June 2016

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® 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.

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Oxford® Medical and Administrative Policy Updates

In This Issue

Clinical Policy Updates Page UPDATED  Gait Analysis - Effective June 1, 2016 ...... 8  Gender Dysphoria (Gender Identity Disorder) Treatment - Effective June 1, 2016...... 8  Gene Expression Tests - Effective June 1, 2016 ...... 13  Manipulative Therapy - Effective June 1, 2016 ...... 15  Occipital Neuralgia and Headache Treatment - Effective June 1, 2016 ...... 16  Otoacoustic Emissions Testing - Effective July 1, 2016 ...... 17  Prolotherapy for Musculoskeletal Indications - Effective June 1, 2016 ...... 22  Remicade® (Infliximab) - Effective July 1, 2016 ...... 22  Total Artificial Disc Replacement - Effective July 1, 2016 ...... 24 REVISED  Ablative Treatment for Spinal Pain - Effective July 1, 2016...... 25  Cardiology Procedures Requiring Precertification for eviCore healthcare Arrangement - Effective July 1, 2016 ...... 28  Computerized Dynamic Posturography - Effective July 1, 2016 ...... 30  Drug Coverage Criteria - New and Therapeutic Equivalent Medications - Effective July 1, 2016 ...... 32  Drug Coverage Guidelines - Effective May 10, 2016 ...... 34 o Kalydeco (Ivacaftor) ...... 34  Drug Coverage Guidelines - Effective June 1, 2016 ...... 34 o Daklinza (Daclatasvir) ...... 34 o Harvoni™ (Ledipasvir/Sofosbuvir) ...... 34 o Olysio (Simeprevir) ...... 34 o Sovaldi (Sofosbuvir) ...... 34 o Technivie (Ombitasvir/Paritaprevir/Ritonavir) ...... 34 o Viekira Pak (Ombitasvir, Paritaprevir (ABT-450) and Ritonavir) ...... 34 o Zepatier (Elbasvir/Grazoprevir) ...... 34  Drug Coverage Guidelines - Effective July 1, 2016 ...... 35 o Active-Pac/Gaba 300 (Gabapentin, Lidocaine Hydrochloride, Menthol) ...... 35 o Aczone 7.5% (Dapsone) ...... 35 o Anafranil (Clomipramine) (Brand) ...... 35 o Anusol HC Suppository (Brand) (Hydrocortisone) ...... 35 o Augmentin (Amoxicillin Clavulanate) (Brand) ...... 35 o Augmentin ED-600 (Amoxicillin Clavulanate) (Brand) ...... 35 o Avodart (Dutasteride) (Brand) ...... 35 o Axert (Almotriptan) (Brand) ...... 35

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In This Issue

o Betapace (Sotalol) (Brand) ...... 35 o Bexarotene Caps (Generic Targretin) ...... 35 o Campath (Alemtuzumab) ...... 35 o Cardizem (Diltiazem) (Brand) ...... 35 o Cardizem CD (Diltiazem) (Brand) ...... 35 o Cardizem LA (Diltiazem) (Brand)...... 35 o Clarifoam EF (Sulfacetamide/Sulfur) (Brand) ...... 35 o Colazal (Balsalazide) (Brand) ...... 36 o Compounds and Bulk Powders: Various Drugs ...... 36 o Corlanor (Ivabradine) ...... 36 o Cymbalta (Duloxetine) (Brand Only) ...... 36 o Depakote (Divalproex Sodium) ...... 36 o Depakote ER (Divalproex Sodium Extended Release) ...... 36 o D.H.E. 45 (Dihydroergotamine) (Brand) ...... 36 o Dibenzyline (Phenoxybenzamine) (Brand) ...... 36 o Duexis (Famotidine and Ibuprofen) ...... 36 o Dulera (Mometasone Furoate/Formoterol Fumarate Dihydrate) ...... 36 o E.E.S. 400 (Erythromycin Ethylsuccinate) (Brand) ...... 37 o Embeda (Morphine Sulphate and Naltrexone HCL)...... 37 o Excelon Patch (Rivastigmine) (Brand) ...... 37 o Farydak (Panobinostat) ...... 37 o Felbatol (Felbamate) ...... 37 o Fluticasone (Topical) ...... 37 o Ibrance (Palbociclib) ...... 37 o Intermezzo (Zolpidem Tartrate) ...... 38 o Invega (Paliperidone) ...... 38 o Invega (Paliperidone) (Brand) ...... 38 o Jublia (Efinaconazole) ...... 38 o Kenalog Spray (Triamcinolone) (Brand) ...... 38 o Keppra (Levetiracetam) ...... 38 o Keppra XR (Levetiracetam Extended Release[XR]) ...... 38 o Kerydin (Tavaborole) ...... 38 o Lamictal (Lamotrigine) ...... 38 o Lamictal ODT (Lamotrigine Orally Disintegrating Tablets) ...... 38 o Lamictal XR (Lamotrigine Extended Release) ...... 38 o Lamotrigine XR ...... 39 o Lemtrada (Alemtuzumab) ...... 39 o Lescol XL (Fluvastatin) (Brand) ...... 39 o Librax (Chlordiazepoxide/Clidinium) (Brand)...... 39 o Lodosyn (Carbidopa) (Brand) ...... 39

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In This Issue

o Loprox Shampoo (Brand) ...... 39 o Lotronex (Alosetron) (Brand) ...... 39 o Lyrica (Pregabalin) ...... 39 o Metrogel 0.75% Vaginal (Metronidazole) (Brand) ...... 39 o Migranal (Dihydroergotamine) (Brand) ...... 39 o Molindone ...... 40 o Mysoline (Primidone) ...... 40 o Namenda XR (Memantine Hydrochloride) ...... 40 o Neurontin (Gabapentin) ...... 40 o Ninlaro (Ixazomib) ...... 40 o Nuvigil (Armodafinil) ...... 40 o Obredon Solution (Hydrocodone/Guaifenesin) ...... 40 o Onzetra Xsail (Sumatriptan) ...... 40 o Oxtellar XR (Oxcarbazepine Extended Release) ...... 41 o Penlac Nail Lacquer (Ciclopirox) (Brand) ...... 41 o Proctocort (Hydrocortisone) (Brand) ...... 41 o Provigil (Modafinil) (Brand) ...... 41 o Provigil (Modafinil) (Generic) ...... 41 o Qudexy XR (Topiramate)...... 41 o Relistor (Methylnatrexone Bromide) ...... 41 o Rosuvastatin (Generic Crestor) ...... 41 o Seebri Neohaler (Glycopyrrolate) ...... 41 o Stavzor (Valproic Acid) ...... 42 o Symbicort (Budesonide/Formoterol Fumarate Dehydrate) ...... 42 o Synalar (Fluocinolone Acetonide) ...... 42 o Synalar 0.01% Solution (Fluocinolone Acetonide) (Brand) ...... 42 o Synalar 0.025% Cream/Ointment (Fluocinolone Acetonide) (Brand) ...... 42 o Tasmar (Tolcapone) (Brand) ...... 42 o Tenoretic (Atenolol/Chlorthalidone) (Brand) ...... 42 o Tenormin (Atenolol) (Brand)...... 42 o Toujeo Solostar (Insulin Glargine) ...... 42 o Topamax (Topiramate) ...... 42 o Treximet (Sumatriptan Naproxen) ...... 42 o Trileptal (Oxcarbazepine) ...... 42 o Trokendi XR (Topiramate) ...... 42 o Utibron Neohaler (Indacaterol/Glycopyrrolate) ...... 43 o Valcyte (Valganciclovir) (Brand) ...... 43 o Vaseretic (Enalapril/Hydrochlorothiazide) (Brand) ...... 43 o Vasotec (Enalapril) (Brand) ...... 43 o Viberzi (Eluxadoline) ...... 43

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In This Issue

o Vimovo (Naproxen Sodium Plus Proton Pump Inhibitor) ...... 43 o Wellbutrin (Bupropion) (Brand) ...... 43 o Xenazine (Tetrabenazine) (Brand) ...... 44 o Zestoretic (Lisinopril/Hydrochlorothiazide) (Brand) ...... 44 o Zestril (Lisinopril) (Brand) ...... 44 o Zonegran (Zonisamide) ...... 44 o Zylfo and Zylfo CR (Zileuton) ...... 44 o Zyvox (Linezolid) (Brand) ...... 44  Glaucoma Surgical Treatments - Effective July 1, 2016 ...... 44  In Utero Fetal Surgery - Effective July 1, 2016 ...... 45  Lemtrada (Alemtuzumab) - Effective July 1, 2016...... 46  Omnibus Codes - Effective July 1, 2016 ...... 47  Oxford's Outpatient Imaging Self-Referral - Effective July 1, 2016 ...... 48  Preventive Care Services - Effective July 1, 2016 ...... 50  Radiology Procedures Requiring Precertification for eviCore healthcare Arrangement - Effective July 1, 2016 ...... 52  Select Brand Medications - Effective July 1, 2016 ...... 55 Administrative Policy Updates REVISED  Accreditation Requirements for Radiology Services - Effective July 1, 2016 ...... 57  Autism - Effective July 1, 2016 ...... 59  Credentialing Guidelines: Participation in the eviCore healthcare Network - Effective July 1, 2016 ...... 60 Reimbursement Policy Updates NEW  Consultation Services - Effective July 1, 2016 ...... 62 UPDATED  Add-On Policy - Effective June 1, 2016 ...... 62  Co-Surgeons/Team Surgeon - Effective June 1, 2016 ...... Error! Bookmark not defined. REVISED  In-Office Laboratory Testing and Procedures List - Effective July 1, 2016 ...... 66  One or More Sessions - Effective June 1, 2016 ...... 69

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In This Issue

REPLACED  Inpatient Consultations - Effective July 1, 2016 ...... 71

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Clinical Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Gait Analysis June 1, 2016  Reformatted and reorganized Gait analysis is unproven and not medically necessary for surgical or policy; transferred content to clinical decision making. new template The available clinical evidence does not establish that gait analysis benefits  Updated/clarified non-coverage health outcomes. rationale to indicate: o Gait analysis is unproven and not medically necessary for surgical or clinical decision making o The available clinical evidence does not establish that gait analysis benefits health outcomes  Updated supporting information to reflect the most current clinical evidence, FDA information, and references Gender Dysphoria June 1, 2016  Reformatted and reorganized Indications for Coverage (Gender Identity policy; transferred content to Non-Surgical Treatment of Gender Dysphoria Disorder) new template Plans may cover non-surgical treatment for gender dysphoria. If there is a Treatment  Updated coverage rationale; difference between a member specific benefit specific document and the added notation to clarify the information below, the member specific benefit plan document should be member specific benefit plan used for making benefit determinations. For plans that cover non-surgical document must be referenced to treatment of gender dysphoria, please see the Covered Services and

determine whether there is a Limitations and Exclusions sections below. basis for coverage of gender dysphoria and whether this policy Covered Services (for Plans that Cover Non-Surgical Treatment for applies Gender Dysphoria)  Updated list of applicable CPT If a plan covers non-surgical treatment for gender dysphoria, the following codes/coding clarification non-surgical treatments are covered: language to indicate the  Psychotherapy for gender dysphoria and associated co-morbid psychiatric exclusion (or benefit, depending diagnoses. on the benefit document) for Note: If mental health services are not covered on the Oxford plan (for gender reassignment treatment example when mental health services are carved out of the plan design), is not limited to CPT codes the plan will not cover psychotherapy for gender dysphoria. 55970 and 55980  Continuous Hormone Replacement Therapy – Hormones of the desired

gender. Hormones injected by a medical provider (for example hormones

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Clinical Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Gender Dysphoria June 1, 2016 injected during an office visit) are covered by the medical plan. Benefits (Gender Identity for these injections vary depending on the plan design. Oral and self- Disorder) injected hormones from a pharmacy are not covered under the medical Treatment plan. Refer to the Outpatient Prescription Drug Rider, or benefit

(continued) document for self-funded plans, for specific prescription drug product

coverage and exclusion terms. Eligibility Qualifications for Continuous Hormone Replacement Therapy: The covered person must meet all of the following eligibility qualifications for hormone replacement: o Persistent, well-documented gender dysphoria (see definition of Gender Identity Disorder); and o Capacity to make a fully informed decision and to consent for

treatment; and o Age of majority in a given country. Note: WPATH guidelines address age of majority in a given country. For the purposes of this guideline, the age of majority is age 18. However, this refers to chronological age not biological age. Where approval or denial of benefits is based solely on the age of the individual a case-by-case medical director review is necessary; and o If significant medical or mental health concerns are present, they

must be reasonably well-controlled.  Laboratory testing to monitor continuous hormone therapy.

Coverage Limitations and Exclusions Certain non-surgical treatments are not covered. Examples that apply to this exclusion include, but are not limited to:

 Treatment received outside of the United States.

 Non-surgical treatments that are not listed in the Covered Services section above.

 Reproduction services including, but not limited to: sperm preservation in advance of hormone treatment or gender dysphoria surgery, cryopreservation of fertilized embryos, oocyte preservation, surrogate parenting, donor eggs, donor sperm and host uterus. (See the Reproduction exclusion in the member specific benefit plan document.)

 Drugs* for hair loss or growth.  Drugs* for sexual performance for patients that have undergone genital

reconstruction.  Drugs* for cosmetic purposes.

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Clinical Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Gender Dysphoria June 1, 2016  Hormone therapy except as described in the Covered Services section (Gender Identity above. Disorder)  Pubertal suppression therapy is considered unsafe in managing children Treatment and adolescents with gender identity dysphoria and is, therefore, not

(continued) covered. See the policy titled Lupron® Depot / Lupron® Depot-Ped

(Leuprolide Acetate).  Voice therapy.  Services that exceed the maximum dollar limit on the plan.  Transportation, meals, lodging or similar expenses.

*The drugs exclusions listed above apply to drugs administered by a provider in a medical setting (including, but not limited to: office, outpatient, or

inpatient facility). For drugs obtained at a pharmacy, check with the pharmacy plan administrator for information on covered and excluded drugs.

Note the following:  Certain plans may have a different list of exclusions. Check the member specific benefit plan document before making a determination.  Additional exclusions are listed in the Surgical Treatment section below.

