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April 2018policy update bulletinMedical & Administrative Policy UpdatesUnitedHealthcare respects the expertise of the physicians, health care professionals, and their staff who participate in our network. Our goal is tosupport you and your patients in making the most informed decisions regarding the choice of quality and cost-effective care, and to support practicestaff with a simple and predictable administrative experience. The Policy Update Bulletin was developed to share important information regardingOxford Medical and Administrative Policy.**Where information in this bulletin conflicts with applicable state and/or federal law, UnitedHealthcare follows such applicable federal and/or state law
OxfordOxford Medical and Administrative Policy UpdatesOverviewThis bulletin provides complete details on Oxford Clinical,Administrative and Reimbursement Policy updates. The inclusion ofa health service (e.g., test, drug, device or procedure) in thisbulletin indicates only that UnitedHealthcare has recently adopted anew policy and/or updated, revised, replaced or retired an existingpolicy; it does not imply that Oxford provides coverage for thehealth service. In the event of an inconsistency or conflict betweenthe information provided in this bulletin and the posted policy, theprovisions of the posted policy will prevail. Note that most benefitplan documents exclude from benefit coverage health servicesidentified as investigational or unproven/not medically necessary.Physicians and other health care professionals may not seek orcollect payment from a member for services not covered by theapplicable benefit plan unless first obtaining the member’s writtenconsent, acknowledging that the service is not covered by thebenefit plan and that they will be billed directly for the service.A complete library of Oxford Medical andAdministrative Policies is available atOxfordHealth.com Providers Tools & Resources Medical Information Medical and Administrative Policies.Tips for using the Policy Update Bulletin:2 From the table of contents, click the policy title to bedirected to the corresponding policy update summary. From the policy updates table, click the policy title to view acomplete copy of a new, updated, or revised policy.Oxford Policy Update Bulletin: April 2018Policy Update ClassificationsNewNew clinical coverage criteria and/or documentation reviewrequirements have been adopted for a health service (e.g., test, drug,device or procedure)UpdatedAn existing policy has been reviewed and changes have not been madeto the clinical coverage criteria or documentation review requirements;however, items such as the clinical evidence, FDA information, and/orlist(s) of applicable codes may have been updatedRevisedAn existing policy has been reviewed and revisions have been made tothe clinical coverage criteria and/or documentation review requirementsReplacedAn existing policy has been replaced with a new or different policyRetiredThe health service(s) addressed in the policy are no longer beingmanaged or are considered to be proven/medically necessary and aretherefore not excluded as unproven/not medically necessary services,unless coverage guidelines or criteria are otherwise documented inanother policyNote: The absence of a policy does not automatically indicate or implycoverage. As always, coverage for a health service must be determinedin accordance with the member’s benefit plan and any applicablefederal or state regulatory requirements. Additionally, UnitedHealthcarereserves the right to review the clinical evidence supporting the safetyand effectiveness of a medical technology prior to rendering a coveragedetermination.
OxfordOxford Medical and Administrative Policy UpdatesIn This IssueClinical Policy UpdatesPageNEW Trogarzo (Ibalizumab-Uiyk) - Effective Apr. 1, 2018 . 7UPDATED Assisted Administration of Clotting Factors and Coagulant Blood Products - Effective Apr. 1, 2018 . 7Bone or Soft Tissue Healing and Fusion Enhancement Products - Effective Apr. 1, 2018 . 7Carrier Testing for Genetic Diseases - Effective May 1, 2018 . 8Clotting Factors and Coagulant Blood Products - Effective Apr. 1, 2018 . 8Collagen Crosslinks and Biochemical Markers of Bone Turnover - Effective Apr. 1, 2018 . 8Eloctate (Antihemophilic Factor (Recombinant), FC Fusion Protein) for Connecticut Lines of Business - Effective Apr. 1, 2018 . 8Exondys 51 (Eteplirsen) - Effective Apr. 1, 2018 . 8Infliximab (Remicade , Inflectra , Renflexis ) - Effective Apr. 1, 2018. 