Download Medical Policy Updates Effective October 1, 2011

VOLUME 13 ISSUE 9
INSIDE
Radiology Benefit Management Program
Provider Education Sessions............................3
BCNEPA’s Annual Provider Seminar/
Webinar.............................................................5
BCNEPA’s Formulary Changes..........................6
BCNEPA Provider Relations Consultants
Odette Ashby 570.200.4658
[email protected]
Cheryl Hashagen
570.200.4670
[email protected]
Jill Jenkins
570.200.4647
[email protected]
Louise LoPresto
570.200.4674
[email protected]
Jeanine Rivera
570.200.4669
[email protected]
Manager, Provider Relations
Dave Levenoskie
570.200.4673
[email protected]
Manager, Special Projects
Kevin Quaglia
570.200.4676
[email protected]
Questions?
Call Provider Relations at
1.800.451.4447
SEPTEMBER 2011
A MONTHLY BULLETIN FOR THE NETWORK FROM BLUE CROSS OF NORTHEASTERN PENNSYLVANIA
BCNEPA to Implement Radiology
Benefit Management Program
As previously communicated in the August Provider Bulletin, Blue Cross of Northeastern
Pennsylvania (BCNEPA) has entered into an agreement with National Imaging Associates,
Inc.* (NIA), an affiliate of Magellan Health Services, to implement a radiology benefit management program. Effective November 1, 2011, this program includes the management and prior
authorization of non-emergent, advanced, outpatient radiology services for both First Priority
Health® (FPH) and First Priority Life Insurance Company® (FPLIC). This program is consistent
with industry-wide efforts to ensure clinically appropriate quality of care and to manage the
increasing utilization of these services.
The NIA radiology benefit management program for BCNEPA does not apply to FPH and
FPLIC self-funded employer groups or individual products. It does apply to CHIP members. Providers will continue to follow the prior authorization process currently in place through
BCNEPA for radiology services for members of FPH and FPLIC self-funded groups, as well as
for members of FPLIC individual products. Beginning November 1, 2011, the following services will be performed by NIA:
1. Prior authorization requests, as of November 1, 2011, will be required for the following
outpatient radiology procedures:
• CT/CTA/CCTA
• MRI/MRA
• PET scans
• Nuclear cardiology
• Stress echo
2. Provider assessment, privileging application and approval program
Under the terms of the agreement between BCNEPA and NIA, BCNEPA will oversee the NIA
program and continue to be responsible for claims adjudication. NIA will manage non-emergent outpatient imaging/radiology services.
Key Provisions
• Imaging services performed in the following settings do not require prior authorization
through NIA: emergency room, observation, inpatient and urgent care centers.
• It is the responsibility of the ordering physician to obtain authorization.
• Providers rendering the above services should verify that the necessary authorization
has been obtained. Failure to do so may result in non-payment of your claim. Providers will be able to obtain prior authorization by contacting NIA at the phone numbers below weekdays, between 8 a.m. and 8 p.m., or via NaviNet® at www.NaviNet.net.
FPH HMO/CHIP—1.800.962.5353
FPLIC Traditional—1.800.638.0505
(See Radiology, continued on page 2)
Blue Cross of Northeastern Pennsylvania administers health care plans offered by Blue Cross of Northeastern Pennsylvania, Highmark Blue Shield, First Priority Health® and First Priority Life Insurance Company®.
(Radiology, continued from page 1)
FPLIC PPO—1.866.262.5623
FPLIC EPO—1.888.345.2360
Please note: Providers will not be able to request prior authorization through www.navinet.net until early November 2011. Providers will be informed once NaviNet can be utilized for these
authorizations. Please use the applicable phone numbers above
until NaviNet is available for these authorizations.
Provider Assessment and Privileging
Any professional or freestanding FPH/FPLIC providers who perform CT/CTA/CCTA, MRI/MRA, PET scans, nuclear cardiology
or stress echocardiography procedures will be required to complete
a BCNEPA Privileging Application as part of the NIA radiology
benefit management program.
NIA’s privileging program policies establish reasonable and consistent standards for the performance of all diagnostic imaging services. The program establishes minimum participation guidelines
that include facility accreditation; equipment capabilities; physician and technologist education, training and certification; documented procedures for handling patient emergencies; ACLS or BLS
Products
FPH—Fully Insured
• BlueCare® HMO
• BlueCare HMO Plus
certified physician supervision on-site during contrast-enhanced
procedures and physician on-site during normal business hours;
and facility management components, such as radiation safety
guidelines (i.e., ALARA—as low as reasonably achievable). These
guidelines are established and refined with the consideration of
the American College of Radiology (ACR) and other accreditation
bodies, diagnostic imaging common practice standards, updated
literature reviews and new technology assessments. NIA provides
ongoing monitoring of imaging practices and facilities.
BCNEPA appreciates your support and looks forward to your
assistance in assuring that our members receive diagnostic imaging services delivered in a quality, clinically appropriate fashion.
We will provide additional information as we get closer to the
implementation date. If you have questions, please contact your
Provider Relations Consultant.
*Blue Cross of Northeastern Pennsylvania provides radiology network management services with administrative assistance from
National Imaging Associates, Inc., an independent radiology benefits management company not affiliated with the Blue Cross and
Blue Shield Association.