Surgical Treatment For Gender Dysphoria

Most plans exclude coverage for surgical treatment for gender dysphoria. However, certain self-funded plans may include a benefit that covers surgical treatment for gender dysphoria. Please refer to the member specific benefit plan document to verify coverage. If there is a difference between a member specific benefit plan document and the information below, the

member specific benefit plan document should be used for making benefit

determinations. For plans that cover surgical treatment for gender dysphoria, please note the following:

Covered Surgical Treatment for Gender Dysphoria If a plan covers surgical treatment for gender dysphoria, the following are covered when the Eligibility Qualifications for Surgery are met below:  Genital surgery (by various techniques which must be appropriate to each

patient), including: complete hysterectomy; orchiectomy; penectomy;

vaginoplasty; vaginectomy; clitoroplasty; labiaplasty; salpingo- oophorectomy; metoidioplasty; scrotoplasty; urethroplasty; placement of

testicular prosthesis; phalloplasty.

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Clinical Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Gender Dysphoria June 1, 2016  Surgery to change specified secondary sex characteristics, specifically: (Gender Identity o Thyroid chondroplasty (removal or reduction of the Adam's Apple), Disorder) and Treatment o Bilateral mastectomy, and

(continued) o Augmentation mammoplasty (including breast prosthesis) if the

Physician prescribing hormones and the surgeon have documented that breast enlargement after undergoing hormone treatment for 18 months is not sufficient for comfort in the social role.  Related Services: In addition to the surgeon fees, the benefit applies to the services related to the surgery, including but not limited to: anesthesia, laboratory testing, pathology, radiologic procedures, hospital and facility fees, and/or surgical center fees.

Eligibility Qualifications for Surgery The following criteria apply to genital surgery, and to surgery to change specified secondary sex characteristics listed above. It is our expectation that surgery be performed by a qualified provider at a facility with a history of treating individuals with gender identity disorder.

If a plan covers surgical treatment for gender dysphoria, the Covered Person must meet all of the following eligibility qualifications prior to surgery:

 Persistent, well-documented gender dysphoria (see definition of Gender Identity Disorder); and  Capacity to make a fully informed decision and to consent for treatment; and  Age of majority in a given country. Note: World Professional Association

for Transgender Health Association (WPATH) guidelines address age of

majority in a given country. For the purposes of this guideline, the age of majority is age 18. However, this refers to chronological age, not

biological age. Where approval or denial of benefits is based solely on the age of the individual a case-by-case medical director review is necessary; and  If significant medical or mental health concerns are present, these must be reasonably well-controlled; and

 The covered person must complete 12 months of successful continuous full time real life experience in the desired gender; and

 The covered person may be required to complete continuous hormone therapy (for those without contraindications). In consultation with the

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Clinical Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Gender Dysphoria June 1, 2016 patient’s physician, this should be determined on a case-by-case basis (Gender Identity through the precertification process; and Disorder)  The treatment plan must conform to identifiable external sources Treatment including the WPATH standards, and/or evidence-based professional

(continued) society guidance.

Clarifications for Breast/Chest Surgery In addition to the Eligibility Qualifications listed above, please note the following:  A biologic female patient that is only requesting a bilateral mastectomy: o Does not need to complete hormone therapy in order to qualify for

the mastectomy. o Although not a requirement for coverage, Oxford recommends that

the patient complete at least 3 months of psychotherapy before having the mastectomy.  A biologic male patient that is only requesting a breast augmentation: o If able to take female hormones, the patient should take the female hormones for at least 12–24 months* before being considered for bilateral breast augmentation since the patient may achieve adequate

breast development without surgery. o Although not a requirement for coverage, Oxford recommends that

the patient complete at least 3 months of psychotherapy before having the breast augmentation.

*12 months is listed by WPATH v7, whereas, 2 years is listed by, Endocrine Treatment of Transsexual Persons: An Endocrine Society

Clinical Practice Guideline (2009).

Note the following:

 Certain plans may have a different list of Covered Services for Treatment of Gender Identity Disorder and may not cover all services listed above. Check the member specific benefit plan document to determine coverage.  Benefits are limited to one sex transformation reassignment per lifetime which may include several staged procedures.

 Check the member specific benefit plan document for any applicable prior authorization or notification requirements, or limits and maximum dollar

amounts to this coverage.  Sterilization surgery is not required in order to receive the covered

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UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Gender Dysphoria June 1, 2016 services under this benefit. (Gender Identity Disorder) Excluded Services for Surgical Treatment of Gender Dysphoria Treatment The following are not covered even if the plan includes coverage for surgical (continued) treatment for gender dysphoria:  Treatment received outside of the United States.

 Reversal of genital surgery or reversal of surgery to revise secondary sex characteristics.  Voice modification surgery.  Facial feminization surgery, including but not limited to: facial bone reduction, face “lift”, facial hair removal, and certain facial plastic reconstruction.  Suction-assisted lipoplasty of the waist.  Rhinoplasty (except if rhinoplasty criteria are met; see the policy titled Rhinoplasty and Other Nasal Surgeries).  Blepharoplasty (except if blepharoplasty criteria are met; see the policy titled Blepharoplasty, Blepharoptosis and Brow Ptosis Repair).  Abdominoplasty (except if abdominoplasty criteria are met; see the policy titled Panniculectomy and Body Contouring Procedures).  Breast reduction (except if breast reduction criteria are met; see the policy titled Breast Reduction Surgery).  For plans that do not cover surgical treatment of gender dysphoria, surgical treatments for gender dysphoria are not covered even if considered to be medically necessary by the prescribing physician or other health practitioner.  For plans that cover surgical treatment of gender dysphoria, coverage does not apply to Members that do not meet the criteria listed in the Eligibility Qualifications for Surgery section above.

Note the following:  Certain plans may have a different list of exclusions. Check the member specific benefit plan document before making a determination.  Additional exclusions are listed in the Non-Surgical Treatment section above. Gene Expression June 1, 2016  Reformatted and reorganized Oncology Indications Tests policy; transferred content to Thyroid Cancer new template Multi-panel gene expression tests (e.g., Afirma®) are proven and  Updated supporting information

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Clinical Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Gene Expression June 1, 2016 to reflect the most current clinical medically necessary for assessing thyroid nodules that are not Tests evidence and references clearly benign or malignant based on fine-needle aspiration biopsy (continued) results alone.

Gene expression tests are unproven and not medically necessary for

the following indications:

Cancer of Unknown Primary

 Identifying tissue of origin in difficult to diagnose cancers (e.g., ResponseDX Tissue of Origin® or CancerTYPE ID®)

Colon Cancer

Predicting the likelihood of colon cancer recurrence (e.g., Oncotype DX®  Colon Cancer Assay)

Multiple Myeloma

®  Guiding therapy in patients with multiple myeloma (e.g., MyPRS )

Prostate Cancer

 Predicting tumor aggressiveness and guiding disease management in ® patients with newly diagnosed prostate cancer (e.g., Oncotype DX Prostate Cancer Assay and Prolaris®)  Predicting risk of recurrence and metastasis and guiding disease management following radical prostatectomy (e.g., Decipher® Prostate Cancer Classifier)

Uveal Melanoma

 Predicting metastatic risk of uveal melanoma (e.g., DecisionDx-UM)

There is insufficient evidence in the clinical literature demonstrating that these tests have a role in clinical decision-making or have a beneficial effect on health outcomes. Further studies are needed to determine the clinical utility of these tests.

Non-Oncology Indications Coronary Artery Disease

Gene expression tests are unproven and not medically necessary for

predicting the likelihood of obstructive coronary artery disease (e.g.,

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Clinical Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Gene Expression June 1, 2016 Corus® CAD). Tests There is insufficient evidence in the clinical literature demonstrating that this (continued) test has a role in clinical decision-making or has a beneficial effect on health outcomes. Further studies are needed to determine the clinical utility of this test. Manipulative June 1, 2016  Updated supporting information Manipulative therapy is proven and medically necessary when used Therapy to reflect the most current clinical in the treatment of musculoskeletal disorders, except as noted evidence, FDA information, and below. references; no change to coverage rationale or lists of Manipulative therapy is unproven and not medically necessary for applicable codes treatment of:  Non-musculoskeletal disorders (e.g., asthma, otitis media, infantile colic, etc)  Prevention/maintenance/custodial care  Internal organ disorders (e.g., gallbladder, spleen, intestinal, kidney, or lung disorders)  Temporomandibular joint (TMJ) disorder  Scoliosis correction  Craniosacral therapy (cranial manipulation/upledger technique)  Manipulative services that utilize nonstandard techniques such as applied kinesiology technique, NUCCA, network and neural organizational technique

The role of manipulation for the above has not been established in scientific literature. A beneficial impact on health outcomes, e.g., improved physical function, durable pain relief, has not been established.

Manipulative therapy is unproven and not medically necessary when ANY of the following apply: 1. The patient's condition has returned to the pre-symptom state. 2. Little or no improvement is demonstrated within 30 days of the initial visit despite modification of the treatment plan. 3. Concurrent manipulative therapy, for the same or similar condition, provided by another health professional whether or not the healthcare professional is in the same professional discipline.

This policy does not address manipulation under anesthesia; refer to the policy titled Manipulation Under Anesthesia.

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Clinical Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Occipital Neuralgia June 1, 2016  Reformatted and reorganized Injection of local anesthetics and/or steroids, used as occipital nerve and Headache policy; transferred content to blocks, is proven and medically necessary for treating pain due to Treatment new template malignancy involving the head and neck.  Updated supporting information

to reflect the most current clinical Injection of local anesthetics and/or steroids, used as occipital nerve

evidence, FDA information, and blocks, is unproven and not medically necessary for diagnosing and references treating occipital neuralgia or headaches including migraine and cervicogenic headaches. There is insufficient evidence that greater occipital nerve blocks can be used as a specific diagnostic test for occipital neuralgia or headaches. The efficacy of local injection therapies for occipital neuralgia or cervicogenic headache and other headaches has not been established in well-designed clinical trials.

Refer to policy titled Botulinum Toxin A and B for information regarding the use of botulinum toxin for treatment of headaches.

Surgery, including but not limited to the following, is unproven and not medically necessary for treating occipital neuralgia or cervicogenic headache.  Occipital neurectomy

 Partial posterior intradural C1-C3 rhizotomy  Rhizotomy of C1-C3 spinal dorsal roots  Surgical decompression of second cervical nerve root and ganglion  Surgical decompression of the greater occipital nerve

The available evidence is insufficient to conclude that surgery is an effective treatment for occipital neuralgia or cervicogenic headache. The long-term

efficacy of surgical procedures for occipital neuralgia or cervicogenic headache has not been established in well-designed clinical trials.

Occipital neurectomy or surgical nerve decompression is unproven and not medically necessary treating headaches. The available evidence is insufficient to conclude that occipital neurectomy or nerve decompression including decompression of the supraorbital, supratrochlear, zygomaticotemporal, or greater occipital nerves is an

effective treatment for headaches. The long-term efficacy of these procedures for headaches has not been established in well-designed clinical trials.

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Clinical Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Occipital Neuralgia June 1, 2016 Radiofrequency ablation (thermal or pulsed) or denervation is and Headache unproven and not medically necessary for treating of occipital Treatment neuralgia or headaches including migraine, cluster and cervicogenic (continued) headaches.

The available evidence from published studies is not sufficient to conclude

that radiofrequency ablation or denervation is an effective treatment for occipital neuralgia or cervicogenic headache. Well-designed studies are needed to evaluate the potential advantages of radiofrequency ablation for these conditions and to identify which patients would benefit from this procedure.

Neurostimulation or electrical stimulation is unproven and not

medically necessary for treating of occipital neuralgia or headaches including migraine, cluster and cervicogenic headaches. The available studies were limited and had significant methodological flaws, making it difficult to draw conclusions regarding the efficacy of electrical stimulation for the treatment of cervicogenic headache or occipital neuralgia. There are no well-designed randomized controlled studies in the medical literature comparing neurostimulation to established treatment options or a sham procedure. Studies on larger populations with longer follow-up are needed to establish the benefits of neurostimulation and electrical stimulation for treating these conditions.

Otoacoustic July 1, 2016  Reformatted and reorganized Neonatal hearing screening as a preventive service using otoacoustic Emissions Testing policy; transferred content to emissions (OAEs) is proven and medically necessary for infants who new template are 90 days or younger.  Updated list of applicable ICD-9

codes: Otoacoustic emissions (OAEs) testing as a diagnostic service is

o Added 200.80; 438.10; proven and medically necessary for the evaluation of hearing loss in 438.11; 438.12; 438.13; one or more of the following: 438.14; 438.19; 438.6;  Infants over 90 days old and children up to 4 years of age 438.81; 438.83; 438.85;  Children and adults who are or who are unable to cooperate with other 438.89; 438.9 and 780.4 methods of hearing testing (e.g. individuals with autism or stroke) o Removed 045.0; 045.9 and  Children with developmental or delayed speech or language disorders 806.7  Individuals with tinnitus, acoustic trauma, noise induced hearing loss, or

 Updated list of applicable ICD-10 sudden hearing loss codes; added T22621S,  Individuals with abnormal auditory perception T22622S, T22629S, T22631S,  Individuals with sensorineural hearing loss T22632S, T22639S, T22641S,  Individuals with abnormal auditory function studies or failed hearing

17 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Otoacoustic July 1, 2016 T22642S, T22649S, T22651S, exam Emissions Testing T22652S, T22659S, T22661S,  Individuals who may be feigning a hearing loss (continued) T22662S, T22669S, T22691S,  Monitoring of ototoxicity in patients before, during, and after T22692S, T22699S, T2270XS, administration of agents known to be ototoxic (e.g., aminoglycosides,

T22711S, T22712S, T22719S, chemotherapy agents)

T22721S, T22722S, T22729S, T22731S, T22732S, T22739S, Auditory screening or diagnostic testing using otoacoustic emissions T22741S, T22742S, T22749S, (OAEs) is unproven and not medically necessary for all other patient T22751S, T22752S, T22759S, populations and conditions other than those listed as proven and T22761S, T22762S, T22769S, medically necessary. T22791S, T22792S, T22799S, There is inadequate evidence that hearing screening with OAEs is superior to T23001S, T23002S, T23009S, screening audiometry in improving health outcomes such as timely

T23011S, T23012S, T23019S, facilitation of speech, language, and communication skills in older children or T23021S, T23022S, T23029S, adults. There is also inadequate evidence to indicate that the use of T23031S, T23032S, T23039S, diagnostic otoacoustic emissions (OAEs) testing is superior to screening T23041S, T23042S, T23049S, audiometry in improving health outcomes such as timely facilitation of T23051S, T23052S, T23059S, speech, language, and communication skills in patients with other conditions T23061S, T23062S, T23069S, other than those indicated as proven and medically necessary.