8Manipulation Under Anesthesia - Effective May 1, 2018 . 8Maximum Dosage - Effective Apr. 1, 2018 . 9Platelet Derived Growth Factors for Treatment of Wounds - Effective Apr. 1, 2018 . 9Rituxan (Rituximab) - Effective Apr. 1, 2018 . 9Routine Foot Care - Effective Apr. 1, 2018 . 9Simponi Aria (Golimumab) Injection for Intravenous Infusion - Effective Apr. 1, 2018 . 9Spinraza (Nusinersen) - Effective Apr. 1, 2018 . 9Stelara (Ustekinumab) - Effective Apr. 1, 2018. 10White Blood Cell Colony Stimulating Factors - Effective Apr. 1, 2018 . 10REVISED 317-Alpha-Hydroxyprogesterone Caproate (Makena and 17P) - Effective May 1, 2018 . 10Buprenorphine (Probuphine & Sublocade ) - Effective Apr. 1, 2018 . 11Buprenorphine (Probuphine & Sublocade ) - Effective Jul. 1, 2018. 16Drug Coverage Criteria - New and Therapeutic Equivalent Medications - Effective Apr. 1, 2018 . 19Drug Coverage Criteria - New and Therapeutic Equivalent Medications - Effective May 1, 2018 . 19Drug Coverage Guidelines - Effective Apr. 1, 2018 . 20o [CAR-T (Chimeric Antigen Receptor) Cell Therapy] . 20o Inflectra (Infliximab) . 20o Renflexis (Infliximab) . 20o Sublocade (Buprenorphine Extended-Release) . 20o Trogarzo (Ibalizumab) . 20Oxford Policy Update Bulletin: April 2018
OxfordOxford Medical and Administrative Policy UpdatesIn This Issue 4Drug Coverage Guidelines - Effective May 1, 2018 . 21o Atralin (Tretinoin) . 21o Aubagio (Teriflunomide) . 21o Avita (Tretinoin) . 21o Avonex (Interferon Beta 1a) . 21o Betaseron (Interferon Beta 1b) . 21o Biktarvy (Bictegravir/Emtricitabine/Tenofovir Alafenamide) . 21o Bonjesta (Doxylamine/Pyridoxine) . 21o Bosulif (Bosutinib). 21o Cayston (Aztreonam for Inhalation Solution) . 21o Cloderm 0.1% Cream (Clocortolone) . 21o Copaxone (Glatiramer Acetate) . 21o Copaxone (Glatiramer Acetate) 40mg . 21o Cosentyx (Secukinumab) . 22o Cordran 0.05% Cream (Clurandrenolide) . 22o Cordran 0.05% Lotion (Flurandrenolide) . 22o Cordran Ointment (Flurandrenolide) . 22o Cultivate (Fluticasone Propionate 0.05%) . 22o Decadron (Dexamethasone) . 22o Desonate 0.05% Gel (Desonide) . 22o Egrifta (Tesamorelin). 22o Enbrel (Etanercept) . 22o Endari (L-Glutamine) . 22o Extavia (Interferon B-1b) . 22o Fabior (Tazarotene). 22o Firvanq (Vancomycin Hydrochloride) . 22o Gilenya (Fingolimod) . 22o Glatopa (Glatiramer 20mg [Generic Copaxone]) . 22o Halog 0.1% Cream (Halcinonide) . 23o Halog 0.1% Ointment (Halcinonide) . 23o Intrarosa (Prasterone) . 23o Keveyis (Dichlorphena-Mide) . 23o Lonhala Magnair (Glycopyrrolate). 23o Luxturna (Voretigene Neparvovecrzyl) . 23o Mytesi (Crofelemer) . 23o Nityr (Nitisinone) . 23o Plegridy Pen & Prefilled Syringe (Peginterferon Beta-1a) . 23o Pulmozyme (Dornase Alfa) . 23o Rebif (Interferon Beta-1a) . 23o Retin-A (Tretinoin) (Brand Only) . 23Oxford Policy Update Bulletin: April 2018
OxfordOxford Medical and Administrative Policy UpdatesIn This Issue oooooooooooooooooooooRetin-A (Tretinoin) (Brand and Generic) . 23Retin-A Micro (Tretinoin) . 24Retin-A Micro Pump (Tretinoin) (Brand and Generic) . 24Rubraca (Rucaparib). 24Selzentry . 24Segluromet (Ertugliflozin/Metformin HCL) . 24Siliq (Brodalumab) . 24Soliqua . 24Taltz (Ixekizumab) . 24Taperdex Pak 6-Day & 12-Day (Dexamethasone) . 24Tazorac (Taxarotene) . 24Tecfidera (Dimethyl Fumarate) . 24Tremfya (Guselkumab) . 24Tretin-X 0.075% Cream (Tretinoin) . 24Tretin-X 0.0375% Cream (Tretinoin) . 25Tretin-X Kit (Tretinoin) . 25Tretinoin (Generic Retin-A) Cream . 25Tretinoin (Generic Retin-A) Gel . 25Ultravate . 25Xeljanz (Tofacitinib) . 25Xeljanz XR . 25Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable - Effective May 1, 2018 . 25Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors - Effective May 1, 2018 . 27Lemtrada (Alemtuzumab) - Effective May 1, 2018 . 28Maximum Dosage - Effective May 1, 2018 . 30Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions - Effective Apr. 1, 2018 . 30Office Based Program - Effective May 1, 2018 . 35Omnibus Codes - Effective May 1, 2018 . 36Radiopharma-ceuticals and Contrast Media - Effective May 1, 2018 . 37Trogarzo (Ibalizumab-Uiyk) - Effective Jul. 1, 2018 . 38RETIRED Thermal Capsulorrhaphy/ Thermal Shrinkage Therapy - Effective Apr. 1, 2018 . 38Administrative Policy UpdatesREVISED 5Precertification Exemptions for Outpatient Services - Effective Apr. 1, 2018 . 39Oxford Policy Update Bulletin: April 2018
