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Oxford® Policy Update Bulletin: June 2016

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Oxford® Policy Update Bulletin: June 2016 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. 2 Oxford® Policy Update Bulletin: June 2016 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) ...................................................................................................................................
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