T23071S, T23072S, T23079S, T23091S, T23092S, T23099S,

T23101S, T23102S, T23109S, T23111S, T23112S, T23119S, T23121S, T23122S, T23129S, T23131S, T23132S, T23139S, T23141S, T23142S, T23149S, T23151S, T23152S, T23159S, T23161S, T23162S, T23169S,

T23171S, T23172S, T23179S, T23191S, T23192S, T23199S, T23201S, T23202S, T23209S, T23211S, T23212S, T23219S, T23221S, T23222S, T23229S, T23231S, T23232S, T23239S, T23241S, T23242S, T23249S, T23251S, T23252S, T23259S,

T23261S, T23262S, T23269S, T23271S, T23272S, T23279S, T23291S, T23292S, T23299S, T23301S, T23302S, T23309S,

18 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Otoacoustic July 1, 2016 T23311S, T23312S, T23319S, Emissions Testing T23321S, T23322S, T23329S, (continued) T23331S, T23332S, T23339S, T23341S, T23342S, T23349S,

T23351S, T23352S, T23359S,

T23361S, T23362S, T23369S, T23371S, T23372S, T23379S, T23391S, T23392S, T23399S, T23401S, T23402S, T23409S, T23411S, T23412S, T23419S, T23421S, T23422S, T23429S, T23431S, T23432S, T23439S,

T23441S, T23442S, T23449S, T23451S, T23452S, T23459S, T23461S, T23462S, T23469S, T23471S, T23472S, T23479S, T23491S, T23492S, T23499S, T23501S, T23502S, T23509S, T23511S, T23512S, T23519S, T23521S, T23522S, T23529S,

T23531S, T23532S, T23539S, T23541S, T23542S, T23549S, T23551S, T23552S, T23559S, T23561S, T23562S, T23569S, T23571S, T23572S, T23579S, T23591S, T23592S, T23599S, T23601S, T23602S, T23609S,

T23611S, T23612S, T23619S, T23621S, T23622S, T23629S, T23631S, T23632S, T23639S, T23641S, T23642S, T23649S, T23651S, T23652S, T23659S, T23661S, T23662S, T23669S, T23671S, T23672S, T23679S, T23691S, T23692S, T23699S,

T23701S, T23702S, T23709S, T23711S, T23712S, T23719S, T23721S, T23722S, T23729S, T23731S, T23732S, T23739S,

19 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Otoacoustic July 1, 2016 T23741S, T23742S, T23749S, Emissions Testing T23751S, T23752S, T23759S, (continued) T23761S, T23762S, T23769S, T23771S, T23772S, T23779S,

T23791S, T23792S, T23799S,

T24001S, T24002S, T24009S, T24011S, T24012S, T24019S, T24021S, T24022S, T24029S, T24031S, T24032S, T24039S, T24091S, T24092S, T24099S, T24101S, T24102S, T24109S, T24111S, T24112S, T24119S,

T24121S, T24122S, T24129S, T24131S, T24132S, T24139S, T24191S, T24192S, T24199S, T24201S, T24202S, T24209S, T24211S, T24212S, T24219S, T24221S, T24222S, T24229S, T24231S, T24232S, T24239S, T24291S, T24292S, T24299S,

T24301S, T24302S, T24309S, T24311S, T24312S, T24319S, T24321S, T24322S, T24329S, T24331S, T24332S, T24339S, T24391S, T24392S, T24399S, T24401S, T24402S, T24409S, T24411S, T24412S, T24419S,

T24421S, T24422S, T24429S, T24431S, T24432S, T24439S, T24491S, T24492S, T24499S, T24501S, T24502S, T24509S, T24511S, T24512S, T24519S, T24521S, T24522S, T24529S, T24531S, T24532S, T24539S, T24591S, T24592S, T24599S,

T24601S, T24602S, T24609S, T24611S, T24612S, T24619S, T24621S, T24622S, T24629S, T24631S, T24632S, T24639S,

20 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Otoacoustic July 1, 2016 T24691S, T24692S, T24699S, Emissions Testing T24701S, T24702S, T24709S, (continued) T24711S, T24712S, T24719S, T24721S, T24722S, T24729S,

T24731S, T24732S, T24739S,

T24791S, T24792S, T24799S, T25011S, T25012S, T25019S, T25021S, T25022S, T25029S, T25031S, T25032S, T25039S, T25091S, T25092S, T25099S, T25111S, T25112S, T25119S, T25121S, T25122S, T25129S,

T25131S, T25132S, T25139S, T25191S, T25192S, T25199S, T25211S, T25212S, T25219S, T25221S, T25222S, T25229S, T25231S, T25232S, T25239S, T25291S, T25292S, T25299S, T25311S, T25312S, T25319S, T25321S, T25322S, T25329S,

T25331S, T25332S, T25339S, T25391S, T25392S, T25399S, T25411S, T25412S, T25419S, T25421S, T25422S, T25429S, T25431S, T25432S, T25439S, T25491S, T25492S, T25499S, T25511S, T25512S, T25519S,

T25521S, T25522S, T25529S, T25531S, T25532S, T25539S, T25591S, T25592S, T25599S, T25611S, T25612S, T25619S, T25621S, T25622S, T25629S, T25631S, T25632S, T25639S, T25691S, T25692S, T25699S, T25711S, T25712S, T25719S,

T25721S, T25722S, T25729S, T25731S, T25732S, T25739S, T25791S, T25792S and T25799S  Updated supporting information

21 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Otoacoustic July 1, 2016 to reflect the most current clinical Emissions Testing evidence, FDA information, and (continued) references

Prolotherapy for June 1, 2016  Reformatted and reorganized Prolotherapy is unproven and not medically necessary. Musculoskeletal policy; transferred content to The available studies are limited to those that include short to medium-term Indications new template follow-up with no significant functional improvement compared to placebo.  Updated supporting information Additional studies are needed to further define treatment parameters and to to reflect the most current determine whether a clinically significant improvement is achieved. description of services, clinical evidence, FDA information and references; no change to coverage rationale or lists of applicable codes Remicade® July 1, 2016  Updated coverage rationale; Remicade (infliximab) is proven and medically necessary for the (Infliximab) modified list of unproven/not treatment of: medically necessary indications: 1. Ankylosing spondylitis when the following criterion is met o Replaced “adult-onset Still’s A. Diagnosis of ankylosing spondylitis (AS)

disease” with “Still’s disease” 2. Crohn’s disease when the following criterion is met:

 Updated supporting information A. One of the following: to reflect the most current clinical 1. Diagnosis of fistulizing Crohn’s disease (Crohn’s Disease Activity evidence and references Index (CDAI) ≥ 220 and ≤ 400); or 2. Both of the following: a. Diagnosis of moderately to severely active adult or pediatric Crohn’s disease; and b. History of failure, contraindication, or intolerance to at least

one conventional therapy (e.g., corticosteroids, 6- mercaptopurine, azathioprine, methotrexate, etc.) 3. Noninfectious uveitis when both of the following criteria are met: A. Diagnosis of refractory noninfectious uveitis that is causing or threatening vision loss (e.g., noninfectious uveitis associated with Behçet’s or Reiter’s syndromes); and B. History of failure, contraindication, or intolerance to all of the following:

1. Topical corticosteroids 2. Systemic corticosteroids 3. Immunosuppressive drugs (e.g., azathioprine, cyclosporine, or methotrexate)

22 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Remicade® July 1, 2016 4. Plaque psoriasis when both of the following criteria are met: (Infliximab) A. Diagnosis of chronic severe plaque psoriasis i.e., extensive and/or (continued) disabling); and B. Patient is a candidate for systemic therapy

5. Psoriatic arthritis when the following criterion is met:

A. Diagnosis of psoriatic arthritis (PsA); 6. Rheumatoid arthritis when both of the following criteria are met: A. Diagnosis of moderately to severely active rheumatoid arthritis (RA); and B. One of the following: 1. Member is receiving concurrent therapy with methotrexate 2. History of contraindication or intolerance to methotrexate

7. Sarcoidosis when all of the following criteria are met: A. Diagnosis of sarcoidosis; and B. History of failure, contraindication, or intolerance to corticosteroids (e.g., prednisone, methylprednisolone); and C. History of failure, contraindication, or intolerance to one

immunosuppressant (e.g., methotrexate, cyclophosphamide, azathioprine); 8. Ulcerative colitis when both of the following criteria are met:

A. Diagnosis of moderately to severely active adult or pediatric ulcerative colitis (UC); and B. History of failure, contraindication, or intolerance to at least one conventional therapy (e.g., 6-mercaptopurine, aminosalicylate, azathioprine, corticosteroids)

There may be other conditions that qualify as serious, rare diseases for

which the use of Remicade may be appropriate. Please refer to the Benefit Considerations section of the policy for additional information.

Remicade is unproven and not medically necessary in the treatment of:  Still's disease  Sjogren's syndrome  Graft-vs-host disease

 Myelodysplastic syndromes  Undifferentiated spondyloarthropathy  Reiter's syndrome  Hidradenitis suppurativa

23 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Remicade® July 1, 2016  Wegener's granulomatosis (Infliximab)  Juvenile idiopathic arthritis (juvenile rheumatoid arthritis) (continued) Remicade is unproven and not medically necessary for the treatment of the above conditions because statistically robust randomized controlled trials are needed to address the issue of whether Remicade has sufficient superiority in clinical efficacy compared to other available treatments to justify the inherent clinical risk in the use of a monoclonal antibody anti- tumor necrosis factor agent. Total Artificial Disc July 1, 2016  Reformatted and reorganized Cervical artificial total disc replacement of FDA-approved prosthesis Replacement policy; transferred content to for degenerative cervical disc disease with symptomatic intractable new template radiculopathy and/or myelopathy is proven and medically necessary  Updated coverage rationale; in a skeletally mature individual when at least one of the following

added language to clarify lumbar criteria is met:

artificial total disc replacement is  Herniated disc unproven and not medically  Osteophyte formation necessary for treating single or And both of the following: multiple level degenerative disc  Documented patient history of neck and/or arm pain and/or a disease in skeletally mature functional/neurological deficit associated with the cervical level to be patients treated  Updated supporting information  Failed at least six weeks of non-operative treatment prior to implantation

to reflect the most current clinical (only applicable for elective surgery; emergent surgery or does not evidence, FDA information, and require prior non-operative treatment) references Cervical artificial disc replacement is proven and medically necessary for treating symptoms of degenerative disc disease at one level even if they have radiological evidence of degenerative disc disease at multiple levels. Radiologic evidence of degenerative disc disease is common in persons who are middle aged and older and does not necessarily correlate

with clinical symptoms.

Cervical artificial total disc replacement is proven and medically necessary for treating symptomatic contiguous two level degenerative disc disease in skeletally mature patients when used according to U.S. Food and Drug Administration (FDA) labeled indications. (Note: not all cervical artificial discs have FDA labeling for

contiguous two level degenerative disc disease. Only cervical artificial discs

FDA labeled for contiguous two-level disease are proven and medically

24 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Coverage Rationale Total Artificial Disc July 1, 2016 necessary for this indication. Refer to the FDA section of the policy.) Replacement (continued) Cervical artificial disc replacement at one level combined with cervical spinal fusion surgery at another level (adjacent or non- adjacent) performed at the same surgical setting is unproven and not medically necessary. This is commonly referred to as a hybrid surgery. There is insufficient published clinical evidence in peer-reviewed medical literature demonstrating the safety and efficacy of combination cervical spine surgery at multiple adjacent or non-adjacent levels.

Lumbar artificial total disc replacement is unproven and not medically necessary for treating single or multiple level degenerative disc disease in skeletally mature patients. The long-term clinical outcome of lumbar disc replacement is unclear. The evidence from uncontrolled long-term studies suggests that potential degeneration of adjacent discs and facets and wear of the polyethylene part of the disc may occur and that, in some cases, revision surgery may be needed.

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Ablative Treatment July 1, 2016  Reformatted and reorganized Thermal radiofrequency ablation of facet joint nerves is proven and for Spinal Pain policy; transferred content to medically necessary for chronic cervical, thoracic and lumbar pain new template when confirmed by:  Revised conditions of  Positive response to medial branch block injection at the side and level of

coverage/special considerations; the proposed ablation

added language to indicate:  Confirmation of needle placement by fluoroscopic guided imaging o Precertification is required for  Operative notes document: services covered under the o temperature 60 degrees celsius or more Member's General Benefits o duration of ablation at least 40 seconds package when performed in the office of a participating A repeat thermal radiofrequency ablation of the same facet joint is provider proven and medically necessary when:

o For Commercial plans,  Performed at a frequency of six months or longer (maximum of 2 times precertification is not over a 12 month period), and required, but is encouraged  There has been a 50% or greater documented reduction in pain for 10 to for out-of-network services 12 weeks following the previous ablation. performed in the office that are covered under the Thermal radiofrequency ablation of facet joint nerves is unproven

25 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Ablative Treatment July 1, 2016 Member's General Benefits and not medically necessary: for Spinal Pain package  When there has been no positive response to medial branch block (continued) o If precertification is not injection; or obtained, Oxford may review  When performed more frequently than every six months

for medical necessity after Documentation requirements for the aforementioned procedures must the service is rendered include:

 Revised coverage rationale:  Temperature of administration of procedure o Updated coverage criteria for  Duration of ablation thermal radiofrequency  Specific identification of side and level of medial branch blocks ablation of facet joint nerves;  Specific cervical, thoracic and/or lumbar ablated by side and level replaced criterion requiring:  Percentage of pain relief with prior ablation if applicable . “Temperature of 60  Duration of improvement from previous ablation if applicable. degrees celsius or more”

with “operative notes Thermal radiofrequency ablation is unproven and not medically

documenting necessary for treating ALL other pain indications including but not temperature of 60 limited to: degrees Celsius or more”  Diabetic neuropathy . “Duration of ablation 40 -  Sacroiliac pain 90 seconds” with  Complex regional pain syndrome or regional pain disorders and “operative notes syndromes in the absence of spinal pain documenting duration of  Definitive clinical and/or imaging findings identifying a condition requiring

ablation at least 40 surgical treatment seconds”  Identified specific causes of spinal pain (e.g., disc herniation) requiring o Updated/clarified list of definitive treatment proven/medically necessary indications for a repeat Studies of radiofrequency ablation for other conditions were limited, thermal radiofrequency uncontrolled, and insufficient to support conclusions regarding efficacy or ablation of the same facet duration of effect. Additional well-designed, longer-term randomized joint; replaced “There has controlled trials are required to evaluate the safety and efficacy of

been a 50% or greater radiofrequency ablation and to compare this technique with other medical or documented reduction in pain surgical therapies for pain. for 10 to 12 weeks” with “there has been a 50% or The following ablation procedures are unproven and not medically greater documented necessary for treating spinal pain: reduction in pain for 10 to 12  Pulsed radiofrequency therapy of the facet nerves of the cervical, weeks following the previous thoracic, or lumbar region, sacral nerve root or dorsal root ganglion.

