September 2020 medical policy update bulletin Medical Policy, Medical Benefit Drug Policy & Coverage Determination Guideline Updates
In This Issue Take Note Page • Change in Policy Application Guidelines for State of Florida ...... 4 • New Look for UnitedHealthcare Community Plan Policies ...... 4 • Annual ICD-10 Code Updates ...... 4 Medical Policy Updates UPDATED • Cardiac Event Monitoring (for Louisiana Only) – Effective Sep. 1, 2020 ...... 5 • Chelation Therapy for Non-Overload Conditions (for Louisiana Only) – Effective Oct. 1, 2020 ...... 5 • Electrical and Ultrasound Bone Growth Stimulators (for Louisiana Only) – Effective Sep. 1, 2020 ...... 5 • Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds (for Tennessee Only) – Effective Oct. 1, 2020 ...... 5 • Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing for Infectious Diarrhea – Effective Sep. 1, 2020 ...... 5 • Genetic Testing for Hereditary Cancer (for Louisiana Only) – Effective Sep. 1, 2020 ...... 5 • Genitourinary Pathogen Nucleic Acid Detection Panel Testing – Effective Sep. 1, 2020 ...... 6 • Inhaled Nitric Oxide for Infants – Effective Oct. 1, 2020 ...... 6 • Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions (for Louisiana Only) – Effective Sep. 1, 2020 ...... 6 REVISED • Autologous Cellular Therapy for Certain Indications (for Florida Only) – Effective Oct. 1, 2020 ...... 6 • Balloon Sinus Ostial Dilation (for Tennessee Only) – Effective Oct. 1, 2020 ...... 7 • Collagen Crosslinks and Biochemical Markers of Bone Turnover (for Louisiana Only) – Effective Oct. 1, 2020 ...... 13 • Facet Injections for Spinal Pain (for Louisiana Only) – Effective Oct. 1, 2020 ...... 13 • Functional Endoscopic Sinus Surgery (FESS) (for Tennessee Only) – Effective Oct. 1, 2020 ...... 16 • Gastrointestinal Motility Disorders, Diagnosis and Treatment (for Louisiana Only) – Effective Oct. 1, 2020 ...... 21 • Glaucoma Surgical Treatments (for Louisiana Only) – Effective Oct. 1, 2020 ...... 22 • Hip Resurfacing and Replacement Surgery (Arthroplasty) (for Florida Only) – Effective Oct. 1, 2020 ...... 23 • Hip Resurfacing and Replacement Surgery (Arthroplasty) (for Tennessee Only) – Effective Oct. 1, 2020...... 28
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• Intrauterine Fetal Surgery (for Louisiana Only) – Effective Oct. 1, 2020 ...... 33 • Knee Replacement Surgery (Arthroplasty), Total and Partial (for Florida Only) – Effective Oct. 1, 2020 ...... 33 • Knee Replacement Surgery (Arthroplasty), Total and Partial (for Tennessee Only) – Effective Oct. 1, 2020 ...... 36 • Manipulation Under Anesthesia (for Louisiana Only) – Effective Oct. 1, 2020 ...... 38 • Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) and Achalasia – Effective Nov. 1, 2020 ...... 39 • Omnibus Codes (for Florida Only) – Effective Oct. 1, 2020 ...... 40 • Shoulder Replacement Surgery (Arthroplasty) (for Florida Only) – Effective Oct. 1, 2020 ...... 45 • Shoulder Replacement Surgery (Arthroplasty) (for Tennessee Only) – Effective Oct. 1, 2020 ...... 48 • Spinal Ultrasonography – Effective Nov. 1, 2020 ...... 50 • Standing Systems and Gait Trainers (for Tennessee Only) – Effective Oct. 1, 2020 ...... 53 • Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins (for Tennessee Only) – Effective Oct. 1, 2020 ...... 55 • Surgical Treatment for Spine Pain (for Louisiana Only) – Effective Oct. 1, 2020 ...... 57 • Surgical Treatment for Spine Pain (for Tennessee Only) – Effective Oct. 1, 2020 ...... 60 • Surgical Treatment for Spine Pain (for Tennessee Only) – Effective Nov. 1, 2020 ...... 61 • Total Artificial Disc Replacement for the Spine (for Tennessee Only) – Effective Oct. 1, 2020 ...... 64 • Transcatheter Heart Valve Procedures (for Tennessee Only) – Effective Oct. 1, 2020 ...... 67 RETIRED • Carrier Testing for Genetic Diseases (for Nebraska Only) – Effective Sep. 1, 2020 ...... 69 • Chromosome Microarray Testing (Non-Oncology Conditions) (for Louisiana Only) – Effective Sep. 1, 2020 ...... 69 • Chromosome Microarray Testing (Non-Oncology Conditions) (for Nebraska Only) – Effective Sep. 1, 2020 ...... 69 • Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood (for Nebraska Only) – Effective Sep. 1, 2020 ...... 69 • Genetic Testing for Cardiac Disease (for Nebraska Only) – Effective Sep. 1, 2020 ...... 69 • High Frequency Chest Wall Compression Devices (for Louisiana Only) – Effective Sep. 1, 2020 ...... 70 • Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions (for Nebraska Only) – Effective Sep. 1, 2020 ...... 70 • Pharmacogenetic Testing (for Nebraska Only) – Effective Sep. 1, 2020 ...... 70 • Preimplantation Genetic Testing (for Nebraska Only) – Effective Sep. 1, 2020 ...... 70 Medical Benefit Drug Policy Updates NEW • Givlaari® (Givosiran) (for Pennsylvania Only) – Effective Oct. 1, 2020 ...... 71 • Scenesse® (Afamelanotide) – Effective Oct. 1, 2020 ...... 72 • Uplizna™ (Inebilizumab-Cdon) – Effective Oct. 1, 2020 ...... 73 UPDATED • Botulinum Toxins A and B – Effective Sep. 1, 2020 ...... 75 REVISED • Crysvita® (Burosumab-Twza) – Effective Oct. 1, 2020 ...... 75
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• Hereditary Angioedema (HAE), Treatment and Prophylaxis – Effective Oct. 1, 2020 ...... 77 • Respiratory Interleukins (Cinqair®, Fasenra®, & Nucala®) – Effective Oct. 1, 2020 ...... 81 Coverage Determination Guideline (CDG) Updates UPDATED • Prosthetic Devices, Specialized, Microprocessor or Myoelectric Limbs (for Louisiana Only) – Effective Sep. 1, 2020 ...... 82 REVISED • Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair (for Tennessee Only) – Effective Oct. 1, 2020 ...... 82 • Breast Reconstruction Post Mastectomy (for Louisiana Only) – Effective Oct. 1, 2020 ...... 82 • Breast Reduction Surgery (for Tennessee Only) – Effective Oct. 1, 2020 ...... 86 • Cosmetic and Reconstructive Procedures (for Tennessee Only) – Effective Oct. 1, 2020 ...... 88 • Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements (for Louisiana Only) – Effective Oct. 1, 2020 ...... 91 • Oral and Enteral Nutrition (for Tennessee Only) – Effective Oct. 1, 2020 ...... 94 • Orthognathic (Jaw) Surgery (for Tennessee Only) – Effective Oct. 1, 2020 ...... 97 • Panniculectomy and Body Contouring Procedures (for Tennessee Only) – Effective Oct. 1, 2020 ...... 99 • Pectus Deformity Repair (for Tennessee Only) – Effective Oct. 1, 2020 ...... 102 • Rhinoplasty and Other Nasal Surgeries (for Tennessee Only) – Effective Oct. 1, 2020 ...... 103
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Take Note
CHANGE IN POLICY APPLICATION GUIDELINES FOR STATE OF FLORIDA
The state of Florida will not be excluded from the following policies on Oct. 1, 2020 as previously announced. These policies will continue to apply to the state of Florida; refer to the policies for complete details on applicable coverage guidelines. • Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair • Breast Reduction Surgery • Cosmetic and Reconstructive Procedures • Epidural Steroid and Facet Injections for Spinal Pain • Hepatitis Screening • Obstructive Sleep Apnea Treatment • Orthognathic (Jaw) Surgery • Panniculectomy and Body Contouring Procedures • Surgical Treatment for Spine Pain • Total Artificial Disc Replacement for the Spine
NEW LOOK FOR UNITEDHEALTHCARE COMMUNITY PLAN POLICIES
Beginning Sep. 1, 2020 and continuing over the next several months, we will be refreshing the look of the UnitedHealthcare Community Plan Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, and Utilization Review Guidelines. Unless otherwise announced, there will be no change to policy content/guidelines as a result of the new look.
ANNUAL ICD-10 CODE UPDATES
Effective Oct. 1, 2020, all applicable Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, and Utilization Review Guidelines will be modified to reflect the annual ICD-10 code additions, revisions, and deletions. Refer to the following sources for information on the code updates: • Centers for Medicare & Medicaid Services (CMS) International Classification of Diseases, Tenth Revision (ICD-10) Clinical Modification (CM) (Diagnosis) Codes • Centers for Medicare & Medicaid Services (CMS) International Classification of Diseases, Tenth Revision (ICD-10) Procedure Coding System (PCS) Codes Complete details on impacted policies and corresponding code edits will be provided in the October 2020 edition of the Medical Policy Update Bulletin.
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Medical Policy Updates
Policy Title Effective Date Summary of Changes UPDATED Cardiac Event Sep. 1, 2020 Applicable Codes Monitoring (for • Updated list of HCPCS codes to reflect annual code edits; added G2066 Louisiana Only) Chelation Therapy Oct. 1, 2020 Applicable Codes for Non-Overload • Added HCPCS codes J0470, J0600, J0895, and J8499 Conditions (for Supporting Information Louisiana Only) • Updated Description of Services, Clinical Evidence, and FDA sections to reflect the most current information Electrical and Sep. 1, 2020 Coverage Rationale Ultrasound Bone • Replaced reference to “MCG™ Care Guidelines, 23rd edition, 2019” with “MCG™ Care Guidelines, [24th edition, Growth Stimulators 2020]” (for Louisiana Only) Extracorporeal Oct. 1, 2020 Title Change Shock Wave • Previously titled Extracorporeal Shock Wave Therapy (ESWT) (for Tennessee Only) Therapy (ESWT) Coverage Rationale for Musculoskeletal • Updated language to clarify: Conditions and Soft o Extracorporeal shock wave therapy (ESWT), whether low energy, high energy or radial wave, is unproven Tissue Wounds (for and not medically necessary for any musculoskeletal or soft tissue indications Tennessee Only) o This policy does not address extracorporeal shock wave lithotripsy (ESWL) used for the treatment of: ▪ Gallstones ▪ Kidney stones ▪ Pancreatic stones ▪ Salivary stones Supporting Information • Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information Gastrointestinal Sep. 1, 2020 Application Pathogen Nucleic • Removed language indicating this policy applies to the state of Texas effective Oct. 1, 2020 Acid Detection • Added language to indicate this policy applies to the states of Kansas, Ohio, and Texas effective Nov. 1, 2020 Panel Testing for Infectious Diarrhea Genetic Testing for Sep. 1, 2020 Applicable Codes Hereditary Cancer • Updated list of applicable Multi-Gene Panel CPT codes to reflect annual code edits; added 0162U (for Louisiana Only)
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Medical Policy Updates
Policy Title Effective Date Summary of Changes UPDATED Genitourinary Sep. 1, 2020 Application Pathogen Nucleic • Removed language indicating this policy applies to the state of Texas effective Oct. 1, 2020 Acid Detection • Added language to indicate this policy applies to the states of Kansas, Ohio, and Texas effective Nov. 1, 2020 Panel Testing Inhaled Nitric Oct. 1, 2020 Application Oxide for Infants • Added language to indicate this policy applies to the state of Florida Molecular Oncology Sep. 1, 2020 Applicable Codes Testing for Cancer • Updated list of applicable CPT codes to reflect annual and quarterly code edits; added 0153U, 0171U, 81277, Diagnosis, 81522, 81542, and 81552 Prognosis, and Treatment Decisions (for Louisiana Only)
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Autologous Cellular Oct. 1, 2020 Template Update Autologous cellular therapy is unproven and not medically for ALL Therapy for Certain • Reformatted policy; content indications, including but not limited to: Indications (for previously located in the policy • Osteoarthritis of the knee Florida Only) titled Omnibus Codes (for Florida • Peripheral arterial disease Only) • Regeneration and/or repair of musculoskeletal tissue Related Policies • Scleroderma of the hands • Added reference link to the Medical Policy titled: o Bone or Soft Tissue Healing and Fusion Enhancement Products (for Florida Only) o Prolotherapy and Platelet Rich Plasma Therapies Coverage Rationale • Added language to indicate Autologous Cellular Therapy is unproven and not medically necessary for all indications • Revised list of unproven and not medically necessary indications: o Replaced “conditions of the
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Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Autologous Cellular Oct. 1, 2020 knee” with “osteoarthritis of Therapy for Certain the knee” Indications (for o Added “regeneration and/or Florida Only) repair of musculoskeletal (continued) tissue” • Removed reference to specific cell therapies: o Intramuscular autologous bone marrow cell therapy o Autologous adipose-derived regenerative cell therapy o Refined autologous adipose cell transfer Definitions • Added definition of: o Adipose-Derived Stem Cells (ACSs) o Autologous Adipose-Derived Regenerative Cell Therapy o Autologous Cell Therapy o Bone Marrow Mononuclear Stem Cells o Regenerative Medicine Applicable Codes • Added CPT codes 0565T and 0566T Supporting Information • Added Description of Services, FDA, and CMS sections • Updated Clinical Evidence and References sections to reflect the most current information Balloon Sinus Oct. 1, 2020 Coverage Rationale Balloon sinus ostial dilation is proven and medically necessary for Ostial Dilation (for • Revised coverage criteria: either of the following conditions: Tennessee Only) Chronic Rhinosinusitis • Chronic Rhinosinusitis which has all of the following: o Added criterion requiring: o Lasted longer than 12 weeks ▪ Computed tomography o Persistence of symptoms despite administration of full courses of all
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Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Balloon Sinus Oct. 1, 2020 (CT) images are of the following treatments: Ostial Dilation (for obtained after ▪ Antibiotic therapy, if bacterial infection is suspected; and Tennessee Only) completion of medical ▪ Intranasal corticosteroids; and (continued) management ▪ Nasal lavage ▪ Scoring of CT images is o Confirmation of Chronic Rhinosinusitis on a computed tomography done by using the (CT) scan for each sinus to be dilated meeting all of the following Modified Lund-Mackay criteria: Scoring System ▪ CT images are obtained after completion of medical ▪ Sinonasal symptoms management; and such as pain, pressure, ▪ Scoring of CT images is done by using the Modified Lund-Mackay or drainage are present Scoring System; and on the same side as CT ▪ CT findings include one or more of the following: scan findings of - Bony remodeling rhinosinusitis - Bony thickening o Replaced criterion requiring - Opacified sinus “CT findings include mucosal - Ostial obstruction (outflow tract obstruction) and mucosal thickening or obstruction of thickening the ostiomeatal complex” o Sinonasal symptoms such as pain, pressure, or drainage are present with “CT findings include on the same side as CT scan findings of rhinosinusitis ostial obstruction (outflow o The balloon sinus ostial dilation limited to the frontal, maxillary, or tract obstruction) and sphenoid sinuses mucosal thickening” o The balloon sinus ostial dilation performed as either a stand-alone Recurrent Acute procedure or part of Functional Endoscopic Sinus Surgery (FESS) Rhinosinusitis • Recurrent Acute Rhinosinusitis with all of the following: o Replaced criterion requiring: o Four or more episodes per year with distinct symptom free intervals ▪ “CT evidence of ostial between episodes; and obstruction and mucosal o CT scan evidence of ostial obstruction (outflow tract obstruction) and thickening in the sinus to mucosal thickening in the sinus to be dilated; and be dilated” with “CT scan o Sinonasal symptoms such as pain, pressure, or drainage are present evidence of ostial on the same side as CT scan findings of rhinosinusitis obstruction (outflow tract obstruction) and Balloon sinus ostial dilation is unproven and not medically necessary mucosal thickening in for treating the following due to insufficient evidence of efficacy: the sinus to be dilated” • Nasal polyps or tumors ▪ “Sinonasal symptoms” • All other conditions that do not meet the above criteria with “sinonasal symptoms such as pain, Self-expanding absorptive sinus ostial dilation is unproven and not pressure, or drainage medically necessary for evaluating or treating sinusitis and all other
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Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Balloon Sinus Oct. 1, 2020 are present on the same conditions due to insufficient evidence of efficacy. Ostial Dilation (for side as CT scan findings Tennessee Only) of rhinosinusitis” Documentation Requirements (continued) • Added language to indicate self- Provide medical notes documenting the following: expanding absorptive sinus • History of illness ostial dilation is unproven and • Recent physical exam not medically necessary for • One of the following: evaluating or treating sinusitis o Chronic Rhinosinusitis including all of the following: and all other conditions due to ▪ Treatments tried and failed including duration of insufficient evidence of efficacy treatments/medical therapies Documentation Requirements ▪ Post medical management CT scan image(s): (new to policy) - That shows the abnormality for which surgery is being • Added requirement for medical requested notes documenting: - Is the optimal image to show the abnormality of the affected o History of illness area o Recent physical exam - With use of the Modified Lund-Mackay Scoring System to o One of the following: define the severity of Chronic Rhinosinusitis ▪ Chronic Rhinosinusitis - Note: CT images are required and must be labeled with the: including all of the • Date taken following: • Applicable case number obtained at time of notification, - Treatments tried and or the member's name and ID number on the image(s) failed including • Whether the image(s) was taken pre- or post-medical duration of therapy treatments/medical - Submission of diagnostic imaging is required via the external therapies portal at www.uhcprovider.com/paan or via email at - Post medical [email protected] (for Hawaii) or [email protected] (for management CT all other states); faxes will not be accepted scan image(s): ▪ CT scan report quantifying the severity of Chronic Rhinosinusitis • That shows the using the Modified Lund-Mackay Scoring System (for each side abnormality for for which treatment is being requested) which surgery is ▪ Evidence that the sinusitis involves frontal, maxillary, or being requested sphenoid sinuses • Is the optimal ▪ Planned procedure, including if the procedure will be part of a image to show the functional endoscopic sinus surgery (FESS) abnormality of the o Recurrent Acute Rhinosinusitis including all of the following: affected area ▪ Number of episodes per year of acute rhinosinusitis • With use of the ▪ Signs and symptoms Modified Lund- ▪ CT scan image(s):
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Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Balloon Sinus Oct. 1, 2020 Mackay Scoring - That shows the abnormality for which surgery is being Ostial Dilation (for System to define requested Tennessee Only) the severity of - Is the optimal image to show the abnormality of the affected (continued) Chronic area Rhinosinusitis - Note: CT images are required and must be labeled with the: • Note: CT images • Date taken are required and • Applicable case number obtained at time of notification, must be labeled or the member's name and ID number on the image(s) with the: • Whether the image(s) was taken pre- or post-medical o Date taken therapy o Applicable case - Submission of diagnostic imaging is required via the external number portal at www.uhcprovider.com/paan or via email at obtained at [email protected] (for Hawaii) or [email protected] (for time of all other states); faxes will not be accepted notification, or ▪ CT scan report quantifying the severity of Chronic Rhinosinusitis the member's using the Modified Lund-Mackay Scoring System (for each side name and ID for which treatment is being requested) number on the image(s) o Whether the image(s) was taken pre- or post-medical therapy • Submission of diagnostic imaging is required via the external portal at www.uhcprovider. com/paan or via email at [email protected] (for Hawaii) or MedicaidCCR@uhc .com (for all other states); faxes will not be accepted - CT scan report
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Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Balloon Sinus Oct. 1, 2020 quantifying the Ostial Dilation (for severity of Chronic Tennessee Only) Rhinosinusitis using (continued) the Modified Lund- Mackay Scoring System (for each side for which treatment is being requested) - Evidence that the sinusitis involves frontal, maxillary, or sphenoid sinuses - Planned procedure, including if the procedure will be part of a functional endoscopic sinus surgery (FESS) ▪ Recurrent Acute Rhinosinusitis including all of the following: - Number of episodes per year of acute rhinosinusitis - Signs and symptoms - CT scan image(s): • That shows the abnormality for which surgery is being requested • Is the optimal image to show the abnormality of the affected area • Note: CT images are required and
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Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Balloon Sinus Oct. 1, 2020 must be labeled Ostial Dilation (for with the: Tennessee Only) o Date taken (continued) o Applicable case number obtained at time of notification, or the member's name and ID number on the image(s) o Whether the image(s) was taken pre- or post-medical therapy • Submission of diagnostic imaging is required via the external portal at www.uhcprovider. com/paan or via email at [email protected] (for Hawaii) or MedicaidCCR@uhc .com (for all other states); faxes will not be accepted - CT scan report quantifying the severity of Chronic Rhinosinusitis using the Modified Lund- Mackay Scoring System (for each side for which
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Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Balloon Sinus Oct. 1, 2020 treatment is being Ostial Dilation (for requested) Tennessee Only) Definitions (continued) • Added definition of “Modified Lund-Mackay Scoring System” Applicable Codes • Added CPT code 31299 Supporting Information • Updated Description of Services, Clinical Evidence, FDA, and References sections to reflect the most current information Collagen Crosslinks Oct. 1, 2020 Coverage Rationale Serum or urine collagen crosslinks or biochemical markers are and Biochemical • Replaced language indicating unproven and not medically necessary to assess risk of fracture, Markers of Bone “serum or urine collagen predict bone loss, or assess response to antiresorptive therapy. Turnover (for crosslinks or biochemical Louisiana Only) markers are unproven and not medically necessary for any indication due to insufficient evidence of efficacy” with “serum or urine collagen crosslinks or biochemical markers are unproven and not medically necessary to assess risk of fracture, predict bone loss, or assess response to antiresorptive therapy” Supporting Information • Updated Clinical Evidence, CMS, and References sections to reflect the most current information Facet Injections for Oct. 1, 2020 Title Change Note: The policy does not address injections for obstetrical or surgical Spinal Pain (for • Previously titled Epidural Steroid anesthetic. The policy addresses Facet Joint Injections of multiple sites and is Louisiana Only) and Facet Injections for Spinal not limited to Facet Joint Injections of the lumbar spine. Pain (for Louisiana Only) Coverage Rationale Diagnostic Facet Joint Injection (FJI) and/or Facet Nerve Block (i.e.,
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Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Facet Injections for Oct. 1, 2020 • Removed content/language Medical Branch Block) are proven and medically necessary to localize Spinal Pain (for pertaining to Epidural Steroid the level of facet joint pain in persons with pain suspected to Louisiana Only) Injections (ESI) originate from a facet joint as based on clinical exam. (continued) • Replaced language indicating “Diagnostic Facet Joint Injection The following are unproven and not medically necessary due to (FJI) and/or facet nerve block insufficient evidence of efficacy: (i.e., medial branch block) to • The use of ultrasound guidance for FJIs localize the source of pain to the • Therapeutic FJI and/or Facet Nerve Block (i.e., Medial Branch Block) for facet joint in persons with spinal treating chronic spinal pain pain” with “Diagnostic Facet Joint Injection (FJI) and/or facet nerve block (i.e., medical branch block) to localize the level of facet joint pain in persons with pain suspected to originate from a facet joint as based on clinical exam” Definitions • Updated definition of “Facet Joint Injection (FJI)” • Removed definition of: o Acute Low Back Pain o Conservative Therapy o Epidural Steroid Injection (ESI) o Non-Radicular Back Pain o Radicular Back Pain o Radiculopathy o Sub-Acute Low Back Pain Applicable Codes • Removed CPT codes 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0230T, 0231T, 62322, 62323, 64483, and 64484 • Removed ICD-10 diagnosis codes E08.41, E09.41, E10.41, E11.41, E13.41, G54.1, G54.4, G57.00, G57.01, G57.02,
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Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Facet Injections for Oct. 1, 2020 G57.03, G57.70, G57.71, Spinal Pain (for G57.72, G57.73, G57.80, Louisiana Only) G57.81, G57.82, G57.83, (continued) G57.90, G57.91, G57.92, G57.93, G58.8, G58.9, G59, G90.50, G90.521, G90.522, G90.523, G90.529, G90.59, M43.00, M43.01, M43.02, M43.03, M43.04, M43.05, M43.06, M43.07, M43.08, M43.09, M43.10, M43.11, M43.12, M43.13, M43.14, M43.15, M43.16, M43.17, M43.18, M43.19, M43.27, M43.28, M47.16, M47.26, M47.27, M47.28, M47.816, M47.817, M47.818, M47.896, M47.897, M47.898, M48.00, M48.061, M48.062, M48.07, M48.08, M51.06, M51.14, M51.15, M51.16, M51.17. M51.26, M51.27, M51.34, M51.35, M51.36, M51.37, M51.46, M51.47, M51.9, M53.2X7, M53.2X8, M53.3, M53.86, M53.87, M53.88, M54.14, M54.15, M54.16, M54.17, M54.30, M54.31, M54.32, M54.40, M54.41, M54.42, M96.1, M99.23, M99.24, M99.25, M99.26, M99.27, M99.28, M99.29, M99.33, M99.34, M99.35, M99.36, M99.37, M99.38, M99.39, M99.43, M99.44, M99.45, M99.46, M99.47, M99.48, M99.49, M99.53, M99.54, M99.55, M99.56,
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Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Facet Injections for Oct. 1, 2020 M99.57, M99.58, M99.59, Spinal Pain (for M99.63, M99.64, M99.65, Louisiana Only) M99.66, M99.67, M99.68, (continued) M99.69, M99.73, M99.74, M99.75, M99.76, M99.77, M99.78, M99.79, S24.2XXA, S32.000A, S32.001A, S32.002A, S32.008A, S32.009A, S32.010A, S32.011A, S32.012A, S32.018A, S32.019A, S32.020A, S32.021A, S32.022A, S32.028A, S32.029A, S32.030A, S32.031A, S32.032A, S32.038A, S32.039A, S32.040A, S32.041A, S32.042A, S32.048A, S32.049A, S32.050A, S32.051A, S32.052A, S32.058A, S32.059A, S34.21XA, S34.22XA, S34.4XXA, S74.00XA, S74.01XA, and S74.02XA Supporting Information • Updated Description of Services, Clinical Evidence, FDA, CMS, and References sections to reflect the most current information Functional Oct. 1, 2020 Coverage Rationale Functional Endoscopic Sinus Surgery (FESS) is proven and medically Endoscopic Sinus • Revised list of conditions for necessary when one or more of the following conditions are present: Surgery (FESS) which Functional Endoscopic • Chronic Rhinosinusitis with or without polyps which has all of the (for Tennessee Sinus Surgery (FESS) is proven following: Only) and medically necessary: o Lasted longer than 12 weeks o Replaced “Chronic o Persistence of symptoms despite administration of full courses of all Rhinosinusitis” with “Chronic of the following treatments: Rhinosinusitis with or ▪ Antibiotic therapy, if bacterial infection is suspected; and without polyps” ▪ Intranasal corticosteroids; and o Added: ▪ Nasal lavage ▪ Polyposis with o Confirmation of Chronic Rhinosinusitis on a computed tomography obstructive symptoms (CT) scan for each sinus to be treated meeting all of the following confirmed on computed criteria: tomography (CT) scan ▪ CT images are obtained after completion of medical
