Oxford® Policy Update Bulletin: October 2015 Oxford

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Oxford® Policy Update Bulletin: October 2015 Oxford Oxford October 2015 policy update bulletin Medical & Administrative Policy Updates UnitedHealthcare respects the expertise of the physicians, health care professionals, and their staff who participate in our network. Our goal is 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. The Policy Update Bulletin was developed to share important information regarding Oxford® Medical and Administrative Policy updates.* *Where information in this bulletin conflicts with applicable state and/or federal law, Oxford® follows such applicable federal and/or state law Oxford Oxford® Medical and Administrative Policy Updates Overview This bulletin provides complete details on Oxford® Medical and Policy Update Classifications Administrative Policy updates. The appearance of a service or New procedure in this bulletin indicates only that Oxford® has recently New clinical coverage criteria and/or documentation review requirements adopted a new policy and/or updated, revised, replaced or have been adopted for a service, procedure, test, or device retired an existing policy; it does not imply that Oxford® provides Updated coverage for the service or procedure. In the event of an An existing policy has been reviewed and changes have not been made inconsistency or conflict between the information provided in this to the clinical coverage criteria or documentation review requirements; bulletin and the posted policy, the provisions of the posted policy however, items such as the clinical evidence, FDA information, and/or will prevail. Note that most benefit plan documents exclude from list(s) of applicable codes may have been updated benefit coverage health services identified as investigational or unproven/not medically necessary. Physicians and other health Revised care professionals may not seek or collect payment from a An existing policy has been reviewed and revisions have been made to member for services not covered by the applicable benefit plan the clinical coverage criteria and/or documentation review requirements unless first obtaining the member’s written consent, Replaced acknowledging that the service is not covered by the benefit plan An existing policy has been replaced with a new or different policy and that they will be billed directly for the service. Retired A complete library of Oxford® Medical and Administrative The procedural codes and/or services previously outlined in the policy are Policies is available at OxfordHealth.com > Providers > no longer being managed or are considered to be proven/medically Tools & Resources > Medical Information > Medical and necessary and are therefore not excluded as unproven/not medically Administrative Policies. necessary services, unless coverage guidelines or criteria are otherwise documented in another policy Note: The absence of a policy does not automatically indicate or imply Tips for using the Policy Update Bulletin: coverage. As always, coverage for a service or procedure must be From the table of contents, click the policy title to be determined in accordance with the member’s benefit plan and any directed to the corresponding policy update summary. applicable federal or state regulatory requirements. Additionally, UnitedHealthcare reserves the right to review the clinical evidence From the policy updates table, click the policy title to view a supporting the safety and effectiveness of a medical technology prior to complete copy of a new, updated, or revised policy. rendering a coverage determination. 2 Oxford® Policy Update Bulletin: October 2015 Oxford Oxford® Medical and Administrative Policy Updates In This Issue Clinical Policy Updates Page NEW Follicle Stimulating Hormone (FSH) Gonadotropins - Effective Nov. 1, 2015 ............................................................................................................. 7 Human Menopausal Gonadotropins (hMG) - Effective Nov. 1, 2015 ......................................................................................................................... 9 UPDATED 17-Alpha-Hydroxypro-gesterone Caproate (Makena and 17P) - Effective Nov. 1, 2015 ............................................................................................ 12 Alemtuzumab - Effective Oct. 1, 2015 ............................................................................................................................................................... 14 Core Decompression for Avascular Necrosis - Effective Oct. 1, 2015 ..................................................................................................................... 15 Diagnostic (Basic) Procedures for Infertility - Effective Oct. 1, 2015 ...................................................................................................................... 16 Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome - Effective Oct. 1, 2015 ........................................................................ 17 Lithotripsy for Salivary Stones - Effective Oct. 1, 2015 ........................................................................................................................................ 17 Mifeprex (Mifepristone, RU-486) - Effective Oct. 1, 2015 ..................................................................................................................................... 18 Nerve Graft to Restore Erectile Function During Radical Prostatectomy - Effective Oct. 1, 2015 ................................................................................ 19 Presacral Neurectomy and Uterine Nerve Ablation for Pelvic Pain - Effective Oct. 1, 2015 ........................................................................................ 19 Repository Corticotropin Injection (H.P. Acthar Gel) - Effective Nov. 1, 2015.......................................................................................................... 20 Rituxan (Rituximab) - Effective Nov. 1, 2015 ..................................................................................................................................................... 21 Routine Foot Care - Effective Oct. 1, 2015 ......................................................................................................................................................... 23 Sandostatin Lar Depot (Octreotide Acetate) - Effective Nov. 1, 2015 ..................................................................................................................... 23 Total Artificial Heart - Effective Oct. 1, 2015 ...................................................................................................................................................... 25 Transcutaneous Electrical Nerve Stimulation (TENS) for the Treatment of Nausea and Vomiting - Effective Oct. 1, 2015 ............................................. 26 Treatment of Infertility - Effective Oct. 1, 2015 .................................................................................................................................................. 26 Treatment of Infertility for Connecticut Groups - Effective Oct. 1, 2015 ................................................................................................................. 29 Treatment of Infertility for New Jersey Large Groups - Effective Oct. 1, 2015 ......................................................................................................... 31 Treatment of Infertility for New York Large and Small Groups - Effective Oct. 1, 2015............................................................................................. 34 Unicondylar Spacer Devices for Treatment of Pain or Disability - Effective Oct. 1, 2015 ........................................................................................... 36 Vaccines - Effective Oct. 1, 2015 ...................................................................................................................................................................... 37 Xolair (Omalizumab) - Effective Nov. 1, 2015 ..................................................................................................................................................... 37 REVISED Abnormal Uterine Bleeding and Uterine Fibroids - Effective Nov. 1, 2015 ............................................................................................................... 40 Botulinum Toxins A and B - Effective Nov. 1, 2015 ............................................................................................................................................. 42 Clotting Factors and Coagulant Blood Products - Effective Nov. 1, 2015 ................................................................................................................. 48 Drug Coverage Criteria - New and Therapeutic Equivalent Medications - Effective Nov. 1, 2015 ................................................................................ 49 3 Oxford® Policy Update Bulletin: October 2015 Oxford Oxford® Medical and Administrative Policy Updates In This Issue Drug Coverage Guidelines - Effective Sep. 10, 2015 ........................................................................................................................................... 49 o Praluent (Alirocumab) ...............................................................................................................................................................................
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