NIA
X
X
FPH—Individual Products
• BlueCare HMO Ind Conversion
FPLIC—Fully Insured
• BlueCare PPO
• BlueCare EPO
• BlueCare Traditional
• BlueCare Comprehensive
• AffordaBlueSM
• BlueCare Qualified High Deductible EPO
• BlueCare Qualified High Deductible PPO
X
X (CTA’s only)*
FPLIC—Individual Products
• BlueCare PPO Ind Conversion
• BlueCare Direct
• BlueCare Direct Select
• BlueCare Direct Essentials
• BlueCare Direct Advantage
X (CTA’s only)*
* Computed Tomography Angiography (75571, 75572, 75574)
2
X
FPLIC—Self-Funded
Blue Cross/Blue Shield—Individual Products
• Blue Care Cooperative
• Special Care
• BlueCare Assure
No Requirement
X
FPH—Self-Funded
FPH—Individual Products
• CHIP
Focus PAC
X
(Policy Update 1309001)
SEPTEMBER 2011
BCNEPA Updates
Radiology Benefit Management Program
Provider Education Sessions
BCNEPA and NIA invite you to attend one of our upcoming provider education meetings to learn more about our new radiology benefit management program and what it means to you. Provider education meetings
will be held at numerous locations throughout northeastern Pennsylvania
according to the schedule below.
The agenda for the meetings is as follows:
•
•
•
Welcome/Introductions
Provider Orientation Presentation
Questions/Answers.
Continental breakfast/lunch will be provided.
Date
Time
City
Tuesday, September 27, 2011
8 a.m. & 12 noon Wilkes-Barre, PA
Wednesday, September 28, 2011 8 a.m. & 12 noon Scranton, PA
Thursday, September 29, 2011
8 a.m. & 12 noon Shawnee, PA
Friday, September 30, 2011
8 a.m. & 12 noon Williamsport, PA
Please RSVP one week before the scheduled date of the session you wish to attend by calling an NIA representative at
1.800.327.0641.
If you are unable to attend one of the above sessions in person,
BCNEPA and NIA welcome you to participate in one of our
upcoming provider education webinars. Hour-long provider
education webinars will take place on the following dates:
• October 18, 2011
• October 19, 2011
• October 20, 2011
• October 25, 2011
• October 27, 2011
Webinar sessions will be held 8 a.m. EST and 12 noon EST each
day. You will need a computer with Internet access to view the
educational materials presented during the webinar.
SEPTEMBER 2011
Location
Best Western Genetti Hotel
77 East Market Street
Wilkes-Barre, PA 18701
Radisson Hotel
700 Lackawanna Avenue
Scranton, PA 18503
Shawnee Inn & Golf Resort
124 Shawnee Inn Drive
Shawnee on Delaware, PA 18356
Holiday Inn
100 Pine Street
Williamsport, PA 17701
Please RSVP at least one week before the webinar session you wish to attend by calling an NIA representative at
1.800.327.0641. After you RSVP, you will receive a confirmation email from NIA for the webinar session you selected. The
confirmation email will also include a toll-free dial-in number
with an access code, web meeting address and instructions on
how to download required software (if needed).
BCNEPA and NIA look forward to working with you to ensure
that your BCNEPA patients receive diagnostic imaging services
delivered in a quality, clinically appropriate fashion.
*Blue Cross of Northeastern Pennsylvania provides radiology network management services with administrative assistance from
National Imaging Associates, Inc., an independent radiology
benefits management company not affiliated with the Blue Cross
and Blue Shield Association.
(Policy Update 1309002)
3
Update:
Blue Cross of Northeastern Pennsylvania (BCNEPA)
Expanding NaviNet Access to our Provider Network
As communicated in the previous editions of our Provider Bulletin,
understanding the importance of real-time electronic capabilities
for our providers, BCNEPA is excited to announce the expansion
of BCNEPA NaviNet access to our entire BCNEPA provider network. Our target for expansion completion is October 1, 2011. Our NaviNet expansion consists of 2 phases:
Phase 1, now complete, enabled providers who had NaviNet access
through another health plan to obtain BCNEPA NaviNet access. Providers who have NaviNet through another health plan will have
received a message on your NaviNet Home page once your access
to BCNEPA NaviNet was granted.
Phase 2 of our NaviNet deployment consists of establishing new
NaviNet access for those providers who currently do not have
NaviNet access through any health plan.
BCNEPA is now beginning Phase 2 of our NaviNet expansion. To
assist us with this expansion, we are asking providers to provide
BCNEPA with the following required information necessary to
establish your NaviNet access:
1.Provider Group/Facility Name
2.Provider TIN
3.Provider (Group/Facility) Type II NPI
4.Provider FPH/FPLIC Legacy Number(s)
5.Provider’s NaviNet Security Officer Contact Name
6.Provider’s NaviNet Security Officer Phone Number
7.Provider’s NaviNet Security Officer Email Address
8.For professional groups, please list all physicians employed
with the group (include each individual provider name and
NPI, FPH/FPLIC legacy numbers).
Please email the above information to BCNEPANavi@bcnepa.
com. Upon receipt of the above information, BCNEPA will work
with NaviNet to establish your BCNEPA NaviNet access as soon
as possible. Once your access has been established, you will be
contacted directly by NaviNet at the email address you provided to
finalize your access.