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Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Functional Oct. 1, 2020 ▪ Sinonasal tumor management; and Endoscopic Sinus confirmed on CT scan ▪ Scoring of CT images is done by using the Modified Lund-Mackay Surgery (FESS) o Removed “tumor confirmed Scoring System; and (for Tennessee on CT scan (such as ▪ CT findings include one or more of the following: Only) polyposis or malignancy)” - Bony remodeling (continued) • Revised coverage criteria: - Bony thickening Chronic Rhinosinusitis - Opacified sinus o Replaced criterion requiring: - Ostial obstruction (outflow tract obstruction) and mucosal ▪ “Confirmation of Chronic thickening Rhinosinusitis on a o Sinonasal symptoms such as pain, pressure, or drainage are present computed tomography on the same side as CT scan findings of rhinosinusitis (CT) scan meeting all of • Recurrent Acute Rhinosinusitis with all of the following: the [listed] criteria” with o Four or more episodes per year with distinct symptom free intervals “confirmation of Chronic between episodes; and Rhinosinusitis on a o CT scan evidence of ostial obstruction (outflow tract obstruction) and computed tomography mucosal thickening in the sinus to be treated; and (CT) scan for each sinus o Sinonasal symptoms such as pain, pressure, or drainage are present to be treated meeting all on the same side as CT scan findings of rhinosinusitis of the [listed] criteria” • Any of the following conditions confirmed on CT scan: ▪ “CT findings include o Complications of sinusitis such as abscess mucosal thickening or o Concha bullosa obstruction of the o Mucocele ostiomeatal complex” o Polyposis with obstructive symptoms (for Chronic Rhinosinusitis with with “CT findings include polyps, see the above criteria) ostial obstruction o Sinonasal tumor (outflow tract obstruction) and Documentation Requirements mucosal thickening” Provide medical notes documenting the following: o Added criterion requiring: • Chronic Rhinosinusitis (CRS) with the following: ▪ CT images are obtained o Signs and symptoms after completion of o Treatments tried and failed including duration of treatments/medical medical management therapies ▪ Scoring of CT images is o Post medical management CT scan images: done by using the ▪ That show the abnormality for which surgery is being requested Modified Lund-Mackay ▪ Are the optimal image to show the abnormality of the affected Scoring System area ▪ Sinonasal symptoms ▪ With use of the Modified Lund-Mackay Scoring System to define such as pain, pressure, the severity of Chronic Rhinosinusitis
17 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Functional Oct. 1, 2020 or drainage are present ▪ Note: CT images are required and must be labeled with the: Endoscopic Sinus on the same side as CT - Date taken Surgery (FESS) scan findings of - Applicable case number obtained at time of notification, or (for Tennessee rhinosinusitis the member's name and ID number on the images Only) Recurrent Acute - Whether the imaging was taken pre-or post-medical therapy (continued) Rhinosinusitis ▪ CT images can be submitted via the external portal at o Replaced criterion requiring: www.uhcprovider.com/paan or via email at [email protected] (for ▪ “CT evidence of ostial Hawaii) or [email protected] (for all other states); faxes and/or mucosal will not be accepted thickening in the sinus to o CT scan report quantifying the severity of Chronic Rhinosinusitis be treated” with “CT using the Modified Lund-Mackay Scoring System (for each side for scan evidence of ostial which treatment is being requested) obstruction (outflow • Recurrent Acute Rhinosinusitis with the following: tract obstruction) and o Number of episodes per year of Acute Rhinosinusitis mucosal thickening in o Signs and symptoms the sinus to be treated” o CT scan images: ▪ “Sinonasal symptoms” ▪ That show the abnormality for which surgery is being requested with “sinonasal ▪ Are the optimal image to show the abnormality of the affected symptoms such as pain, area pressure, or drainage ▪ Note: CT images are required and must be labeled with the: are present on the same - Date taken side as CT scan findings - Applicable case number obtained at time of notification, or of rhinosinusitis” the member's name and ID number on the images Documentation Requirements - Whether the images were taken pre- or post-medical therapy (new to policy) ▪ CT images can be submitted via the external portal at • Added requirement for medical www.uhcprovider.com/paan or via email at [email protected] (for notes documenting: Hawaii) or [email protected] (for all other states); faxes o Chronic Rhinosinusitis will not be accepted (CRS) with the following: o CT scan report quantifying the severity of Acute Rhinosinusitis using ▪ Signs and symptoms the Modified Lund-Mackay Scoring System (for each side for which ▪ Treatments tried and treatment is being requested) failed including duration of treatments/medical therapies ▪ Post medical management CT scan images: - That show the
18 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Functional Oct. 1, 2020 abnormality for Endoscopic Sinus which surgery is Surgery (FESS) being requested (for Tennessee - Are the optimal Only) image to show the (continued) abnormality of the affected area - With use of the Modified Lund- Mackay Scoring System to define the severity of Chronic Rhinosinusitis - Note: CT images are required and must be labeled with the: • Date taken • Applicable case number obtained at time of notification, or the member's name and ID number on the images • Whether the imaging was taken pre-or post- medical therapy - CT images can be submitted via the external portal at www.uhcprovider.co m/paan or via email at [email protected] (for Hawaii) or [email protected] om (for all other states); faxes will
19 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Functional Oct. 1, 2020 not be accepted Endoscopic Sinus ▪ CT scan report Surgery (FESS) quantifying the severity (for Tennessee of Chronic Rhinosinusitis Only) using the Modified Lund- (continued) Mackay Scoring System (for each side for which treatment is being requested) o Recurrent Acute Rhinosinusitis with the following: ▪ Number of episodes per year of Acute Rhinosinusitis ▪ Signs and symptoms ▪ CT scan images: - That show the abnormality for which surgery is being requested - Are the optimal image to show the abnormality of the affected area - Note: CT images are required and must be labeled with the: • Date taken • Applicable case number obtained at time of notification, or the member's name and ID number on the images • Whether the images were taken
20 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Functional Oct. 1, 2020 pre- or post- Endoscopic Sinus medical therapy Surgery (FESS) - CT images can be (for Tennessee submitted via the Only) external portal at (continued) www.uhcprovider.co m/paan or via email at [email protected] (for Hawaii) or [email protected] om (for all other states); faxes will not be accepted ▪ CT scan report quantifying the severity of Acute Rhinosinusitis using the Modified Lund- Mackay Scoring System (for each side for which treatment is being requested) Definitions • Added definition of “Modified Lund-Mackay Scoring System” Supporting Information • Updated Clinical Evidence and References sections to reflect the most current information Gastrointestinal Oct. 1, 2020 Coverage Rationale The following procedures are proven and medically necessary: Motility Disorders, • Revised list of proven and • Gastric electrical stimulation (GES) therapy for treating refractory Diagnosis and medically necessary indications; gastroparesis that has failed other therapies, or chronic intractable Treatment (for replaced “gastric electrical (drug-refractory) nausea and vomiting secondary to gastroparesis of Louisiana Only) stimulation (GES) therapy for diabetic or idiopathic etiology treating refractory diabetic • Rectal manometry, rectal sensation, tone and compliance test, and gastroparesis that has failed anorectal manometry other therapies, or chronic • Conventional defecography for evaluating intractable constipation or intractable (drug-refractory) constipation in members who have one or more of the following
21 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Gastrointestinal Oct. 1, 2020 nausea and vomiting secondary conditions that are suspected to be the cause of impaired defecation: Motility Disorders, to gastroparesis of diabetic or o Pelvic floor dyssynergia (inappropriate contraction of the puborectalis Diagnosis and idiopathic etiology” with “gastric muscle); or Treatment (for electrical stimulation (GES) o Enterocele (e.g., after hysterectomy); or Louisiana Only) therapy for treating refractory o Anterior rectocele (continued) gastroparesis that has failed other therapies, or chronic See the U.S. Food and Drug Administration (FDA) section of the policy for intractable (drug-refractory) information regarding FDA labeling and Humanitarian Device Exemption nausea and vomiting secondary (HDE) for GES. to gastroparesis of diabetic or idiopathic etiology” The following procedures are unproven and not medically necessary Definitions (new to policy) due to insufficient evidence of efficacy: • Added definition of: • Colonic manometry for evaluating colon motility o Anorectal Disorders • Conventional defecography for evaluating all other conditions not o Anorectal Manometry included above o Colonic Manometry • Magnetic resonance imaging (MRI) defecography for evaluating o Constipation constipation and anorectal or pelvic floor disorders o Defecography • Cutaneous, mucous, or serosal electrogastrography or o Electrogastrography (EGG) electroenterography for diagnosing intestinal or gastric disorders o Fecal Incontinence (FI) including gastroparesis o Gastroparesis o Magnetic Resonance Defecography Supporting Information • Updated Description of Services, Clinical Evidence, CMS, and References sections to reflect the most current information Glaucoma Surgical Oct. 1, 2020 Coverage Rationale The following are proven and medically necessary: Treatments (for • Revised list of proven and • Canaloplasty (ab externo) for treating primary open-angle glaucoma Louisiana Only) medically necessary indications; • Glaucoma drainage devices for treating refractory glaucoma when replaced “canaloplasty for medical or surgical treatments have failed or are inappropriate treating primary open-angle • iStent®, iStent inject®, and the Hydrus® Microstent when used in glaucoma” with “canaloplasty combination with cataract surgery for treating mild to moderate open- (ab externo) for treating primary angle glaucoma and a cataract in adults currently being treated with open-angle glaucoma” ocular hypotensive medication • Revised list of unproven and not
22 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Glaucoma Surgical Oct. 1, 2020 medically necessary indications: The following are unproven and not medically necessary for treating Treatments (for o Added: any type of glaucoma due to insufficient evidence of efficacy and/or Louisiana Only) ▪ Canaloplasty (ab safety: (continued) interno) • Canaloplasty (ab interno) ▪ Gonioscopy-Assisted • Glaucoma drainage devices that are not FDA approved Transluminal • Gonioscopy-Assisted Transluminal Trabeculotomy Trabeculotomy • Viscocanalostomy o Removed CyPass® Micro- • XEN® Glaucoma Treatment System Stent System Applicable Codes • Added CPT code 66185 • Removed CPT code 66170 Supporting Information • Updated Description of Services, Clinical Evidence, CMS, and References sections to reflect the most current information Hip Resurfacing Oct. 1, 2020 Coverage Rationale Hip Replacement Surgery (Arthroplasty) and Replacement Documentation Requirements Hip replacement surgery (arthroplasty) is proven and medically Surgery (new to policy) necessary in certain circumstances. (Arthroplasty) (for • Added requirement for medical For medical necessity clinical coverage criteria, see the following MCG™ Care Florida Only) notes documenting: Guidelines, [24th edition, 2020]: Acetabuloplasty and • Hip Arthroplasty, S-560 (ISC) Displaced Fracture of • Hip: Displaced Fracture of Femoral Neck, Hemiarthroplasty, S-600 (ISC) Femoral Neck, Hemi- Arthroplasty Click here to view the MCG™ Care Guidelines. o Specific diagnostic image(s) that shows the abnormality Hip Resurfacing Arthroplasty for which surgery is being Hip resurfacing is proven and medically necessary in certain requested, which may circumstances. include MRI, CT scan, X-ray, For medical necessity clinical coverage criteria, see MCG™ Care Guidelines, and/or bone scan; [24th edition, 2020], Hip Resurfacing, S-565 (ISC). consultation with requesting surgeon may be of benefit to Click here to view the MCG™ Care Guidelines. select the optimal image(s) ▪ Note: Diagnostic images Documentation Requirements
must be labeled with Acetabuloplasty and Displaced Fracture of Femoral Neck, Hemi-
23 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Hip Resurfacing Oct. 1, 2020 the: Arthroplasty and Replacement - Date taken Provide medical notes documenting the following: Surgery - Applicable case • Specific diagnostic image(s) that shows the abnormality for which (Arthroplasty) (for number obtained at surgery is being requested, which may include MRI, CT scan, X-ray, Florida Only) time of notification, and/or bone scan; consultation with requesting surgeon may be of (continued) or the member's benefit to select the optimal image(s) name and ID o Note: Diagnostic images must be labeled with the: number on the ▪ Date taken image(s) ▪ Applicable case number obtained at time of notification, or the ▪ Submission of diagnostic member's name and ID number on the image(s) imaging is required via o Submission of diagnostic imaging is required via the external portal the external portal at at www.uhcprovider.com/paan or via email at [email protected] (for www.uhcprovider.com/pa Hawaii) or [email protected] (for all other states); faxes will an or via email at not be accepted [email protected] (for • Diagnostic imaging report(s) Hawaii) or • Condition requiring procedure [email protected] • Severity of pain and details of functional disability(ies) interfering with (for all other states); activities of daily living (preparing meals, dressing, driving, walking) faxes will not be accepted using a standard scale, such as the Western Ontario and McMaster o Diagnostic imaging report(s) Universities Arthritis Index (WOMAC) or the Hip Dysfunction and o Condition requiring Osteoarthritis Outcome Score (HOOS) procedure • Physician’s treatment plan, including pre-op discussion o Severity of pain and details • Pertinent physical examination of the relevant joint of functional disability(ies) • Co-morbid medical conditions interfering with activities of • Therapies tried and failed of the following, including dates: daily living (preparing meals, o Orthotics dressing, driving, walking) o Medications/injections using a standard scale, such o Physical therapy as the Western Ontario and o Surgery McMaster Universities o Other pain management procedures Arthritis Index (WOMAC) or • If the location is being requested as an inpatient stay, provide medical the Hip Dysfunction and notes to support at least one of the following: Osteoarthritis Outcome o Surgery is bilateral Score (HOOS) o Member has significant co-morbidities; include the list of o Physician’s treatment plan, comorbidities and current treatment including pre-op discussion • Member does not have appropriate resources to support post-operative o Pertinent physical care after an outpatient procedure; include the barriers to care as an examination of the relevant outpatient
24 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Hip Resurfacing Oct. 1, 2020 joint Hip Arthroplasty and Replacement o Co-morbid medical Provide medical notes documenting the following: Surgery conditions • Specific diagnostic image(s) that shows the abnormality for which (Arthroplasty) (for o Therapies tried and failed of surgery is being requested, which may include MRI, CT scan, X-ray, Florida Only) the following, including and/or bone scan; consultation with requesting surgeon may be of (continued) dates: benefit to select the optimal image(s) ▪ Orthotics o Note: Diagnostic images must be labeled with the: ▪ Medications/injections ▪ Date taken ▪ Physical therapy ▪ Applicable case number obtained at time of notification, or the ▪ Surgery member's name and ID number on the image(s) ▪ Other pain management o Submission of diagnostic imaging is required via the external portal at procedures www.uhcprovider.com/paan or via email at [email protected] (for o If the location is being Hawaii) or [email protected] (for all other states); faxes will not requested as an inpatient be accepted stay, provide medical notes • Diagnostic imaging report(s) to support at least one of • Condition requiring procedure the following: • Severity of pain and details of functional disability(ies) interfering with ▪ Surgery is bilateral activities of daily living (preparing meals, dressing, driving, walking) ▪ Member has significant using a standard scale, such as the Western Ontario and McMaster co-morbidities; include Universities Arthritis Index (WOMAC) or the Hip Dysfunction and the list of comorbidities Osteoarthritis Outcome Score (HOOS) and current treatment • Physician’s treatment plan, including pre-op discussion o Member does not have • Pertinent physical examination of the relevant joint appropriate resources to • Co-morbid medical conditions (cardiovascular diseases, hypertension, support post-operative care diabetes, cancer, pulmonary diseases, neurodegenerative diseases) after an outpatient • Therapies tried and failed of the following, including dates: procedure; include the o Orthotics barriers to care as an o Medications/injections outpatient o Physical therapy Hip Arthroplasty o Surgical o Specific diagnostic image(s) o Other pain management procedures that shows the abnormality • That more conservative measures have been considered (e.g., for which surgery is being osteotomy, hemiarthroplasty) or that the member has failed or is not a requested, which may candidate for more conservative measure (e.g., osteotomy, include MRI, CT scan, X-ray, hemiarthroplasty) and/or bone scan; • Date of failed previous hip fracture fixation, if applicable consultation with requesting • If the location is being requested as an inpatient stay, provide medical surgeon may be of benefit to notes to support at least one of the following:
25 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Hip Resurfacing Oct. 1, 2020 select the optimal image(s) o Surgery is bilateral and Replacement ▪ Note: Diagnostic images o Member has significant co-morbidities; include the list of Surgery must be labeled with comorbidities and current treatment (Arthroplasty) (for the: o Member does not have appropriate resources to support post- Florida Only) - Date taken operative care after an outpatient procedure; include the barriers to (continued) - Applicable case care as an outpatient number obtained at • For revision surgery, include documentation of the complication and time of notification, complete (staged) surgical plan or the member's name and ID number on the image(s) ▪ Submission of diagnostic imaging is required via the external portal at www.uhcprovider.com/p aan or via email at [email protected] (for Hawaii) or [email protected] (for all other states); faxes will not be accepted o Diagnostic imaging report(s) o Condition requiring procedure o Severity of pain and details of functional disability(ies) interfering with activities of daily living (preparing meals, dressing, driving, walking) using a standard scale, such as the Western Ontario and McMaster Universities Arthritis Index (WOMAC) or the Hip Dysfunction and Osteoarthritis Outcome Score (HOOS)
26 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Hip Resurfacing Oct. 1, 2020 o Physician’s treatment plan, and Replacement including pre-op discussion Surgery o Pertinent physical (Arthroplasty) (for examination of the relevant Florida Only) joint (continued) o Co-morbid medical conditions (cardiovascular diseases, hypertension, diabetes, cancer, pulmonary diseases, neurodegenerative diseases) o Therapies tried and failed of the following, including dates: ▪ Orthotics ▪ Medications/injections ▪ Physical therapy ▪ Surgical ▪ Other pain management procedures o That more conservative measures have been considered (e.g., osteotomy, hemiarthroplasty) or that the member has failed or is not a candidate for more conservative measure (e.g., osteotomy, hemiarthroplasty) o Date of failed previous hip fracture fixation, if applicable o If the location is being requested as an inpatient stay, provide medical notes to support at least one of the following: ▪ Surgery is bilateral
27 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Hip Resurfacing Oct. 1, 2020 ▪ Member has significant and Replacement co-morbidities; include Surgery the list of comorbidities (Arthroplasty) (for and current treatment Florida Only) ▪ Member does not have (continued) appropriate resources to support post-operative care after an outpatient procedure; include the barriers to care as an outpatient o For revision surgery, include documentation of the complication and complete (staged) surgical plan Hip Resurfacing Oct. 1, 2020 Coverage Rationale Hip Replacement Surgery (Arthroplasty) and Replacement Documentation Requirements Hip replacement surgery (arthroplasty) is proven and medically Surgery (new to policy) necessary in certain circumstances. (Arthroplasty) (for • Added requirement for medical For medical necessity clinical coverage criteria, see the following MCG™ Care Tennessee Only) notes documenting: Guidelines, [24th edition, 2020]: Acetabuloplasty and • Hip Arthroplasty, S-560 (ISC) Displaced Fracture of • Hip: Displaced Fracture of Femoral Neck, Hemiarthroplasty, S-600 (ISC) Femoral Neck, Hemi- Arthroplasty Click here to view the MCG™ Care Guidelines. o Specific diagnostic image(s) that shows the abnormality Hip Resurfacing Arthroplasty for which surgery is being Hip resurfacing is proven and medically necessary in certain requested, which may circumstances. include MRI, CT scan, X-ray, For medical necessity clinical coverage criteria, see MCG™ Care Guidelines, and/or bone scan; [24th edition, 2020], Hip Resurfacing, S-565 (ISC). consultation with requesting surgeon may be of benefit to Click here to view the MCG™ Care Guidelines. select the optimal image(s) ▪ Note: Diagnostic images Documentation Requirements
must be labeled with Acetabuloplasty and Displaced Fracture of Femoral Neck, Hemi-
the: Arthroplasty - Date taken Provide medical notes documenting the following:
28 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Hip Resurfacing Oct. 1, 2020 - Applicable case • Specific diagnostic image(s) that shows the abnormality for which and Replacement number obtained at surgery is being requested, which may include MRI, CT scan, X-ray, Surgery time of notification, and/or bone scan; consultation with requesting surgeon may be of (Arthroplasty) (for or the member's benefit to select the optimal image(s) Tennessee Only) name and ID o Note: Diagnostic images must be labeled with the: (continued) number on the ▪ Date taken image(s) ▪ Applicable case number obtained at time of notification, or the ▪ Submission of diagnostic member's name and ID number on the image(s) imaging is required via o Submission of diagnostic imaging is required via the external portal the external portal at at www.uhcprovider.com/paan or via email at [email protected] (for www.uhcprovider.com/pa Hawaii) or [email protected] (for all other states); faxes will an or via email at not be accepted [email protected] (for • Diagnostic imaging report(s) Hawaii) or • Condition requiring procedure [email protected] • Severity of pain and details of functional disability(ies) interfering with (for all other states); activities of daily living (preparing meals, dressing, driving, walking) faxes will not be accepted using a standard scale, such as the Western Ontario and McMaster o Diagnostic imaging report(s) Universities Arthritis Index (WOMAC) or the Hip Dysfunction and o Condition requiring Osteoarthritis Outcome Score (HOOS) procedure • Physician’s treatment plan, including pre-op discussion o Severity of pain and details • Pertinent physical examination of the relevant joint of functional disability(ies) • Co-morbid medical conditions interfering with activities of • Therapies tried and failed of the following, including dates: daily living (preparing meals, o Orthotics dressing, driving, walking) o Medications/injections using a standard scale, such o Physical therapy as the Western Ontario and o Surgery McMaster Universities o Other pain management procedures Arthritis Index (WOMAC) or • If the location is being requested as an inpatient stay, provide medical the Hip Dysfunction and notes to support at least one of the following: Osteoarthritis Outcome o Surgery is bilateral Score (HOOS) o Member has significant co-morbidities; include the list of o Physician’s treatment plan, comorbidities and current treatment including pre-op discussion • Member does not have appropriate resources to support post-operative o Pertinent physical care after an outpatient procedure; include the barriers to care as an examination of the relevant outpatient joint o Co-morbid medical Hip Arthroplasty
29 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Hip Resurfacing Oct. 1, 2020 conditions Provide medical notes documenting the following: and Replacement o Therapies tried and failed of • Specific diagnostic image(s) that shows the abnormality for which Surgery the following, including surgery is being requested, which may include MRI, CT scan, X-ray, (Arthroplasty) (for dates: and/or bone scan; consultation with requesting surgeon may be of Tennessee Only) ▪ Orthotics benefit to select the optimal image(s) (continued) ▪ Medications/injections o Note: Diagnostic images must be labeled with the: ▪ Physical therapy ▪ Date taken ▪ Surgery ▪ Applicable case number obtained at time of notification, or the ▪ Other pain management member's name and ID number on the image(s) procedures o Submission of diagnostic imaging is required via the external portal at o If the location is being www.uhcprovider.com/paan or via email at [email protected] (for requested as an inpatient Hawaii) or [email protected] (for all other states); faxes will not stay, provide medical notes be accepted to support at least one of • Diagnostic imaging report(s) the following: • Condition requiring procedure ▪ Surgery is bilateral • Severity of pain and details of functional disability(ies) interfering with ▪ Member has significant activities of daily living (preparing meals, dressing, driving, walking) co-morbidities; include using a standard scale, such as the Western Ontario and McMaster the list of comorbidities Universities Arthritis Index (WOMAC) or the Hip Dysfunction and and current treatment Osteoarthritis Outcome Score (HOOS) o Member does not have • Physician’s treatment plan, including pre-op discussion appropriate resources to • Pertinent physical examination of the relevant joint support post-operative care • Co-morbid medical conditions (cardiovascular diseases, hypertension, after an outpatient diabetes, cancer, pulmonary diseases, neurodegenerative diseases) procedure; include the • Therapies tried and failed of the following, including dates: barriers to care as an o Orthotics outpatient o Medications/injections Hip Arthroplasty o Physical therapy o Specific diagnostic image(s) o Surgical that shows the abnormality o Other pain management procedures for which surgery is being • That more conservative measures have been considered (e.g., requested, which may osteotomy, hemiarthroplasty) or that the member has failed or is not a include MRI, CT scan, X-ray, candidate for more conservative measure (e.g., osteotomy, and/or bone scan; hemiarthroplasty) consultation with requesting • Date of failed previous hip fracture fixation, if applicable surgeon may be of benefit to • If the location is being requested as an inpatient stay, provide medical select the optimal image(s) notes to support at least one of the following: ▪ Note: Diagnostic images o Surgery is bilateral