OxfordOxford Medical and Administrative Policy UpdatesIn This IssueReimbursement Policy UpdatesUPDATED Ambulance - Effective May 7, 2018 . 40From - To Date Policy - Effective May 1, 2018 . 40Once in a Lifetime Procedures - Effective May 1, 2018. 40One or More Sessions - Effective Apr. 16, 2018 . 40Procedure and Place of Service - Effective Apr. 16, 2018 . 40Time Span Codes - Effective Apr. 16, 2018 . 40REVISED 6Ambulance - Effective May 1, 2018 . 40Maximum Frequency Per Day Policy - Effective May 1, 2018 . 43Prolonged Services - Effective May 1, 2018 . 49Same Day/Same Service Policy (CES) - Effective May 1, 2018 . 51Time Span Codes - Effective May 1, 2018 . 54Oxford Policy Update Bulletin: April 2018
OxfordClinical Policy UpdatesPolicy TitleEffective DateCoverage RationaleApr. 1, 2018Trogarzo (ibalizumab-uiyk) is proven and/or medically necessary for1 the treatment of multi-drugresistant human immunodeficiency virus (HIV) in patients who meet ALL of the following criteria:NEWTrogarzo (Ibalizumab-Uiyk)Policy Title For initial therapy, all of the following:o Both of the following: Diagnosis of HIV-1 infection Physician attestation that the patient has multi-drug resistant HIV-1 infectionando Physician confirms that the patient has been prescribed an optimized backround antiretroviral regimen,containing at least one antiretroviral agent that demonstrates full viral sensitivity/susceptibility; ando Ibalizumab initial and maintenance dosing is in accordance with the US Food and Drug Administrationprescribing information: A single loading dose of 2,000mg intravenously (IV) followed by a maintenancedose of 800mg IV every two weeks thereafter; ando Initial authorization is for no more than 6 months. For continuation therapy, all of the following:o Patient has previously received treatment with ibalizumab; ando Physician confirms that the patient has achieved a clinically significant viral response to ibalizumab therapy;ando Physician confirms that the patient will continue to take an optimized backround antiretroviral regimen, incombination with ibalizumab; ando Ibalizumab maintenance dosing is in accordance with the US Food and Drug Administration prescribinginformation; ando Authorization is for no more than 12 months.Effective DateSummary of ChangesAssistedAdministration ofClotting Factorsand CoagulantBlood ProductsApr. 1, 2018 Updated list of applicable HCPCS codes to reflect quarterly code edits; revised description for J7188 and J7205Bone or Soft TissueHealing and FusionEnhancementProductsApr. 1, 2018 Updated coverage rationale; replaced language indicating:o “[The listed services] are proven and medically necessary” with “[the listed services] are proven and/ormedically necessary”o “[The listed services] are unproven and not medically necessary” with “[the listed services] are unprovenand/or not medically necessary”Updated supporting information to reflect the most current clinical evidence and referencesUPDATED 7Oxford Policy Update Bulletin: April 2018
OxfordClinical Policy UpdatesPolicy TitleEffective DateSummary of ChangesCarrier Testing forGenetic DiseasesMay 1, 2018 Updated list of applicable CPT codes; removed 81161Clotting Factorsand CoagulantBlood ProductsApr. 1, 2018 Updated list of applicable HCPCS codes to reflect quarterly code edits; revised description for J7188 and J7205Collagen Crosslinksand BiochemicalMarkers of BoneTurnoverApr. 1, 2018 Updated non-coverage rationale; replaced language indicating “serum or urine collagen crosslinks or biochemicalmarkers are unproven and not medically necessary” with “serum or urine collagen crosslinks or biochemicalmarkers are unproven and/or not medically necessary”Updated supporting information to reflect the most current clinical evidence, FDA information, and referencesEloctate (AntihemophilicFactor(Recombinant), FCFusion Protein) forConnecticut Linesof BusinessApr. 1, 2018 Updated list of applicable HCPCS codes to reflect quarterly code edits; revised description for J7205Exondys 51 (Eteplirsen)Apr. 1, 2018 Updated coverage rationale; reformatted/clarified coverage criterion addressing applicable diagnosis and treatingphysicianInfliximab(Remicade ,Inflectra ,Renflexis )Apr. 1, 2018 Updated list of applicable HCPCS codes to reflect quarterly code edits:o Added Q5103 and Q5104o Removed Q5102 and corresponding modifiers ZB (Pfizer) and ZC (Merck)Updated supporting information to reflect the most current clinical evidence and referencesManipulation UnderAnesthesiaMay 1, 2018UPDATED 8Updated coverage rationale; replaced language indicating:o “[The listed s
Tips for using the Policy Update Bulletin: From the table of contents, click the policy title to be . Simponi Aria (Golimumab) Injection for Intravenous Infusion - Effective Apr. 1, .
