Health Evidence Review Commission’s Value-based Benefits Subcommittee January 10, 2013 Meridian Park Hospital Community Health Education Center, Room 117B&C 19300 SW 65th Avenue, Tualatin, OR 97062 Section 1 Agenda AGENDA VALUE-BASED BENEFITS SUBCOMMITTEE January 10, 2013 9:00am - 1:00pm Meridian Park Room 117B&C Community Health Education Center Tualatin, OR 97062 A working lunch will be served at approximately 12:00 PM All times are approximate I. Call to Order, Roll Call, Approval of Minutes – Lisa Dodson 9:00 AM II. Staff report – Ariel Smits, Cat Livingston, Darren Coffman 9:05 AM III. Straightforward 9:15 AM A. Coronary brachytherapy IV. New discussion items 9:30 AM A. External elements exposure issues B. Stereotactic radiation therapy for intracranial AVMs C. Personal history of cancer V codes V. Previous Discussion Items 10:00 AM A. Other December follow up A. Auricular acupuncture B. Enzyme replacement therapy A. Gaucher’s disease C. Silver compounds for caries treatment VI. Coverage guidances 11:30 AM A. Viscosupplementation for osteoarthritis of the knee B. Percutaneous interventions for low back pain C. Management of chronic otitis media in children VII. Guidelines 12:15 AM A. Immunization table/Prevention tables B. Expensive/marginally effective drug guideline C. Guideline Note 37 abnormal reflexes radiculopathy VIII. Public comment 12:55 PM IX. Adjournment – Lisa Dodson 1:00 PM Section 2 Minutes Value-based Benefits Subcommittee Recommendations Summary For Presentation to: Health Evidence Review Commission on 1/10/13 For specific coding recommendations and guideline wording, please see the text of the 12/13/12 VbBS minutes. CODE MOVEMENT ■The 2013 CPT, HCPCS, and CDT codes were placed as shown in Attachment A These proposed placements will be placed on the HERC website to be available for viewing by the various health plans. Final approval of these placements will be done at the HERC meeting on January 10, 2013. These codes will appear on the April 1, 2013 Prioritized List as approved by the HERC in January. ■ A missing tympanostomy tube removal procedure code was added to the acute mastoiditis line ■Tympanostomy procedure codes that were mistakenly not removed from the hearing loss line were removed ■A pharyngoplasty procedure code was added to the line with congenital neck problems ITEMS CONSIDERED BUT NO CHANGES MADE ■ The use of silver compounds for treatment of dental caries was discussed but no decision regarding coverage was reached ■ The prioritization of pseudobulbar affect was discussed but no decision was reached ■ A prenatal genetic testing guideline was discussed, and a work group will be convened to write it ■ Changes to the guideline for hysterectomy for menstrual bleeding disorder were discussed, and will be readdressed at a future meeting GUIDELINE CHANGES ■The coding specifications regarding cognitive behavioral therapy for low back pain were changed to indicate the correct CPT code ■Mistakes in the coding specification for bariatric surgery on the type 2 diabetes line were corrected ■The non-prenatal genetic testing guideline was modified to reflect changes needed for the new 2013 CPT genetic testing codes, as shown in Appendix C ■Two dental guidelines were modified and one deleted as shown in Appendix C ■ The chronic otitis media with effusion treatment guideline was modified as shown in Appendix C ■ A new guideline allowing coverage of puberty suppression in adolescents under new gender dysphoria line was adopted for the ICD-10 (October 2014) Prioritized List as shown in Appendix B Value-based Benefits Subcommittee Summary Recommendations, 12/13/12 VALUE-BASED BENEFITS SUBCOMMITTEE Meridian Park Health Education Center December 13, 2012 8:300 AM – 2:30 PM Members Present: Lisa Dodson, MD, Chair; Kevin Olson, MD, Vice-chair; Chris Kirk, MD; James Tyack, DMD; David Pollack MD; Mark Gibson; Irene Croswell RPh; Laura Ocker, LAc; Susan Williams, MD. Members Absent: none Staff Present: Darren Coffman; Ariel Smits, MD, MPH; Cat Livingston, MD, MPH; Jason Gingerich; Dorothy Allen. Also Attending: Denise Taray, DMAP; Kristi Jacobo, DMAP; Dr. Wally Shaffer, DMAP; David Fischer, AMH; Dr. Bruce Boston, OHSU Pediatric Endocrinology; Dr. Karin Selva, Legacy Pediatric Endocrinology; Jenn Burleton, Transactive; Dr. Ericka King, OHSU Pediatric Otolaryngology; Camille Kerr, Allergan; Gary Allen, DMD, Advantage Dental; Christina Schad, MD, and Julie Brown, Avenir Pharmaceuticals; Steven Duffin, Oral Health Outreach; Beryl Fletcher, ODA; Deborah Loy, Capital Dental; Aubrey Harrison, Basic Rights Oregon. Roll Call/Minutes Approval/Staff Report The meeting was called to order at 8:35 am and roll was called. Dr. Williams, an orthopedic surgeon practicing in Roseburg, was introduced as a new member of the subcommittee. Minutes from the 10/11/12 VbBS meeting were reviewed and approved with one change requested by Pollack regarding his remarks on the treatment resistant depression section. Action: HERC staff