30 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Hip Resurfacing Oct. 1, 2020 must be labeled with o Member has significant co-morbidities; include the list of and Replacement the: comorbidities and current treatment Surgery - Date taken o Member does not have appropriate resources to support post- (Arthroplasty) (for - Applicable case operative care after an outpatient procedure; include the barriers to Tennessee Only) number obtained at care as an outpatient (continued) time of notification, • For revision surgery, include documentation of the complication and or the member's complete (staged) surgical plan name and ID number on the image(s) ▪ Submission of diagnostic imaging is required via the external portal at www.uhcprovider.com/p aan or via email at [email protected] (for Hawaii) or [email protected] (for all other states); faxes will not be accepted o Diagnostic imaging report(s) o Condition requiring procedure o Severity of pain and details of functional disability(ies) interfering with activities of daily living (preparing meals, dressing, driving, walking) using a standard scale, such as the Western Ontario and McMaster Universities Arthritis Index (WOMAC) or the Hip Dysfunction and Osteoarthritis Outcome Score (HOOS) o Physician’s treatment plan, including pre-op discussion
31 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Hip Resurfacing Oct. 1, 2020 o Pertinent physical and Replacement examination of the relevant Surgery joint (Arthroplasty) (for o Co-morbid medical Tennessee Only) conditions (cardiovascular (continued) diseases, hypertension, diabetes, cancer, pulmonary diseases, neurodegenerative diseases) o Therapies tried and failed of the following, including dates: ▪ Orthotics ▪ Medications/injections ▪ Physical therapy ▪ Surgical ▪ Other pain management procedures o That more conservative measures have been considered (e.g., osteotomy, hemiarthroplasty) or that the member has failed or is not a candidate for more conservative measure (e.g., osteotomy, hemiarthroplasty) o Date of failed previous hip fracture fixation, if applicable o If the location is being requested as an inpatient stay, provide medical notes to support at least one of the following: ▪ Surgery is bilateral ▪ Member has significant co-morbidities; include
32 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Hip Resurfacing Oct. 1, 2020 the list of comorbidities and Replacement and current treatment Surgery ▪ Member does not have (Arthroplasty) (for appropriate resources to Tennessee Only) support post-operative (continued) care after an outpatient procedure; include the barriers to care as an outpatient o For revision surgery, include documentation of the complication and complete (staged) surgical plan Intrauterine Fetal Oct. 1, 2020 Coverage Rationale Intrauterine fetal surgery (IUFS) is proven and medically necessary Surgery (for • Added language to indicate for treating the following conditions: Louisiana Only) intrauterine fetal surgery (IUFS) • Congenital Cystic Adenomatoid Malformation (CCAM) and Extralobar is proven and medically Pulmonary Sequestration (EPS): Fetal lobectomy or thoracoamniotic necessary for treating pleural shunt placement for CCAM and thoracoamniotic shunt placement for EPS effusion with thoracoamniotic • Pleural Effusion: Thoracoamniotic shunt placement shunt placement • Sacrococcygeal Teratoma (SCT): SCT resection Supporting Information • Urinary Tract Obstruction (UTO): Urinary decompression via • Updated Description of Services, vesicoamniotic shunt placement Clinical Evidence, and • Twin-Twin Transfusion Syndrome (TTTS): Fetoscopic laser surgery References sections to reflect • Twin Reversed Arterial Perfusion (TRAP): Ablation or occlusion of the most current information anastomotic vessels (e.g., laser coagulation or radiofrequency ablation) • Myelomeningocele (MMC) repair
Due to insufficient evidence of efficacy, IUFS is unproven and not medically necessary for treating all other conditions, including but not limited to: • Congenital diaphragmatic hernia (CDH) • Congenital heart disease (CHD) Knee Replacement Oct. 1, 2020 Coverage Rationale Knee replacement surgery (arthroplasty) is proven and medically Surgery Documentation Requirements necessary in certain circumstances. (Arthroplasty), (new to policy) For medical necessity clinical coverage criteria, see the following MCG™ Care Total and Partial • Added requirement for medical Guidelines, [24th edition, 2020]: (for Florida Only) notes documenting: • For Total Knee Arthroplasty: Knee Arthroplasty, Total, S-700 (ISC)
33 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Knee Replacement Oct. 1, 2020 o Specific diagnostic image(s) • For Unicompartmental Knee Arthroplasty: Musculoskeletal Surgery or Surgery that shows the abnormality Procedure GRG: SG-MS (ISC GRG) (Arthroplasty), for which surgery is being Total and Partial requested, which may Click here to view the MCG™ Care Guidelines. (for Florida Only) include MRI, CT scan, X-ray, (continued) and/or bone scan; Documentation Requirements consultation with requesting Provide medical notes documenting the following: surgeon may be of benefit to • Specific diagnostic image(s) that shows the abnormality for which select the optimal image(s) surgery is being requested, which may include MRI, CT scan, X-ray, ▪ Note: Diagnostic images and/or bone scan; consultation with requesting surgeon may be of must be labeled with benefit to select the optimal image(s) the: o Note: Diagnostic images must be labeled with the: - Date taken ▪ Date taken - Applicable case ▪ Applicable case number obtained at time of notification, or the number obtained at member's name and ID number on the image(s) time of notification, o Submission of diagnostic image(s) is required via the external portal or the member's at www.uhcprovider.com/paan or via email at [email protected] (for name and ID Hawaii) or [email protected] (for all other states); faxes will number on the not be accepted image(s) • Diagnostic image(s) report(s) ▪ Submission of diagnostic • Condition requiring procedure image(s) is required via • Severity of pain and details of functional disability(ies) interfering with the external portal at activities of daily living (preparing meals, dressing, driving, walking) www.uhcprovider.com/p using a standard scale, such as the Western Ontario and McMaster aan or via email at Universities Arthritis Index (WOMAC) or the Knee injury and [email protected] (for Osteoarthritis Outcome Score (KOOS) Hawaii) or • Physician’s treatment plan including pre-op discussion [email protected] • Pertinent physical examination of the relevant joint (for all other states); • Co-morbid medical condition(s) faxes will not be • Therapies tried and failed of the following, including dates: accepted o Orthotics o Diagnostic image(s) o Medications/injections report(s) o Physical therapy o Condition requiring o Surgical procedure o Other pain management procedures o Severity of pain and details • Date of failed previous surgery to the same joint (proximal tibial or distal of functional disability(ies) femoral osteotomy, if applicable) interfering with activities of • For revision surgery, include documentation of the complication and the
34 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Knee Replacement Oct. 1, 2020 daily living (preparing meals, complete (staged) surgical plan Surgery dressing, driving, walking) • For CPT codes 27446 and 27447, if the location is being requested as an (Arthroplasty), using a standard scale, such inpatient stay, provide medical notes to support at least one of the Total and Partial as the Western Ontario and following: (for Florida Only) McMaster Universities o Surgery is bilateral (continued) Arthritis Index (WOMAC) or o Member has significant co-morbidities; include the list of the Knee injury and comorbidities and current treatment Osteoarthritis Outcome o Member does not have appropriate resources to support post- Score (KOOS) operative care after an outpatient procedure; include the barriers to o Physician’s treatment plan care as an outpatient including pre-op discussion o Pertinent physical examination of the relevant joint o Co-morbid medical condition(s) o Therapies tried and failed of the following, including dates: ▪ Orthotics ▪ Medications/injections ▪ Physical therapy ▪ Surgical ▪ Other pain management procedures o Date of failed previous surgery to the same joint (proximal tibial or distal femoral osteotomy, if applicable) o For revision surgery, include documentation of the complication and the complete (staged) surgical plan o For CPT codes 27446 and 27447, if the location is being requested as an
35 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Knee Replacement Oct. 1, 2020 inpatient stay, provide Surgery medical notes to support at (Arthroplasty), least one of the following: Total and Partial ▪ Surgery is bilateral (for Florida Only) ▪ Member has significant (continued) co-morbidities; include the list of comorbidities and current treatment ▪ Member does not have appropriate resources to support post-operative care after an outpatient procedure; include the barriers to care as an outpatient Knee Replacement Oct. 1, 2020 Coverage Rationale Knee replacement surgery (arthroplasty) is proven and medically Surgery Documentation Requirements necessary in certain circumstances. (Arthroplasty), (new to policy) For medical necessity clinical coverage criteria, see the following MCG™ Care Total and Partial • Added requirement for medical Guidelines, [24th edition, 2020]: (for Tennessee notes documenting: • For Total Knee Arthroplasty: Knee Arthroplasty, Total, S-700 (ISC) Only) o Specific diagnostic image(s) • For Unicompartmental Knee Arthroplasty: Musculoskeletal Surgery or that shows the abnormality Procedure GRG: SG-MS (ISC GRG) for which surgery is being requested, which may Click here to view the MCG™ Care Guidelines. include MRI, CT scan, X-ray, and/or bone scan; Documentation Requirements consultation with requesting Provide medical notes documenting the following: surgeon may be of benefit to • Specific diagnostic image(s) that shows the abnormality for which select the optimal image(s) surgery is being requested, which may include MRI, CT scan, X-ray, ▪ Note: Diagnostic images and/or bone scan; consultation with requesting surgeon may be of must be labeled with benefit to select the optimal image(s) the: o Note: Diagnostic images must be labeled with the: - Date taken ▪ Date taken - Applicable case ▪ Applicable case number obtained at time of notification, or the number obtained at member's name and ID number on the image(s) time of notification, o Submission of diagnostic image(s) is required via the external portal or the member's at www.uhcprovider.com/paan or via email at [email protected] (for name and ID
36 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Knee Replacement Oct. 1, 2020 number on the Hawaii) or [email protected] (for all other states); faxes will Surgery image(s) not be accepted (Arthroplasty), ▪ Submission of diagnostic • Diagnostic image(s) report(s) Total and Partial image(s) is required via • Condition requiring procedure (for Tennessee the external portal at • Severity of pain and details of functional disability(ies) interfering with Only) www.uhcprovider.com/p activities of daily living (preparing meals, dressing, driving, walking) (continued) aan or via email at using a standard scale, such as the Western Ontario and McMaster [email protected] (for Universities Arthritis Index (WOMAC) or the Knee injury and Hawaii) or Osteoarthritis Outcome Score (KOOS) [email protected] • Physician’s treatment plan including pre-op discussion (for all other states); • Pertinent physical examination of the relevant joint faxes will not be • Co-morbid medical condition(s) accepted • Therapies tried and failed of the following, including dates: o Diagnostic image(s) o Orthotics report(s) o Medications/injections o Condition requiring o Physical therapy procedure o Surgical o Severity of pain and details o Other pain management procedures of functional disability(ies) • Date of failed previous surgery to the same joint (proximal tibial or distal interfering with activities of femoral osteotomy, if applicable) daily living (preparing meals, • For revision surgery, include documentation of the complication and the dressing, driving, walking) complete (staged) surgical plan using a standard scale, such • For CPT codes 27446 and 27447, if the location is being requested as an as the Western Ontario and inpatient stay, provide medical notes to support at least one of the McMaster Universities following: Arthritis Index (WOMAC) or o Surgery is bilateral the Knee injury and o Member has significant co-morbidities; include the list of Osteoarthritis Outcome comorbidities and current treatment Score (KOOS) o Member does not have appropriate resources to support post- o Physician’s treatment plan operative care after an outpatient procedure; include the barriers to including pre-op discussion care as an outpatient o Pertinent physical examination of the relevant joint o Co-morbid medical condition(s) o Therapies tried and failed of the following, including
37 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Knee Replacement Oct. 1, 2020 dates: Surgery ▪ Orthotics (Arthroplasty), ▪ Medications/injections Total and Partial ▪ Physical therapy (for Tennessee ▪ Surgical Only) ▪ Other pain management (continued) procedures o Date of failed previous surgery to the same joint (proximal tibial or distal femoral osteotomy, if applicable) o For revision surgery, include documentation of the complication and the complete (staged) surgical plan o For CPT codes 27446 and 27447, if the location is being requested as an inpatient stay, provide medical notes to support at least one of the following: ▪ Surgery is bilateral ▪ Member has significant co-morbidities; include the list of comorbidities and current treatment ▪ Member does not have appropriate resources to support post-operative care after an outpatient procedure; include the barriers to care as an outpatient Manipulation Under Oct. 1, 2020 Coverage Rationale Manipulation under anesthesia (MUA) is proven and medically Anesthesia (for • Removed language indicating necessary for: Louisiana Only) manipulation under anesthesia • Knee joint for arthrofibrosis following total knee arthroplasty, knee
38 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Manipulation Under Oct. 1, 2020 (MUA) is proven and medically surgery, or fracture Anesthesia (for necessary for: • Shoulder joint for adhesive capsulitis (frozen shoulder) Louisiana Only) o Elbow joint for arthrofibrosis (continued) following elbow surgery or MUA is unproven and not medically necessary for all other conditions fracture (whether for single or serial manipulations) including but not limited o Pelvis for acute traumatic to the following, due to insufficient evidence of efficacy: fracture or dislocation • Ankle • Revised list of conditions for • Finger which MUA is unproven and not • Hip joint or adhesive capsulitis of the hip medically necessary; replaced • Knee joint - any condition other than for arthrofibrosis following total “pelvis for diastasis or knee arthroplasty, knee surgery, or fracture subluxation” with “pelvis” • Pelvis • Added language to indicate this • Shoulder - any condition other than adhesive capsulitis (frozen shoulder) policy does not apply to MUA for • Spine elbow joint for arthrofibrosis • Temporomandibular joint (TMJ) following elbow surgery or • Toe fracture • Wrist Definitions • Added definition of This policy does not apply to the following: “Arthrofibrosis” • Manipulation of the finger on the day following the injection of ® Applicable Codes collagenase clostridium histolyticum (Xiaflex ) to treat Dupuytren’s • Removed CPT code 24300 contracture • Removed ICD-10 diagnosis • Closed reduction of a fracture or joint dislocation unless specified codes M24.621, M24.622, and • Elbow joint for arthrofibrosis following elbow surgery or fracture M24.629 Supporting Information • Updated Description of Services, Clinical Evidence, CMS, and References sections to reflect the most current information Minimally Invasive Nov. 1, 2020 Title Change The Per Oral Endoscopic Myotomy (POEM) procedure is proven and Procedures for • Previously titled Minimally medically necessary for Achalasia OR Diffuse Esophageal Spasm. Gastroesophageal Invasive Procedures for Reflux Disease Gastroesophageal Reflux Disease The following are unproven and not medically necessary for treating (GERD) and (GERD) gastroesophageal reflux disease (GERD) due to insufficient evidence Achalasia Application of efficacy: • Added language to indicate this • Endoscopic therapies
39 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Minimally Invasive Nov. 1, 2020 policy does not apply to the • Injection or implantation techniques Procedures for states of Nebraska and New • LINX Reflux Management System Gastroesophageal Jersey; refer to the state-specific Reflux Disease policy version Endoluminal therapy with GERDx™ is investigational, unproven, and (GERD) and Coverage Rationale not medically necessary for treating GERD as it has not received U.S. Achalasia • Added language to indicate the Food and Drug Administration (FDA) approval. (continued) Per Oral Endoscopic Myotomy (POEM) procedure is proven and See the Medical Policy titled Bariatric Surgery for information regarding medically necessary for endoscopic therapies for the treatment of obesity. achalasia or diffuse esophageal spasm Definitions • Added definition of: o Achalasia o Diffuse Esophageal Spasm o Gastroesophageal Reflux Disease Supporting Information • Updated Description of Services, Clinical Evidence, FDA, CMS, and References sections to reflect the most current information Omnibus Codes Oct. 1, 2020 Coverage Rationale Refer to the policy for complete details. (for Florida Only) Autologous adipose-derived regenerative cell therapy for scleroderma of the hands (CPT code 0489T and 0490T) (removed from policy) • Relocated coverage guidelines; refer to the Medical Policy titled Autologous Cellular Therapy for Certain Indications (for Florida Only) Biomarker panel based algorithmic analysis test (CPT code 0163U) (new to policy) • Added language to indicate the
40 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Omnibus Codes Oct. 1, 2020 use of a biomarker panel based (for Florida Only) algorithmic analysis test (e.g., (continued) BeScreened using three tumor proteins teratocarcinoma derived growth factor-1 [TDGF-1, Cripto- 1], carcinoembryonic antigen [CEA], extracellular matrix protein [ECM]) to screen for colorectal cancer or advanced adenomas is unproven and not medically necessary due to insufficient evidence of safety and/or efficacy High dose rate electronic brachytherapy (CPT codes 0394T and 0395T) • Removed language indicating high dose rate electronic brachytherapy may be covered for treating certain facial nonmelanoma skin cancers (i.e., basal cell or squamous cell carcinomas) when location can impact treatment outcomes; requests for these exceptions will be evaluated on a case-by- case basis Implantable cardiac devices for percutaneous closure (occlusion) of the left atrial appendage (LAA) (CPT codes 33340 and 33999) • Updated list of applicable CPT codes; added 33999 • Revised language to indicate: o Implantable cardiac devices for percutaneous closure (occlusion) of the left atrial
41 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Omnibus Codes Oct. 1, 2020 appendage (LAA) are proven (for Florida Only) and medically necessary to (continued) reduce the risk of stroke when using a U.S. Food and Drug Administration (FDA) approved device, and all of the following criteria are met: ▪ Device is used according to FDA labeled indications, contraindications, warnings and precautions ▪ Diagnosis of nonvalvular atrial fibrillation ▪ Moderate to high risk of embolic stroke (CHA2DS2-VASc score ≥2 in men or ≥3 in women) ▪ Documented medical contraindication to long- term anticoagulation o Surgical closure (occlusion) of the LAA using AtriClip, whether performed during open-heart surgery or as a stand-alone thoracoscopic procedure, is unproven due to insufficient evidence of safety and/or efficacy Insertion of a temporary intraurethral valve-pump (CPT codes 0596T and 0597T) (new to policy) • Added language to indicate the insertion of a temporary
42 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Omnibus Codes Oct. 1, 2020 intraurethral valve-pump is (for Florida Only) unproven and not medically (continued) necessary due to insufficient evidence of safety and/or efficacy Intramuscular autologous bone marrow cell therapy (CPT codes 0263T, 0264T, and 0265T) (removed from policy) • Relocated coverage guidelines; refer to the Medical Policy titled Autologous Cellular Therapy for Certain Indications (for Florida Only) Microscopic examination of hair to determine telogen and anagen counts or structural hair shaft abnormality (CPT code 96902) (removed from policy) • Removed coverage guidelines; CPT code 96902 no longer requires clinical review
Noncontact real-time
fluorescence wound imaging for
bacterial presence (CPT codes
0598T and 0599T) (new to policy)
• Added language to indicate noncontact real-time fluorescence wound imaging for
bacterial presence is unproven
and not medically necessary due
to insufficient evidence of safety
and/or efficacy
Proteonomic biomarker based
algorithmic analysis test
(PreTrm) (CPT code 81599) (new
to policy)
43 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Omnibus Codes Oct. 1, 2020 • Added language to indicate the (for Florida Only) use of a proteonomic biomarker (continued) based algorithmic analysis test (PreTrm) for screening asymptomatic individuals to predict the risk of preterm labor is unproven and not medically necessary due to insufficient evidence of safety and/or efficacy Real time spectral analysis of prostate tissue by fluorescence spectroscopy (CPT code 0443T) (removed from policy) • Removed coverage guidelines; CPT code 0443T no longer requires clinical review Refined autologous adipose cell transfer (CPT code 27599) (removed from policy) • Relocated coverage guidelines; refer to the Medical Policy titled Autologous Cellular Therapy for Certain Indications (for Florida Only)
Right ventricular leadless pacemakers (CPT codes 33274 and 33275)
• Replaced language indicating
“leadless pacemakers are
unproven and not medically
necessary for treating cardiac
arrhythmias” with “right ventricular leadless pacemakers are unproven and not medically necessary for treating cardiac
arrhythmias”
44 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Omnibus Codes Oct. 1, 2020 Three dimensional (3D) printed (for Florida Only) anatomic models (CPT codes (continued) 0559T, 0560T, 0561T, and 0562T) • Revised list of unproven and not medically necessary indications; added “manufacturing of customized devices” Wireless cardiac stimulation for left ventricular pacing (CPT codes 0515T, 0516T, 0517T, 0518T, and 0519T) (new to policy) • Added language to indicate wireless cardiac stimulation for left ventricular pacing is unproven and not medically necessary for treating cardiac arrhythmias due to insufficient evidence of safety and/or efficacy Supporting Information • Updated Clinical Evidence and References sections to reflect the most current information Shoulder Oct. 1, 2020 Coverage Rationale Shoulder replacement surgery is proven and medically necessary in Replacement Documentation Requirements certain circumstances. Surgery (new to policy) For medical necessity clinical coverage criteria, see the following MCG™ Care (Arthroplasty) (for • Added requirement for medical Guidelines, [24th edition, 2020]: Florida Only) notes documenting: • Shoulder Arthroplasty, S-634 (ISC) o Pertinent physical • Shoulder Hemiarthroplasty, S-633 (ISC) examination of the relevant joint Click here to view the MCG™ Care Guidelines. o Severity of pain as documented on a validated Documentation Requirements pain scale Provide medical notes documenting the following: o Functional disability(ies) as • Pertinent physical examination of the relevant joint documented on a validated • Severity of pain as documented on a validated pain scale
45 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Shoulder Oct. 1, 2020 functional disability scale or • Functional disability(ies) as documented on a validated functional Replacement described as interfering with disability scale or described as interfering with activities of daily living Surgery activities of daily living (preparing meals, dressing, driving, walking) (Arthroplasty) (for (preparing meals, dressing, • Specific diagnostic image(s) that documents the severity of joint disease Florida Only) driving, walking) using a validated scale (e.g., Walch classification of primary (continued) o Specific diagnostic image(s) glenohumeral osteoarthritis) and shows the abnormality for which that documents the severity surgery is being requested, which may include MRI, CT scan, X-ray, of joint disease using a and/or bone scan; consultation with requesting surgeon may be of validated scale (e.g., Walch benefit to select the optimal image(s) classification of primary o Note: Diagnostic images: glenohumeral osteoarthritis) ▪ May include MRI, CT scan, X-ray, and/or bone scan, and and shows the abnormality ▪ Must be labeled with the: for which surgery is being - Date taken requested, which may - Applicable case number obtained at time of notification, or include MRI, CT scan, X-ray, the member's name and ID number on the image(s) and/or bone scan; o Submission of diagnostic imaging is required via the external portal consultation with requesting at www.uhcprovider.com/paan or via email at [email protected] (for surgeon may be of benefit to Hawaii) or [email protected] (for all other states); faxes will select the optimal image(s) not be accepted ▪ Note: Diagnostic • Advanced joint disease using a validated scale (e.g., Walch classification images: of primary glenohumeral osteoarthritis) - May include MRI, CT • Diagnostic image(s) report(s) scan, X-ray, and/or • Condition requiring procedure bone scan, and • Physician’s treatment plan including pre-op discussion - Must be labeled with • Co-morbid medical condition(s) the: • Therapies tried (including dates) and failed as documented by a lack of • Date taken clinically significant improvement between at least two measurements • Applicable case concurrent to the therapy, on validated pain or functional disability number obtained scale(s) or quantifiable symptoms; these therapies could include: at time of o Nonoperative Therapy (i.e., orthotics, medications/injections, notification, or the physical therapy, other pain management procedures, etc.) member's name o Surgery and ID number on the image(s) ▪ Submission of diagnostic imaging is required via the external portal at www.uhcprovider.com/p
46 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Shoulder Oct. 1, 2020 aan or via email at Replacement [email protected] (for Surgery Hawaii) or (Arthroplasty) (for [email protected] Florida Only) (for all other states); (continued) faxes will not be accepted o Advanced joint disease using a validated scale (e.g., Walch classification of primary glenohumeral osteoarthritis) o Diagnostic image(s) report(s) o Condition requiring procedure o Physician’s treatment plan including pre-op discussion o Co-morbid medical condition(s) o Therapies tried (including dates) and failed as documented by a lack of clinically significant improvement between at least two measurements concurrent to the therapy, on validated pain or functional disability scale(s) or quantifiable symptoms; these therapies could include: ▪ Nonoperative Therapy (i.e., orthotics, medications/injections, physical therapy, other pain management procedures, etc.)