ablation”  Endoscopic radiofrequency ablation (rhizotomy)

o Updated/clarified list of  Cryoablation (cryodenervation, cryoneurolysis, cryosurgery, or unproven/not medically

26 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Ablative Treatment July 1, 2016 necessary indications for cryoanesthesia) for Spinal Pain thermal radiofrequency  Chemical ablation (including but not limited to alcohol, phenol or sodium (continued) ablation of facet joint morrhuate nerves; replaced “there has  Laser ablation (including pulsed, continuous, or low level) been no significant improvement after medial There is insufficient evidence to establish the efficacy of the ablation branch block injection” with therapies bulleted immediately above to reduce or relieve spinal pain. “there has been no positive Studies are limited by small sample size retrospective and case series response to medial branch studies. The clinical value needs to be examined in well-designed, block injection” randomized controlled trials with large sample size and long term follow-up. o Removed language indicating ablation procedures performed more frequently than every 6 months increase the risk of adverse events without improving the clinical outcome o Replaced language indicating “thermal radiofrequency ablation is unproven and not medically necessary for the treatment of all other causes of spinal pain” with “thermal radiofrequency ablation is unproven and not medically necessary for treating all other pain indications”  Reformatted list of applicable CPT codes; removed descriptor classifying codes as “reimbursable” or “non- reimbursable”  Updated supporting information to reflect the most current clinical evidence, FDA information, and references

27 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Cardiology July 1, 2016 Notice of Revision: The following Oxford has engaged eviCore healthcare to perform initial reviews of requests Procedures summary of changes has been for pre-certification (Oxford continues to be responsible for decisions to limit Requiring modified. Revisions to the policy or deny coverage and for appeals). Precertification for update announcement previously

eviCore healthcare appearing in the Policy Update All pre-certification requests are handled by eviCore healthcare. To pre-

Arrangement Bulletin are outlined in red below. certify a cardiology procedure, please contact eviCore healthcare via one of Please take note of the additional the three options below: updates to be implemented on July  Providers can call 1-877-PRE-AUTH (1-877-773-2884); or 1, 2016.  Providers can send a fax to 1-888-622-7369; or  Providers can log onto the eviCore website at www.evicore.com  Reformatted policy; transferred content to new template eviCore healthcare has established correct coding and evidence-based

 Updated benefit considerations; criteria to determine the medical necessity and appropriate billing of added language for Essential cardiology services. These criterions have been carefully researched and are Health Benefits for Individual and continually updated in order to be consistent with the most current evidence- Small Group plans to indicate: based criteria. o For plan years beginning on or after January 1, 2014, the The cardiology evidence-based criteria and management criteria are Affordable Care Act of 2010 available on the eviCore healthcare website at www.evicore.com. (ACA) requires fully insured

non-grandfathered individual Treating Cardiology providers may be asked to submit a clinical submission and small group plans (inside form. The following information/documentation may be required: and outside of Exchanges) to  Copies of office notes and treatment planning documents. provide coverage for ten  Results of key diagnostic studies and/or office notes. categories of Essential Health Benefits (“EHBs”) In conjunction with board certified cardiologists and radiologists, eviCore o Large group plans (both self- healthcare staff will evaluate the submitted treatment and billing plans.

funded and fully insured), Providers will be informed, in writing, as to which services have been and small group ASO plans, approved for payment. are not subject to the requirement to offer Where provided by state regulations, a board certified cardiologist will be coverage for EHBs; however, available to discuss the payment decision with the treating provider. if such plans choose to provide coverage for benefits Privileging and Accreditation Requirements which are deemed EHBs Participating providers will be reimbursed for radiology and cardiology

(such as maternity benefits), services rendered in the office or in an outpatient setting. The following is a the ACA requires all dollar list of services that are payable to participating physicians based on their limits on those benefits to be specialty as well as accreditation/certification requirements are required. removed on all Precertification is required.

28 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale

Cardiology July 1, 2016 Grandfathered and Non- Note: Hospitals are currently excluded from the privileging and accreditation Procedures Grandfathered plans requirements below. Requiring o The determination of which Precertification for benefits constitute EHBs is Exception: Radiologists and cardiologists who are currently participating in eviCore healthcare made on a state by state the Oxford network or wish to participate in the Oxford network and perform Arrangement basis; as such, when using Coronary CT Angiography (CCTA) are required to complete the physician

(continued) this guideline, it is important application from eviCore healthcare. Documents can be sent to a provider to refer to the member upon request or obtained on the eviCore healthcare website at specific benefit plan www.evicore.com. document to determine benefit coverage Privileging requirement for participating providers to perform cardiac  Revised coverage services:

rationale/privileging and accreditation requirements: Modality Privileged o Updated exception language Nuclear Medicine, Cardiac Radiologist to indicate radiologists and CT Scan, PET and MRI Radiology center/facility cardiologists who are Certified cardiologist Cardiovascular disease specialists currently participating in the Oxford network or wish to Diagnostic Cardiac Heart Cardiovascular Disease participate in the Oxford Catheterizations Cardiology Group network and perform Pediatric cardiology Coronary CT Angiography Cardiology

(CCTA) are required to Clinical Cardiac Electro physician complete a physician Cardiac Electrophysiology application from eviCore healthcare; removed Accreditation requirement for participating providers to perform language indicating a cardiac services: Professional Physician Practice Assessment (PPPA) Modality Certification Required is required for hospitals and Nuclear Medicine American Board of Radiology (ABR), cardiologists who wish to American Board of Nuclear Medicine (ABNM), perform Coronary CT American Osteopathic Board of Nuclear Angiography (CCTA) Medicine (AOBNM), Certification Board of Nuclear Cardiology (CBNC), or The Joint o Updated accreditation requirements for participating Commission (TJC)

providers to perform cardiac Cardiac CT Scan ACR (American College of Radiology), IAC services: Cardiac PET (Intersocietal Accreditation Commission), or . Nuclear Medicine: Cardiac MRI The Joint Commission (TJC)

- Updated list of

29 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Cardiology July 1, 2016 acceptable Payment Guidelines Procedures certifications; added  Current Procedural Terminology (CPT) codes that are not subject to Requiring “American TC/PC component may be reimbursed to both the physician and facility Precertification for Osteopathic Board of when billed for the same date of service (DOS). eviCore healthcare Nuclear Medicine  ECG, diagnostic studies, and injection procedures must be billed in Arrangement (AOBNM)” and “The conjunction with an authorized cardiac catheterization code in order to be (continued) Joint Commission reimbursed on the same date of service. When billed in conjunction with (TJC)” an authorized cardiac catheterization, no separate authorization will be . Cardiac CT, Cardiac PET required in addition to the catheterization code for these services. and Cardiac MRI: - Updated list of acceptable certifications ; added “The Joint Commission (TJC)” - Removed notation indicating a Professional Physician Practice Assessment (PPPA) is required for radiology centers and hospitals who wish to perform Coronary CT Angiography (CCTA)

Computerized July 1, 2016  Reformatted and reorganized Computerized dynamic posturography (CDP) testing, also called Dynamic policy; transferred content to balance board testing or equilibrium platform testing (EPT), is Posturography new template unproven and not medically necessary for evaluating any condition  Revised coverage rationale to including but not limited to balance disorders.

indicate computerized dynamic Overall, there is weak evidence in the peer-reviewed literature regarding the posturography (CDP) testing, efficacy of CDP for evaluating vestibular and other disorders. There is a lack also called balance board testing of well-designed, randomized controlled trials (RCTs) with blinded or equilibrium platform testing assessments to demonstrate the diagnostic utility of CDP compared with (EPT), is unproven and not standard tests. Furthermore, there is insufficient evidence demonstrating medically necessary for consistent and beneficial effects of CDP testing on patient-relevant outcomes. evaluating any condition Therefore, CDP is considered unproven and not medically necessary. including but not limited to

balance disorders o Overall, there is weak

30 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Computerized July 1, 2016 evidence in the peer- Dynamic reviewed literature regarding Posturography the efficacy of CDP for (continued) evaluating vestibular and other disorders o There is a lack of well- designed, randomized controlled trials (RCTs) with blinded assessments to demonstrate the diagnostic utility of CDP compared with standard tests o Furthermore, there is insufficient evidence demonstrating consistent and beneficial effects of CDP testing on patient-relevant outcomes o Therefore, CDP is considered unproven and not medically necessary  Modified list of applicable CPT codes: o Removed descriptor classifying codes as “non- reimbursable” o Removed coding clarification notation reiterating computerized dynamic posturography is unproven and not medically necessary for all diagnosis codes  Updated supporting information to reflect the most current clinical evidence, FDA information, and references

31 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Drug Coverage July 1, 2016  Revised list of medications Refer to the policy for Drug Coverage Criteria - New and Therapeutic Criteria - New and requiring precertification through Equivalent Medications. Therapeutic the pharmacy benefit manager Equivalent (PBM):

Medications o Added:

. Aczone 7.5% . Anafranil (Brand Only) . Anusol HC Suppository (Brand Only) . Augmentin (Brand Only) . Augmentin ES-600 (Brand Only)

. Avodart (Brand Only) . Axert (Brand Only) . Betapace (Brand Only) . bexarotene caps (generic Targretin) . Cardizem (Brand only) . Cardizem CD (Brand only)

. Cardizem LA (Brand Only) . Clarifoam EF (Brand Only) . Colazal (Brand Only) . D.H.E. 45 (Brand Only) . Dibenzyline (Brand Only)

. E.E.S. 400 (Brand Only) . Embeda . Exelon Patch (Brand only) . Intermezzo . Invega (Brand Only) . Kenalog Spray (Brand Only)

. Lescol XL (Brand Only) . Librax (Brand Only) . Lodosyn (Brand Only) . Loprox Shampoo (Brand

32 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Drug Coverage July 1, 2016 Only) Criteria - New and . Lotronex (Brand Only) Therapeutic . Metrogel 0.75% Vaginal Equivalent (Brand Only)

Medications . Migranal (Brand Only)

(continued) . Namenda XR . Nuvigil . Onzetra Xsail . Penlac Nail Lacquer (Brand Only) . Proctocort (Brand Only) . rosuvastatin (generic

Crestor) . Synalar 0.01% solution (Brand Only) . Synalar 0.025% cream, ointment (Brand Only) . Tasmar (Brand Only) . Tenoretic (Brand Only) . Tenormin (Brand Only)

. Valcyte (Brand Only) . Vaseretic (Brand Only) . Vasotec (Brand Only) . Wellbutrin (Brand Only) . Xenazine (Brand Only) . Zestoretic (Brand Only) . Zestril (Brand Only)

. Zyvox (Brand Only) o Removed: . Active-Pac/Gaba 300 . Duexis . Molindone . Obredon solution . Provigil (generic) . Seebri Neohaler

. Symbicort . Utibron Neohaler . Viberzi . Vimovo

33 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Drug Coverage July 1, 2016 o Updated formulary Criteria - New and alternatives for: Therapeutic . Augmentin XR Equivalent . Ciclodan Kit Medications . Pedipirox-4 (continued) . Provigil (brand) . Toujeo Solo

REVISED Policy Title Effective Date Drug/Medication Status Summary of Changes Drug Coverage May 10, 2016 Kalydeco (Ivacaftor) Revised  Revised coverage criteria/precertification requirements: Guidelines o Removed reference link to policy titled Prior Authorization/Notification Guidelines: Kalydeco (Ivacaftor) o Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Kalydeco for complete details Drug Coverage June 1, 2016 Daklinza (Daclatasvir) Revised  Revised prior authorization/medical necessity guidelines for New York Guidelines plan members; refer to Prior Authorization/ Medical Necessity Guidelines: Daklinza – NY for complete details Harvoni™ Revised  Revised prior authorization/medical necessity guidelines for New York (Ledipasvir/Sofosbuvir) plan members; refer to Prior Authorization/ Medical Necessity Guidelines: Harvoni – NY for complete details Olysio (Simeprevir) Revised  Revised prior authorization/medical necessity guidelines for New York plan members; refer to Prior Authorization/ Medical Necessity Guidelines: Olysio – NY for complete details Sovaldi (Sofosbuvir) Revised  Revised prior authorization/medical necessity guidelines for New York plan members; refer to Prior Authorization/ Medical Necessity Guidelines: Sovaldi – NY for complete details Technivie (Ombitasvir/ Revised  Revised prior authorization/medical necessity guidelines for New York Paritaprevir/Ritonavir) plan members; refer to Prior Authorization/ Medical Necessity Guidelines: Technivie– NY for complete details Viekira Pak (Ombitasvir, Revised  Revised prior authorization/medical necessity guidelines for New York Paritaprevir (ABT-450) plan members; refer to Prior Authorization/ Medical Necessity and Ritonavir) Guidelines: Viekira Pak – NY for complete details Zepatier (Elbasvir/ Revised  Revised prior authorization/medical necessity guidelines for New York Grazoprevir) plan members; refer to Prior Authorization/ Medical Necessity Guidelines: Zepatier – NY for complete details

34 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Drug/Medication Status Summary of Changes Drug Coverage July 1, 2016 Active-Pac/Gaba 300 Removed  Removed coverage guidelines/drug listing Guidelines (Gabapentin, Lidocaine Hydrochloride, Menthol) Aczone 7.5% (Dapsone) New  Added coverage criteria/precertification requirements: Anafranil (Clomipramine) o Added language to indicate precertification is required through the (Brand) Pharmacy Benefit Manager (PBM) Anusol HC Suppository o Added therapeutic equivalent guidelines; refer to Therapeutic (Brand) (Hydrocortisone) Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Augmentin (Amoxicillin Equivalent Medications for complete details Clavulanate) (Brand)

