Health Evidence Review Commission's Value-based Benefits Subcommittee September 28, 2017 8:00 AM - 1:00 PM Clackamas Community College Wilsonville Training Center, Room 111-112 29373 SW Town Center Loop E, Wilsonville, Oregon, 97070 Section 1.0 Call to Order AGENDA VALUE-BASED BENEFITS SUBCOMMITTEE September 28, 2017 8:00am - 1:00pm Wilsonville Training Center, Rooms 111-112 29353 SW Town Center Loop E Wilsonville, Oregon 97070 A working lunch will be served at approximately 12:00 PM All times are approximate I. Call to Order, Roll Call, Approval of Minutes – Kevin Olson 8:00 AM II. Staff report – Ariel Smits, Cat Livingston, Darren Coffman 8:05 AM A. Chronic Pain Task Force meeting report B. Errata C. Retreat III. Straightforward/Consent agenda – Ariel Smits 8:15 AM A. Consent table B. Straightforward Modifications to the Prioritized List Changes: Continuous Glucose Monitoring in Diabetes Mellitus C. Straightforward changes to the PPI guideline for Barrett’s esophagus with dysplasia D. Tobacco cessation guideline clarification IV. Advisory Panel reports 8:25 AM A. OHAP 1. 2018 CDT code placement recommendations V. Previous discussion items 8:30 AM A. Consideration for prioritization on lines 500/660, Services with Minimal or No Clinical Benefit and/or Low Cost-Effectiveness 1. New medications for the treatment of Duchenne muscular dystrophy i. deflazacort (Emflaza) ii. etepliren (Exondys 51) VI. New discussion items 9:30 AM A. Testicular prostheses B. Capsulorrhaphy for recurrent shoulder dislocation C. Transcutaneous neurostimulators D. Physical therapy for interstitial cystitis E. Acute peripheral nerve injuries F. SOI on role of Prioritized List in Coverage G. Graphs, flaps and pedicles Health Evidence Review Commission (503) 373-1985 H. IT band syndrome VII. Coverage guidances 11:30 AM A. Colon cancer screening modalities VIII. Public comment 12:55 PM IX. Adjournment – Kevin Olson 1:00 PM Health Evidence Review Commission (503) 373-1985 Value-based Benefits Subcommittee Recommendations Summary For Presentation to: Health Evidence Review Commission on August 10, 2017 For specific coding recommendations and guideline wording, please see the text of the 08/10/2017 VbBS minutes. RECOMMENDED CODE MOVEMENT (effective 10/1/2017 unless otherwise noted) • Various straightforward coding changes were made • Add limited coverage for lattice degeneration • Move the frenotomy procedure code from one uncovered line to another, more appropriate uncovered line • Add coverage for orthodontics for patients with craniofacial anomalies with a new guideline. Add additional facial and dental reconstruction procedures codes for these patients as well. [effective January 1, 2018] • Add the HCPCS code for counseling for alcohol misuse to the substance use disorder line • Psychological testing CPT codes were made diagnostic rather than included on the Prioritized List or Ancillary File • Re-add the HCPCS code for supported employment to the lines where it appeared on the October, 2016 Prioritized List and remove from the Ancillary File • Add the 2018 ICD-10 codes to various HSD files and lines on the Prioritized List • Delete the remaining CPT codes for sinus surgery from the acute sinusitis line • Move recurrent acute rhinosinusitis (RARS) from the acute sinusitis line to the chronic sinusitis line • Delete the procedure codes for insertion, maintenance and removal of intrathecal/epidural pumps from the central nervous system (CNS) cancer lines due to no longer being used for this indication • Delete the procedure codes for orthoptic and/or pleoptic training from all but 1 line with a coding specification limiting use to 3 diagnoses RECOMMENDED GUIDELINE CHANGES (effective 10/1/2017 unless otherwise noted) • Add a new guideline regarding lattice degeneration, round holes, and retinal tears • Edit the frenulectomy guideline to add a CDT code • Edit the preventive dental guideline to delete reference to dental assessments and to add a CPT procedure code in place of a CDT code • Edit the silver diamine fluoride guideline to specify that this application is only covered for the treatment of caries, not for the prevention of caries • Add a new multisector intervention statement on the Prevention of Early Childhood Caries • Edit the acupuncture guideline to correct the line number for post-stroke depression and to soften the visit limits for this diagnosis • Edit the sinus surgery guideline note to clarify when recurrent acute rhinosinusitis and chronic sinusitis qualify for surgery Value-based Benefits Subcommittee Summary Recommendations, 8/10/2017 • Add a new guideline clarifying coverage for