47 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Shoulder Oct. 1, 2020 ▪ Surgery Replacement Definitions Surgery • Added definition of (Arthroplasty) (for “Nonoperative Therapy” Florida Only) Supporting Information (continued) • Added References section to reflect the most current information Shoulder Oct. 1, 2020 Coverage Rationale Shoulder replacement surgery is proven and medically necessary in Replacement Documentation Requirements certain circumstances. Surgery (new to policy) For medical necessity clinical coverage criteria, see the following MCG™ Care (Arthroplasty) (for • Added requirement for medical Guidelines, [24th edition, 2020]: Tennessee Only) notes documenting: • Shoulder Arthroplasty, S-634 (ISC) o Pertinent physical • Shoulder Hemiarthroplasty, S-633 (ISC) examination of the relevant joint Click here to view the MCG™ Care Guidelines. o Severity of pain as documented on a validated Documentation Requirements pain scale Provide medical notes documenting the following: o Functional disability(ies) as • Pertinent physical examination of the relevant joint documented on a validated • Severity of pain as documented on a validated pain scale functional disability scale or • Functional disability(ies) as documented on a validated functional described as interfering with disability scale or described as interfering with activities of daily living activities of daily living (preparing meals, dressing, driving, walking) (preparing meals, dressing, • Specific diagnostic image(s) that documents the severity of joint disease driving, walking) using a validated scale (e.g., Walch classification of primary o Specific diagnostic image(s) glenohumeral osteoarthritis) and shows the abnormality for which that documents the severity surgery is being requested, which may include MRI, CT scan, X-ray, of joint disease using a and/or bone scan; consultation with requesting surgeon may be of validated scale (e.g., Walch benefit to select the optimal image(s) classification of primary o Note: Diagnostic images: glenohumeral osteoarthritis) ▪ May include MRI, CT scan, X-ray, and/or bone scan, and and shows the abnormality ▪ Must be labeled with the: for which surgery is being - Date taken requested, which may - Applicable case number obtained at time of notification, or include MRI, CT scan, X-ray, the member's name and ID number on the image(s) and/or bone scan; o Submission of diagnostic imaging is required via the external portal
48 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Shoulder Oct. 1, 2020 consultation with requesting at www.uhcprovider.com/paan or via email at [email protected] (for Replacement surgeon may be of benefit to Hawaii) or [email protected] (for all other states); faxes will Surgery select the optimal image(s) not be accepted (Arthroplasty) (for ▪ Note: Diagnostic • Advanced joint disease using a validated scale (e.g., Walch classification Tennessee Only) images: of primary glenohumeral osteoarthritis) (continued) - May include MRI, CT • Diagnostic image(s) report(s) scan, X-ray, and/or • Condition requiring procedure bone scan, and • Physician’s treatment plan including pre-op discussion - Must be labeled with • Co-morbid medical condition(s) the: • Therapies tried (including dates) and failed as documented by a lack of • Date taken clinically significant improvement between at least two measurements • Applicable case concurrent to the therapy, on validated pain or functional disability number obtained scale(s) or quantifiable symptoms; these therapies could include: at time of o Nonoperative Therapy (i.e., orthotics, medications/injections, notification, or the physical therapy, other pain management procedures, etc.) member's name o Surgery and ID number on the image(s) ▪ Submission of diagnostic imaging is required via the external portal at www.uhcprovider.com/p aan or via email at [email protected] (for Hawaii) or [email protected] (for all other states); faxes will not be accepted o Advanced joint disease using a validated scale (e.g., Walch classification of primary glenohumeral osteoarthritis) o Diagnostic image(s) report(s) o Condition requiring procedure
49 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Shoulder Oct. 1, 2020 o Physician’s treatment plan Replacement including pre-op discussion Surgery o Co-morbid medical (Arthroplasty) (for condition(s) Tennessee Only) o Therapies tried (including (continued) dates) and failed as documented by a lack of clinically significant improvement between at least two measurements concurrent to the therapy, on validated pain or functional disability scale(s) or quantifiable symptoms; these therapies could include: ▪ Nonoperative Therapy (i.e., orthotics, medications/injections, physical therapy, other pain management procedures, etc.) ▪ Surgery Definitions • Added definition of “Nonoperative Therapy” Supporting Information • Added References section to reflect the most current information Spinal Nov. 1, 2020 Related Policies Spinal and paraspinal ultrasonography are proven and medically Ultrasonography • Removed reference link to the necessary in newborns and infants for evaluating and managing Medical Policy titled Collagen suspected spinal disorders including: Crosslinks and Biochemical • Caudal regression syndrome, including sacral agenesis, anal atresia, or Markers of Bone Turnover stenosis Application • Detection of sequelae of injury, such as: • Added language to indicate this o Hematoma following injury such as birth injury
50 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Spinal Nov. 1, 2020 policy does not apply to the o Infection or hemorrhage secondary to prior instrumentation such as Ultrasonography states of Nebraska and New lumbar puncture (continued) Jersey; refer to the state-specific o Post-traumatic leakage of cerebrospinal fluid policy version • Evaluation of suspected defects such as cord tethering, diastematomylia, Coverage Rationale hydromyelia, or syringomyelia • Revised list of • Guidance for lumbar puncture conditions/indications for which • Lumbosacral stigmata known to be associated with spinal dysraphism spinal and paraspinal • Post-operative assessment for cord retethering ultrasonography is proven and • Visualization of blood products within the spinal canal in newborns and medically necessary to include: infants with intracranial hemorrhage o Caudal regression syndrome, including sacral agenesis, Spinal and paraspinal ultrasonography are unproven and not anal atresia, or stenosis medically necessary for the following uses due to insufficient o Detection of sequelae of evidence of efficacy: injury, such as: • To diagnose and manage spinal pain and radiculopathies ▪ Hematoma following • To guide rehabilitation of neuromusculoskeletal disorders and spinal pain injury such as birth injury ▪ Infection or hemorrhage secondary to prior instrumentation such as lumbar puncture ▪ Post-traumatic leakage of cerebrospinal fluid o Evaluation of suspected defects such as cord tethering, diastematomyelia, hydromyelia, or syringomyelia o Guidance for lumbar puncture o Lumbosacral stigmata known to be associated with spinal dysraphism o Post-operative assessment for cord retethering o Visualization of blood products within the spinal
51 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Spinal Nov. 1, 2020 canal in newborns and Ultrasonography infants with intracranial (continued) hemorrhage • Replaced language indicating “spinal and paraspinal ultrasonography (including extremities, pelvis, or soft tissues of the head and neck) are unproven and not medically necessary for the [listed] uses” with “spinal and paraspinal ultrasonography is unproven and not medically necessary for the [listed] uses” Applicable Codes • Removed CPT codes 76536, 76856, 76857, 76881, and 76882 • Added diagnosis codes G95.0, G95.11, G95.89, G96.0, G97.51, G97.61, G97.63, M41.00, M41.02, M41.03, M41.04, M41.05, M41.06, M41.07, M41.08, M41.112, M41.113, M41.114, M41.115, M41.116, M41.117, M41.119, M41.122, M41.123, M41.124, M41.125, M41.126, M41.127, M41.129, M41.20, M41.22, M41.23, M41.24, M41.25, M41.26, M41.27, M41.30, M41.34, M41.35, M41.40, M41.41, M41.42, M41.43, M41.44, M41.45, M41.46, M41.47, M41.50, M41.52, M41.53, M41.54, M41.55, M41.56, M41.57, M41.80, M41.82, M41.83, M41.84, M41.85,
52 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Spinal Nov. 1, 2020 M41.86, M41.87, M41.9, Ultrasonography M51.86, M51.87, P10.0, P10.1, (continued) P10.2, P10.3, P10.8, P10.9, P11.5, P52.0, P52.1, P52.21, P52.22, P52.3, P52.4, P52.5, P52.6, P52.8, P52.9, Q05.0, Q05.1, Q05.2, Q05.3, Q05.4, Q05.5, Q05.6, Q05.7, Q05.8, Q05.9, Q06.0, Q06.1, Q06.2, Q06.3, Q06.4, Q06.8, Q06.9, Q07.00, Q07.01, Q07.02, Q07.03, Q07.8, Q07.9, Q42.2, Q42.3, Q76.49, Q87.2, and Q89.8 Supporting Information • Updated Description of Services, Clinical Evidence, CMS, and References sections to reflect the most current information Standing Systems Oct. 1, 2020 Coverage Rationale Standing Systems and Gait Trainers • Revised coverage criteria for Stationary, mobile and active standing systems are proven and (for Tennessee stationary, mobile, and active medically necessary for treating individuals who are non-ambulatory Only) standing systems for treating when ALL of the following criteria are met: individuals who are non- • There is a goal of prevention of one or more of the following medical ambulatory; added criterion complications: requiring “the individual is under o Decubitus Ulcer: Where there is a need for off-loading of a decubitus the age of 21” ulcer which cannot be accomplished by other means; • Removed language indicating o Osteoporosis: Where improvement or stabilization of bone density powered standing systems are cannot be achieved with other treatment or activities; not medically necessary because o Contracture Development: High potential for progressive contracture they are a convenience feature formation including but not limited to post-operative release of contractures; o Compromised Bowel/Bladder Function: Where there has been demonstration there is incomplete emptying of bladder or constipation refractory to other medical treatment; o Pulmonary Complications: Where there has been demonstration of recurrent infections and poor clearance of pulmonary secretions
53 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Standing Systems Oct. 1, 2020 despite the use of other medical treatment; and/or and Gait Trainers o Hip Dislocation: Where hip subluxation/dislocation is worsening, and (for Tennessee alternate treatments have not been successful; Only) and (continued) • The patient is unable to accomplish the above goals with his/her current medical device/equipment or alternate medical treatment; and • The individual has been evaluated in physical therapy with a trial using the standing device and has shown compliance, tolerance and demonstrated potential for clinical benefit, as determined by the evaluator; and • There is a written plan of care; and • The individual is under the age of 21
Standers attached to a wheelchair or electric lift mechanisms are not medically necessary because they are a convenience feature.
Gait Trainers Gait Trainers are proven and medically necessary for treating non- ambulatory individuals when the following criteria are met: • The individual has the potential for functional or therapeutic ambulation; and • The individual is able to ambulate and uses the gait trainer as a walker where documentation shows other walkers or assistive devices have not been effective
For medical necessity clinical coverage criteria for pediatric gait trainers, see MCG™ Care Guidelines, [24th edition, 2020], Pediatric Gait Trainer MCG A0886.
Click here to view the MCG™ Care Guidelines.
54 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Surgical and Oct. 1, 2020 Coverage Rationale Varicose Vein Ablative and Stripping Procedures Ablative Documentation Requirements The initial and subsequent radiofrequency ablation, endovenous Procedures for (new to policy) laser ablation, Stripping, Ligation and excision of the Great Venous • Added requirement for medical Saphenous Vein (GSV) and Small Saphenous Veins (SSV) are Insufficiency and notes documenting: considered reconstructive, proven and medically necessary when ALL Varicose Veins (for o Evaluation and complaints of the following criteria are present: Tennessee Only) o Pain/other symptoms that • Junctional Reflux: interfere with daily activities o Ablative therapy for the GSV or SSV only if Junctional Reflux is related to vein disease demonstrated in these veins; or o Functional impairment o Ablative therapy for Accessory Veins only if anatomically related specifics (preparing meals, persistent Junctional Reflux is demonstrated after the GSV or SSV ability to walk, how long have been removed or ablated member can stand, getting • Individual must have one of the following Functional or Physical dressed, driving) Impairments: o Specific diagnostic studies o Skin ulceration; or that show the abnormality o Documented episode(s) of frank bleeding of the Varicose Vein due to for which surgery is being erosion of/or trauma to the skin; or requested; consultation with o Documented Superficial Thrombophlebitis or documented Venous requesting surgeon may be Stasis Dermatitis; or of benefit to select the o Moderate to Severe Pain causing Functional or Physical Impairment optimal image(s) • Venous Size: ▪ Note: Diagnostic studies o The GSV must be 5.5 mm or greater when measured at the proximal must be labeled with thigh immediately below the sapheno-femoral junction via Duplex the: Ultrasonography - Date taken o The Small Saphenous Vein or Accessory Veins must measure 5 mm - Applicable case or greater in diameter immediately below the sapheno-popliteal number obtained at junction time of notification, • Duration of reflux, in the standing or reverse Trendelenburg position that or the member's meets the following parameters: name and ID o Greater than or equal to 500 milliseconds (ms) for the GSV, SSV number on the Veins or principle tributaries image(s) o Perforating veins > 350ms ▪ Submission of diagnostic o Some Duplex Ultrasound readings will describe this as moderate to study(ies) is required via severe reflux which will be acceptable the external portal at www.uhcprovider.com/p Refer to the Coding Clarification in the Applicable Codes section of the policy. aan or via email at Adherence to American Medical Association (AMA) coding guidance is [email protected] (for required when requesting coverage of endovenous ablation procedures.