Augmentin ED-600 New  Added coverage criteria/precertification requirements: (Amoxicillin Clavulanate) o Added language to indicate precertification is required through the (Brand) Pharmacy Benefit Manager (PBM) o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Avodart (Dutasteride) Revised  Revised drug/medication name; added “(Brand)” (Brand)  Revised coverage criteria/precertification requirements: Axert (Almotriptan) o Added therapeutic equivalent guidelines; refer to Therapeutic (Brand) Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Betapace (Sotalol) New  Added coverage criteria/precertification requirements: (Brand) o Added language to indicate precertification is required through the Bexarotene Caps Pharmacy Benefit Manager (PBM) (Generic Targretin) o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Campath (Alemtuzumab) Removed  Removed coverage guidelines/drug listing Cardizem (Diltiazem) New  Added coverage criteria/precertification requirements: (Brand) o Added language to indicate precertification is required through the Cardizem CD (Diltiazem) Pharmacy Benefit Manager (PBM) (Brand) o Added therapeutic equivalent guidelines; refer to Therapeutic Cardizem LA (Diltiazem) Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic (Brand) Equivalent Medications for complete details Clarifoam EF (Sulfacetamide/ Sulfur) (Brand)

35 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Drug/Medication Status Summary of Changes Drug Coverage July 1, 2016 Colazal (Balsalazide) New  Added coverage criteria/precertification requirements: Guidelines (Brand) o Added language to indicate precertification is required through the (continued) Pharmacy Benefit Manager (PBM) o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Compounds and Bulk Revised  Revised prior authorization/notification guidelines; refer to Prior Powders: Various Drugs Authorization/ Notification Guidelines: Compounds and Bulk Powders for complete details Corlanor (Ivabradine) Revised  Revised coverage criteria/precertification requirements; removed therapeutic equivalent guidelines and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications Cymbalta (Duloxetine) Revised  Revised coverage criteria/precertification requirements to indicate (Brand Only) precertification is no longer required; removed therapeutic equivalent guidelines and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications Depakote (Divalproex Revised  Revised prior authorization/medical necessity guidelines; refer to Prior Sodium) Authorization/ Medical Necessity Guidelines: Depakote for complete details Depakote ER (Divalproex Revised  Revised prior authorization/medical necessity guidelines; refer to Prior Sodium Extended Authorization/ Medical Necessity Guidelines: Depakote XR for complete Release) details D.H.E. 45 New  Added coverage criteria/precertification requirements: (Dihydroergotamine) o Added language to indicate precertification is required through the (Brand) Pharmacy Benefit Manager (PBM) Dibenzyline o Added therapeutic equivalent guidelines; refer to Therapeutic (Phenoxybenzamine) Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic (Brand) Equivalent Medications for complete details Duexis (Famotidine and Revised  Revised coverage criteria/precertification requirements to indicate Ibuprofen) precertification is no longer required: o Removed language indicating precertification is required through the Pharmacy Benefit Manager (PBM) o Removed therapeutic equivalent guidelines and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Added notation to indicate prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are excluded from

36 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Drug/Medication Status Summary of Changes Drug Coverage July 1, 2016 Duexis (Famotidine and Revised coverage; refer to the member specific benefit plan document, as Guidelines Ibuprofen) applicable (continued) (continued) Dulera (Mometasone New  Added coverage criteria/precertification requirements: Furoate/Formoterol o Added language to indicate precertification is required through the Fumarate Dihydrate) Pharmacy Benefit Manager (PBM) o Added step therapy guidelines; refer to Step Therapy Guidelines: Dulera for complete details E.E.S. 400 New  Added coverage criteria/precertification requirements: (Erythromycin o Added language to indicate precertification is required through the Ethylsuccinate) (Brand) Pharmacy Benefit Manager (PBM) o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Embeda (Morphine Revised  Revised coverage criteria/precertification requirements: Sulphate and Naltrexone o Added therapeutic equivalent guidelines; refer to Therapeutic HCL) Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Excelon Patch New  Added coverage criteria/precertification requirements: (Rivastigmine) (Brand) o Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM) o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Farydak (Panobinostat) Revised  Revised prior authorization/notification guidelines; refer to Prior Authorization/ Notification Guidelines: Farydak for complete details Felbatol (Felbamate) New  Added coverage criteria/precertification requirements: o Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM) o Added prior authorization/ medical necessity guidelines; refer to Prior Authorization/ Medical Necessity Guidelines: Felbatol for complete details Fluticasone (Topical) Revised  Revised prior authorization/notification guidelines; refer to Prior Authorization/ Notification Guidelines: Compounds and Bulk Powders for complete details Ibrance (Palbociclib) Revised  Revised prior authorization/notification guidelines; refer to Prior Authorization/ Notification Guidelines: Ibrance for complete details

37 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Drug/Medication Status Summary of Changes Drug Coverage July 1, 2016 Intermezzo (Zolpidem Revised  Revised coverage criteria/precertification requirements: Guidelines Tartrate) o Removed step therapy guidelines and corresponding reference link to (continued) policy titled Step Therapy Guidelines: Intermezzo (zolpidem tartrate sublingual tablets) o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Invega (Paliperidone) Revised  Changed dosage form from “oral/injection” to “injection”  Revised list of applicable CPT/HCPCS codes; replaced J8499 with J3490  Changed benefit type from “pharmacy” to “medical” Invega (Paliperidone) New  Added coverage criteria/precertification requirements: (Brand) o Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM) o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Jublia (Efinaconazole) Revised  Revised prior authorization/notification guidelines; refer to Prior Authorization/ Notification Guidelines: Jublia for complete details Kenalog Spray New  Added coverage criteria/precertification requirements: (Triamcinolone) (Brand) o Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM) o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Keppra (Levetiracetam) Revised  Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/ Medical Necessity Guidelines: Keppra for complete details Keppra XR Revised  Revised prior authorization/medical necessity guidelines; refer to Prior (Levetiracetam Extended Authorization/ Medical Necessity Guidelines: Keppra XR for complete Release[XR]) details Kerydin (Tavaborole) Revised  Revised prior authorization/notification guidelines; refer to Prior Authorization/ Notification Guidelines: Kerydin for complete details Lamictal (Lamotrigine) Revised  Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/ Medical Necessity Guidelines: Lamictal for complete details Lamictal ODT Revised  Revised prior authorization/medical necessity guidelines; refer to Prior (Lamotrigine Orally Authorization/ Medical Necessity Guidelines: Lamictal ODT for complete Disintegrating Tablets) details Lamictal XR (Lamotrigine Revised  Revised prior authorization/medical necessity guidelines; refer to Prior Extended Release) Authorization/ Medical Necessity Guidelines: Lamictal XR for complete

38 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Drug/Medication Status Summary of Changes Drug Coverage July 1, 2016 Lamictal XR (Lamotrigine Revised details Guidelines Extended Release) (continued) (continued) Lamotrigine XR Revised  Revised coverage criteria/precertification requirements: o Added prior authorization/notification guidelines; refer to Prior Authorization/ Notification Guidelines: Lamotrigine XR for complete details Lemtrada Updated  Changed title of reference link to related policy from “Precertification (Alemtuzumab) Guidelines: Alemtuzumab” to “Precertification Guidelines: Lemtrada (Alemtuzumab)” Lescol XL (Fluvastatin) Revised  Revised drug/medication name; added “(Brand)” (Brand)  Revised coverage criteria/precertification requirements: o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Librax New  Added coverage criteria/precertification requirements: (Chlordiazepoxide/ o Added language to indicate precertification is required through the Clidinium) (Brand) Pharmacy Benefit Manager (PBM) Lodosyn (Carbidopa) o Added therapeutic equivalent guidelines; refer to Therapeutic (Brand) Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Loprox Shampoo (Brand) Equivalent Medications for complete details Lotronex (Alosetron) Revised  Revised drug/medication name; added “(Brand)” (Brand)  Revised coverage criteria/precertification requirements: o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Lyrica (Pregabalin) Revised  Revised prior authorization/notification guidelines; refer to Step Therapy Guidelines: Lyrica for complete details Metrogel 0.75% Vaginal New  Added coverage criteria/precertification requirements: (Metronidazole) (Brand) o Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM) o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Migranal Revised  Revised drug/medication name; added “(Brand)” (Dihydroergotamine)  Revised coverage criteria/precertification requirements: (Brand) o Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)

39 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Drug/Medication Status Summary of Changes Drug Coverage July 1, 2016 Migranal Revised o Added therapeutic equivalent guidelines; refer to Therapeutic Guidelines (Dihydroergotamine) Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic (continued) (Brand) Equivalent Medications for complete details (continued) Molindone Revised  Revised coverage criteria/precertification requirements to indicate precertification is no longer required: o Removed language indicating precertification is required through the Pharmacy Benefit Manager (PBM) o Removed therapeutic equivalent guidelines and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications Mysoline (Primidone) New  Added coverage criteria/precertification requirements: o Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM) o Added prior authorization/ medical necessity guidelines; refer to Prior Authorization/ Medical Necessity Guidelines: Mysoline for complete details Namenda XR Revised  Revised coverage criteria/precertification requirements: (Memantine o Added language to indicate precertification is required through the Hydrochloride) Pharmacy Benefit Manager (PBM) o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Neurontin (Gabapentin) Revised  Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/ Medical Necessity Guidelines: Neurontin for complete details Ninlaro (Ixazomib) Revised  Revised prior authorization/notification guidelines; refer to Prior Authorization/ Notification Guidelines: Ninlaro for complete details Nuvigil (Armodafinil) Revised  Revised coverage criteria/precertification requirements: o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Obredon Solution Revised  Revised coverage criteria/precertification requirements; removed (Hydrocodone/ therapeutic equivalent guidelines and corresponding reference link to Guaifenesin) policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications Onzetra Xsail New  Added coverage criteria/precertification requirements: (Sumatriptan) o Added language to indicate precertification is required through the

40 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Drug/Medication Status Summary of Changes Drug Coverage July 1, 2016 Onzetra Xsail New Pharmacy Benefit Manager (PBM) Guidelines (Sumatriptan) o Added therapeutic equivalent guidelines; refer to Therapeutic (continued) (continued) Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Oxtellar XR Revised  Revised prior authorization/medical necessity guidelines; refer to Prior (Oxcarbazepine Authorization/ Medical Necessity Guidelines: Oxtellar XR for complete Extended Release) details Penlac Nail Lacquer New  Added coverage criteria/precertification requirements: (Ciclopirox) (Brand) o Added language to indicate precertification is required through the Proctocort Pharmacy Benefit Manager (PBM) (Hydrocortisone) (Brand) o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Provigil (Modafinil) Updated  Revised drug/medication name; added “(Brand)” (Brand) Provigil (Modafinil) Revised  Revised coverage criteria/precertification requirements to indicate (Generic) precertification is no longer required; removed therapeutic equivalent guidelines and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications Qudexy XR (Topiramate) Revised  Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/ Medical Necessity Guidelines: Qudexy XR for complete details Relistor New  Added coverage criteria/precertification requirements: (Methylnatrexone o Added language to indicate precertification is required through the Bromide) Pharmacy Benefit Manager (PBM) o Added prior authorization/ medical necessity guidelines; refer to Prior Authorization/ Medical Necessity Guidelines: Relistor for complete details Rosuvastatin (Generic New  Added coverage criteria/precertification requirements: Crestor) o Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM) o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Seebri Neohaler Revised  Revised coverage criteria/precertification requirements to indicate (Glycopyrrolate) precertification is no longer required: o Removed language indicating precertification is required through the Pharmacy Benefit Manager (PBM)

41 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Drug/Medication Status Summary of Changes Drug Coverage July 1, 2016 Seebri Neohaler Revised o Removed therapeutic equivalent guidelines and corresponding Guidelines (Glycopyrrolate) reference link to policy titled Drug Coverage Criteria - New and (continued) (continued) Therapeutic Equivalent Medications Stavzor (Valproic Acid) Revised  Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/ Medical Necessity Guidelines: Stavzor for complete details Symbicort (Budesonide/ Revised  Revised coverage criteria/precertification requirements to indicate Formoterol Fumarate precertification is no longer required: Dehydrate) o Removed language indicating precertification is required through the Pharmacy Benefit Manager (PBM) o Removed therapeutic equivalent guidelines and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications Synalar (Fluocinolone Removed  Removed coverage guidelines/drug listing Acetonide) Synalar 0.01% Solution New  Added coverage criteria/precertification requirements: (Fluocinolone Acetonide) o Added language to indicate precertification is required through the (Brand) Pharmacy Benefit Manager (PBM) Synalar 0.025% Cream/ o Added therapeutic equivalent guidelines; refer to Therapeutic Ointment (Fluocinolone Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Acetonide) (Brand) Equivalent Medications for complete details Tasmar (Tolcapone) (Brand) Tenoretic (Atenolol/ Chlorthalidone) (Brand) Tenormin (Atenolol) (Brand) Toujeo Solostar (Insulin Updated  Corrected typographical error in drug/medication name Glargine) Topamax (Topiramate) Revised  Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/ Medical Necessity Guidelines: Topamax for complete details Treximet (Sumatriptan Revised  Revised coverage criteria/precertification requirements: Naproxen) o Added precertification guidelines; refer to Precertification Guidelines: Select Brand Medications for complete details Trileptal Revised  Revised prior authorization/medical necessity guidelines; refer to Prior (Oxcarbazepine) Authorization/ Medical Necessity Guidelines: Trileptal for complete details Trokendi XR Revised  Revised prior authorization/medical necessity guidelines; refer to Prior (Topiramate) Authorization/ Medical Necessity Guidelines: Trokendi XR for complete