In addition, if you would like to participate in a NaviNet training
webinar by a BCNEPA Provider Relations representative, please
make sure to indicate such in your email. A BCNEPA Provider
Relations representative will follow up with you accordingly to
schedule your NaviNet training webinar.
4
Please note:
• As providers become enabled with BCNEPA NaviNet, you
must utilize our Eligibility and Benefits Inquiry, Claims
Status Inquiry and Claims Investigation transactions for routine E&B and claims inquiries rather than calling BCNEPA
Customer Service. Providers who receive BCNEPA NaviNet
access in Phase 1 must begin using these transactions for
routine inquiries as of November 1, 2011. Phase 2 providers
will also be given a 90-day grace period from the date they
receive access before being mandated to utilize NaviNet for
routine E&B and claims inquiries.
• As of December 1, all PCPs who become enabled with
BCNEPA NaviNet in Phase 1will no longer receive your cap
rosters via regular mail. Rather, PCPs must obtain your cap
rosters via NaviNet.
Please continue to read future editions of our Provider Bulletin for
additional information on our NaviNet expansion.
(Policy Update 1309003)
BCNEPA/FPLIC
Precertification Update
Effective October 1, 2011 for BCNEPA and FPLIC products,
the following procedure codes will be added to the FOCUS
PAC listing. These procedure codes require precertification
for any setting. Review of specific information is also required
before precertification can be obtained.
43.82 Laparoscopic, vertical (sleeve) gastrectomy
44.5
Revision of gastric anastomosis: closure
of gastric anastomosis, gastroduodenostomy,
gastrojejunostomy, pantaloon operation
(Policy Update 1309004)
FPLIC Courtesy Reviews
Please be aware that, effective September 1, 2011,
courtesy preauthorization approvals will be valid for a
period of 60 days from the date of determination. (Policy Update 1309005)
SEPTEMBER 2011
Reserve Your Seat Today for
BCNEPA’s Annual Provider Seminar/Webinar
Blue Cross of Northeastern Pennsylvania, Highmark Blue Shield, First
Priority Health and First Priority Life Insurance Company will host an
informational seminar on Wednesday, October 5, 2011 in the Seasons
Ballroom of Mohegan Sun at Pocono Downs, 1280 Highway 315 Blvd.,
Wilkes-Barre, PA.
We are pleased to announce that the seminar is being offered free of
charge and includes a continental breakfast. Space is limited, so please
make your reservations as soon as possible; the last day to register is September 23. Late registrations will not be accepted, but we will create a
waiting list if necessary. If you register and then cannot attend, please
notify us so that we may offer your seat to someone on the waiting list.
To register, please complete the registration form below.
Additionally, we will be offering a webinar again this year. If you cannot
attend in person or simply prefer to join us via webinar, you will have the
opportunity on Wednesday, October 12, 2011. To register for the webinar, please complete the registration form below.
Seminar Agenda
8:15 a.m.–9:00 a.m.
Registration and continental breakfast
9:00 a.m.–12:00 p.m.
• Welcome
• Blue Health Plan Updates
• 5010/ICD-10 Update
• Medical Home Neighborhood
– Medical Home Concept
– Process Improvement
– Disease Management/Case Management
– Behavioral Health
• NaviNet Updates
• NaviNet Roll-Out
The webinar will follow the same agenda; however,
it will begin 9:00 a.m. on October 12, 2011.
Webinar attendees will be e-mailed all pertinent information
regarding computer and phone connection capabilities at a
later date.
Fax to: Administrative Assistant at 570.200.6880
OR
From I-81 North, take Exit 170B. Take Exit 1 off Route 309 (Cross Valley
Mail to: Administrative Assistant
Expressway). Turn left onto Route 315 North. Casino/race track is 1.5 miles on
Provider Relations Department
the left.
Blue Cross of Northeastern Pennsylvania From I-81 South, take Exit 175A. Follow Route 315 South for 4 miles. Casino/
19 North Main St.
race track is on the right.
Wilkes-Barre, PA 18711
From the Poconos, take I-80 West to I-380. Take I-81 South to Exit 175A. Follow Route 315 South for 4 miles. Casino/race track is on the right.
Directions
Registration Form
Please check one:
 SEMINAR, OCTOBER 5, 2011  WEBINAR, OCTOBER 12, 2011
Please print legibly and complete all fields. Registration form must be received by September 23, 2011.
Name of Facility or Professional Office: _____________________________________________________________________
Number Attending: _ _______________________ Phone : ______________________________________________________
Fax: _____________________________________ Contact Person Email Address: ___________________________________
Name(s) of Attendee(s) (please print):
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
(Policy Update 1309006)
SEPTEMBER 2011
5
BCNEPA’s Multi-Tiered Formulary Changes
The following Multi-Tiered prescription drug formulary changes will be effective 10/01/2011:
Tier 1
Tier 2
Tier 3
Autonomic and CNS Medications
Class III Narcotics
Butrans Transdermal Patches1,2,8
(buprenorphine)
Antipsychotic Medications
Latuda2,8
(lurasidone)
Other Medications for ADHD
Kapvay ER2,8
(clonidine)
Dermatological Medications
Scabicides
Natroba Topical2,8 Suspension
(spinosad)
Gastrointestinal Medications
Antispasmodics/Medications Affecting the
GI Tract
Cuvposa Solution7
(glycopyrrolate)
Obstetrical and Gynecological Medications
Progestin Medications
Makena2,3,4,7
(17-alpha hydroxyProgesterone caproate)
Ophthalmic Medications
Other Ophthalmic Medications
Lastacaft2,8 Ophthalmic Solution
(alcaftadine)
New Medications Covered Under the Medical Benefit
Xgeva
(denosumab)
Denosumab is a RANK Ligand (RANKL) inhibitor indicated for the prevention of skeletal-related events in patients
with bone metastases from solid tumors. A dose of 120 mg (1.7 ml) is administered subcutaneously by a health
care professional, once monthly. Although Xgeva does not require a prior authorization, a diagnosis of icd-9 198.5
must be documented.