55 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Surgical and Oct. 1, 2020 Hawaii) or Note that only one primary code may be requested for the initial vein Ablative [email protected] treated, and only one add-on code per extremity may be requested for any Procedures for (for all other states); subsequent vein(s) treated. Venous faxes will not be Insufficiency and accepted Ablation of perforator veins is considered reconstructive, proven and Varicose Veins (for o Diagnostic study reports medically necessary when the following criteria are present: Tennessee Only) o Which extremity (right, left • Evidence of perforator Venous Insufficiency measured by recent Duplex (continued) or both) Ultrasonography report (see criteria above); and o Vein(s) that will be treated • Perforator vein size is 3.5 mm or greater; and [i.e., great saphenous vein • Perforating vein lies beneath a healed or active venous stasis ulcer (GSV) and small saphenous vein (SSV), etc.] Endovenous mechanochemical ablation (MOCA) of Varicose Veins is o Vein diameter including the unproven and not medically necessary due to insufficient evidence of specific anatomic location efficacy. where the measurement was taken (i.e., proximal thigh, Ligation Procedures proximal calf, etc.) The following procedure is proven and medically necessary: o Duration of reflux including • Ligation at the saphenofemoral junction, as a stand-alone procedure, the position of member at when used to prevent the propagation of an active clot to the deep the time of measurement venous system in individuals with ascending Superficial Thrombophlebitis and the anatomic location who fail or are intolerant of anticoagulation therapy where the measurement was taken [i.e., standing, The following procedures are unproven and not medically necessary saphenofemoral junction for treating Venous Reflux due to insufficient evidence of efficacy: (SFJ)] • Ligation of the GSV at the saphenofemoral junction, as a stand-alone o Prior conservative treatment procedure and duration • Ligation of the SSV at the saphenopopliteal junction, as a stand-alone o Pulses procedure o Presence or absence of DVT • Ligation at the saphenofemoral junction, as an adjunct to radiofrequency (deep vein thrombosis), ablation or endovenous laser ablation of the main saphenous veins aneurysm, and/or tortuosity o Proposed treatment plan Other Procedures with procedure code The following procedures are unproven and not medically necessary o For inpatient requests, for treating Venous Reflux due to insufficient evidence of efficacy: clinical documentation • Endovascular embolization of Varicose Veins using cyanoacrylate-based supporting the intent to adhesive admit the member to the • Endovenous low-nitrogen foam sclerotherapy of incompetent GSV, lesser inpatient level of care saphenous veins, and accessory saphenous veins
56 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Surgical and Oct. 1, 2020 Documentation Requirements Ablative Provide medical notes documenting the following: Procedures for • Evaluation and complaints Venous • Pain/other symptoms that interfere with daily activities related to vein Insufficiency and disease Varicose Veins (for • Functional impairment specifics (preparing meals, ability to walk, how Tennessee Only) long member can stand, getting dressed, driving) (continued) • Specific diagnostic studies that show the abnormality for which surgery is being requested; consultation with requesting surgeon may be of benefit to select the optimal image(s) o Note: Diagnostic studies must be labeled with the: ▪ Date taken ▪ Applicable case number obtained at time of notification, or the member's name and ID number on the image(s) o Submission of diagnostic study(ies) is required via the external portal at www.uhcprovider.com/paan or via email at [email protected] (for Hawaii) or [email protected] (for all other states); faxes will not be accepted • Diagnostic study reports • Which extremity (right, left or both) • Vein(s) that will be treated [i.e., great saphenous vein (GSV) and small saphenous vein (SSV), etc.] • Vein diameter including the specific anatomic location where the measurement was taken (i.e., proximal thigh, proximal calf, etc.) • Duration of reflux including the position of member at the time of measurement and the anatomic location where the measurement was taken [i.e., standing, saphenofemoral junction (SFJ)] • Prior conservative treatment and duration • Pulses • Presence or absence of DVT (deep vein thrombosis), aneurysm, and/or tortuosity • Proposed treatment plan with procedure code • For inpatient requests, clinical documentation supporting the intent to admit the member to the inpatient level of care Surgical Treatment Oct. 1, 2020 Coverage Rationale Spinal procedures for the treatment of spine pain are proven and for Spine Pain (for Spinal Procedures for the medically necessary in certain circumstances. Louisiana Only) Treatment of Spine Pain For medical necessity clinical coverage criteria, see the following MCG™ Care
57 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Surgical Treatment Oct. 1, 2020 • Replaced reference to “MCG™ Guidelines, [24th edition, 2020]: for Spine Pain (for Care Guidelines, 23rd edition, • Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy, S- Louisiana Only) 2019” with “MCG™ Care 310 (ISC) (continued) Guidelines, [24th edition, 2020]”; • Lumbar Diskectomy, Foraminotomy, or Laminotomy S-810 (ISC) refer to the 24th edition for • Cervical Laminectomy S-340 (ISC) complete details on applicable • Lumbar Laminectomy S-830 (ISC) updates to the MCG™ Care • Cervical Fusion, Anterior S-320 (ISC) Guidelines • Cervical Fusion, Posterior S-330 (ISC) • Added language to clarify: • Lumbar Fusion S-820 (ISC) o Spinal procedures for the treatment of spine pain are Click here to view the MCG™ Care Guidelines. proven and medically necessary in certain The following techniques for lumbar interbody fusion (LIF) are circumstances proven and medically necessary: o For medical necessity clinical • Anterior LIF (ALIF) including lateral approaches [e.g., extreme lateral coverage criteria for the interbody fusion (XLIF®), Direct Lateral Interbody Fusion (DLIF)] spinal procedures listed in • Posterior LIF (PLIF), including Transforaminal Lumbar Interbody Fusion the policy, see the applicable (TLIF) MCG™ Care Guidelines, [24th edition, 2020] The following spinal procedures are unproven and not medically Techniques for Lumbar necessary due to insufficient evidence of efficacy (this includes Interbody Fusion (LIF) procedures that utilize interbody cages, screws, and pedicle screw • Updated language to clarify the fixation devices*): following techniques for lumbar • Laparoscopic Anterior Lumbar Interbody Fusion (LALIF)* interbody fusion (LIF) are • Transforaminal Lumbar Interbody Fusion (TLIF) which utilizes only proven and medically necessary: endoscopy visualization (such as a percutaneous incision with video o Anterior LIF (ALIF) including visualization)* lateral approaches [e.g., • Axial Lumbar Interbody Fusion (AxiaLIF®)* extreme lateral interbody • Interlaminar Lumbar Instrumented Fusion (ILIF) (e.g., Coflex-F®)* fusion (XLIF®), direct lateral • Spinal decompression and Interspinous Process Decompression systems interbody fusion (DLIF)] for the treatment of Lumbar Spinal Stenosis [e.g. Interspinous Process o Posterior LIF (PLIF), Decompression (IPD), Minimally Invasive Lumbar Decompression including transforaminal (Mild®)] lumbar interbody fusion • Spinal Stabilization systems: (TLIF) o Stabilization systems for the treatment of degenerative Definitions Spondylolisthesis • Added definition of: o Total Facet Joint Arthroplasty, including facetectomy, laminectomy, o Anterior Lumbar Spine foraminotomy, vertebral column fixation
58 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Surgical Treatment Oct. 1, 2020 Surgery o Percutaneous sacral augmentation (Sacroplasty) with or without a for Spine Pain (for o Arthrodesis balloon or bone cement for the treatment of back pain Louisiana Only) o Axial Lumbar Interbody • Stand-alone Facet Fusion without an accompanying decompressive (continued) Fusion (ALIF) procedure: o Conservative Therapy o This includes procedures performed with or without bone grafting o Direct Lateral Interbody and/or the use of posterior intrafacet implants such as fixation Fusion (DLIF) systems, facet screw systems or anti-migration dowels o Disabling Symptoms o Dynamic Stabilization o Facet Arthroplasty o Facet Fusion o Facet Syndrome o Image-Guided Minimally Invasive Lumbar Decompression (Mild®) o Interlaminar Lumbar Instrumented Fusion (ILIF) o Interlaminar Stabilization Device o Interspinous Process Decompression (IPD) o Laparoscopic Anterior Lumbar Interbody Fusion (LALIF) o Lumbar Spinal Stenosis (LSS) o Neurogenic Claudication (also known as pseudoclaudication) o Percutaneous or Endoscopic Lumbar Fusion o Posterior Lumbar Spine Surgery o Progressive o Radicular Pain o Sacroplasty o Spinal Fusion o Spinal Instability
59 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Surgical Treatment Oct. 1, 2020 o Spinal Stabilization for Spine Pain (for o Spondylolisthesis Louisiana Only) o Spondylolysis (continued) o Total Facet Joint Arthroplasty o Transforaminal Lumbar Interbody Fusion (TLIF) o Unremitting o X-STOP Interspinous Process Decompression (IPD) System Applicable Codes • Revised description for 0202T, 0274T, and 0275T Supporting Information • Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information Surgical Treatment Oct. 1, 2020 Coverage Rationale and Spinal procedures for the treatment of spine pain are proven and for Spine Pain (for References medically necessary in certain circumstances. Tennessee Only) • Replaced references to “MCG™ For medical necessity clinical coverage criteria, see the following MCG™ Care Care Guidelines, 23rd edition, Guidelines, [24th edition, 2020]: 2019” with “MCG™ Care • Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy, S- Guidelines, [24th edition, 2020]”; 310 (ISC) refer to the 24th edition for • Lumbar Diskectomy, Foraminotomy, or Laminotomy S-810 (ISC) complete details on applicable • Cervical Laminectomy S-340 (ISC) updates to the MCG™ Care • Lumbar Laminectomy S-830 (ISC) Guidelines • Cervical Fusion, Anterior S-320 (ISC) Definitions • Cervical Fusion, Posterior S-330 (ISC) • Added definition of: • Lumbar Fusion S-820 (ISC) o Conservative Therapy o Disabling Symptoms Click here to view the MCG™ Care Guidelines. o Neurogenic Claudication (also known as The following techniques for lumbar interbody fusion (LIF) are pseudoclaudication) proven and medically necessary: o Progressive • Anterior LIF (ALIF) including lateral approaches [e.g., extreme lateral
60 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Surgical Treatment Oct. 1, 2020 o Radicular Pain interbody fusion (XLIF®), Direct Lateral Interbody Fusion (DLIF)] for Spine Pain (for o Spinal Instability • Posterior LIF (PLIF), including Transforaminal Lumbar Interbody Fusion Tennessee Only) o Unremitting (TLIF) (continued) • Updated definition of “Spondylolisthesis” The following spinal procedures are unproven and not medically Supporting Information necessary due to insufficient evidence of efficacy (this includes • Updated References section to procedures that utilize interbody cages, screws, and pedicle screw reflect the most current fixation devices*): information • Laparoscopic Anterior Lumbar Interbody Fusion (LALIF)* • Transforaminal Lumbar Interbody Fusion (TLIF) which utilizes only endoscopy visualization (such as a percutaneous incision with video visualization)* • Axial Lumbar Interbody Fusion (AxiaLIF®)* • Interlaminar Lumbar Instrumented Fusion (ILIF) (e.g., Coflex-F®)* • Spinal decompression and Interspinous Process Decompression systems for the treatment of Lumbar Spinal Stenosis [e.g. Interspinous Process Decompression (IPD), Minimally Invasive Lumbar Decompression (Mild®)] • Spinal Stabilization systems: o Stabilization systems for the treatment of degenerative Spondylolisthesis o Total Facet Joint Arthroplasty, including facetectomy, laminectomy, foraminotomy, vertebral column fixation o Percutaneous sacral augmentation (Sacroplasty) with or without a balloon or bone cement for the treatment of back pain • Stand-alone Facet Fusion without an accompanying decompressive procedure: o This includes procedures performed with or without bone grafting and/or the use of posterior intrafacet implants such as fixation systems, facet screw systems or anti-migration dowels Surgical Treatment Nov. 1, 2020 Coverage Rationale Spinal procedures for the treatment of spine pain are proven and for Spine Pain (for Documentation Requirements medically necessary in certain circumstances. Tennessee Only) (new to policy) For medical necessity clinical coverage criteria, see the following MCG™ Care • Added requirement for medical Guidelines, [24th edition, 2020]: notes documenting: • Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy, S- o Condition requiring 310 (ISC) procedure • Lumbar Diskectomy, Foraminotomy, or Laminotomy S-810 (ISC) o History and co-morbid • Cervical Laminectomy S-340 (ISC)
61 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Surgical Treatment Nov. 1, 2020 medical condition(s) • Lumbar Laminectomy S-830 (ISC) for Spine Pain (for o Member’s symptoms, pain, • Cervical Fusion, Anterior S-320 (ISC) Tennessee Only) location, and severity • Cervical Fusion, Posterior S-330 (ISC) (continued) including functional • Lumbar Fusion S-820 (ISC) impairment that is interfering with activities of Click here to view the MCG™ Care Guidelines. daily living (meals, walking, getting dressed, driving) The following techniques for lumbar interbody fusion (LIF) are o Failure of Conservative proven and medically necessary: Therapy through lack of • Anterior LIF (ALIF) including lateral approaches [e.g., extreme lateral clinically significant interbody fusion (XLIF®), Direct Lateral Interbody Fusion (DLIF)] improvement between at • Posterior LIF (PLIF), including Transforaminal Lumbar Interbody Fusion least two measurements, on (TLIF) a validated pain or function scale or quantifiable The following spinal procedures are unproven and not medically symptoms despite necessary due to insufficient evidence of efficacy (this includes concurrent Conservative procedures that utilize interbody cages, screws, and pedicle screw Therapies (see definition), if fixation devices*): applicable • Laparoscopic Anterior Lumbar Interbody Fusion (LALIF)* o Progressive deficits with • Transforaminal Lumbar Interbody Fusion (TLIF) which utilizes only clinically significant endoscopy visualization (such as a percutaneous incision with video worsening based on at least visualization)* two measurements over • Axial Lumbar Interbody Fusion (AxiaLIF®)* time, if applicable • Interlaminar Lumbar Instrumented Fusion (ILIF) (e.g., Coflex-F®)* o Disabling Symptoms, if • Spinal decompression and Interspinous Process Decompression systems applicable for the treatment of Lumbar Spinal Stenosis [e.g. Interspinous Process o Specific diagnostic image(s) Decompression (IPD), Minimally Invasive Lumbar Decompression that shows the abnormality (mild®)] for which surgery is being • Spinal Stabilization systems: requested which may include o Stabilization systems for the treatment of degenerative MRI, CT scan, X-ray, and/or Spondylolisthesis bone scan; consultation with o Total Facet Joint Arthroplasty, including facetectomy, laminectomy, requesting surgeon may be foraminotomy, vertebral column fixation needed to select the optimal o Percutaneous sacral augmentation (Sacroplasty) with or without a image(s) balloon or bone cement for the treatment of back pain ▪ Note: Diagnostic images • Stand-alone Facet Fusion without an accompanying decompressive must be labeled with procedure: the: o This includes procedures performed with or without bone grafting
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Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Surgical Treatment Nov. 1, 2020 - Date taken and/or the use of posterior intrafacet implants such as fixation for Spine Pain (for - Applicable case systems, facet screw systems or anti-migration dowels Tennessee Only) number obtained at (continued) time of notification, Documentation Requirements or the member's Provide medical notes documenting the following: name and ID • Condition requiring procedure number on the • History and co-morbid medical condition(s) image(s) • Member’s symptoms, pain, location, and severity including functional ▪ Submission of diagnostic impairment that is interfering with activities of daily living (meals, imaging is required via walking, getting dressed, driving) the external portal at • Failure of Conservative Therapy through lack of clinically significant www.uhcprovider.com/p improvement between at least two measurements, on a validated pain or aan or via email at function scale or quantifiable symptoms despite concurrent Conservative [email protected] (for Therapies (see definition), if applicable Hawaii) or • Progressive deficits with clinically significant worsening based on at least [email protected] two measurements over time, if applicable (for all other states); • Disabling Symptoms, if applicable faxes will not be • Specific diagnostic image(s) that shows the abnormality for which accepted surgery is being requested which may include MRI, CT scan, X-ray, o Diagnostic image(s) and/or bone scan; consultation with requesting surgeon may be needed report(s) to select the optimal image(s) o Physical exam, including o Note: Diagnostic images must be labeled with the: neurologic exam, including ▪ Date taken degree and progression of ▪ Applicable case number obtained at time of notification, or the curvature (for scoliosis), if member's name and ID number on the image(s) applicable o Submission of diagnostic imaging is required via the external portal o Whether the surgery will be at www.uhcprovider.com/paan or via email at [email protected] (for performed with direct Hawaii) or [email protected] (for all other states); faxes will visualization or only with not be accepted endoscopic visualization • Diagnostic image(s) report(s) o Complete report(s) of • Physical exam, including neurologic exam, including degree and diagnostic tests progression of curvature (for scoliosis), if applicable o Describe the surgical • Whether the surgery will be performed with direct visualization or only technique(s) planned [e.g., with endoscopic visualization AxiaLIF®, XLIF, ILIF, OLIF, • Complete report(s) of diagnostic tests LALIF, image-guided • Describe the surgical technique(s) planned [e.g., AxiaLIF®, XLIF, ILIF, minimally invasive lumbar OLIF, LALIF, image-guided minimally invasive lumbar decompression decompression (mild®), (mild®), percutaneous endoscopic discectomy with or without laser, etc.]
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Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Surgical Treatment Nov. 1, 2020 percutaneous endoscopic for Spine Pain (for discectomy with or without Tennessee Only) laser, etc.] (continued) Total Artificial Disc Oct. 1, 2020 Coverage Rationale Cervical artificial total disc replacement with an FDA-approved Replacement for Documentation Requirements prosthetic intervertebral disc is proven and medically necessary for the Spine (for (new to policy) treating one-level or two contiguous levels of cervical Degenerative Tennessee Only) • Added requirement for medical Disc Disease (C3 to C7), in a Skeletally Mature individual with notes documenting: symptomatic radiculopathy and/or myelopathy when the following Cervical and Lumbar Surgery criteria are met: o Condition requiring • Documented individual history of neck and/or upper extremity pain procedure and/or a functional/neurological deficit associated with the cervical level o History and co-morbid to be treated medical condition(s) • Imaging studies (i.e., computerized tomography [CT] scan or magnetic o Member’s symptoms, pain, resonance imaging [MRI]) confirming herniated nucleus pulposus or location, and severity osteophyte formation including functional • Failed at least six weeks of non-operative treatment prior to implantation impairment that is interfering with activities of Cervical artificial disc replacement at one level combined with daily living (eating or cervical spinal fusion surgery at another level (adjacent or non- preparing meals, walking, adjacent) is unproven and not medically necessary due to getting dressed, driving) insufficient evidence of efficacy.
o Specific diagnostic image(s) Lumbar artificial total disc replacement with an FDA-approved that shows the abnormality prosthetic intervertebral disc is proven and medically necessary for for which surgery is being treating single level lumbar Degenerative Disc Disease with requested, which may symptomatic intractable discogenic low back pain in a Skeletally include MRI, CT scan, X-ray, Mature individual when there are no contraindications and ALL of the and/or bone scan; following criteria are met: consultation with requesting • Advanced Degenerative Disc Disease (DDD) in only one vertebral level surgeon may be of benefit to between L3 and S1 confirmed by complex imaging studies (i.e., select the optimal image(s) computerized tomography [CT] scan or magnetic resonance imaging ▪ Note: Diagnostic images [MRI]) that indicate either moderate to severe Degenerative Disease or must be labeled with Modic Changes the: • Symptoms correlate with imaging findings - Date taken • No more than Grade 1 Spondylolisthesis at the involved level or any - Applicable case listhesis at two or more lumbar segments number obtained at • Presence of symptoms for at least six months
64 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Total Artificial Disc Oct. 1, 2020 time of notification, • Failed at least 6 months of conservative treatment immediately prior to Replacement for or the member's implantation of artificial disc; conservative treatment shall include all of the Spine (for name and ID the following, unless contraindicated: physical therapy, anti- Tennessee Only) number on the inflammatory medications, analgesics, muscle relaxants, and epidural (continued) image(s) steroid injections ▪ Submission of diagnostic • Age 18 to 60 years imaging is required via • Favorable psychosocial-behavioral evaluation to be conducted by an the external portal at individual who is professionally recognized as part of a behavioral health www.uhcprovider.com/p discipline to provide screening and identification of risk factors or aan or via email at potential postoperative challenges that may contribute to a poor [email protected] (for postoperative outcome Hawaii) or [email protected] Contraindications to lumbar artificial total disc replacement include but are (for all other states); not limited to the following: faxes will not be • Moderate or severe facet arthropathy or pars defect at the operative accepted level on a preoperative MRI scan, CT scan or plain radiograph o Diagnostic image(s) • Lumbosacral spinal fracture report(s) • Scoliosis of the lumbosacral spine o Physical exam, including • Active systemic infection or infection localized to the site of implantation neurologic exam • Tumor in the peritoneum, retroperitoneum or site of implantation o History and duration of • Osteoporosis or osteopenia as defined by recent (within one year) DEXA previous therapy when scan applicable, including: • Isolated radicular compression syndromes especially due to disc ▪ Physical therapy herniation ▪ Medications/injections • Spinal stenosis or radiculopathy ▪ Previous spinal surgery • Previous lumbar spine surgery where the previous surgery destabilized ▪ Other attempted the spine or where the spine at the level of the previous surgery is an treatments alternate source of pain o Specify the brand-named • Vascular, urological, or other peritoneal or retroperitoneal pathology that tools to be used may preclude safe and adequate anterior spine exposure as required for Lumbar Surgery the surgery o For lumbar surgery, in addition to the above: Lumbar artificial total disc replacement is unproven and not ▪ Psychological face-to- medically in the following situations due to insufficient evidence of face evaluation efficacy: ▪ Instability (listhesis, • More than one spinal level spondylolisthesis and • Prior history of lumbar fusion or when combined with a lumbar fusion at grade) any level
65 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Total Artificial Disc Oct. 1, 2020 ▪ Surgical technique to be • Treating any other indications not listed above Replacement for used and the number of the Spine (for levels involved and their Documentation Requirements Tennessee Only) location Cervical and Lumbar Surgery (continued) Provide medical notes documenting the following: • Condition requiring procedure • History and co-morbid medical condition(s) • Member’s symptoms, pain, location, and severity including functional impairment that is interfering with activities of daily living (eating or preparing meals, walking, getting dressed, driving) • Specific diagnostic image(s) that shows the abnormality for which surgery is being requested, which may include MRI, CT scan, X-ray, and/or bone scan; consultation with requesting surgeon may be of benefit to select the optimal image(s) o Note: Diagnostic images must be labeled with the: ▪ Date taken ▪ Applicable case number obtained at time of notification, or the member's name and ID number on the image(s) o Submission of diagnostic imaging is required via the external portal at www.uhcprovider.com/paan or via email at [email protected] (for Hawaii) or [email protected] (for all other states); faxes will not be accepted • Diagnostic image(s) report(s) • Physical exam, including neurologic exam • History and duration of previous therapy when applicable, including: o Physical therapy o Medications/injections o Previous spinal surgery o Other attempted treatments • Specify the brand-named tools to be used
Lumbar Surgery For lumbar surgery, in addition to the above, provide medical notes documenting the following: • Psychological face-to-face evaluation • Instability (listhesis, spondylolisthesis and grade) • Surgical technique to be used and the number of levels involved and their location
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Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Transcatheter Oct. 1, 2020 Coverage Rationale Aortic Heart Valve • Replaced language indicating Transcatheter aortic heart valve replacement is proven and medically Procedures (for “transcatheter aortic heart valve necessary when performed according to U.S. Food and Drug Tennessee Only) replacement is proven and Administration (FDA) labeled indications, contraindications, medically necessary for treating warnings and precautions, and ALL of the following criteria are met: individuals at intermediate or • Diagnosis of severe calcific native aortic valve stenosis as indicated by higher surgical risk when [the one of the following: listed] criteria are met” with o Mean aortic valve gradient ≥ 40 mmHg; or “transcatheter aortic heart valve o Peak aortic jet velocity ≥ 4.0 m/s; or replacement is proven and o Aortic valve area of ≤ 0.8 cm2 medically necessary when [the • Individual is symptomatic (New York Heart Association [NYHA] class II or listed] criteria are met” greater) and symptoms are due to aortic valve stenosis • Revised coverage criteria for • Individual does not have a bicuspid aortic valve transcatheter aortic heart valve • An interventional cardiologist and an experienced cardiothoracic surgeon replacement: have determined that the procedure is appropriate o Replaced criterion requiring • Individual has engaged in a Shared Decision Making conversation with an “severe calcific native aortic interventional cardiologist and an experienced cardiothoracic surgeon valve stenosis” with • Procedure is performed in a center that meets all of the following “diagnosis of severe calcific criteria: native aortic valve stenosis” o On-site heart valve surgery and interventional cardiology programs; o Added criterion requiring: and ▪ The individual does not o Post-procedure intensive care unit with personnel experienced in have a bicuspid aortic managing patients who have undergone open-heart valve valve procedures; and ▪ An interventional o Volume requirements consistent with the Centers for Medicare and cardiologist and an Medicaid Services (CMS) experienced cardiothoracic surgeon Note: Requests for transcatheter aortic heart valve replacement for low- have determined that flow/low-gradient aortic stenosis will be evaluated on a case-by-case basis. the procedure is appropriate Mitral ▪ The individual has Transcatheter mitral valve repair is proven and medically necessary engaged in a Shared when used according to FDA labeled indications, contraindications, Decision-Making warnings and precautions in individuals with ONE of the following conversation with an clinical indications for intervention: interventional • Primary (degenerative) mitral regurgitation (MR) when all of the cardiologist and an following criteria are met: experienced o Moderate-to-severe or severe MR (grade ≥ 3); and
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Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Transcatheter Oct. 1, 2020 cardiothoracic surgeon o Symptomatic NYHA class III or IV; and Heart Valve ▪ The procedure is o Prohibitive Surgical Risk as defined by one of the following: Procedures (for performed in a center ▪ PROM score of ≥ 8% for patients deemed likely to undergo mitral Tennessee Only) that meets all of the valve replacement; or (continued) following criteria: ▪ PROM score of ≥ 6% for patients deemed likely to undergo mitral - On-site heart valve valve repair; or surgery and ▪ Predicted risk of death or major morbidity at 1 year of over 50%; interventional and cardiology programs o Care directed by a multidisciplinary heart team which includes a - Post-procedure heart failure specialist, interventional cardiologist and cardiothoracic intensive care unit surgeon experienced in the evaluation and treatment of heart failure with personnel and mitral valve disease experienced in • Secondary (functional) MR when all of the following criteria are met: managing patients o Moderate-to-severe or severe MR (grade ≥ 3) with LVEF ≥ 20 and ≤ who have undergone 50; and open-heart valve o Symptomatic NYHA class II –IV (ambulatory); and procedures o Optimal evidence-based management which includes pharmacologic - Volume therapy plus cardiac resynchronization therapy as indicated; and requirements o High Surgical Risk; and consistent with the o Care directed by a multidisciplinary heart team which includes a Centers for Medicare heart failure specialist, interventional cardiologist and cardiothoracic and Medicaid surgeon experienced in the evaluation and treatment of heart failure Services (CMS) and mitral valve disease o Removed criterion requiring the individual requires Pulmonary transcatheter aortic valve Transcatheter pulmonary heart valve replacement is proven and replacement surgery but is medically necessary, when used according to FDA labeled at intermediate or higher indications, contraindications, warnings and precautions, in risk for serious surgical individuals with right ventricular outflow tract (RVOT) dysfunction complications or death from with ONE of the following clinical indications for intervention: open valve replacement • Moderate or greater pulmonary regurgitation; and/or surgery as determined by an • Pulmonary stenosis with a mean RVOT gradient ≥ 35 mmHg interventional cardiologist and an experienced The following transcatheter heart valve devices and/or procedures cardiothoracic surgeon are unproven and not medically necessary due to insufficient Definitions evidence of efficacy: • Added definition of “Shared • Cerebral protection devices (e.g., Sentinel™) Decision-Making (SDM)” • Mitral valve repair, reconstruction or replacement, except where noted
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Medical Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Transcatheter Oct. 1, 2020 • Updated definition of “Surgical above Heart Valve Risk” (previously addressed in • Tricuspid valve repair, reconstruction or replacement Procedures (for the Coverage Rationale section • Valve-in-Valve (ViV) replacement within a failed bioprosthesis Tennessee Only) of the policy) (continued) Supporting Information • Updated Clinical Evidence, FDA, CMS, and References sections to reflect the most current information
Policy Title Effective Date Summary of Changes RETIRED Carrier Testing for Sep. 1, 2020 • Policy retired; genetic testing services are not covered and/or managed for the state of Nebraska Genetic Diseases (for Nebraska Only) Chromosome Sep. 1, 2020 • Policy retired; refer to state or contractual requirements for benefit plan coverage of chromosome microarray Microarray Testing testing services for non-oncology conditions (Non-Oncology Conditions) (for Louisiana Only) Chromosome Sep. 1, 2020 • Policy retired; genetic testing services are not covered and/or managed for the state of Nebraska Microarray Testing (Non-Oncology Conditions) (for Nebraska Only) Fetal Aneuploidy Sep. 1, 2020 • Policy retired; genetic testing services are not covered and/or managed for the state of Nebraska Testing Using Cell- Free Fetal Nucleic Acids in Maternal Blood (for Nebraska Only) Genetic Testing for Sep. 1, 2020 • Policy retired; genetic testing services are not covered and/or managed for the state of Nebraska Cardiac Disease (for Nebraska Only)
69 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Policy Updates
Policy Title Effective Date Summary of Changes RETIRED High Frequency Sep. 1, 2020 • Policy retired; refer to state or contractual requirements for benefit plan coverage of high frequency chest wall Chest Wall compression devices Compression Devices (for Louisiana Only) Molecular Oncology Sep. 1, 2020 • Policy retired; genetic testing services are not covered and/or managed for the state of Nebraska Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions (for Nebraska Only) Pharmacogenetic Sep. 1, 2020 • Policy retired; genetic testing services are not covered and/or managed for the state of Nebraska Testing (for Nebraska Only) Preimplantation Sep. 1, 2020 • Policy retired; genetic testing services are not covered and/or managed for the state of Nebraska Genetic Testing (for Nebraska Only)
70 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Benefit Drug Policy Updates
Policy Title Effective Date Coverage Rationale NEW Givlaari® Oct. 1, 2020 Givlaari is proven and/or medically necessary for the treatment of acute hepatic porphyrias: (Givosiran) (for Pennsylvania Only) Initial Therapy • Diagnosis of an acute hepatic porphyria (AHP) (i.e., acute intermittent porphyria, hereditary coproporphyria, variegate porphyria, ALA dehydratase deficient porphyria); and • One of the following: o Patient has active disease as defined in the clinical trial by having at least 2 documented porphyria attacks within the past 6 months; or o Patient is currently receiving treatment with prophylactic hemin to prevent porphyria attacks; and • Provider attestation that the patient’s baseline (before givosiran is initiated) hemin administration requirements (prophylactic or treatment) and rate and/or number of porphyria attacks has been documented; and • Patient has not had a liver transplant; and • Patient will not receive concomitant prophylactic hemin treatment while on Givlaari; and • Prescribed by, or in consultation with, a hematologist, or a specialist with expertise in the diagnosis and management of AHPs; and • Givlaari dosing is in accordance with the United States Food and Drug Administration approved labeling: up to a maximum of 2.5 mg/kg (body weight) subcutaneously once monthly; and • Initial authorization will be for no more than 6 months
Continuation Therapy • Patient has previously received Givlaari for the treatment of AHP; and • Documentation that the patient has experienced a positive clinical response while on Givlaari by demonstrating both of the following from pre-treatment baseline: o Reduction in hemin administration requirements (if previously required, including prophylactic and/or treatment doses); and o One of the following: ▪ Reduction in the rate and/or number of porphyria attacks; or ▪ Improvement of signs and symptoms of AHPs (e.g., pain, neurological, gastrointestinal, renal, quality of life, etc.); and • Patient has not had a liver transplant; and • Patient will not receive concomitant prophylactic hemin treatment while on Givlaari; and • Prescribed by, or in consultation with, a hematologist, or a specialist with expertise in the diagnosis and management of AHPs; and • Givlaari dosing is in accordance with the United States Food and Drug Administration approved labeling: up to a maximum of 2.5 mg/kg (body weight) subcutaneously once monthly; and • Reauthorization will be for no more than 12 months
71 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Benefit Drug Policy Updates
Policy Title Effective Date Coverage Rationale NEW Scenesse® Oct. 1, 2020 Scenesse has been added to the Review at Launch program. Please reference the Medical Benefit Drug Policy titled (Afamelanotide) Review at Launch for New to Market Medications for additional details.