42 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Drug/Medication Status Summary of Changes Drug Coverage July 1, 2016 Trokendi XR Revised details Guidelines (Topiramate) (continued) (continued) Utibron Neohaler Revised  Revised coverage criteria/precertification requirements to indicate (Indacaterol/ precertification is no longer required: Glycopyrrolate) o Removed language indicating precertification is required through the Pharmacy Benefit Manager (PBM) o Removed therapeutic equivalent guidelines and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications Valcyte (Valganciclovir) New  Added coverage criteria/precertification requirements: (Brand) o Added language to indicate precertification is required through the Vaseretic (Enalapril/ Pharmacy Benefit Manager (PBM) Hydrochlorothiazide) o Added therapeutic equivalent guidelines; refer to Therapeutic (Brand) Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Vasotec (Enalapril) Equivalent Medications for complete details (Brand) Viberzi (Eluxadoline) Revised  Revised coverage criteria/precertification requirements: o Removed therapeutic equivalent guidelines and corresponding reference link to policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications o Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Viberzi for complete details Vimovo (Naproxen Revised  Revised coverage criteria/precertification requirements to indicate Sodium Plus Proton precertification is no longer required: Pump Inhibitor) o Removed language indicating precertification is required through the Pharmacy Benefit Manager (PBM) o Removed therapeutic equivalent guidelines and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Added notation to indicate prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are excluded from coverage; refer to the member specific benefit plan document, as applicable Wellbutrin (Bupropion) Revised  Revised drug/medication name; added “(Brand)” (Brand)  Revised coverage criteria/precertification requirements: o Added therapeutic equivalent guidelines; refer to Therapeutic

43 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Drug/Medication Status Summary of Changes Drug Coverage July 1, 2016 Wellbutrin (Bupropion) Revised Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Guidelines (Brand) Equivalent Medications for complete details (continued) (continued) Xenazine New  Added coverage criteria/precertification requirements: (Tetrabenazine) (Brand) o Added language to indicate precertification is required through the Zestoretic (Lisinopril/ Pharmacy Benefit Manager (PBM) Hydrochlorothiazide) o Added therapeutic equivalent guidelines; refer to Therapeutic (Brand) Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Zestril (Lisinopril) Equivalent Medications for complete details (Brand) Zonegran (Zonisamide) Revised  Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/ Medical Necessity Guidelines: Zonegran for complete details Zylfo and Zylfo CR New  Added coverage criteria/precertification requirements: (Zileuton) o Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM) o Added step therapy guidelines; refer to Step Therapy Guidelines: Zylfo for complete details Zyvox (Linezolid) New  Added coverage criteria/precertification requirements: (Brand) o Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM) o Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Glaucoma Surgical July 1, 2016  Reformatted and reorganized Glaucoma drainage devices, such as the ExPRESS™ mini glaucoma Treatments policy; transferred content to shunt, Molteno implant, Baerveldt tube shunt, Krupin Eye Valve, or new template the Ahmed glaucoma valve implant, are proven and medically  Revised coverage rationale; necessary for treating refractory glaucoma when conventional replaced language indicating medical or surgical treatments have failed or are inappropriate. “glaucoma drainage devices, such as the ExPRESS™ mini The iStent® Trabecular Micro-Bypass Stent System is proven and glaucoma shunt, Molteno medically necessary when used in combination with cataract surgery implant, Baerveldt tube shunt, for treating mild to moderate open-angle glaucoma and a cataract in Krupin Eye Valve, or the Ahmed adults currently being treated with ocular hypotensive medication. glaucoma valve implant, are

44 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Glaucoma Surgical July 1, 2016 proven and medically necessary Glaucoma drainage devices, such as Eyepass, DeepLight SOLX® Gold Treatments for treatment of refractory Shunt and other shunts that do not have FDA approval are (continued) glaucoma when there is investigational and unproven and not medically necessary for intolerance, contraindication, or treating glaucoma. failure of topical or oral Clinical evidence is limited to small studies; therefore, additional studies are medication, when used according needed to establish the safety and efficacy of these devices. to U.S. Food and Drug Administration (FDA) labeled Canaloplasty is proven and medically necessary for the treatment of indications” with “glaucoma primary open-angle glaucoma. drainage devices, such as the ExPRESS™ mini glaucoma shunt, Viscocanalostomy is unproven and not medically necessary for Molteno implant, Baerveldt tube treating glaucoma. shunt, Krupin Eye Valve, or the Evidence from the majority of available randomized controlled trials indicates Ahmed glaucoma valve implant, that viscocanalostomy is not as effective as trabeculectomy in reducing are proven and medically intraocular pressure (IOP). necessary for treating refractory glaucoma when conventional medical or surgical treatments have failed or are inappropriate”  Updated supporting information to reflect the most current description of services, clinical evidence, FDA information, and references In Utero Fetal July 1, 2016  Reformatted and reorganized Intrauterine fetal surgery is considered to be proven and medically Surgery policy; transferred content to necessary for the following indications: new template  Congenital cystic adneomatoid malformation (CCAM) and extralobar  Revised coverage rationale: pulmonary sequestration (EPS): fetal lobectomy or thoracoamniotic shunt o Removed documentation placement for CCAM and thoracoamniotic shunt placement for EPS. requirements for Medical  Sacrococcygeal teratoma (SCT): SCT resection. Director review  Urinary tract obstruction (UTO): urinary decompression via  Reformatted lists of applicable vesicoamniotic shunt placement. CPT and HCPCS codes; removed  Twin-twin transfusion syndrome: fetoscopic laser surgery. descriptor classifying codes as  Twin reversed arterial perfusion (TRAP): ablation or occlusion of “reimbursable” or “non- anastomotic vessels (e.g., laser coagulation or radiofrequency ablation). reimbursable”  Myelomeningocele (MMC) repair.  Updated supporting information to reflect the most current clinical Intrauterine fetal surgery is considered to be unproven and not

45 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale In Utero Fetal July 1, 2016 evidence and references medically necessary for the following indications: Surgery  Congenital diaphragmatic hernia (CDH). There is insufficient evidence (continued) that in utero correction of CDH improves health outcomes for fetuses with CDH compared with standard postnatal surgery. Consistent improvements in survival following in utero fetal surgery have not been observed.  Congenital heart disease (CHD). There is insufficient evidence that in utero fetal surgery for complex heart disease improves health outcomes or survival. Lemtrada July 1, 2016  Changed policy title; previously Lemtrada (alemtuzumab) is proven and medically necessary for (Alemtuzumab) titled Alemtuzumab treatment of relapsing-remitting multiple sclerosis when all of the  Removed reference link to policy following criteria are met: titled Injectable Chemotherapy A. Diagnosis of relapsing-remitting multiple sclerosis (RRMS); and Drugs: Application of NCCN B. One of the following: Clinical Practice Guidelines 1. Treatment - naïve to alemtuzumab:  Revised coverage rationale; a. Member has history of failure following a trial for at least 4 weeks removed coverage criteria for or history of intolerance or contraindication to two of the following: Campath - interferon β-1a (Avonex® or Rebif®))  Updated benefit considerations; - interferon β-1b (Betaseron® or Extavia®) added language for Essential - glatiramer acetate (Copaxone®) Health Benefits for Individual and - dimethyl fumarate (Tecfidera®) Small Group plans to indicate: - teriflunomide (Aubagio®) o For plan years beginning on - fingolimod (Gilenya®) or after January 1, 2014, the - peginterferon beta-1a (Plegridy™) Affordable Care Act of 2010 and (ACA) requires fully insured b. Member has not been previously treated with alemtuzumab; and non-grandfathered individual c. Member is not receiving alemtuzumab in combination with another and small group plans (inside disease modifying agent (e.g., interferon beta preparations, and outside of Exchanges) to glatiramer acetate, natalizumab, fingolimod, or teriflunomide); and provide coverage for ten d. Initial dosing is administered: 12 mg intravenously daily for 5 categories of Essential Health consecutive days; and Benefits (“EHBs”) e. Regimen is administered only once within 12 months o Large group plans (both self- or funded and fully insured), 2. Treatment-experienced with alemtuzumab: and small group ASO plans, a. Member has previously received treatment with alemtuzumab; and are not subject to the b. Member is not receiving alemtuzumab in combination with another requirement to offer disease modifying agent (e.g., interferon beta preparations, coverage for EHBs; however, glatiramer acetate, natalizumab, fingolimod, or teriflunomide); and if such plans choose to c. Retreatment dosing is administered: 12 mg intravenously daily for

46 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Lemtrada July 1, 2016 provide coverage for benefits 3 consecutive days; and (Alemtuzumab) which are deemed EHBs d. Regimen is administered only once within 12 months (continued) (such as maternity benefits), the ACA requires all dollar Coverage of Lemtrada is limited up to two treatment courses (5 day initial limits on those benefits to be and 3 day end course). Requests for additional doses/courses beyond two removed on all courses will not be approved. Grandfathered and Non- Grandfathered plans Alemtuzumab is unproven and not medically necessary for the o The determination of which treatment of: benefits constitute EHBs is  Rheumatoid arthritis made on a state by state  Autoimmune neutropenia basis; as such, when using  Autoimmune hemolytic anemia this guideline, it is important  Pure red cell aplasia to refer to the member  Immune thrombocytopenic purpura specific benefit plan  Evan's syndrome document to determine  Autoimmune pancytopenia benefit coverage  Updated list of applicable ICD-9 codes; removed notation indicating the listed codes are used post-transplant in the absence of complications  Updated supporting information to reflect the most current clinical evidence, FDA information, and references Omnibus Codes July 1, 2016  Revised coverage rationale to Refer to the policy for complete details on the coverage guidelines for reflect quarterly code edits Omnibus Codes. (effective July 1, 2016); added language to indicate the following procedures are unproven/not medically necessary: o Transperineal placement of biodegradable material, peri- prostatic (via needle) (CPT code 0438T) o Percutaneous cryoablation of upper/lower extremity

47 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Omnibus Codes July 1, 2016 distal/peripheral nerve(s), of (continued) nerve plexuses or of other truncal nerves (CPT codes 0440T–0442T) o Real time spectral analysis of prostate tissue by fluorescence spectroscopy (CPT code 0443T) o Placement of drug eluting ocular inserts under the eyelid(s) (CPT codes 0444T and 0445T) Oxford's Outpatient July 1, 2016 Notice of Revision: The following Refer to the policy for complete details on Oxford's Outpatient Imaging Self- Imaging Self- summary of changes has been Referral guidelines. Referral modified. Revisions to the policy update announcement previously

appearing in the Policy Update

Bulletin are outlined in red below. Please take note of the additional updates to be implemented on July 1, 2016.

 Reformatted policy; transferred

content to new template

 Added benefit considerations language for Essential Health Benefits for Individual and Small Group plans to indicate: o For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010

(ACA) requires fully insured

non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”)

48 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Oxford's Outpatient July 1, 2016 o Large group plans (both self- Imaging Self- funded and fully insured), Referral and small group ASO plans, (continued) are not subject to the requirement to offer coverage for EHBs; however, if such plans choose to provide coverage for benefits which are deemed EHBs (such as maternity benefits), the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non- Grandfathered plans

o The determination of which benefits constitute EHBs is

made on a state by state basis; as such, when using

this guideline, it is important to refer to the member specific benefit plan document to determine benefit coverage  Revised coverage rationale for; o Cardiologists - Nuclear Medicine and Cardiologists - Pediatric only to indicate laboratories performing nuclear studies require: . Nuclear medicine certification by the American Board of Radiology (ABR), the American Board of Nuclear Medicine (ABNM), the American Osteopathic Board of

49 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Oxford's Outpatient July 1, 2016 Nuclear Medicine Imaging Self- (AOBNM), the American Referral Osteopathic Board of (continued) Radiology (AOBR), Certification Board for Nuclear Cardiology (CBNC), Royal College of Physicians and Surgeons of Canada (RCPSC), or Le college des Medicine du Quebec (LMQ) . Laboratories accredited by the Intersocietal Commission (IAC Nuclear/PET) for the

Accreditation of Nuclear Laboratories (ICANL),

the American College of Radiology (ACR), The

Joint Commission (TJC), or Radsite in SPECT o Nuclear Medicine to indicate nuclear medicine studies require physicians certified by the American Board of Radiology (ABR), the American Board of Nuclear Medicine (ABNM), Royal College of Physicians and Surgeons of Canada (RCPSC) or Le college des Medicine du Quebec (LMQ) Preventive Care July 1, 2016  Reformatted and reorganized Refer to the policy for complete details on the coverage guidelines for Services policy; transferred content to Preventive Care Services. new template  Revised list of applicable procedure and diagnosis codes: Preventive Care Services

50 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Preventive Care July 1, 2016 o Revised coverage guidelines Services for Colorectal Cancer (continued) Screening: . Updated list of applicable procedure codes for Fecal Occult Blood Testing (FOBT), Sigmoidoscopy, or Colonoscopy: Code Group 1; added S0285 [colonoscopy pre-op consultation (new code effective July 1, 2016)] o Revised service description for Depression in Children and Adolescents (Screening) [previously titled Major Depressive Disorder in Children and Adolescents (Screening)]: . Removed March 2009 USPSTF ‘B’ rating . Added February 2016 USPSTF ‘B’ rating: - The USPSTF recommends screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years; screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up Expanded Women’s Preventive Health

51 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Preventive Care July 1, 2016 o Revised coverage guidelines Services for Contraceptive Methods (continued) (Including Sterilizations): . Updated list of applicable procedure codes for Tubal Ligation Followup Hysterosalpingogram: Code Group 1; added Q9967 (contrast material)  Reformatted Appendix A – USPSTF Grade Definitions Radiology July 1, 2016  Reformatted policy; transferred Refer to the policy for complete details on Radiology Procedures Requiring Procedures content to new template Precertification for eviCore healthcare Arrangement. Requiring  Added benefit considerations Precertification for language for Essential Health eviCore healthcare Benefits for Individual and Small Arrangement Group plans to indicate: o For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”) o Large group plans (both self- funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs; however, if such plans choose to provide coverage for benefits which are deemed EHBs (such as maternity benefits),

52 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Radiology July 1, 2016 the ACA requires all dollar Procedures limits on those benefits to be Requiring removed on all Precertification for Grandfathered and Non- eviCore healthcare Grandfathered plans Arrangement o The determination of which (continued) benefits constitute EHBs is made on a state by state basis; as such, when using this guideline, it is important to refer to the member specific benefit plan document to determine benefit coverage  Revised coverage rationale/accreditation requirements for participating providers: o Removed exception language indicating a Professional Physician Practice Assessment (PPPA) is required for hospitals who wish to perform Coronary CT Angiography (CCTA) o MRI, PET and CT Studies: . Updated language to indicate MRI, PET and CT studies must be performed on an American College of Radiology (ACR), Intersocietal Accreditation Commission (IAC), RadSite, or The Joint Commission (TJC) accredited unit or at accredited facilities o Nuclear Medicine Procedures:

53 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Radiology July 1, 2016 . Updated list of acceptable Procedures accreditations for Requiring facilities [for Precertification for reimbursement of eviCore healthcare procedure codes noted Arrangement with an asterisk (*)]; (continued) added: - Intersocietal Accreditation Commission (IAC) . Updated list of acceptable certifications for radiologists and cardiologists [for reimbursement of procedure codes noted with an asterisk (*)]; added: - American Osteopathic Board of radiology (AOBR) - American Osteopathic Board of Nuclear Medicine (AOBNM) - American Board of Internal Medicine  Updated list of applicable CPT codes; removed 72202, 76070, 76075, 76830, 78110, 78111, 78120, 78121, 78122, 78130, 78135, 78140, 78190, 78191, 78220, 78223, 78270, 78271, 78272, 78350, 78351, 78584, 78585, 78586, 78587, 78588, 78591, 78593, 78594, 78594, G0030, G0031, G0032, G0033, G0034, G0035, G0036, G0037, G0038, G0039, G0040, G0041, G0042, G0043, G0044, G0045,

54 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Radiology July 1, 2016 G0046, G0047, G0125, G0210, Procedures G0211, G0212, G0213, G0214, Requiring G0215, G0216, G0217, G0218, Precertification for G0219, G0220, G0221, G0222, eviCore healthcare G0223, G0224, G0226, G0227, Arrangement G0228, G0229, G0230, G0231, (continued) G0232, G0233, G0234, G0253 and G0254 Select Brand July 1, 2016  Revised coverage rationale; This policy applies to the following brand medications: Medications added language to indicate the  Abilify (aripiprazole) brand medication Treximet will  Aplenzin (bupropion extended-release) be approved for 12 months based  Celexa (citalopram) on both of the following criteria:  Cymbalta (duloxetine) o History of a trial and failure,  Effexor XR (venlafaxine extended-release) intolerance or  Forfivo XL (bupropion extended-release) contraindication to  Lexapro (escitalopram) sumatriptan (generic Imitrex)  Pexeva (paroxetine) coadministered with  Prozac (fluoxetine) naproxen (generic Aleve,  Treximet (sumatriptan/naproxen) Anaprox); and  Wellbutrin SR (bupropion sustained-release) o Submission of medical  Wellbutrin XL (bupropion extended-release) records documenting the  Zoloft (sertraline) inadequate response, intolerance, or The brand medications Abilify, Aplenzin, Celexa, Cymbalta, Effexor XR, contraindication to Forfivo XL, Lexapro, Pexeva, Prozac, Wellbutrin SR, Wellbutrin XL, or sumatriptan co-administered Zoloft will be approved based on one of the following criteria: with naproxen 1. Both of the following: a. History of greater than or equal to 4 week trial of the therapeutically equivalent generic (Document date and duration of trial. For Wellbutrin XL, trial must be in 2014 or later. For Aplenzin and Forfivo XL a trial of bupropion extended-release (generic Wellbutrin XL) is required. For Pexeva a trial of paroxetine (generic Paxil) is required); and b. Submission of medical records documenting the inadequate response to the therapeutically equivalent generic OR 2. Both of the following: a. Documented history of intolerance to the therapeutically equivalent

55 Oxford® Policy Update Bulletin: June 2016

Clinical Policy Updates

REVISED Policy Title Effective Date Summary of Changes Coverage Rationale Select Brand July 1, 2016 generic which is unable to be resolved with attempts to minimize the Medications adverse effects where appropriate (e.g. take with food to minimize (continued) nausea, take prior to bedtime to manage fatigue, take in the morning to manage insomnia, eat high-fiber diet with plenty of water to minimize constipation, etc.); and b. Submission of medical records documenting the adverse effect of the therapeutically equivalent generic

Authorization will be issued for 12 months.

The brand medication Treximet will be approved based on both of the following criteria: a. History of a trial and failure, intolerance or contraindication to sumatriptan (generic Imitrex) coadministered with naproxen (generic Aleve, Anaprox); and b. Submission of medical records documenting the inadequate response, intolerance, or contraindication to sumatriptan co-administered with naproxen

Authorization will be issued for 12 months.

56 Oxford® Policy Update Bulletin: June 2016

Administrative Policy Updates

REVISED Policy Title Effective Date Summary of Changes Administrative Guidelines Accreditation July 1, 2016 Notice of Revision: The following In diagnostic imaging, accreditation programs have emerged as key Requirements for summary of changes has been initiatives to advance the quality and safety of imaging studies. It is Radiology Services modified. Revisions to the policy important that Members receive services from facilities whose equipment, update announcement previously technologists, and physicians are in compliance with established

appearing in the Policy Update accreditation performance standards.

Bulletin are outlined in red below. Please take note of the additional All freestanding facilities and physician offices performing outpatient updates to be implemented on July radiology imaging studies are required to obtain and maintain accreditation 1, 2016. as a condition for reimbursement for the below services.

Changed policy title; previously  Provider Accreditation Modality/Procedure titled Accreditation Requirements Specialty

For Radiologists and Radiology Radiologist, ACR MRI, Breast MRI, CT, *Nuclear

Centers Radiology Medicine, PET, Ultrasound, Breast  Reformatted policy; transferred Facilities, and Ultrasound, Mammography, content to new template Multi-Specialty Stereotactic Biopsy  Updated policy overview to Provider Groups AIUM MRI, CT, *Nuclear Medicine, PET, indicate the purpose of this policy Ultrasound (vascular), is to outline the process and Echocardiography accreditation requirements for ASBS Breast Ultrasound, Stereotactic radiologists, radiology centers Breast Biopsy

and multi-speciality provider IAC MRI, CT, Nuclear Medicine*, PET, groups interested in participating Ultrasound (vascular), in the Oxford network; removed Echocardiography content/language specific to RadSite (except MRI, CT, Nuclear Medicine (SPECT)*, credentialingrequirements cardiac PET  Updated definitions: procedures) o Added definition of: TJC MRI, CT, Nuclear Medicine*, PET, . ASBA: American Society Ultrasound, X-ray, Breast

of Breast Surgeons Ultrasound, Stereotactic Breast

. TJC - The Joint Biopsy Commission

o Removed defintion of: Note: *Nuclear Medicine procedures noted with an * are only reimbursable . ABR - American Board of to radiologists when they have the appropriate certification. Radiology

. ABNM - American Board Please see Radiology Procedures Requiring Precertification for eviCore of Nuclear Medicine healthcare Arrangement for applicable CPT codes. . CBNC - Certification

Board of Nuclear

57 Oxford® Policy Update Bulletin: June 2016

Administrative Policy Updates

REVISED Policy Title Effective Date Summary of Changes Administrative Guidelines Accreditation July 1, 2016 Cardiology (CBNC) Oxford has engaged eviCore healthcare to manage the accreditation process Requirements for [formerly known as the for our provider network. Accreditations should be faxed to eviCore Radiology Services Certification Council of healthcare at 866-699-8160 with the Accreditation Fax Cover sheet that can (continued) Nuclear Cardiology be found on the eviCore healthcare website at www.evicore.com.

(CCNC)]

. CCTA - Coronary CT To ensure prompt handling of the accreditation please ensure that all Angiography applicable facility and physician information is included. . CT-PPPA - Coronary CT Angiography & Cardiac If you have specific questions about the application process for accreditation, CT Professional Physician contact the ACR or IAC on their websites or by phone. For questions about Practice Assessment Oxford’s accreditation requirements, call 1-800-666-1353. . ICANL - The Intersocietal

Commission for the In addition to accreditation, all radiologists and radiology centers in New York Accreditation of Nuclear (NY) and New Jersey (NJ), who are interested in participating in the Oxford Medicine Laboratories network and/or radiologists and radiology centers that already participate in  Revised accreditation the Oxford network and want to add a modality to their practice must also be requirements for radiologists, credentialed. Please refer to the policy titled Credentialing Guidelines: radiology centers and multi- Participation in the eviCore healthcare Network for additional information. speciality provider groups to indicate all freestanding facilities Exception:

and physician offices performing  Radiologists and radiology centers performing outpatient radiology outpatient radiology imaging imaging studies in Connecticut (CT) are excluded from credentialing studies are required to obtain requirements (accreditation requirements are applicable). and maintain accreditation as a  Hospitals performing outpatient radiology imaging studies are excluded condition for reimbursement for from the accreditation requirements. the below services: All radiologists, radiology centers, and cardiologists in NY, NJ and CT who are Accredi Modality/ currently participating in the Oxford network or wish to participate in the -tation Procedure ACR MRI, Breast MRI, CT, Oxford network and perform Coronary CT Angiography (CCTA) must also be

Nuclear Medicine*, PET, credentialed. Refer to the policy titled Credentialing Guidelines: Participation Ultrasound, Breast in the eviCore healthcare Network for additional information.

Ultrasound, Mammography, Stereotactic Biopsy

AIUM MRI, CT, Nuclear

Medicine*, PET, Ultrasound (vascular),

Echocardiography

58 Oxford® Policy Update Bulletin: June 2016

Administrative Policy Updates

REVISED Policy Title Effective Date Summary of Changes Administrative Guidelines Accreditation July 1, 2016 ASBS MRI, CT, Nuclear Requirements for Medicine*, PET, Radiology Services Ultrasound, X-ray Breast (continued) Ultrasound, Stereotactic Breast Biopsy IAC MRI, CT, Nuclear Medicine (SPECT)*, PET, Ultrasound (vascular), Echocardiography RadSite Ultrasound MRI, CT, (except Nuclear Medicine cardiac (SPECT)*, PET proced ures) TJC MRI, CT, Nuclear Medicine*, PET, Ultrasound, X-ray, Breast Ultrasound, Stereotactic Breast Biopsy *Nuclear Medicine procedures are only reimbursable to radiologists when they have the appropriate certification.

Autism July 1, 2016  Reformatted and reorganized Refer to the policy for complete details on the coverage guidelines for policy; transferred content to treatment of Autism. new template  Revised coverage rationale: o Updated coverage guidelines for Applied Behavioral Analysis (ABA) Therapy for New York plan members; added language to indicate no benefit limits apply for plan years on or after January 1, 2016

59 Oxford® Policy Update Bulletin: June 2016

Administrative Policy Updates

REVISED Policy Title Effective Date Summary of Changes Administrative Guidelines Credentialing July 1, 2016  Reformatted policy; transferred Oxford has engaged eviCore healthcare (eviCore) to perform Credentialing as Guidelines: content to new template well as Quality and Equipment review of Outpatient Diagnostic Radiology Participation in the  Revised process and credentialing Centers who participate or wish to participate in the Oxford network. eviCore healthcare guidelines for radiologists and The minimum standards for consideration into the Oxford network can be Network cardiologists interested in found at http://www.evicore.com/solution/Pages/Radiology.aspx. participating in the eviCore Healthcare Network for Oxford Radiology centers in New York (NY) and New Jersey (NJ) who are interested o Updated reference link to in participating in the Oxford network and radiology centers that already eviCore.com for information participate in the Oxford network and want to add a modality to their on minimum standards to practice are required to email the eviCore Provider Contracting Services participate in the Oxford (PCS) Department at [email protected] stating the nature of the request network along with the name, address and contact email for facility. Credentials to o Updated credentialing access the online Facility Application will then be forwarded to the requestor request guidelines: via email. . Removed language indicating current or new Exception: Radiology centers performing outpatient radiology imaging Oxford providers in NY, studies in Connecticut (CT) are excluded from the above credentialing NJ and CT performing requirements.

Coronary CT Angiography Interpreting radiologists at facilities that are applying for a contract who are (CCTA) are required to not currently credentialed by eviCore will need to complete a Physician complete the Coronary Application and complete the physician credentialing process. CT Angiography & Cardiac CT Professional Physician Practice Assessment (CT-PPPA) from eviCore Healthcare . Added language to indicate: - Radiology centers in New York (NY) and New Jersey (NJ) who are interested in participating in the Oxford network and radiology centers that already participate in the Oxford network and want to add a modality to their

60 Oxford® Policy Update Bulletin: June 2016

Administrative Policy Updates

REVISED Policy Title Effective Date Summary of Changes Administrative Guidelines Credentialing July 1, 2016 practice are required Guidelines: to email the eviCore Participation in the Provider Contracting eviCore healthcare Services (PCS) Network Department at (continued) [email protected] stating the nature of the request along with the name, address and contact email for facility; credentials to access the online Facility Application will then be forwarded to the requestor via email - Interpreting radiologists at facilities that are applying for a contract who are not currently credentialed by eviCore will need to complete a Physician Application and complete the physician credentialing process

61 Oxford® Policy Update Bulletin: June 2016

Reimbursement Policy Updates

NEW Policy Title Effective Date Reimbursement Guidelines Consultation July 1, 2016 Consultation Services Services The American Medical Association (AMA) Current Procedural Terminology (CPT ®) book describes a consultation as a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient's entire care or for the care of a specific condition or problem.

Oxford will consider a claim for a consultation service for reimbursement if the requesting physician or other qualified source is identified on the claim.

Services initiated by a patient and/or family and not requested by a physician or other appropriate source should not be reported using CPT consultation codes 99241-99245 or 99251-99255 or HCPCS consultation codes G0406-G0408 or G0425-G0427, but may be reported using appropriate office visit, hospital care, home service or domiciliary/rest home care codes.

Note: AMA guidelines state that only one inpatient consultation (99251-99255) should be reported by a consultant per admission. Evaluation and Management (EM) services after the initial consultation during a single admission should be reported using non-consultation EM codes.

\ UPDATED Policy Title Effective Date Summary of Changes Reimbursement Guidelines Add-On Policy June 1, 2016  Reformatted and reorganized The basis for add-on codes is to enable physicians or other health care policy; transferred content to professionals to separately identify a service that is performed in certain new template situations as an additional service or a commonly performed supplemental  Routine review; no content service complementary to the primary service/procedure.

changes Oxford follows the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) with respect to the reporting of "add- on" CPT and HCPCS codes. Per CPT add-on codes describe additional intra- service work associated with a primary procedure/service, are always reported in addition to the primary service/procedure, and must be performed by the Same Individual Physician or Other Health Care Professional reporting the primary service/procedure. Many add-on codes are designated by the AMA with a "+" symbol and are

also listed in Appendix D of the CPT book. CMS assigns add-on codes a Global Days indicator of "ZZZ" on the CMS National Physician Fee Schedule (NPFS).