New Pharmacy Prior Authorization/Step Therapy Criteria
Protease Inhibitors in the Treatment of
Hepatitis C
(Victrelis and Incivek)
Prior Authorization
Incivek (telaprevir) and Victrelis (boceprevir) are both hepatitis C virus (HCV) NS3/4A protease inhibitors, indicated
in combination with Peginterferon alfa and ribavirin, for the treatment of genotype 1 chronic hepatitis C (CHC).
This is for use in patients with compensated liver disease, including cirrhosis, who are treatment naïve or who
have been previously treated with interferon-based treatment, including prior null responders, partial responders
and relapsers. Please see entire policy for full criteria, with quantity limits, as well as treatment futility rules.
Sylatron
Sylatron is an alpha interferon indicated for the adjuvant treatment of melanoma.
(Peginterferon alfa-2b) Prior Authorization The following criteria must be met for approval of Sylatron: must be prescribed by an oncologist, and medical
records documenting the use as an adjuvant treatment of melanoma with microscopic or gross nodal involvement
within 85 days of definitive surgical resection, including complete lymphadenectomy, must be submitted for
review. When approved, Sylatron must be obtained through CuraScript.
6
Caprelsa (vandetanib) Prior Authorization
Caprelsa is a kinase inhibitor indicated for the treatment of symptomatic or
progressive medullary thyroid cancer. Criteria include: must be prescribed by a physician enrolled in the
vandetanib REMS program, and medical records documenting symptomatic or progressive medullary thyroid
cancer with unresectable locally advanced or metastatic disease. When approved, the med must be obtained
through a specialty pharmacy.
Zytiga (abiraterone acetate) Prior
Authorization
Zytiga is a CYP17 inhibitor indicated for the treatment of patients with metastatic castration resistant prostate
cancer. All of the following criteria must be met for coverage of Zytiga: documented diagnosis of prostate cancer
with evidence of metastatic disease, prescribed by an oncologist or urologist, documented use of docetaxel with
evidence that the member is no longer responding, documentation that the member is no longer responding
to castration or is hormone resistant and has progressed, and Prednisone 5 mg twice daily is administered
concomitantly with the Zytiga.
SEPTEMBER 2011
BCNEPA’s Multi-Tiered Formulary Changes continued
The following Multi-Tiered prescription drug formulary changes will be effective 10/01/2011:
Tier 1
Tier 2
Tier 3
New Medical Prior Authorization/Step Therapy Criteria
Yervoy (ipilimumab) Prior Authorization
Yervoy is a recombinant human monoclonal antibody, indicated for the treatment of unresectable or metastatic
melanoma. For approval of coverage, the medication must be prescribed by an oncologist; also, medical records
documenting the presence of unresectable or metastatic melanoma (ICD-9 172.0 -172.9) must be documented.
Yervoy is given as an IV infusion over 90 minutes, dosed at 3 mg/kg. It is administered every 3 weeks for a total
treatment course of 4 doses. The safety and efficacy of further doses has not been established and will not be
approved.
Revised Pharmacy Prior Authorization/Step Therapy Criteria
Gabapentin/Lyrica Criteria
The existing Lyrica policy has been revised to include 2 new formulations of gabapentin: Gralise (gabapentin
extended release) and Horizant (gabapentin enacarbil). Gralise requires submission for prior authorization. The
clinical information submitted must include documentation of a diagnosis of postherpetic neuralgia as well as a
trial with documented intolerance/failure to gabapentin. Horizant also requires that a prior authorization request
be submitted. Approval for coverage of Horizant requires a documented diagnosis.
SNRI (serotonin norepinephrine receptor
inhibitor)
Step Therapy/Prior Authorization
The existing policy was revised to take into account Cymbalta’s new indication for the treatment of chronic
musculoskeletal pain. When prescribed for this indication, the physician must submit medical records documenting
the presence of pain associated with osteoarthritis or chronic lower back pain. In addition, the prescription claims
history must document that the member has failed standard med therapy and/or pain management, including 2
prescription analgesics.
Tetracycline Extended Release Prior
Authorization
The existing policy was revised to require prior authorization for the generic equivalents of the extended release
doxycycline/minocycline products in addition to the brand-name products. The criteria remain the same.
Revised Medical Prior Authorization/Step Therapy Criteria
Botulinum Toxin Prior Authorization
The existing policy was revised to include prior authorization criteria for the treatment of primary axillary
hyperhydrosis and chronic migraines. Please see policy for complete indications and criteria.
Prolia/Xgeva Prior Authorization
Denosumab is now commercially available in 2 formulations: Prolia, for the treatment of osteoporosis and Xgeva,
for the prevention of skeletal-related events in patients with bone metastases from solid tumors. There is already
an existing policy for prior authorization of Prolia. The policy for the use of Xgeva has been added to this policy.