Scenesse (afamelanotide) is proven and medically necessary for the treatment of erythropoietic protoporphyria (EPP) when all the following criteria are met:
Initial Therapy • Submission of medical records (e.g., chart notes, laboratory values, etc.) to support the diagnosis of erythropoietic protoporphyria (EPP) confirming one of the following: o Both of the following: ▪ Increased total erythrocyte protoporphyrin (usually 300 to 8000 mcg/dL; normal <80 mcg/dL) ▪ Increased percentage of erythrocyte metal-free protoporphyrin rather than zinc protoporphyrin (generally greater than 85% of total porphyrins); or o Molecular/genetic testing confirming one of the following genetic abnormalities: ▪ Ferrochelatase (FECH) gene mutation ▪ Delta-aminolevulinate synthase-2 (ALAS2) gain-of-function gene mutation; and • Patient is 18 years of age or older; and • Patient has a history of phototoxic reactions due to EPP; and • Prescribed by, or in consultation with, a hematologist, or a specialist with expertise in the diagnosis and management of EPP; and • Scenesse is to be administered by a healthcare professional proficient in the subcutaneous implantation procedure; and • The administering healthcare professional has completed requisite procedural training provided by product manufacturer; and • Scenesse dosing is in accordance with the United States Food and Drug Administration approved labeling; and • Initial authorization will be for no more than 6 months
Continuation Therapy • Patient has previously received Scenesse for the treatment of EPP; and • Patient has experienced a positive clinical response while on Scenesse by demonstrating both of the following from pre-treatment baseline: o Reduction in phototoxic reactions o Increased duration of pain-free time in direct sunlight; and • Prescribed by, or in consultation with, a hematologist, or a specialist with expertise in the diagnosis and management of EPP; and
72 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Benefit Drug Policy Updates
Policy Title Effective Date Coverage Rationale NEW Scenesse® Oct. 1, 2020 • Scenesse is to be administered by a healthcare professional proficient in the subcutaneous implantation (Afamelanotide) procedure; and (continued) • The administering healthcare professional has completed requisite procedural training provided by product manufacturer; and • Scenesse dosing is in accordance with the United States Food and Drug Administration approved labeling; and • Reauthorization will be for no more than 12 months Uplizna™ Oct. 1, 2020 Uplizna has been added to the Review at Launch program. Please reference the Medical Benefit Drug Policy titled (Inebilizumab- Review at Launch for New to Market Medications for additional details. Cdon) Uplizna (inebilizumab-cdon) is proven and medically necessary for the treatment of neuromyelitis optica spectrum disorder (NMOSD) when all of the following criteria are met: • Initial therapy: o Submission of medical records (e.g., chart notes, laboratory values, etc.) to support the diagnosis of neuromyelitis optica spectrum disorder (NMOSD) by a neurologist confirming all of the following: ▪ Past medical history of one of the following: - Optic neuritis - Acute myelitis - Area postrema syndrome: episode of otherwise unexplained hiccups or nausea and vomiting - Acute brainstem syndrome - Symptomatic narcolepsy or acute diencephalic clinical syndrome with NMOSD-typical diencephalic MRI lesions - Symptomatic cerebral syndrome with NMOSD-typical brain lesions; and ▪ Positive serologic test for anti-aquaporin-4 immunoglobulin G (AQP4-IgG)/NMO-IgG antibodies; and ▪ Diagnosis of multiple sclerosis or other diagnoses have been ruled out; and o One of the following: ▪ History of failure of rituximab therapy; or ▪ Both of the following: - History of intolerance or contraindication to rituximab; and - Physician attests that, in their clinical opinion, the same intolerance or severe adverse event would not be expected to occur with Uplizna; and o One of the following: ▪ History of one or more relapses that required rescue therapy during the previous 12 months prior to initiating Uplizna ▪ History of two or more relapses that required rescue therapy during the previous 24 months, prior to initiating Uplizna;
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Medical Benefit Drug Policy Updates
Policy Title Effective Date Coverage Rationale NEW Uplizna™ Oct. 1, 2020 and (Inebilizumab- o Uplizna is initiated according to the U.S. FDA labeled dosing for NMOSD; and Cdon) o Prescribed by, or in consultation with, a neurologist; and (continued) o Patient is not receiving Uplizna in combination with any of the following: ▪ Disease modifying therapies for the treatment of multiple sclerosis [e.g., Gilenya (fingolimod), Tecfidera (dimethyl fumarate), Ocrevus (ocrelizumab), etc.] ▪ Complement inhibitors [e.g., Soliris (eculizumab)] ▪ Anti-IL6 therapy [e.g., Actemra (tocilizumab)] ▪ Anti-CD20 therapy [e.g., rituximab]; and o Initial authorization will be for no more than 6 months • Continuation therapy, all of the following: o Documentation of positive clinical response; and o Submission of medical records (e.g., chart notes, laboratory tests) to demonstrate a positive clinical response from baseline as demonstrated by at least both of the following: ▪ Reduction in the number and/or severity of relapses or signs and symptoms of NMOSD ▪ Maintenance, reduction, or discontinuation of dose(s) of any baseline immunosuppressive therapy (IST) prior to starting Uplizna. Note: Add on, dose escalation of IST, or additional rescue therapy from baseline to treat NMOSD or exacerbation of symptoms while on Uplizna therapy will be considered as treatment failure; and o Uplizna is dosed according to the U.S. FDA labeled dosing for NMOSD; and o Prescribed by, or in consultation with, a neurologist; and o Patient is not receiving Uplizna in combination with any of the following: ▪ Disease modifying therapies for the treatment of multiple sclerosis [e.g., Gilenya (fingolimod), Tecfidera (dimethyl fumarate), Ocrevus (ocrelizumab), etc.] ▪ Anti-IL6 therapy [e.g., Actemra (tocilizumab)] ▪ Complement inhibitors [e.g., Soliris (eculizumab)] ▪ Anti-CD20 therapy [e.g., rituximab]; and o Reauthorization will be for no more than 12 months
74 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Benefit Drug Policy Updates
Policy Title Effective Date Summary of Changes UPDATED Botulinum Toxins A Sep. 1, 2020 Template Update and B • Reformatted policy; transferred content to new template Application • Added language to indicate this policy does not apply to the state of Florida; refer to the state's Medicaid clinical policy
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Crysvita® Oct. 1, 2020 Template Update Crysvita (burosumab) is proven and medically necessary for the (Burosumab-Twza) • Reformatted policy; transferred treatment of X-linked hypophosphatemia (XLH) when the following content to new template criteria are met: Coverage Rationale • For initial therapy, all of the following: • Revised coverage criteria for o Diagnosis of XLH, confirmed by one of the following: treatment of X-linked ▪ Genetic testing (e.g., confirmed PHEX gene mutation in patient hypophosphatemia (XLH); or first-degree relative) replaced criterion requiring ▪ Elevated Serum fibroblast growth factor 23 (FGF23) level > 30 “failure, contraindication, or pg/mL; intolerance to therapy with and calcitriol in combination with an o Patient is age 6 months or greater; and oral phosphate agent (e.g., K- o One of the following: Phos®, K-Phos Neutra®)” with ▪ Patient epiphyseal plate has not fused; or “failure, contraindication, or ▪ All of the following: intolerance to vitamin D analog - Patients’ epiphyseal plate has fused; and therapy (e.g., calcitriol, - Patient is experiencing clinical signs and symptoms of the paricalcitol, doxercalciferol) in disease (e.g., limited mobility, musculoskeletal pain, bone combination with an oral fractures); and phosphate agent (e.g., K-Phos®, - Failure, contraindication, or intolerance to vitamin D analog K-Phos Neutra®)” therapy (e.g., calcitriol, paricalcitol, doxercalciferol) in • Added language to indicate combination with an oral phosphate agent (e.g., K-Phos®, K- Crysvita (burosumab) is proven Phos Neutra®); and medically necessary for the and treatment of Fibroblast o Prescribed by, or in consultation with, an endocrinologist or specialist Growth Factor 23 (FGF23)- experienced in the treatment of metabolic bone disorders; and related hypophosphatemia in o Fasting serum phosphorus is below the normal range for age; and tumor-induced osteomalacia o Dosing is in accordance with the United States Food and Drug (TIO) when the following Administration approved labeling; and criteria are met: o Initial authorization will be for no more than 12 months
75 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Benefit Drug Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Crysvita® Oct. 1, 2020 Initial Therapy • For continuation therapy, all of the following: (Burosumab-Twza) o Diagnosis of FGF23-related o Patient has previously received treatment with burosumab; and (continued) hypophosphatemia in TIO o Prescribed by, or in consultation with, an endocrinologist or specialist associated with phosphaturic experienced in the treatment of metabolic bone disorders; and mesenchymal tumors; and o Patient has experienced normalization of serum phosphate while on o Disease cannot be curatively therapy; and resected or localized; and o Patient has experienced a positive clinical response to burosumab o Patient is age 2 years or (e.g., enhanced height velocity, improvement in skeletal deformities, greater; and reduction of fractures, reduction of generalized bone pain); and o Prescribed by, or in o Dosing is in accordance with the United States Food and Drug consultation with, an Administration approved labeling; and oncologist, an o Reauthorization will be for no more than 12 months endocrinologist, or specialist experienced in the treatment Crysvita (burosumab) is proven and medically necessary for the of metabolic bone disorders; treatment of Fibroblast Growth Factor 23 (FGF23)-related and hypophosphatemia in tumor-induced osteomalacia (TIO) when the o History of failure, following criteria are met: contraindication, or • For initial therapy, all of the following: intolerance to vitamin D o Diagnosis of FGF23-related hypophosphatemia in TIO associated with analog therapy (e.g., phosphaturic mesenchymal tumors; and calcitriol, paricalcitol, o Disease cannot be curatively resected or localized; and doxercalciferol) in o Patient is age 2 years or greater; and combination with an oral o Prescribed by, or in consultation with, an oncologist, an phosphate agent (e.g., K- endocrinologist, or specialist experienced in the treatment of Phos®, K-Phos Neutra®); metabolic bone disorders; and and o History of failure, contraindication, or intolerance to vitamin D analog o Fasting serum phosphorus is therapy (e.g., calcitriol, paricalcitol, doxercalciferol) in combination below the normal range for with an oral phosphate agent (e.g., K-Phos®, K-Phos Neutra®); and age; and o Fasting serum phosphorus is below the normal range for age; and o Dosing is in accordance with o Dosing is in accordance with the United States Food and Drug the United States Food and Administration approved labeling; and Drug Administration o Initial authorization will be for no more than 12 months approved labeling; and • For continuation therapy, all of the following: o Initial authorization will be o Patient has previously received treatment with burosumab; and for no more than 12 months o Prescribed by, or in consultation with, an oncologist, an Continuation Therapy endocrinologist, or specialist experienced in the treatment of o Patient has previously metabolic bone disorders; and received treatment with o Patient has experienced an increase of serum phosphate while on
76 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Benefit Drug Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Crysvita® Oct. 1, 2020 burosumab; and therapy; and (Burosumab-Twza) o Prescribed by, or in o Patient has experienced a positive clinical response to burosumab (continued) consultation with, an (e.g., enhanced height velocity, improvement in skeletal deformities, oncologist, an reduction of fractures, reduction of generalized bone pain); and endocrinologist, or specialist o Dosing is in accordance with the United States Food and Drug experienced in the treatment Administration approved labeling; and of metabolic bone disorders; o Reauthorization will be for no more than 12 months and o Patient has experienced an increase of serum phosphate while on therapy; and o Patient has experienced a positive clinical response to burosumab (e.g., enhanced height velocity, improvement in skeletal deformities, reduction of fractures, reduction of generalized bone pain); and o Dosing is in accordance with the United States Food and Drug Administration approved labeling; and o Reauthorization will be for no more than 12 months Applicable Codes • Added diagnosis code M83.8 Supporting Information • Updated Background, Clinical Evidence, FDA, and References sections to reflect the most current information Hereditary Oct. 1, 2020 Template Update This policy refers only to the following drug products: Angioedema (HAE), • Reformatted policy; transferred • C1 Esterase Inhibitor [human]: Treatment and content to new template o Berinert® (for intravenous injection) Prophylaxis Coverage Rationale o Cinryze® (for intravenous injection) • Revised medical necessity • C1 Esterase Inhibitor [recombinant]:
77 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Benefit Drug Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Hereditary Oct. 1, 2020 criteria for initial therapy with o Ruconest® (for intravenous injection) Angioedema (HAE), Berinert, Ruconest, and Kalbitor: • Plasma Kallikrein Inhibitor [human]: Treatment and o Updated criterion pertaining o Kalbitor® (ecallantide, for subcutaneous injection) Prophylaxis to confirmation of diagnosis (continued) of hereditary angioedema Firazyr (icatibant), Haegarda (C1 esterase inhibitor [human]), and Takhzyro (HAE) to reflect/include: (lanadelumab) are self-administered injections and obtained under the ▪ A C1 inhibitor (C1-INH) member’s pharmacy benefit. deficiency or dysfunction (Type I or II HAE) as Hereditary Angioedema documented by one of Berinert, Ruconest, and Kalbitor are proven and medically necessary the following: for the treatment of hereditary angioedema (HAE) when ALL of the - C1 inhibitor (C1- following are met: INH) antigenic level • Initial therapy: below the lower limit o Diagnosis of hereditary angioedema (HAE) as confirmed by one of of normal the following: - C1-INH functional ▪ A C1 inhibitor (C1-INH) deficiency or dysfunction (Type I or II level below the lower HAE) as documented by one of the following: limit of normal; or - C1 inhibitor (C1-INH) antigenic level below the lower limit of ▪ Normal C1 inhibitor normal levels and one of the - C1-INH functional level below the lower limit of normal; following: or - Confirmed presence ▪ Normal C1 inhibitor levels and one of the following: of a FXII, - Confirmed presence of a FXII, angiopoietin-1, or angiopoietin-1, or plasminogen gene mutation plasminogen gene - Recurring angioedema attacks that are refractory to high- mutation dose antihistamines with confirmed family history of - Recurring angioedema; angioedema attacks and that are refractory to o Used for treatment of an acute HAE attack; and high-dose o Not used in combination with other approved treatments for acute antihistamines with HAE attacks (e.g., Berinert, Firazyr, Kalbitor, or Ruconest); and confirmed family o Prescribed by one of the following specialists: history of ▪ Immunologist angioedema ▪ Allergist; o Removed criterion requiring and Berinert, Ruconest, and o For Berinert and Ruconest Requests Only: Physician attestation Kalbitor are prescribed by a that the patient is unable to self-administer or there is no competent rheumatologist caregiver to administer the drug; and
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Medical Benefit Drug Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Hereditary Oct. 1, 2020 o Added criterion requiring o Initial authorization will be for no more than 12 months Angioedema (HAE), initial authorization will be • Continuation therapy, all of the following: Treatment and for no more than 12 months o Documentation of positive clinical response; and Prophylaxis • Added medical necessity criteria o Used for treatment of an acute HAE attack; and (continued) for continuation of therapy o Not used in combination with other approved treatments for acute with Berinert, Ruconest, and HAE attacks (e.g., Berinert, Firazyr, Kalbitor, or Ruconest); and Kalbitor to reflect/include: o Prescribed by one of the following specialists: o Documentation of positive ▪ Immunologist clinical response; and ▪ Allergist; o Used for treatment of an and acute HAE attack; and o For Berinert and Ruconest Requests Only: Physician attestation o Not used in combination with that the patient is unable to self-administer or there is no competent other approved treatments caregiver to administer the drug; and for acute HAE attacks (e.g., o Reauthorization will be for no more than 12 months Berinert, Firazyr, Kalbitor, or Ruconest); and Cinryze is proven and medically necessary for the treatment of o Prescribed by one of the hereditary angioedema (HAE) when ALL of the following are met: following specialists: • Diagnosis of hereditary angioedema (HAE) as confirmed by one of the ▪ Immunologist following: ▪ Allergist o A C1 inhibitor (C1-INH) deficiency or dysfunction (Type I or II HAE) and as documented by one of the following: o For Berinert and Ruconest ▪ C1 inhibitor (C1-INH) antigenic level below the lower limit of Requests Only: Physician normal attestation that the patient ▪ C1-INH functional level below the lower limit of normal; is unable to self-administer or or there is no competent o Normal C1 inhibitor levels and one of the following: caregiver to administer the ▪ Confirmed presence of a FXII, angiopoietin-1, or plasminogen drug; and gene mutation o Reauthorization will be for ▪ Recurring angioedema attacks that are refractory to high-dose no more than 12 months antihistamines with confirmed family history of angioedema; • Revised medical necessity and criteria for the treatment of • Prescribed by one of the following specialists: hereditary angioedema (HAE) o Immunologist with Cinryze: o Allergist; o Updated criterion pertaining and to confirmation of diagnosis • Physician attestation that the patient is unable to self-administer or there of hereditary angioedema is no competent caregiver to administer the drug; and (HAE) to reflect/include: • All of the following:
79 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Benefit Drug Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Hereditary Oct. 1, 2020 ▪ A C1 inhibitor (C1-INH) o For prophylaxis against HAE attacks; and Angioedema (HAE), deficiency or dysfunction o Not used in combination with other products indicated for the Treatment and (Type I or II HAE) as prophylaxis against HAE attacks (e.g., Haegarda, Takhzyro); and Prophylaxis documented by one of o Prescriber attests that patient has experienced attacks of a severity (continued) the following: and/or frequency such that they would clinically benefit from - C1 inhibitor (C1- prophylactic therapy with Cinryze; and INH) antigenic level o One of the following: below the lower limit ▪ History of failure, contraindication, or intolerance to Haegarda; of normal or - C1-INH functional ▪ Patient is currently on Cinryze therapy level below the lower limit of normal; or ▪ Normal C1 inhibitor levels and one of the following: - Confirmed presence of a FXII, angiopoietin-1, or plasminogen gene mutation - Recurring angioedema attacks that are refractory to high-dose antihistamines with confirmed family history of angioedema o Removed criterion requiring: ▪ Cinryze is prescribed by a rheumatologist ▪ Cinryze is used for treatment of an acute HAE attack ▪ Cinryze is not used in combination with other approved treatments for acute HAE attacks (e.g.,
80 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Medical Benefit Drug Policy Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Hereditary Oct. 1, 2020 Berinert, Firazyr, Angioedema (HAE), Kalbitor, or Ruconest) Treatment and ▪ History of failure, Prophylaxis contraindication, or (continued) intolerance to Berinert (C1 esterase inhibitor [human]) and Firazyr (icatibant) ▪ Patient is currently on Cinryze therapy Supporting Information • Updated Clinical Evidence and References sections to reflect the most current information Respiratory Oct. 1, 2020 Template Update This policy provides information about the use of certain specialty pharmacy Interleukins • Reformatted policy; transferred medications administered by either the subcutaneous (SC) or intravenous (Cinqair®, content to new template (IV) route. Fasenra®, & Coverage Rationale Nucala®) • Revised medical necessity *Fasenra and Nucala for self-administration are obtained under the criteria for Nucala for provider pharmacy benefit. administration: o Updated list of applicable This policy refers to the following drug products: documentation • Cinqair® (reslizumab) requirements; added • Fasenra® (benralizumab) “patient is ≤11 years of age” • Nucala® (mepolizumab) Applicable Codes • Updated list of applicable Refer to the policy for complete details. diagnosis codes to reflect annual updates: o Added J82.81, J82.82, J82.83, and J82.89 o Removed J82 Supporting Information • Updated Clinical Evidence and References sections to reflect the most current information
81 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Coverage Determination Guideline (CDG) Updates
Policy Title Effective Date Summary of Changes UPDATED Prosthetic Devices, Sep. 1, 2020 Applicable Codes Specialized, • Updated list of applicable HCPCS codes for Breast Prosthesis to reflect annual code edits; added L8033 Microprocessor or Myoelectric Limbs (for Louisiana Only)
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Blepharoplasty, Oct. 1, 2020 Coverage Rationale Refer to the policy for complete details. Blepharoptosis, • Added notation pertaining to and Brow Ptosis Submission of High-Quality Repair (for Photograph(s) to indicate: Tennessee Only) o All photographs must be full face and labeled with the: ▪ Date taken ▪ Applicable case number obtained at time of notification, or the member’s name and ID number on the photograph(s) o Submission of color photograph(s) can be submitted via the external portal at www.uhcprovider.com/paan or via email at [email protected] (for Hawaii) or [email protected] (for all other states); faxes of color photos will not be accepted Breast Oct. 1, 2020 Coverage Rationale Indications for Coverage Reconstruction • Added language to indicate The following are eligible for coverage as reconstructive and Post Mastectomy removal of a breast implant and medically necessary: (for Louisiana capsulectomy is covered, In accordance with Women’s Health and Cancer Rights Act of 1998, the Only) regardless of the indication for
82 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Coverage Determination Guideline (CDG) Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Breast Oct. 1, 2020 the initial implant placement, following services are covered (with or without a diagnosis of cancer): Reconstruction for: • Reconstruction of the breast on which the Mastectomy was performed Post Mastectomy o Treatment of Anaplastic • Surgery and reconstruction of the other breast to produce a symmetrical (for Louisiana Lymphoma of the breast appearance, including nipple tattooing Only) when there is pathologic • Prosthesis (implanted and/or external) (continued) confirmation of the diagnosis • Treatment of physical complications of Mastectomy, including by cytology or biopsy lymphedema o Individuals with an increased risk of implant-associated Note: The Women’s Health and Cancer Rights Act of 1998 does not provide Anaplastic Lymphoma of the a timeframe by which the member is required to have the reconstruction breast due to use of Allergan performed post Mastectomy. BIOCELL textured breast implants and tissue Removal, replacement, or revision of an implant may be considered expanders reconstructive in certain circumstances: • Revised list of procedures that • When the original implant or reconstructive surgery was considered may be utilized during breast reconstructive surgery under the terms of the member’s benefit plan, reconstruction; added coverage may exist for removal, replacement, and/or reconstruction. “mastopexy or breast reduction • When the original implant or reconstructive surgery was considered when required prior to reconstructive surgery under the terms of the member’s benefit plan, mastectomy to preserve the then removal of a ruptured prosthesis is treating a “complication arising viability of the nipple” from a medical or surgical intervention”. Definitions • Removal of a breast implant and capsulectomy is covered, regardless of • Added definition of “Anaplastic the indication for the initial implant placement, for the following: Lymphoma” o Treatment of Anaplastic Lymphoma of the breast when there is Applicable Codes pathologic confirmation of the diagnosis by cytology or biopsy; or • Updated list of applicable CPT o Individuals with an increased risk of implant-associated Anaplastic codes to reflect annual code Lymphoma of the breast due to use of Allergan BIOCELL textured edits; removed 19304 breast implants and tissue expanders Revision of a reconstructed breast (CPT code 19380) when the original Supporting Information • reconstruction was performed following mastectomy or for another • Updated References section to covered health service (see Applicable Codes section of the policy for a reflect the most current list of codes that meet the criteria for a reconstructed breast). information
The breast reconstruction benefit does not include coverage for any of the following: • Aspirations • Biopsy (open or core) • Excision of cysts