insertion, maintenance and removal of intrathecal/epidural pump systems for medical delivery • Make extensive edits to the spine surgery guideline to improve readability and to clarify intent • Make extensive edits to the new guidelines on services with minimal or no clinical benefit and/or low cost-effectiveness; the previous Services Recommended for Non-Coverage entries were incorporated into these guidelines [effective January 1, 2018] • Edit the enzyme replacement therapy guideline to clarify which lines were referenced • Edit the continuous glucose monitoring guideline to broaden coverage to a larger group of patients with type 1 diabetes [effective January 1, 2018] VALUE-BASED BENEFITS SUBCOMMITTEE Clackamas Community College Wilsonville Training Center, Rooms 111-112 Wilsonville, Oregon August 10, 2017 8:00 AM – 1:00 PM Members Present: Kevin Olson, MD, Chair; David Pollack, MD; Susan Williams, MD (via phone); Mark Gibson; Holly Jo Hodges, MD; Gary Allen, DMD. Members Absent: Vern Saboe, DC; Irene Croswell, RPh. Staff Present: Darren Coffman; Ariel Smits, MD, MPH; Cat Livingston, MD, MPH; Denise Taray, RN; Daphne Peck (via phone). Also Attending: Kim Wentz, MD, MPH and Bruce Austin, DMD (via phone)( OHA HSD); Judah Garfinkle, DDS (via phone); Andreas Lauer, MD (via phone) (OHSU); Laura Keller (American Diabetes Association); Carly Rodriguez and Jim Rickards, MD (MODA Health); Mike Donabedian and Lisa Borland (Sarepta Therapeutics); Jamie Saukko; Billy Ellsworth; Terri Ellsworth; Tomas Welken, MD and Elena Burns (Dexcom). Roll Call/Minutes Approval/Staff Report The meeting was called to order at 8:15 am and roll was called. Minutes from the May 18, 2017 VbBS meeting were reviewed and approved. Smits reviewed the errata and there were no questions or concerns. Coffman announced that Pollack is resigning from VbBS at the end of the year due to retirement. Pollack has been a member of HSC/HERC or one of their subcommittees since the inception of OHP legislation in 1989. He was thanked for his extensive service. Coffman also announced that Croswell’s term is completed at the end of the year and he is working with the pharmacy board to identify a new pharmacy member for VbBS. Value-based Benefits Subcommittee Minutes, 8/10/2017 Page 3 Topic: Straightforward/Consent Agenda Discussion: There was no discussion about the consent agenda items. Recommended Actions: 1) Add 44310 (Ileostomy or jejunostomy, non-tube) to line 220 CANCER OF STOMACH 2) Add 35251 (Repair blood vessel with vein graft; intra-abdominal) and 35281 (Repair blood vessel with graft other than vein; intra-abdominal) and 64680 (Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus) to line 321 CANCER OF PANCREAS 3) Add 38542 (Dissection, deep jugular node(s)) to line 280 CANCER OF SKIN, EXCLUDING MALIGNANT MELANOMA 4) Add 49255 (Omentectomy, epiploectomy, resection of omentum) to line 243 CANCER OF OVARY 5) Add 67840 (Excision of lesion of eyelid (except chalazion) without closure or with simple direct closure) to line 280 CANCER OF SKIN, EXCLUDING MALIGNANT MELANOMA 6) Add 92002-92014 (Ophthalmological services: medical examination and evaluation) and 92081-92083 (Visual field examination) to line 130 BENIGN NEOPLASM OF THE BRAIN AND SPINAL CORD 7) Add 65435 (Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage)) and 65450 (Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization) to line 117 CANCER OF EYE AND ORBIT 8) Add 99356 and 99357 (Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service) to all lines containing other prolonged E&M inpatient CPT codes (i.e., 99358 and 99359) on which 99356 and 99357 do not already appear 9) Add 99468-99480 (Initial/subsequent inpatient neonatal critical care) to line 152 ACQUIRED HEMOLYTIC ANEMIAS 10) Remove 49424 (Contrast injection for assessment of abscess or cyst via previously placed drainage catheter or tube) from lines 51,105,368,427,570,574 a. Advise HSD to place 49424 on the Diagnostic Procedures File 11) Add 13133 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less) and 99406 & 99407 (Smoking and tobacco use cessation counseling visit; intermediate) to line 1 PREGNANCY 12) Add 99460-99463 (Initial and subsequent hospital or birthing center care, per day, for evaluation and management) to lines 23 LOW BIRTH WEIGHT (1500-2500 GRAMS), 105 CONGENITAL ANOMALIES OF DIGESTIVE SYSTEM AND ABDOMINAL WALL EXCLUDING NECROSIS; CHRONIC INTESTINAL PSEUDO-OBSTRUCTION, and 146 CONDITIONS INVOLVING THE TEMPERATURE REGULATION OF NEWBORNS 13) Add 97530 (Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes) to line 353 MILD/MODERATE BIRTH TRAUMA FOR BABY