Although Xgeva does not require a prior authorization, a diagnosis of 198.5 must be documented.
Step Therapy, 2Quantity Limit, 3Prior Authorization, 4Specialty Pharmacy, 5Tier 0, 6Tier 1, 7Tier 2, 8Tier 3
1
(Policy Update 1309007)
FPH Updates
The following changes were made to the FPH Criteria for Initial
and Continuing Participation Specialist Physician:
Each specialist in the field of cardiology who performs nuclear cardiology studies in his/her office must:
a) Be accredited by the Joint Commission, American
College of Radiology (ACR) or Intersocietal Commission
for the Accreditation of Nuclear Medicine Laboratories
(ICANML).
b) If the office is not accredited at the time of initial credentialing, accreditation must be obtained within 2 years of
the date of the initial credentialing. If accreditation is not
obtained within that timeframe, the practitioner will no
longer be able to provide nuclear cardiology services in his/
her office.
c) If the office is not accredited at the time of initial credentialing, the office will be required to undergo a satisfactory onsite quality assessment.
d)Maintain radioactive material license/registration and/or
nuclear material license in good standing, as applicable.
e) Be participating with Medicare.
f) Meet Nuclear Regulatory Commission standards.
g) Utilize technologists who are certified by the appropriate
registry to perform nuclear cardiology studies.
h)Be board certified. Only physicians that are board certified
by the appropriate specialty shall perform diagnostic test
interpretation.
These criteria changes were effective 7/20/2010. The full FPH
Criteria for Initial and Continuing Participation Specialist
Physician is available upon request from your Provider Relations
Consultant.
(Policy Update 1309008)
SEPTEMBER 2011
7
Medical Policy Updates
Transplant (MPO-490-0001)
Corneal Transplantation
The policy changes are as follows:
Corneal transplant may be considered medically necessary for the
following indications:
a) Pseudophakic corneal edema
b) Aphakic corneal edema
c) Stromal corneal dystrophies
d)Primary corneal endotheliopathies
e) Ectasias/thinnings
f) Congenital opacities
g) Viral/post-viral keratitis
h)Microbial/post-microbial keratitis
i) Noninfectious ulcerative keratitis or perforation
j) Corneal degenerations
k) Chemical injuries
l) Mechanical trauma, non-surgical
m)Regraft related to allograft rejection
n)Regraft unrelated to allograft rejection
o) Other causes of corneal opacification/distortion
p) Mechanical complication of corneal graft
q) Complications of transplanted organ
Corneal transplant for indications other than those listed above are
considered not medically necessary.
Small Bowel/Liver and Multivisceral Transplant
The policy language has been updated as follows:
A small bowel/liver transplant or multivisceral transplant is
not medically necessary in patients with the following absolute
contraindications:
a) Known current malignancy, including metastatic cancer;
b) Recent malignancy with a high incidence of recurrence;
c) Untreated systemic infection making immunosuppression unsafe, including chronic infection; or
d)Other irreversible end-stage disease not attributed to
intestinal failure.
Candidates should meet the following criteria:
a) Adequate cardiopulmonary status;
b) Documentation of patient compliance with medical
management.
HIV-positive patients who meet the following criteria, as stated in
the 2001 guidelines of the American Society of Transplantation,
could be considered candidates for small bowel/live or multivisceral transplantation:
a) CD4 count >200 cells per cubic millimeter for >6 months
8
Effective October 1, 2011
b) HIV-1 RNA undetectable
c) On stable anti-retroviral therapy >3 months
d)No other complications from AIDS (e.g., opportunistic
infection, including aspergillus, tuberculosis, coccidiosis
mycosis, resistant fungal infections, Kaposi’s sarcoma
or other neoplasm), and meeting all other criteria for
transplantation.
Positron Emission Tomography (PET) (MPO-490-0002)
Cardiac Applications of PET Scanning
The policy language has been updated as follows:
Cardiac PET scanning may be considered medically necessary:
• To assess myocardial perfusion and, thus, diagnose coronary
artery disease in patients with indeterminate SPECT scan; or
in patients for whom SPECT could be reasonably expected to
be suboptimal in quality on the basis of body habitus.
• For the diagnosis of cardiac sarcoidosis in patients who are
unable to undergo magnetic resonance imaging (MRI) scanning. Examples of patients who are unable to undergo MRI
include, but are not limited to, patients with pacemakers,
automatic implanted cardioverter-defibrillators (AICDs) or
other metal implants.
Electrical Bone Growth Stimulator (MPO-490-0025)
The following statements have been added to address when
policy criteria have not been met:
Noninvasive electrical bone growth stimulation is considered not
medically necessary as a treatment of fracture non-unions or congenital pseudoarthroses in the appendicular skeleton when all of
the above guidelines have not been met.
Invasive and non-invasive methods of electrical bone growth stimulation are considered not medically necessary as an adjunct to
lumbar spinal fusion surgery in patients not meeting criteria for
high-risk fusion failure.
Cosmetic Procedures vs. Reconstructive Procedures
(MPO-490-0027)
Autologous Fat Grafting to the Breast and Adipose-derived
Stem Cells
The following new policy statement has been added:
BCNEPA shall not provide coverage for the use of autologous fat
grafting and adipose-derived stem cells for augmentation or reconstruction of the breast, as this is considered investigational.