83 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Coverage Determination Guideline (CDG) Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Breast Oct. 1, 2020 • Fibroadenomas or other benign or malignant tumors Reconstruction • Aberrant breast tissue Post Mastectomy • Duct lesions (for Louisiana • Nipple or areolar lesions Only) • Treatment of gynecomastia (continued) Breast Reconstruction The following procedures may be utilized during breast reconstruction: • A woman’s own muscle, fat and skin are repositioned to create a breast mound by one of the following methods: o Transverse Rectus Abdominus Myocutaneous (TRAM) Flap – The muscle, fat and skin from the lower abdomen is used to reconstruct the breast o Deep Inferior Epigastric Perforator (DIEP) or Superior Gluteal Artery Perforator SGAP Flap – The fat and skin but not muscle is used from the lower abdomen or buttocks to reconstruct the breast o Latissimus Dorsi (LD) Flap – The muscle, fat and skin from the back are used to reconstruct the breast – may also need a breast implant o Other methods may also be used to move muscle, fat and skin to reconstruct a breast • Tissue expansion is used to stretch the skin and tissue to provide coverage for a breast implant to create a breast mound. The procedure can be done with or without a dermal matrix including but not limited to Alloderm, Allomax, DermACELL, or FlexHD which are a covered benefit. Note: Reconstruction alone may be done with an implant, but a tissue expander may be needed. o Tissue expansion requires several office visits over 4-6 months to fill the device through an internal valve to expand the skin. • After the tissue expansion is completed, surgical placement of an FDA approved breast implant (either silicone or saline) is performed. The breast implant may be used with a flap or alone following tissue expansion. • After the breast implant is completed, creation of a nipple (by various techniques) and areola (tattooing) may be performed. • Mastopexy or breast reduction when required prior to mastectomy to preserve the viability of the nipple.
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Coverage Determination Guideline (CDG) Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Breast Oct. 1, 2020 Treatments for Complications Post Mastectomy Reconstruction • Lymphedema: Post Mastectomy o Complex decongestive physiotherapy (CDP) is covered for the (for Louisiana complication of lymphedema post Mastectomy Only) o Lymphedema pumps when required are covered (when covered, (continued) these pumps are covered as Durable Medical Equipment) o Compression lymphedema sleeves are covered (when covered, these sleeves are covered as a prosthetic device) o Elastic bandages and wraps associated with covered treatments for the complications of lymphedema • Treatment of a post-operative infection(s) • Removal of a ruptured breast implant (either silicone or saline) is reconstructive for implants done post Mastectomy; placement of a new breast implant will be covered if the original implantation was done post Mastectomy or for a covered reconstructive health service
Note: A gap exception may be granted if there is not an in-network provider able to provide the requested Reconstructive Procedure. Check the federal, state or contractual requirements for benefit coverage.
Coverage Limitations and Exclusions UnitedHealthcare excludes Cosmetic Procedures from coverage including but not limited to the following: • Breast reconstruction has been successfully completed post Mastectomy and the member chooses to enlarge their breasts for cosmetic reasons. • Breast reconstruction or scar revision after breast biopsy or removal of a cyst with or without a biopsy. • Insertion of breast implants or reinsertion of breast implants for the purpose of improving appearance unless covered under a state or federal mandate. • Liposuction other than to achieve breast symmetry during post Mastectomy. • Procedures that correct an anatomical congenital anomaly without improving or restoring physiologic function are considered Cosmetic Procedures. The fact that a covered person may suffer psychological consequences or socially avoidant behavior as a result of an injury, sickness or congenital anomaly does not classify surgery (or other procedures done to relieve such consequences or behavior) as a
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Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Breast Oct. 1, 2020 reconstructive procedure. Reconstruction • Removal or replacement of an implant that is not ruptured and Post Mastectomy unassociated with local breast complications. (for Louisiana • Tissue protruding at the end of a scar (“dog ear”/standing cone), painful Only) scars or donor site scar revisions must meet the definition of a (continued) reconstructive procedure to be considered for coverage. • Revision of a prior reconstructed breast due to normal aging. Breast Reduction Oct. 1, 2020 Coverage Rationale Indications for Coverage Surgery (for Documentation Requirements Most UnitedHealthcare plans have a specific exclusion for breast reduction Tennessee Only) • Revised list of applicable surgery except as required by the Women's Health and Cancer Rights Act of documentation requirements to 1998. See the Coverage Limitations and Exclusions section below. reflect/include medical notes documenting: For plans that include breast reduction surgery benefits, the o History of the medical following are eligible for coverage as reconstructive and medically condition(s) requiring necessary when the following criteria are met: treatment or surgical • Following mastectomy to achieve symmetry (per WHCRA); or intervention and all of the • Prior to mastectomy to preserve the viability of the nipple; or following: • Macromastia is the primary etiology of the member’s Functional ▪ Chief complaint, history Impairment(s): of the complaint, and o The following are examples of Functional Impairments that must be physical exam attributable to Macromastia to be considered (not an all-inclusive ▪ Previous evaluations and list): diagnostic tests results ▪ Severe skin excoriation/intertrigo unresponsive to medical used to rule out management orthopedic, neurologic, ▪ Headache rheumatologic, ▪ Severe restriction of physical activities due to Functional endocrine or metabolic Impairment: causes - Signs and symptoms of nerve compression that are ▪ Member’s bra size, unresponsive to medical management (e.g., ulnar height, weight paresthesias) o Description of physiologic - Acquired kyphosis that is attributed to Macromastia functional impairments and - Chronic breast pain due to weight of the breasts etiology (e.g., back pain, - Upper back, neck, or shoulder pain grooving from bras straps, ▪ Shoulder grooving from bra straps; skin breakdown, etc.) and ▪ With a diagnosis of o The amount of tissue to be removed plots equal to or greater than macromastia, include the 22nd percentile; and high-quality color
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Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Breast Reduction Oct. 1, 2020 image(s) o The proposed procedure is likely to result in significant improvement Surgery (for - Note: All images of the Functional Impairment Tennessee Only) must be labeled with (continued) the: Documentation Requirements • Date taken Provide medical notes documenting the following: • Applicable case • History of the medical condition(s) requiring treatment or surgical number obtained intervention and all of the following: at time of o Chief complaint, history of the complaint, and physical exam notification, or the o Previous evaluations and diagnostic tests results used to rule out member's name orthopedic, neurologic, rheumatologic, endocrine or metabolic causes and ID number on o Member’s bra size, height, weight the image(s) • Description of physiologic functional impairments and etiology (e.g., back - Submission of pain, grooving from bras straps, skin breakdown, etc.) diagnostic imaging is o With a diagnosis of macromastia, include high-quality color required via the image(s) external portal at ▪ Note: All images must be labeled with the: www.uhcprovider.co - Date taken m/paan or via email - Applicable case number obtained at time of notification, or at [email protected] the member's name and ID number on the image(s) (for Hawaii) or ▪ Submission of diagnostic imaging is required via the external [email protected] portal at www.uhcprovider.com/paan or via email at om (for all other [email protected] (for Hawaii) or [email protected] (for all states); faxes will other states); faxes will not be accepted not be accepted • Previous conservative measures, response, and duration o Previous conservative • Amount of breast tissue to be removed per breast measures, response, and • Reduction mammoplasty documentation should include the: duration o Evaluation and management note for the date of service o Amount of breast tissue to o Note for the day the decision to perform surgery was made be removed per breast o Reduction mammoplasty Coverage Limitations and Exclusions documentation should UnitedHealthcare excludes Cosmetic Procedures from coverage including but include the: not limited to the following: ▪ Evaluation and • Breast reduction surgery when done to improve appearance without management note for improving a Functional/Physiologic Impairment the date of service • Liposuction as the sole procedure for breast reduction surgery ▪ Note for the day the • Procedures that correct an anatomical Congenital Anomaly without decision to perform improving or restoring physiologic function are considered Cosmetic surgery was made Procedures. The fact that a Covered Person may suffer psychological
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Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Breast Reduction Oct. 1, 2020 consequences or socially avoidant behavior as a result of an Injury, Surgery (for Sickness or Congenital Anomaly does not classify surgery (or other Tennessee Only) procedures done to relieve such consequences or behavior) as a (continued) reconstructive procedure. • Procedures that do not meet the reconstructive criteria in the Indications for Coverage section above, e.g., psychological or social reasons, breast size asymmetry unless post mastectomy, exercise
Appendix This Schnur chart* may be used to assess whether the amount of tissue (per breast) that will be removed is reasonable for the body habitus, and whether the procedure is cosmetic or reconstructive in nature. • If the amount plots equal to or greater than the 22nd percentile and the member has a Functional Impairment, the procedure is reconstructive • If the amount plots below the 5th percentile, the procedure is cosmetic
To calculate body surface area (BSA), see: • http://www.calculator.net/body-surface-area-calculator.html (use Du Bois formula) • Du Bois formula: o BSA = 0.007184 × W0.425 × H0.725 Du Bois D, Du Bois EF. A formula to estimate the approximate surface area if height and weight be known. Arch Intern Med. 1916; 17(6):863-871.
*Refer to the policy for the Modified Schnur Nomogram Chart. Cosmetic and Oct. 1, 2020 Coverage Rationale Some states require benefit coverage for services that UnitedHealthcare Reconstructive Documentation Requirements considers Cosmetic Procedures, such as repair of external Congenital Procedures (for (new to policy) Anomalies in the absence of a Functional Impairment. Tennessee Only) • Added requirement for medical notes documenting: Indications for Coverage
Muscle Flap Procedure For plans that include benefits for Cosmetic Procedures, the
o History of medical conditions following are eligible for coverage as reconstructive and medically
requiring treatment or necessary when all of the following criteria are met: surgical intervention which • There is documentation that the physical abnormality and/or includes all of the following: physiological abnormality is causing a Functional Impairment that ▪ A well-defined requires correction; and
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Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Cosmetic and Oct. 1, 2020 physical/physiologic • The proposed treatment is of proven efficacy and is deemed likely to Reconstructive abnormality resulting in significantly improve or restore the patient’s physiological function Procedures (for a medical condition that Tennessee Only) requires treatment Microtia (continued) ▪ Recurrent or persistent Microtia repair is reconstructive; although no Functional Impairment functional deficit caused may be documented for Microtia, this has been deemed by the abnormality Reconstructive Surgery. o Clinical studies/tests addressing the Documentation Requirements physical/physiologic Muscle Flap Procedure abnormality confirming its Provide medical notes documenting the following: presence and degree to • History of medical conditions requiring treatment or surgical intervention which it causes impairment which includes all of the following: o Color photos, where o A well-defined physical/physiologic abnormality resulting in a medical applicable, of the physical condition that requires treatment and/or physiological o Recurrent or persistent functional deficit caused by the abnormality abnormality • Clinical studies/tests addressing the physical/physiologic abnormality o Physician plan of care with confirming its presence and degree to which it causes impairment proposed procedures • Color photos, where applicable, of the physical and/or physiological including expected outcome abnormality All Other Cosmetic • Physician plan of care with proposed procedures including expected Procedures outcome o History of medical conditions
requiring treatment or All Other Cosmetic Procedures surgical invention which includes all of the following: Provide medical notes documenting the following: ▪ To prove medical • History of medical conditions requiring treatment or surgical invention necessity, a well-defined which includes all of the following: o physical/physiologic To prove medical necessity, a well-defined physical/physiologic abnormality resulting in abnormality resulting in a medical condition that requires treatment o a medical condition that Recurrent or persistent functional impairment caused by the requires treatment abnormality ▪ Recurrent or persistent • Clinical studies/tests addressing the physical/physiologic abnormality functional impairment confirming its presence and degree to which it causes impairment caused by the • High-quality color photograph(s) o abnormality Note: All photographs must be labeled with the: o Clinical studies/tests ▪ Date taken addressing the ▪ Applicable case number obtained at time of notification, or the
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Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Cosmetic and Oct. 1, 2020 physical/physiologic member’s name and ID number on the photograph(s) Reconstructive abnormality confirming its o Submission of diagnostic photograph(s) is required via the external Procedures (for presence and degree to portal at www.uhcprovider.com/paan or via email at [email protected] Tennessee Only) which it causes impairment (for Hawaii) or [email protected] (for all other states); faxes (continued) o High-quality color will not be accepted photograph(s) • Physician plan of care with proposed procedures and whether this ▪ Note: All photographs request is part of a staged procedure; indicate how the procedure will must be labeled with improve and/or restore function the: - Date taken Coverage Limitations and Exclusions - Applicable case UnitedHealthcare excludes Cosmetic Procedures from coverage including but number obtained at not limited to the following: time of notification, • Procedures that correct an anatomical Congenital Anomaly without or the member’s improving or restoring physiologic function are considered Cosmetic name and ID Procedures. The fact that a Covered Person may suffer psychological number on the consequences or socially avoidant behavior as a result of an Injury, photograph(s) Sickness or Congenital Anomaly does not classify surgery (or other ▪ Submission of diagnostic procedures done to relieve such consequences or behavior) as a photograph(s) is Reconstructive Procedure. required via the external • Procedures that do not meet the reconstructive criteria in the Indications portal at for Coverage section above. www.uhcprovider.com/p • Pharmacological regimens, nutritional procedures or treatments. aan or via email at • Scar or tattoo removal or revision procedures (such as salabrasion, [email protected] (for chemosurgery and other such skin abrasion procedures). Hawaii) or • Skin abrasion procedures performed as a treatment for acne. [email protected] • Liposuction or removal of fat deposits considered undesirable, including (for all other states); fat accumulation under the male breast and nipple. faxes will not be • Treatment for skin wrinkles or any treatment to improve the appearance accepted of the skin. o Physician plan of care with • Treatment for spider veins. proposed procedures and • Hair removal or replacement by any means. whether this request is part of a staged procedure; indicate how the procedure will improve and/or restore function Applicable Codes • Updated list of applicable HCPCS
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Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Cosmetic and Oct. 1, 2020 codes to reflect quarterly edits; Reconstructive added J0591 Procedures (for • Added language to clarify: Tennessee Only) o HCPCS codes L8600, L8607, (continued) Q2026, and Q2028 may be cosmetic; review is required to determine if considered cosmetic or reconstructive o HCPCS code J0591 is considered cosmetic; the code does not improve a functional, physical, or physiological impairment Durable Medical Oct. 1, 2020 Coverage Rationale Refer to the policy for complete details. Equipment, Indications for Coverage Orthotics, Ostomy • Combined and reformatted Supplies, Medical content/language previously Supplies and included in the sections titled Repairs/ Medical Supplies and Ostomy Replacements (for Supplies Louisiana Only) • Added instruction to refer to federal, state or contractual requirements for coverage of urinary catheters • Added coverage guidelines for Safety Enclosure with Beds to indicate: o Safety enclosure with beds (e.g., pediatric enclosed bed, adult bed, safety enclosure) are covered as DME for individuals that have a risk for safety in bed when all of the following criteria are met: ▪ Use of equipment is required due to a
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Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Durable Medical Oct. 1, 2020 diagnosis related to Equipment, cognitive impairment Orthotics, Ostomy (e.g., traumatic brain Supplies, Medical injury, cerebral palsy, Supplies and seizure disorder) or a Repairs/ severe behavioral Replacements (for disorder Louisiana Only) ▪ There is a safety risk (continued) that includes but is not limited to any of the following: - Claustrophobia - High risk of falls due to a clinical condition - Uncontrolled movements - Violent or self- destructive behaviors such as uncontrolled head banging ▪ Less restrictive alternatives methods such as the following have been tried and have not been successful or are contraindicated; - A mattress on the floor - Protective helmet - Side rails - Weighted blankets o The physician documentation must include: ▪ A signed physicians order for the enclosed bed ▪ Behavioral Management
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Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Durable Medical Oct. 1, 2020 Program, if applicable Equipment, ▪ Evaluation for Orthotics, Ostomy contraindications to use Supplies, Medical of the equipment Supplies and ▪ Member assessment for Repairs/ physical, environmental, Replacements (for and behavioral factors Louisiana Only) ▪ Name and model of (continued) protective or enclosure bed with a valid HCPCS code ▪ Physician directed written monitoring plan ▪ The medical, neurologic, or behavioral diagnosis Coverage Limitations and Exclusions • Revised list of services excluded from coverage: o Updated list of examples of accessories to DME items or devices which are primarily for the comfort or convenience of the member and not covered; added “non-medical mobility devices (e.g., commercial stroller); this exclusion does not apply to pediatric wheelchairs” o Replaced “diagnostic or monitoring equipment purchased for home use unless identified for coverage by the federal, state or contractual requirements (e.g., blood pressure monitor,
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Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Durable Medical Oct. 1, 2020 oximeters)” with “diagnostic Equipment, or monitoring equipment Orthotics, Ostomy purchased for home use Supplies, Medical (e.g., blood pressure Supplies and monitor, oximeters) unless Repairs/ the service is identified for Replacements (for coverage by the federal, Louisiana Only) state or contractual (continued) requirements (e.g., oximeter use with a ventilator)” Definitions • Added definition of “Behavioral Management Program” Supporting Information • Updated References section to reflect the most current information Oral and Enteral Oct. 1, 2020 Coverage Rationale Enteral Nutrition administered by tube is proven and/or medically Nutrition (for • Added reference link to the necessary when all of the following criteria are met: Tennessee Only) Coverage Determination • Ordered by a physician; and Guideline titled Durable Medical • The item(s) meets the plan’s medically necessary definition (refer to Equipment, Orthotics, Ostomy state specific documents); and Supplies, Medical Supplies and • Service is not otherwise excluded from coverage Repairs/Replacements (for o Adults (For members 21 years of age and older): Covered when Tennessee Only) for information Enteral Nutrition formula used for tube feedings and phenylalanine- pertaining to enteral pumps and free formula (not foods) used to treat PKU, as required by T.C.A. § supplies 56-7-2505. In addition, oral liquid nutrition may be covered when • Revised coverage guidelines for medically necessary for adults with swallowing or breathing disorders Enteral Nutrition administered who are severely underweight (BMI<15 kg/m2) and physically by tube when the service is not incapable of otherwise consuming a sufficient intake of food to meet otherwise excluded from basic nutritional requirements. coverage for: o Children: Pediatric enteral formulas (B4160) may be appropriate for Adults children ages 0–20 years. o Added language to indicate: o The medical necessity for special nutrient formulas (B4149, B4153– ▪ An adult is defined as a B4155, B4157, B4161 and B4162) must be justified for each member 21 years of age member. Special enteral formula is produced to meet unique nutrient or older needs for specific conditions and requires documentation to establish
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Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Oral and Enteral Oct. 1, 2020 ▪ Enteral Nutrition formula medical necessity. Nutrition (for used for tube feedings o If a pump is requested (B9002), justification as to why gravity Tennessee Only) and phenylalanine-free administration is not satisfactory and the rate of infusion must be (continued) formula (not foods) used included. to treat PKU are covered, as required by Formula for Metabolic Diseases or Inborn Errors of Metabolism T.C.A. §56-7-2505 The American Academy of Pediatric Consensus Statement 2002, reaffirmed ▪ Oral liquid nutrition may 2006: “Metabolic diseases include inborn errors of amino acid metabolism be covered when such as phenylketonuria, maternal phenylketonuria, maple syrup urine medically necessary for disease, homocystinuria, methylmalonicacidemia, propionicacidemia, adults with swallowing or isovalericacidemia, and other disorders of leucine metabolism; glutaric breathing disorders who aciduria type I and tyrosinemia types I and II; and urea cycle disorders.” are severely underweight (BMI<15 “These are all disorders treatable by dietary modifications, which can prevent kg/m2) and physically complications like severe mental retardation and death.” incapable of otherwise consuming a sufficient Examples (not all-inclusive list): intake of food to meet • Glutaric aciduria basic nutritional • Glycogen storage disease requirements • Homocystinuria o Removed language • Maple syrup urine disease indicating enteral formulas • Methylmalonic aciduria consisting of semi-synthetic • Organic acid metabolism disorders intact protein/protein • Phenylketonuria (PKU) isolates (HCPCS code B4150 • Tyrosinemias or B4152) are appropriate • Urea cycle disorders for the majority of adults requiring Enteral Nutrition Oral Nutritional Supplements for Other Medical Conditions Children Specialized oral formula will be covered when: o Replaced language indicating • All of the following criteria are met: “pediatric enteral formulas o A physician prescribes the therapy; and (HCPCS code B4160) may be o The condition is chronic and is expected to last for an undetermined appropriate for children ages or prolonged period of time; and 0-13 years” with “pediatric o Adequate nutrition is not possible by dietary adjustment; and enteral formulas (HCPCS o Nutritional therapy is provided as replacement therapy; and code B4160) may be o The material used is specially formulated as a nutrition replacement appropriate for children ages AND 0-20 years” • The individual has one of the following conditions:
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Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Oral and Enteral Oct. 1, 2020 Supporting Information o Crohn's disease; or Nutrition (for • Updated References section to o Disorders of gastrointestinal motility such as chronic intestinal Tennessee Only) reflect the most current pseudo-obstruction; or (continued) information o Severe malabsorption syndrome; or o Individuals who will become malnourished or suffer from severe disorders such as physical disability, mental retardation or death if the nutritional therapy is not instituted; or o Severe food allergies, those which if left untreated will cause malnourishment, chronic physical disability, mental retardation or death (mild and moderate food allergies or food intolerance can usually be treated with formula that is readily available in food stores and pharmacies, or by careful food selection. Formulas for the treatment of such conditions are not covered); or o GE reflux with failure to thrive; or o In members 21 years of age and older: Weight loss greater than 10% of body weight over a three to six month period
Enteral Pumps and Supplies Enteral pumps and supplies are addressed in the policy titled Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements (for Tennessee Only).
