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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.