Genetic Testing (MPO-490-0083)
Gene Expression Testing to Predict Coronary Artery Disease
The following new policy statement has been added:
BCNEPA will not provide coverage for gene expression testing to
predict coronary artery disease, as this is considered investigational.
SEPTEMBER 2011
Medical Policy Updates
Preimplantation Genetic Testing
The policy language has been updated as follows:
Effective October1,
October 1,2011
2011 Continued
partial response to Rituxan in combination with
chemotherapy
BCNEPA will not provide coverage for preimplantation genetic
screening (PGS) as an adjunct to in vitro fertilization (IVF), as it is
considered investigational in members/couples who are undergoing IVF in all situations.
b) When used with CHOP or other anthracycline-based
chemotherapy, as first-line treatment for patients with
diffuse large B-cell lymphoma (DLBCL)
Experimental/Investigative Services Pathology/Laboratory
(MPO-490-0134)
d)For previously untreated or relapsed/refractory mantle
cell lymphoma
Intracellular Micronutrient Analysis
The following new policy statement has been added:
BCNEPA will not provide coverage for intracellular micronutrient
panel testing, as this is considered investigational.
Experimental/Investigative Services Radiology
(MPO-490-0137)
c) For recurrent, aggressive CD20-positive NHL
e) As combination therapy in previously untreated and
previously treated B-cell chronic lymphocytic leukemia
(B-CLL).
Experimental/Investigative Services Therapy
(MPO-490-0140)
Diagnosis and Treatment of Chronic Cerebrospinal Venous
Insufficiency in Multiple Sclerosis
Magnetoencephalography/Magnetic Source Imaging
The following new policy statement has been added:
The policy language has been updated as follows:
BCNEPA will not provide coverage for the identification and subsequent treatment of chronic cerebrospinal venous insufficiency
(CCSVI) in patients with multiple sclerosis, as this is considered
investigational.
Magnetoencephalography/magnetic source imaging as part of the
preoperative evaluation of patients with intractable epilepsy (seizures refractory to medical therapy) may be considered medically
necessary when standard techniques, such as MRI, are inconclusive.
Magnetoencephalography/magnetic source imaging is considered
investigational for all other indications.
Experimental/Investigative Services Medicine
(MPO-490-0138)
Acoustic Cardiography
The following new policy statement has been added:
BCNEPA will not provide coverage for acoustic cardiography for
the diagnosis of heart failure and for the optimization of CRT
hemodynamic parameters, as this is considered investigational.
Uses of Monoclonal Antibodies for the Treatment of NonHodgkin’s Lymphoma, including Chronic Lymphocytic Leukemia, and Acute Myeloid Leukemia in the Non-Hematopoietic
Stem-Cell Transplant Setting
Inhaled Nitric Oxide
Policy statements were updated as follows to be consistent with
FDA approval:
BCNEPA will provide coverage for inhaled nitric oxide, when
medically necessary.
1. Inhaled nitric oxide may be considered medically necessary as a component of treatment of hypoxic respiratory failure in neonates born at more than 34 weeks of
gestation.
2. Other indications for inhaled nitric oxide are investigational, including, but not limited to, its use in premature
neonates born at less than or equal to 34 weeks of gestation, adults and children with acute hypoxemic respiratory failure and postoperative management of pulmonary
hypertension in children with congenital heart disease.
The policy language has been updated as follows:
Tumor Markers (MPO-490-0144)
Rituximab (Rituxan®) may be considered medically necessary to
treat patients with B-cell non-Hodgkin’s lymphoma (NHL) in any
of the following clinical situations:
Serum Tumor Markers for Breast and
Gastrointestinal Malignancies
a) For follicular lymphoma:
• As first-line therapy (as combination therapy or as
monotherapy)
• As second or subsequent therapy (as combination
therapy or as monotherapy)
• As single-agent maintenance therapy (first- or
second-line) in patients who achieve a complete or
SEPTEMBER 2011
The policy language has been updated as follows:
Measurement of serum tumor markers CA15-3 or CA 27.29 is considered not medically necessary when performed for patients with
non-malignant diagnoses.
9
Medical Policy Updates
BCNEPA will not provide coverage for measurement of serum
tumor marker CA 72-4 when performed for patients with cancer
diagnoses, as it is considered investigational.
BCNEPA will not provide coverage for measurement of serum
tumor marker CA 72-4 when performed for patients with nonmalignant diagnoses, as it is considered not medically necessary.
BCNEPA will not provide coverage for measurement of other
tumor markers described by CPT code 86316 (immunoassay for
tumor antigen) when performed for patients with cancer diagnoses, as these are considered investigational. BCNEPA will not provide coverage for measurement of other
tumor markers described by CPT code 86316 (Immunoassay for
tumor antigen) when performed for patients with non-malignant
diagnoses, as it is considered not medically necessary.
Cryosurgical Ablation and Radiofrequency Ablation (RFA)
(MPO-490-0165)
Radiofrequency Ablation of Primary or Metastatic
Liver Tumors
The policy language has been updated as follows:
Radiofrequency ablation of primary hepatocellular carcinoma
(HCC) is considered investigational when used to downstage
(downsize) hepatocellular carcinoma (HCC) in patients being considered for liver transplant.
