving adjuvant endocrine therapy. 
  • A note that therapy with denosumab (Prolia, Xgeva) is appropriate for continuation when an individual shows stability or improvement in their condition. 

Read the update.

Highmark WV Medicare Advantage reviewed its Minimally Invasive Treatment for Benign Prostatic Hyperplasia Involving Prostatic Urethral Life (Urolift) Policy removing language stating diagnosis code N40.1 is covered for procedure codes 52441, 52442, C9739, C9740, and L8699.

Read the update.

ICYMI: Updates from the AUA Policy & Advocacy Brief blog

AUA Legislative Priorities: Survey in the Field Now

The 2021 Legislative Priorities survey currently is in the field. If you have not seen the email for it, please be sure to check your spam filter. As a reminder, this survey is a tool used by the Legislative Affairs and State Advocacy Committees to help determine the federal and state advocacy priorities for upcoming sessions of the U.S. Congress and state legislatures. It is important that you complete the survey and ask your colleagues to do the same!

The survey can be completed and shared by clicking this link:  https://www.surveymonkey.com/r/AUA2020.

If you have any questions or issues, please contact Joshua Webster at JWebster@auanet.org.

State Advocacy Update: Prostate Cancer Awareness Month Proclamations in New Jersey, New Mexico, South Carolina; Standalone Measure in California

Proclamations
Over the past few weeks, members of the AUA’s State Advocacy Committee received proclamations from New Mexico Governor Michelle Lujan Grisham, New Jersey Governor Phil Murphy, and South Carolina Governor Henry McMaster declaring September 2020 as Prostate Cancer Awareness Month. In addition, HR 104 introduced by Assemblymember Mike Gibson (D) in California, a resolution that raises awareness on prostate cancer and touches on the barriers to early screening detection so that patients can make an informed decision about their healthcare. The AUA State Advocacy Committee, the California Urological Association, and ZERO – The End to Prostate Cancer partnered to get this measure introduced in California. 

A proclamation is important because they create awareness on important state issues and are granted by the Governor. The AUA plans to replicate this effort by working with Medical and Urological Societies to further promote urological awareness months across the United States.

Centers for Medicare & Medicaid Services (CMS) Update:  Delayed Implementation of Appropriate Use Criteria

CMS announced the Appropriate Use Criteria (AUC) testing period is extended through calendar year 2021. CMS stated there will be no payment consequences during the testing period. Currently, the program is set to be fully implemented on January 1, 2022, at which time payment consequences will go into effect. This extension comes after extensive lobbying from the American Hospital Association, American Medical Association, and numerous other specialty organizations.  The AUA has opposed the use of the Appropriate Use Criteria in the past, and welcomes the delay. 

The AUC program requires providers who order advanced diagnostic imaging (such as CT, MRI, and PET) for Medicare patients to consult a qualified Clinical Decision Support Mechanism (CDSM) prior to officially ordering the imaging test. It is noteworthy that, while providers are required to consult the CDSM, they are not required to follow the tool’s recommendations.

CMS states the purpose of the AUC program is to verify medical necessity for advanced imaging, before a provider orders the service, in order to avoid unnecessary testing. However, there is concern among ordering providers that CMS is attempting to replace physician judgement. There is an even greater concern among radiologists, who will be penalized if the ordering physician does not consult the clinical decision tool. Under the AUC program, payment for the radiologist’s interpretation will be denied if the ordering physician did not consult the Medicare CDSM prior to ordering services.

Providers should take advantage of the implementation delay, using the additional time to:

  • Conduct vendor and EHR testing
  • Evaluate the policies, procedures and processes related to the ordering and performance of advancing imaging
  • Conduct provider and staff training

Additional AUC resources can be found on the CMS website.

Patient and Research Advocacy: AUA Convenes More Than 30 Advocacy Organizations to Advance Initiatives that Improve Outcomes for the Prostate Cancer Community

On August 25, the Friends of the Prostate Cancer Care Community (FoPCCC) convened for a bi-monthly update meeting. The AUA-led coalition was established in January 2020 with the aim of identifying and addressing gaps in prostate cancer advocacy, awareness, education, and research. The update meeting presented the coalition’s formalized vision, mission, and values statements, in addition to the coalition’s four main initiatives. The FoPCCC’s framework focuses on equity of access to the highest possible quality of care and informed decision making for men at risk for, or diagnosed with, prostate cancer. Questions about the coalition can be directed to Kimberly Serota at kserota@AUAnet.org.

Research Advocacy: AUA Supports Enactment of the Fiscal Year 2021 Defense Appropriations Act 

The AUA supported a coalition letter led by the Defense Health Research Consortium (DHRC) that calls on House of Representatives and Senate leadership to work towards the enactment of the fiscal year (FY) 2021 Defense Appropriations Act. Enactment will ensure that the Defense Health Research Programs, including the Congressionally Directed Medical Research Programs (CDMRP), are fully funded in fiscal year 2021. Further, the letter expresses concern about the possibility of Congress enacting a year-long continuing resolution in lieu of completing the FY 2021 Defense Appropriations Act. Under a year-long continuing resolution, the CDMRP would receive no funding in FY 2021. This would result in major negative health implications for the millions of Americans – especially veterans, military service members and their families – who live with chronic and debilitating disorders including prostate, bladder, and kidney cancer.                                       

With my warmest wishes for your good health,

Kathy