Coverage Limitations and Exclusions (Unless Otherwise Mandated)
• Self-blenderized formulas are not covered.
• Commercial food thickeners (B4100) have no significant nutritional
value, are a convenience item and are not medically necessary. Baby
food, gravy, other grocery products and other food preparation
techniques are preferred alternatives.
• Code B4104 is an enteral formula additive. The enteral formula codes
include all nutrient components, including vitamins, mineral, and fiber.
Therefore, code B4104 will be denied as not separately payable.
• Codes B4102 and B4103 describe electrolyte-containing fluids that are
not covered.
• Nutritional or cosmetic therapy using high-dose or mega quantities of
vitamins, minerals or elements and other nutrition based therapy are
excluded from coverage. Examples include supplements, electrolytes,
and foods of any kind. This includes, but is not limited to: high protein
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Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Oral and Enteral Oct. 1, 2020 foods, low protein foods, and low carbohydrate foods. Nutrition (for • Formula that is not specifically made for inborn errors of metabolism. Tennessee Only) Even when a formula is the sole source of nutrition, formula that is not (continued) specifically made for persons with inborn errors of metabolism is not covered. • Formulas for the treatment of mild and moderate food allergies or food intolerance are not covered (severe food allergies, those which if left untreated will cause malnourishment, chronic physical disability, mental retardation or death, may be medically necessary). • Oral Nutrition for lack of appetite or cognitive conditions is not covered (e.g., lack of appetite secondary to stimulant medications). Orthognathic (Jaw) Oct. 1, 2020 Coverage Rationale The following represents exceptions to the orthognathic (jaw) Surgery (for Documentation Requirements surgery exclusion and may be eligible for coverage as reconstructive Tennessee Only) (new to policy) and medically necessary: • Added requirement for medical • Acute traumatic injury notes documenting: • Cancerous or non-cancerous tumors and cysts o Comprehensive history of • Obstructive sleep apnea the medical condition(s) • Congenital anomalies requiring treatment or surgical intervention, Criteria including all of the Orthognathic (jaw) surgery may be eligible for coverage as following: reconstructive and medically necessary for the conditions cited ▪ A well-defined physical above when the following criteria below are met: and/or physiological • The presence of one or more of the following facial skeletal deformities abnormality (e.g., associated with masticatory malocclusion: congenital abnormality, o Anteroposterior Discrepancies (established norm=2mm): functional or skeletal ▪ Maxillary/Mandibular Incisor Relationship: Overjet of 5mm or impairments) resulting more or a 0 to a negative value in a medical condition ▪ Maxillary/Mandibular Anteroposterior Molar Relationship: that has required or Discrepancy of 4mm or more requires treatment ▪ These values represent two or more standard deviation from ▪ The physical and/or published norm physiological o Vertical Discrepancies: Presence of a vertical facial skeletal deformity abnormality has resulted which is two or more standard deviations from published norms for in a functional deficit accepted skeletal landmarks ▪ The functional deficit is ▪ Open bite: recurrent or persistent in - No vertical overlap of anterior teeth nature - Unilateral or bilateral posterior open bite greater than 2mm
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Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Orthognathic (Jaw) Oct. 1, 2020 o Appropriate clinical ▪ Deep overbite with impingement or irritation of buccal or lingual Surgery (for studies/tests including soft tissues of the opposing arch Tennessee Only) cephalometric tracings and ▪ Supraeruption of a dentoalveolar segment due to lack of (continued) analysis addressing the occlusion physical and/or physiological o Transverse Discrepancies: abnormality that confirm its ▪ Presence of a transverse skeletal discrepancy which is two or presence and the degree to more standard deviations from published norms which it is causing ▪ Total bilateral maxillary palatal cusp to mandibular fossa impairment, with discrepancy of 4mm or greater, or a unilateral discrepancy of appropriate measurements, 3mm or greater, given normal axial inclination of the posterior when applicable teeth o Radiologic film o Asymmetries: Anteroposterior, transverse or lateral asymmetries interpretations including greater than 3mm with concomitant occlusal asymmetry lateral cephalometric AND radiograph, AP radiograph • The individual must also have one or more of the following Functional and panoramic radiograph Impairments: o Clinical photographs of the o Masticatory (chewing) and swallowing dysfunction due to skeletal member’s occlusion malocclusion (e.g., inability to incise/and or chew solid foods, o Treating physician’s plan of choking on incompletely masticated solid foods, damage to soft care including surgical tissue during mastication, malnutrition) treatment objectives, which o Documentation of speech deficits to support existence of speech must include the expected impairment due to skeletal malocclusion outcome for the o Moderate to Severe Obstructive Sleep Apnea (OSA) with improvement of the Oropharyngeal narrowing secondary to maxillomandibular deficiency functional deficit ▪ For medical necessity clinical coverage criteria for OSA, also refer o Diagnostic polysomnography to the following: (sleep study) for obstructive - Maxillomandibular Advancement Surgery (MMA): For sleep apnea surgery medical necessity clinical coverage criteria, see MCG™ Care o History of previous non- Guidelines, [24th edition, 2020], Maxillomandibular surgical and surgical Osteotomy and Advancement, A-0248 (ACG). treatment (e.g., obstructive - Multilevel Procedures Whether Done in a Single sleep apnea) Surgery or Phased Multiple Surgeries: There are a variety of procedure combinations, including mandibular osteotomy and genioglossal advancement with hyoid myotomy (GAHM). For medical necessity clinical coverage criteria, see MCG™ Care Guidelines, [24th edition, 2020], Mandibular Osteotomy, A-0247 (ACG).
Click here to view the MCG™ Care Guidelines.
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Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Orthognathic (Jaw) Oct. 1, 2020 Documentation Requirements Surgery (for Provide medical notes documenting the following: Tennessee Only) • Comprehensive history of the medical condition(s) requiring treatment or (continued) surgical intervention, including all of the following: o A well-defined physical and/or physiological abnormality (e.g., congenital abnormality, functional or skeletal impairments) resulting in a medical condition that has required or requires treatment o The physical and/or physiological abnormality has resulted in a functional deficit o The functional deficit is recurrent or persistent in nature • Appropriate clinical studies/tests including cephalometric tracings and analysis addressing the physical and/or physiological abnormality that confirm its presence and the degree to which it is causing impairment, with appropriate measurements, when applicable • Radiologic film interpretations including lateral cephalometric radiograph, AP radiograph and panoramic radiograph • Clinical photographs of the member’s occlusion • Treating physician’s plan of care including surgical treatment objectives, which must include the expected outcome for the improvement of the functional deficit • Diagnostic polysomnography (sleep study) for obstructive sleep apnea surgery • History of previous non-surgical and surgical treatment (e.g., obstructive sleep apnea)
Coverage Limitations and Exclusions Orthognathic surgery for the following is not covered: • Cosmetic and non-reconstructive Jaw Surgery and jaw alignment procedures • Pre- and post-surgical orthodontic treatment Panniculectomy Oct. 1, 2020 Coverage Rationale Indications for Coverage and Body Documentation Requirements The following are eligible for coverage when the below criteria are Contouring (new to policy) met. Procedures (for • Added requirement for medical Tennessee Only) notes documenting: Panniculectomy when ALL of the following criteria have been met: o Primary complaint, history of • Panniculus hangs at or below symphysis pubis complaint and physical exam • The Panniculus is the primary cause of skin conditions when present,
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Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Panniculectomy Oct. 1, 2020 o Intertriginous rashes or such as cellulitis requiring systemic antibiotics or transdermal skin and Body other skin problems with ulcerations that require medical treatment Contouring documentation of treatment • There is presence of a Functional Impairment (interference with activities Procedures (for and response of daily living) due to the Panniculus Tennessee Only) o Functional limitations due to • The surgery is expected to restore or improve the Functional Impairment (continued) pannus o High-quality color Note: photographs of a full-frontal • After Significant Weight Loss Unrelated to Bariatric Surgery: In addition view of the hanging pannus, to the criteria listed above, there must be documentation that a stable a full-frontal view of pannus weight has been maintained for six months. elevated that allows any skin • After Significant Weight Loss Following Bariatric Surgery: In addition to damage can be evaluated, meeting the criteria listed above, there must be documentation that a and a full-lateral view of the stable weight has been maintained for six months. This often occurs 12- hanging pannus 18 months after surgery. ▪ Note: All photographs must be labeled with The following are not considered reconstructive and are not covered the: services: - Date taken • Abdominoplasty - Applicable case • Lipectomy when performed on any site including (not an all-inclusive number obtained at list): time of notification, o Abdomen or the member’s o Arms name and ID o Buttocks number on the o Legs photographs o Medial thigh ▪ Submission of diagnostic o Neck photographs is required • Panniculectomy (not an all-inclusive list): via the external portal at o When performed to relieve neck or back pain as there is no evidence www.uhcprovider.com/p that reduction of redundant skin and tissue results in less spinal aan or via email at stress or improved posture/alignment [email protected] (for o When performed in conjunction with abdominal or gynecologic Hawaii) or surgery including (not an all-inclusive list): [email protected] ▪ Hernia repair (for all other states); ▪ Obesity surgery faxes will not be ▪ C-section and hysterectomy (unless the member meets the accepted criteria for Panniculectomy as stated above in this document) o Performed post childbirth in order to return to pre-pregnancy shape o Performed for:
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Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Panniculectomy Oct. 1, 2020 ▪ Intertrigo and Body ▪ Superficial inflammatory response Contouring ▪ Any other condition that does not meet the criteria above in this Procedures (for document Tennessee Only) • Repair of Diastasis Recti (continued) • Suction-assisted lipectomy (unless part of an approved procedure). For post-mastectomy, refer to the Coverage Determination Guideline titled Breast Reconstruction Post Mastectomy (for Tennessee Only).
Note: Documentation may be requested as part of the review, including but not limited to photographs and physician office notes.
Documentation Requirements
Provide medical notes documenting the following:
• Primary complaint, history of complaint and physical exam
• Intertriginous rashes or other skin problems with documentation of
treatment and response
• Functional limitations due to pannus
• High-quality color photographs of a full-frontal view of the hanging
pannus, a full-frontal view of pannus elevated that allows any skin
damage can be evaluated, and a full-lateral view of the hanging pannus
o Note: All photographs must be labeled with the:
▪ Date taken
▪ Applicable case number obtained at time of notification, or the
member’s name and ID number on the photographs
o Submission of diagnostic photographs is required via the external
portal at www.uhcprovider.com/paan or via email at [email protected]
(for Hawaii) or [email protected] (for all other states); faxes
will not be accepted
Coverage Limitations and Exclusions
UnitedHealthcare excludes Cosmetic Procedures from coverage including but not limited to the following: • Procedures that correct an anatomical Congenital Anomaly without improving or restoring physiologic function are considered Cosmetic Procedures. The fact that a Covered Person may suffer psychological consequences or socially avoidant behavior as a result of an Injury,
101 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Coverage Determination Guideline (CDG) Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Panniculectomy Oct. 1, 2020 Sickness or Congenital Anomaly does not classify surgery (or other and Body procedures done to relieve such consequences or behavior) as a Contouring Reconstructive Procedure. Procedures (for • Procedures that do not meet the reconstructive criteria in the Indications Tennessee Only) for Coverage section above. (continued) • For liposuction for the treatment of lipedema, refer to the Medical Policy titled Omnibus Codes (for Tennessee Only). Pectus Deformity Oct. 1, 2020 Coverage Rationale Indications for Coverage Repair (for Documentation Requirements Surgical repair of Pectus Excavatum is considered reconstructive and Tennessee Only) (new to policy) medically necessary when the following criteria has been met: • Added requirement for medical • Imaging studies confirm a Haller Index of greater than 3.25; and notes documenting: • The Functional Impairment is defined in physician office notes; and Pectus Excavatum o For restrictive lung capacity, the total lung capacity is documented in o Results of imaging studies the physician office notes as <80% of the predicted value; or (CT scan confirming Haller o There is cardiac compromise as demonstrated by decreased cardiac Index greater than 3.25) output on the echocardiogram; or o Functional o There is objective evidence of exercise intolerance as documented by limitation/impairment cardiopulmonary exercise testing that is below the predicted values o Results of: ▪ Pulmonary function test Surgical repair of Pectus Carinatum may be considered (confirming restrictive reconstructive and medically necessary. lung capacity) the total Requests for coverage of repair of Pectus Carinatum will be reviewed by a lung capacity is UnitedHealthcare Medical Director on a case-by-case basis. documented as <80% of the predicted value; or Documentation Requirements ▪ One of the following: Pectus Excavatum
- An echocardiogram Provide medical notes documenting the following:
(Ejection Fraction) • Results of imaging studies (CT scan confirming Haller Index greater than
confirming by 3.25)
decreased cardiac • Functional limitation/impairment
output • Results of:
- Stress test o Pulmonary function test (confirming restrictive lung capacity) the
demonstrating total lung capacity is documented as <80% of the predicted value;
cardiopulmonary or
function that is o One of the following:
below the predicted ▪ An echocardiogram (Ejection Fraction) confirming by decreased
values cardiac output
102 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Coverage Determination Guideline (CDG) Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Pectus Deformity Oct. 1, 2020 o Physician treatment plan ▪ Stress test demonstrating cardiopulmonary function that is below Repair (for Pectus Carinatum the predicted values Tennessee Only) o Functional • Physician treatment plan (continued) limitation/impairment o Physician treatment plan Pectus Carinatum Provide medical notes documenting the following: • Functional limitation/impairment • Physician treatment plan
Coverage Limitations and Exclusions UnitedHealthcare excludes Cosmetic Procedures from coverage including but not limited to the following: • Procedures that correct an anatomical Congenital Anomaly without improving or restoring physiologic function are considered Cosmetic Procedures. The fact that a Covered Person may suffer psychological consequences or socially avoidant behavior as a result of an Injury, Sickness or Congenital Anomaly does not classify surgery (or other procedures done to relieve such consequences or behavior) as a reconstructive procedure. • Procedures that do not meet the reconstructive criteria in the Indications for Coverage section above. Rhinoplasty and Oct. 1, 2020 Coverage Rationale Refer to the policy for complete details. Other Nasal Documentation Requirements Surgeries (for (previously titled Potential Required Tennessee Only) Documentation) • Revised list of applicable documentation requirements to reflect/include medical notes documenting: o Diagnosis o Detailed history of nasal symptoms including evaluation and management notes for the date of service and the note for the day the decision to perform surgery was made
103 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Coverage Determination Guideline (CDG) Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Rhinoplasty and Oct. 1, 2020 o Evidence of chronic sinusitis Other Nasal with treatment, response, Surgeries (for and duration Tennessee Only) o History of treatments tried, (continued) failed, or contraindicated o Specific diagnostic image(s) that shows the abnormality for which surgery is being requested; consultation with requesting surgeon may be of benefit to select the optimal image(s) ▪ Note: Diagnostic images must be labeled with the: - Date taken - Applicable case number obtained at time of notification, or the member's name and ID number on the image(s) ▪ Submission of diagnostic image(s) is required via the external portal at www.uhcprovider.com/p aan or via email at [email protected] (for Hawaii) or [email protected] (for all other states); faxes will not be accepted o Diagnostic image(s) report(s) o Details of functional impairment, if applicable
104 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
Coverage Determination Guideline (CDG) Updates
Policy Title Effective Date Summary of Changes Coverage Rationale REVISED Rhinoplasty and Oct. 1, 2020 o Physician’s plan of care Other Nasal o High-quality color image(s) Surgeries (for (full face photos in cases of Tennessee Only) post-traumatic nasal (continued) deformity) ▪ Note: All images must be labeled with the: - Date taken - Applicable case number obtained at time of notification, and the member’s name and ID number on the image(s) ▪ Submission of color image(s) is required via the external portal at www.uhcprovider.com/p aan or via email at [email protected] (for Hawaii) or [email protected] (for all other states); faxes will not be accepted o In addition to the above, additional documentation requirements may apply for CPT code 30560; refer to the Coverage Determination Guideline titled Cosmetic and Reconstructive Procedures (for Tennessee Only)
105 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020
General Information
The inclusion of a health service (e.g., test, drug, device or procedure) Policy Update Classifications in this bulletin indicates only that UnitedHealthcare is adopting a new New policy and/or updated, revised, replaced or retired an existing policy; it New clinical coverage criteria have been adopted for a health service does not imply that UnitedHealthcare provides coverage for the health (e.g., test, drug, device or procedure) service. Note that most benefit plan documents exclude from benefit coverage health services identified as investigational or unproven/not Updated medically necessary. Physicians and other health care professionals An existing policy has been reviewed and changes have not been made may not seek or collect payment from a member for services not to the clinical coverage criteria; however, items such as the clinical covered by the applicable benefit plan unless first obtaining the evidence, FDA information, and/or list(s) of applicable codes may have member’s written consent, acknowledging that the service is not been updated covered by the benefit plan and that they will be billed directly for the Revised service. An existing policy has been reviewed and revisions have been made to
the clinical coverage criteria Note: The absence of a policy does not automatically indicate or imply coverage. As always, coverage for a health service must be determined Replaced in accordance with the member’s benefit plan and any applicable An existing policy has been replaced with a new or different policy federal or state regulatory requirements. Additionally, UnitedHealthcare Retired reserves the right to review the clinical evidence supporting the safety and effectiveness of a medical technology prior to rendering a coverage The health service(s) addressed in the policy are no longer being determination. managed or are considered to be proven/medically necessary and are therefore not excluded as unproven/not medically necessary services, UnitedHealthcare respects the expertise of the physicians, health care unless coverage guidelines or criteria are otherwise documented in professionals, and their staff who participate in our network. Our goal is another policy to support you and your patients in making the most informed decisions regarding the choice of quality and cost-effective care, and to support practice staff with a simple and predictable administrative experience. Tips for using the Medical Policy Update Bulletin The Medical Policy Update Bulletin was developed to share important • From the table of contents, click the policy title to be directed to the information regarding UnitedHealthcare Medical Policy, Medical Benefit corresponding policy update summary. Drug Policy, Coverage Determination Guideline, Utilization Review • From the policy updates table, click the policy title to view a Guideline, and Quality of Care Guideline updates. When information in complete copy of a new, updated, or revised policy. this bulletin conflicts with applicable state and/or federal law, UnitedHealthcare follows such applicable federal and/or state law.
The complete library of UnitedHealthcare Community Plan Medical Policies, Medical Benefit Drug Policies, CDGs, and URGs is available at UHCprovider.com > Policies and Protocols > Community Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan.
106 UnitedHealthcare Community Plan Medical Policy Update Bulletin: September 2020