Radiofrequency ablation may be considered medically necessary
as a primary treatment of hepatic metastases 5 cm or less in diameter from colorectal cancer in the absence of extrahepatic metastatic
disease when all tumor foci can be adequately treated.
Cardiac Rhythm Devices (MPO-490-0169)
Implantable Cardioverter Defibrillator (ICD)
The policy language has been updated as follows:
The use of the automatic implantable cardioverter-defibrillator
(ICD) may be considered medically necessary for primary prevention in patients who meet the following criteria:
a) Ischemic cardiomyopathy with New York Heart Association (NYHA) functional class II or class III symptoms, a
history of myocardial infarction at least 40 days before
ICD treatment and left ventricular ejection fraction of
35% or less; or
b) Ischemic cardiomyopathy with NYHA functional class I
symptoms, a history of myocardial infarction at least 40
days before ICD treatment and left ventricular ejection
fraction of 30% or less; or
Effective October 1, 2011 Continued
have been excluded, and the response to optimal medical
therapy has been adequately determined.
BCNEPA will provide coverage for an automatic implantable
cardioverter-defibrillator in pediatric patients, when medically
necessary.
1. The use of the ICD may be considered medically necessary in children who meet any of the following criteria:
a) Survivors of cardiac arrest, after reversible causes have
been excluded;
b) Symptomatic, sustained ventricular tachycardia in
association with congenital heart disease in patients
who have undergone hemodynamic and electrophysiologic evaluation; or
c) Congenital heart disease with recurrent syncope of
undetermined origin in the presence of either ventricular dysfunction or inducible ventricular arrhythmias.
2. The use of the ICD is considered investigational for all
other indications in pediatric patients.
Hematopoietic Stem-Cell Transplantation (MPO-490-0171)
Donor Lymphocyte Infusion for Malignancies Treated with an
Allogeneic Hematopoietic Stem-Cell Transplant
The policy language has been updated as follows:
BCNEPA will provide coverage for donor lymphocyte infusion,
when medically necessary.
1. Donor lymphocyte infusion may be considered medically
necessary following allogeneic-hematopoietic stem cell
transplantation (HSCT) that was originally considered
medically necessary for the treatment of a hematologic
malignancy that has relapsed or is refractory, to prevent
relapse in the setting of a high risk of relapse, or to convert
a patient from mixed to full donor chimerism.
• Settings considered high risk for relapse include T-cell
depleted grafts or nonmyeloablative (reduced-intensity conditioning) allogeneic HSCT.
2. Donor lymphocyte infusion is considered investigational
following allogeneic-hematopoietic stem cell transplantation (HSCT) that was originally considered investigational for the treatment of a hematologic malignancy.
3. Donor lymphocyte infusion is considered investigational
as a treatment of nonhematologic malignancies following
a prior allogeneic HSCT.
4. Genetic modification of donor lymphocytes is considered
investigational.
c) Nonischemic dilated cardiomyopathy and left ventricular ejection fraction of 35% or less, after reversible causes
(Policy Update 1309009)
10
SEPTEMBER 2011
BCNEPA’s Generic-Based Formulary Changes
The following generic-based drug formulary changes will be effective 10/01/2011:
Tier 1
Tier 2
Not Covered
Specialty
Autonomic and CNS Medications
Class III Narcotics
Butrans Transdermal Patches (buprenorphine)
Antipsychotic Medications
Latuda (lurasidone)
Other Medications for ADHD
Kapvay ER (clonidine)
Dermatological Medications
Scabicides
Natroba Topical Suspension (spinosad)
Gastrointestinal Medications
Antispasmodics/Medications Affecting the
GI Tract
Cuvposa Solution (glycopyrrolate)
Obstetrical and Gynecological Medications
Progestin Medications
Makena2,3,4,8
Ophthalmic Medications
Other Ophthalmic Medications
Lastacaft Ophthalmic Solution (alcaftadine)
New Medications Covered Under the Medical Benefit
Xgeva
(denosumab)
Denosumab is a RANK Ligand (RANKL) inhibitor indicated for the prevention of skeletal-related events in patients with bone metastases from solid
tumors. A dose of 120 mg (1.7 ml) is administered subcutaneously by a health care professional, once monthly. Although Xgeva does not require a
prior authorization, a diagnosis of icd-9 198.5 must be documented.
New Pharmacy Prior Authorization/Step Therapy Criteria
Protease Inhibitors in the Treatment of
Hepatitis C
(Victrelis and Incivek)
Prior Authorization
Incivek (telaprevir) and Victrelis (boceprevir) are both hepatitis C virus (HCV) NS3/4A protease inhibitors, indicated in combination with Peginterferon
alfa and ribavirin, for the treatment of genotype 1 chronic hepatitis C (CHC). For use in patients with compensated liver disease, including cirrhosis,
who are treatment naïve or who have been previously treated with interferon-based treatment, including prior null responders, partial responders
and relapsers. If approved, must be obtained through a specialty pharmacy, subject to specialty copay. Please see entire policy for full criteria, with
quantity limits, as well as treatment futility rules
Sylatron
(Peginterferon alfa-2b) Prior Authorization
Sylatron is an alpha interferon indicated for the adjuvant treatment of melanoma. The following criteria must be met for approval of Sylatron:
must be prescribed by an oncologist, medical records documenting the use as an adjuvant treatment of melanoma with microscopic or gross nodal
involvement within 85 days of definitive surgical resection, including complete lymphadenectomy, must be submitted for review. If approved, must
be obtained through a specialty pharmacy, subject to specialty copay. Please see entire policy for full criteria, with quantity limits.