In some instances, a Definitive Source specifies the primary procedure/service codes that must be reported in conjunction with a given

62 Oxford® Policy Update Bulletin: June 2016

Reimbursement Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Reimbursement Guidelines Add-On Policy June 1, 2016 add-on code. (continued) In other situations, a primary/add-on code relationship may exist but the guidance from CPT or CMS is not as well-defined. Specifically, the code

description does not directly identify the add-on code or identify any specific

primary codes that correspond with that code. In those instances an interpretation is necessary utilizing CPT, CMS and/or specialty society guidelines. Oxford will interpret these sources to identify additional primary/add-on relationships. For these code pairs, Oxford also requires that the add-on code must be reported with a given primary procedure/service code. Please see the Definitions section of the policy for further explanations of Definitive and Interpretative sources.

Key phrases to identify add-on codes when not specified in the code description include, but are not limited to, the following:  List separately in addition to; and  Each additional; and  Done at time of other major procedure.

Unless otherwise specified within this policy, add-on procedures must be

reported with the primary procedure for the same date of service.

Mohs Micrographic Surgery The Mohs micrographic surgery codes (CPT codes 17311, +17312, 17313, +17314, +17315), describe procedures that involve surgery and pathology services performed together by the same individual physician. In some instances, the Mohs surgical procedure may extend beyond the initial date of

service, thus there are 3 add-on codes (+17312, +17314 and +17315) that might be performed on a different date of service than their primary procedure. Consistent with the November 2006 CPT Assistant, the add-on code should be reported on same claim as the primary Mohs procedure even though the dates of service may differ.

Critical Care Services (CPT Codes 99291, +99292) Critical care codes are time based Evaluation and Management (E/M)

services. CPT code 99291 is reported for the first 30-74 minutes of care; add-on code +99292 is reported for each additional 30 minutes. Oxford will reimburse for critical care add-on services (code +99292) in the following situations:

63 Oxford® Policy Update Bulletin: June 2016

Reimbursement Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Reimbursement Guidelines Add-On Policy June 1, 2016  The Same Individual Physician or Other Health Care Professional (continued) reporting provides more than 74 minutes, thus submitting add-on code +99292 indicating each additional 30 minutes of care beyond the first 74 minutes.  The Same Specialty Physician or Other Health Care Professionals each supplying critical care services for the same patient on the same date of service may report using one of the following methods: o The primary code 99291 is reported by physician or other healthcare professional that provides the first 30-74 minutes of critical care. The add-on code +99292 is reported for each additional 30 minutes of care beyond the first 74 minutes of critical care when provided by the Same Specialty Physician or Other Health Care Professional. o A single physician may report all critical care service codes on behalf of the other members within the same group/same specialty.  The Same Group Physician and/or Other Health Care Professionals each supplying critical care services for the same patient on the same date of service would each individually report their own critical care services. For example, two physicians within the same provider group, but of different specialties each provide critical care services for the same patient on the same date of service. Because the physicians are of different specialties, each would report their critical care services separately. Both physicians may individually report code 99291, and +99292 for each additional 30 minutes of critical care services depending of the length of services provided by each physician.

Note: For reimbursement policies regarding add-on CPT code 69990, refer to the policy titled Microsurgery.

Co-Surgeon/Team June 1, 2016  Reformatted and reorganized Co-Surgeon Services Surgeon policy; transferred content to Modifier 62 identifies a Co-Surgeon involved in the care of a patient at new template surgery. Each Co-Surgeon should submit the same Current Procedural  Revised Co-Surgeon Eligible List Terminology (CPT) code with modifier 62.

(attachment file listing

procedures allowed for co- For services included on the Co-Surgeon Eligible List, Oxford will reimburse surgeon reimbursement); Co-Surgeon services at 63% of the Allowable Amount to each surgeon removed 37250, 37251, 47136, subject to additional multiple procedure reductions if applicable (see Multiple 47630, 67112, 77776, 77777 and Procedure Reduction section of this policy). The Allowable Amount is G6021 determined independently for each surgeon and is calculated from the  Revised Team Surgeon Eligible Allowable Amount that would be given to that surgeon performing the

64 Oxford® Policy Update Bulletin: June 2016

Reimbursement Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Reimbursement Guidelines Co-Surgeon/Team June 1, 2016 List (attachment file listing surgery without a Co-Surgeon. The reimbursable percentage amount (63%) Surgeon procedures allowed for surgical of allowable is based on the rate adopted by the Centers for Medicare and (continued) team reimbursement); removed Medicaid Services (CMS), which allows 62.5% of allowable to each Co- 47136 and G6021 Surgeon.

Exception: For New Jersey individual and small group plans, standard reimbursement is based on the 80th percentile of Prevailing Healthcare Charges System (PHCS).

Team Surgeon Services Modifier 66 identifies Team Surgeons involved in the care of a patient during surgery. Each Team Surgeon should submit the same CPT code with modifier

66.

Each Team Surgeon is required to submit written medical documentation describing the specific surgeon's involvement in the total procedure. For services included on the Team Surgeon Eligible List, Oxford will review each submission with its appropriate medical documentation and will make reimbursement decisions on a case-by-case basis.

Co-Surgeon and Team Surgeon Eligible Lists The Co-Surgeon and Team Surgeon Eligible List are developed based on the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS) Relative Value File status indicators.

All codes in the NPFS with status code indicators "1" or "2" for "Co-Surgeons" are considered by Oxford to be eligible for Co-Surgeon services as indicated

by the co-surgeon modifier 62.

Oxford applies the payment indicators for HCPCS codes G0412-G0415 when adjudicating CPT codes 27215-27218 for the purposes of this policy.

All codes in the NPFS with the status code indicators "1" or "2" for "Team Surgeons" are considered by Oxford to be eligible for Team Surgeon services as indicated by the team surgeon modifier 66.

CMS Files for Download

Multiple Procedure Reductions

65 Oxford® Policy Update Bulletin: June 2016

Reimbursement Policy Updates

UPDATED Policy Title Effective Date Summary of Changes Reimbursement Guidelines Co-Surgeon/Team June 1, 2016 Multiple procedure reductions apply to Co-Surgeon and Team Surgeon claim Surgeon submissions when one or more physicians are billing multiple CPT codes that (continued) are eligible for reductions. Refer to Oxford Multiple Procedures for application of multiple procedure reductions.

Assistant Surgeon and Co-Surgeon Services During the Same Encounter Oxford follows CMS guidelines and does not reimburse for Assistant Surgeon services, as indicated by modifiers 80, 81, 82, or AS, for procedures where reimbursement has been provided for eligible Co-Surgeon services, using the same surgical procedure code, during the same encounter.

If a Co-Surgeon acts as an Assistant Surgeon in the performance of additional procedure(s) during the same surgical session, the procedures are reimbursable services (if eligible per the Assistant Surgeon Eligible List) when indicated by separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.

Simultaneous Bilateral Services Simultaneous bilateral services are those procedures in which each surgeon performs the same procedure on opposite sides. Each surgeon should report the simultaneous bilateral procedures with modifiers 50 and 62. Assistant Surgeon services will not be reimbursed services in addition to the simultaneous bilateral submission as described in the Assistant Surgeon and Co-Surgeon Services During Same Encounter section of the policy.

REVISED Policy Title Effective Date Summary of Changes Reimbursement Guidelines In-Office July 1, 2016  Reformatted and reorganized In Office Laboratory Testing and Procedures Laboratory Testing policy; transferred content to Reimbursement of network physicians for the performance of in-office and Procedures List new template laboratory testing/procedures is limited to those codes listed on the In-  Removed reference links to Office Laboratory Testing and Procedures List. Reimbursement for some of policies titled: the Laboratory testing/procedures is limited to certain physician specialties. o Infertility Procedures Refer to the Applicable Codes section of the policy for a list of specific CPT Requiring Notification and/or codes. Precertification o Laboratory Services Protocol All in office laboratory testing/procedures; o Treatment of Infertility  Marked with *, **, ***, ****, ***** will be limited to one procedure

66 Oxford® Policy Update Bulletin: June 2016

Reimbursement Policy Updates

REVISED Policy Title Effective Date Summary of Changes Reimbursement Guidelines In-Office July 1, 2016 o Treatment of Infertility for within the same family of asterisks, per visit. Laboratory Testing New Jersey Large Groups (Example: All laboratory testing/procedure codes that are marked with and Procedures List o Treatment of Infertility for one * will only be allowed to have one laboratory test/procedure (continued) New York Small and Large performed, per visit, out of all of the codes designated with the single*.) Groups  Marked with a # symbol, will only be considered for reimbursement if the o Treatment of Infertility for Member has an infertility benefit and the provider has the appropriate Connecticut Groups specialty. Refer to the policy titled Infertility Diagnosis and Treatment for  Added reference links to policies additional information related to infertility coverage. titled: o Infertility Diagnosis and Specimen Handling and Venipuncture Treatment When specimen handling and venipuncture codes are billed; o New York Participating  With a laboratory/procedure code on the In-office Laboratory Testing and Provider Laboratory & Procedures List, only the laboratory testing/procedure and venipuncture Pathology Protocol codes will be considered for reimbursement. Note: The laboratory  Added policy application testing/procedure code will only be considered for reimbursement if the language to indicate: code is listed in the Applicable Codes section of the policy and the o This policy applies to all provider has the appropriate specialty, if required. network physicians providing  Without a laboratory testing/procedure code on the In-Office Laboratory laboratory testing/procedures Testing and Procedures List or with other non-laboratory provided in an office setting testing/procedure services, the specimen handling and venipuncture o Certain physician contracts codes will be considered for reimbursement. allow for additional laboratory testing/procedures that Oxford to be considered for reimbursement when provided in the physician’s office; review the provider contract for additional coverage guidelines  Revised policy overview language; added instuction to: o Refer to the policy titled New York Participating Provider Laboratory & Pathology Protocol for additional information on participating provider repsponsibilities for New York plan members o Refer to the Provider

67 Oxford® Policy Update Bulletin: June 2016

Reimbursement Policy Updates

REVISED Policy Title Effective Date Summary of Changes Reimbursement Guidelines In-Office July 1, 2016 Administrative Guide for Laboratory Testing additional information on and Procedures List participating provider (continued) responsibilities for all Connecticut and New York plan members  Revised reimbursement guidelines to indicate: o Reimbursement to network physicians for in-office laboratory testing/procedures is limited to codes on the In- Office Laboratory Testing and Procedures List . Reimbursement for some laboratory testing/procedures is limited to certain physician specialties . Refer to the Applicable Codes section of the policy for the list of specific CPT codes o When specimen handling and venipuncture codes are billed; . With a laboratory/procedure code on the In-office Laboratory Testing and Procedures List, only the laboratory testing/procedure and venipuncture codes will be considered for reimbursement - The laboratory testing/procedure

68 Oxford® Policy Update Bulletin: June 2016

Reimbursement Policy Updates

REVISED Policy Title Effective Date Summary of Changes Reimbursement Guidelines In-Office July 1, 2016 code will only be Laboratory Testing considered for and Procedures List reimbursement if the (continued) code is listed in the Applicable Codes section of the policy and the provider has the appropriate specialty, if required . Without a laboratory testing/procedure code on the In-Office Laboratory Testing and Procedures List or with other non-laboratory testing/procedure services, the specimen handling and venipuncture codes will be considered for reimbursement  Reformatted and revised In- Office Laboratory Testing and Procedures List: o Updated table sub-header; replaced “Ophthalmologists” with “Ophthalmologists and Connecticut CLIA Certified Optometrists” o Added list applicable codes for Ophthalmologists and Optometrists: 83516 and 87809

One or More June 1, 2016 Notice of Revision: The following Oxford will reimburse a CPT or HCPCS code only once during the Defined Sessions summary of changes has been Treatment or Monitoring Period. modified. The revision noted in red The Defined Treatment Period mirrors the National Physician Fee Schedule below will not be applied on June 1, (NPFS) global fee period. The Monitoring Period is in accordance with the 2016 as previously announced.

69 Oxford® Policy Update Bulletin: June 2016

Reimbursement Policy Updates

REVISED Policy Title Effective Date Summary of Changes Reimbursement Guidelines One or More June 1, 2016  Reformatted policy; transferred code description and/or coding guidelines. Sessions content to new template National Physician Fee Schedule (continued)  Updated Questions and Answers; added Q&A #5 to indicate: Multiple submissions of the same CPT or HCPCS code by the Same Physician, o Q5: When does the defined Hospital, Ambulatory Surgical Center or Other Health Care Professional for treatment or monitoring the same patient during the Defined Treatment Period or Monitoring Period period of a procedure begin will be denied as part of the global service unless an appropriate modifier is and end? reported. Refer to the Modifiers and Attachments sections of the policy. o A5: The defined treatment or monitoring period begins the Services addressed in the One or More Sessions Policy may also be subject day of the procedure and to global surgical package guidelines. Please refer to the Global Days policy then 10, 30 or 90 days for additional information. before the procedure and following the procedure, Modifiers beginning the first day of the Modifiers offer the physician, hospital, ambulatory surgical center or procedure [example: a healthcare professional a way to identify that a service or procedure has procedure having a defined been altered in some way. Under appropriate circumstances, modifiers treatment or monitoring should be used to identify unusual circumstances, staged or related period of 90 days is procedures, distinct procedural services or separate anatomical location(s). performed on 10/1; procedures reported on 10/1 Oxford recognizes the following designated modifiers, when appropriately and during the 90-day reported, under this reimbursement policy: treatment or monitoring period before and after (7/3 Modifier Description Left side (used to identify procedures performed on through and including 12/30) LT are included in the treatment the left side of the body) Right side (used to identify procedures performed or monitoring period] RT  Revised One or More Sessions on the left side of the body) Policy List (attachment file listing 50 Bilateral procedure codes with a defined treatment or 52 Reduced services monitoring period): 53 Discontinued procedure o Added A0000 54 Surgical care only o Removed 65855 55 Postoperative management only 56 Preoperative management only Unrelated Procedure or Service by the Same 79 Physician or Other Qualified Health Care Professional During the Postoperative Period

70 Oxford® Policy Update Bulletin: June 2016

Reimbursement Policy Updates

REPLACED Policy Title Effective Date Summary of Changes Inpatient July 1, 2016  Policy replaced; refer to the policy titled Consultation Services for details on applicable reimbursement guidelines. Consultations

71 Oxford® Policy Update Bulletin: June 2016