will post the approved minutes on the website as soon as possible. Coffman shared the work of a group that is trying to make the coverage guidance process more efficient and more reflective of the actual authority of these guidances. There was a general discussion about what authority the guidances and Prioritized List guidelines have. The HERC has the authority to prioritize conditions, and the Legislature determines the coverage level. Other insurers or other bodies may or may not choose to follow these guidances. Value-based Benefits Subcommittee Minutes, 12/13/12 Page 2 Straightforward Discussion Topic: Straightforward Issues Table Discussion: Smits introduced a document with straightforward coding changes. There was no discussion. Actions: 1) Add 69424 to line 178. 2) Remove 69424 and 69433 from line 383 3) Add 42950 to line 71 Topic: Low Back Pain Coding Specifications Discussion: Smits introduced a document with changes needed for the low back pain line coding specifications. There was no discussion. Actions: 1) Add the following coding recommendation to Line 400 for the April 1, 2013 Prioritized List a. Cognitive behavioral therapy (90785-90840) only pairs on Line 400 with the low back diagnoses (344.60, 722.1, 722.2, 722.7, 724.4) 2) Add the following coding recommendation to Line 562 for the April 1, 2013 Prioritized List a. Cognitive behavioral therapy (90785-90840) only pairs on Line 562 with the low back diagnoses (720.2, 721.3, 721.7, 721.8, 721.90, 722.1, 722.2, 722.32, 722.39, 722.5, 722.6, 722.8, 722.9, 724.1, 724.2, 724.5-724.9, 739.2-739.4, 847.1-847.9). 3) Change the following coding recommendation for Line 400 for the April 1, 2013 Prioritized List a. Cognitive behavioral therapy (90785-90840) only pairs on Line 400 with the low back diagnoses (344.60, 722.1, 722.2, 722.7, 724.4) 4) Change the following coding recommendation for Line 562 for the April 1, 2013 Prioritized List a. Cognitive behavioral therapy (90785-90840) only pairs on Line 562 with the low back diagnoses (720.2, 721.3, 721.7, 721.8, 721.90, 722.1, 722.2, 722.32, 722.39, 722.5, 722.6, 722.8, 722.9, 724.1, 724.2, 724.5-724.9, 739.2-739.4, 847.1-847.9). Value-based Benefits Subcommittee Minutes, 12/13/12 Page 3 Topic: Bariatric Surgery Coding Specification Discussion: Smits introduced a document with changes needed for the bariatric surgery line coding specifications on the April 1, 2013 list. There was no discussion. Actions: 1) The coding specification for line 33 was changed to read: CPT codes 43644-43645 and 43846-43848 (Roux-En-Y gastric bypass) and 43770-437745 (laparoscopic adjustable gastric banding) are only included on this line as treatment according to the requirements in Guideline Note 8 when paired with: 1) a primary diagnosis of 250.x0 or 250.x2 (Type II Diabetes with or without complication); 2) a secondary diagnosis of 278.00 (Obesity, Unspecified) or 278.01 (Morbid Obesity); AND, 3) a tertiary diagnosis code of V85.35-V85.405 (BMI >= 35). New Codes 2013 Topic: 2013 CPT codes Discussion: Smits introduced several documents with recommendations for the placement of the 2013 CPT, CDT and HPCPS codes. These recommendations were accepted as shown in the meeting materials (see Appendix A), with the exceptions below. Other code changes recommended in the various issue documents were also accepted as shown in the meeting materials unless noted below. This discussion section includes the genetic testing and psychiatric CPT codes. 1) 52287 (chemodenervation of the bladder). The subcommittee altered the suggested guideline for this procedure to clarify that it was to be used for overactive bladder caused by several types of spinal diseases and that a patient must have failed appropriate pharmacologic management first rather than antimuscarinic medications, as there may be other types of appropriate medication. 2) 64615 (Chemodenervation for migraine). This code is recommended to be added to the Excluded File as suggested by staff. There was considerable discussion about the differing recommendations of trusted sources (MED vs NICE). There was some discussion about these sources possibly using different studies or having differing amounts of industry and patient/provider input. Livingston said the MED report found studies with statistically significant differences with botulinum therapy, but that these differences were Value-based Benefits Subcommittee Minutes, 12/13/12 Page 4 not clinically significant. Dodson noted that this treatment might be cost effective if it lowered ER costs/utilization. Croswell as noted that chronic migraine patients are not very functional, and any therapy that would allow them to be more productive should be considered. Gibson recommended not covering due to lack of clinically significant outcomes. Kirk felt that this therapy was not medically appropriate based on the evidence. Payers could make exceptions for high ER utilizing patients if the payer felt that this might decrease their overall costs.