Caprelsa (vandetanib) Prior Authorization
Caprelsa is a kinase inhibitor indicated for the treatment of symptomatic or
progressive medullary thyroid cancer. Criteria include: must be prescribed by a physician enrolled in the vandetanib REMS program, medical records
documenting symptomatic or progressive medullary thyroid cancer with unresectable locally advanced or metastatic disease. If approved, must be
obtained through a specialty pharmacy, subject to specialty copay. Please see entire policy for full criteria, with quantity limits.
Zytiga (abiraterone acetate) Prior
Authorization
Zytiga is a CYP17 inhibitor indicated for the treatment of patients with metastatic castration resistant prostate cancer. All of the following criteria
must be met for coverage of Zytiga: documented diagnosis of prostate cancer with evidence of metastatic disease, prescribed by an oncologist
or urologist, documented use of docetaxel with evidence that the member is no longer responding, documentation that the member is no longer
responding to castration or is hormone resistant and has progressed, and Prednisone 5 mg twice daily is administered concomitantly with the Zytiga.
If approved, must be obtained through a specialty pharmacy, subject to specialty copay. Please see entire policy for full criteria, with quantity limits.
New Medical Prior Authorization/Step Therapy Criteria
Yervoy (ipilimumab) Prior Authorization
Yervoy is a recombinant human monoclonal antibody, indicated for the treatment of unresectable or metastatic melanoma. For approval of coverage,
the medication must be prescribed by an oncologist; also, medical records documenting the presence of unresectable or metastatic melanoma
(ICD-9 172.0 -172.9) must be documented. Yervoy is given as an IV infusion over 90 minutes, dosed at 3 mg/kg. It is administered every 3 weeks for
a total treatment course of 4 doses. The safety and efficacy of further doses has not been established and will not be approved.
Revised Pharmacy Prior Authorization/Step Therapy Criteria
SNRI (serotonin norepinephrine receptor
inhibitor)
Step Therapy/Prior Authorization
The existing policy was revised to take into account Cymbalta’s new indication for the treatment of chronic musculoskeletal pain. When prescribed
for this indication, the physician must submit medical records documenting the presence of pain associated with osteoarthritis or chronic lower
back pain. In addition, the prescription claims history must document that the member has failed standard med therapy and/or pain management,
including 2 prescription analgesics.
Revised Medical Prior Authorization/Step Therapy Criteria
Botulinum Toxin Prior Authorization
The existing policy was revised to include prior authorization criteria for the treatment of primary axillary hyperhydrosis and chronic migraines.
Please see policy for complete indications and criteria.
Prolia/Xgeva Prior Authorization
Denosumab is now commercially available in 2 formulations; Prolia, for the treatment of osteoporosis and Xgeva, for the prevention of skeletalrelated events in patients with bone metastases from solid tumors. There is already an existing policy for prior authorization of Prolia. The policy for
the use of Xgeva has been added to this policy. Although Xgeva does not require a prior authorization, a diagnosis of 198.5 must be documented.
Step Therapy, 2Quantity Limit, 3Prior Authorization, 4Specialty Pharmacy, 5Tier `, 6Tier 1, 7Tier 2, 8Specialty Copay
1
(Policy Update 1309010)
SEPTEMBER 2011
11
PRESORTED
STANDARD
U.S. POSTAGE
PAID
19 North Main Street, Wilkes-Barre, Pennsylvania 18711
Blue Cross of
Northeastern Pennsylvania
Address Service Requested
Provider Relations Department: 1.800.451.4447
FPH Revises Focus
Outpatient Precertification
Listings
FPH has revised the listing of Focus Outpatient procedures that
require precertification. Please see the revised list below. FPH precertification can be conducted either by phone at 1.800.962.5353
or via NaviNet. The following codes no longer require precertification effective October 1, 2011:
15820
BLEPHAROPLASTY, LOWER EYELID;
15821
BLEPHAROPLASTY, LOWER EYELID, WITH EXTENSIVE HERNIATED
FAT PAD
15822
BLEPHAROPLASTY, UPPER EYELID;
15823
BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN
WEIGHTING DOWN LID;
(Policy Update 1309011)
For questions about benefits,
eligibility or claims, please call
weekdays, between 8 a.m. and 5 p.m.:
• BlueCare HMO/HMO Plus—1.800.822.8752
• BlueCare PPO—1.866.262.5635
• BlueCare Traditional—1.888.827.7117
• BlueCare EPO—1.888.345.2353
Valuable Health Resources:
Refer your BlueCare patients to the following Blue Health
SolutionsSM health and wellness resources:
• Health Management Programs for disease, care and lifestyle
management—1.866.262.4764
• MyHealth Coach, 24/7 health care information—
1.866.442.BLUE and available online at www.bcnepa.com.
Login to “Member Self-Service” and click on “MyHealth
Coach Chat.”
Report Fraud:
Call our Fraud Hotline at 1.800.352.9100, or email our Special
Investigations Unit at [email protected].
© Blue Cross of Northeastern Pennsylvania. 2011.