July 2019 - AUA Public Policy Council Update for MAS

From the Chair

I am pleased to share updates from the AUA Public Policy Council that may benefit your Section members. Our updates include information on our year-round meetings on Capitol Hill and the AUA’s Research Advocacy Committee meeting with National Cancer Institute officials to advocate for urologic oncology research that advances treatments for bladder, kidney, and prostate cancers.

Capitol Hill Fly In: 155 Meetings Covering 33 States

Almost a dozen members of the AUA’s Legislative Affairs Committee (LAC), Regulatory Workgroup, and Quality Improvement and Patient Safety Committee joined the Alliance of Specialty Medicine to advocate on Capitol Hill this month. The AUA delegation met with Senators, Representatives, and congressional staff to discuss issues impacting urologists and their patients: reforming U.S. Preventive Services Task Force, improving network adequacy, reforming medical liability, improving the workforce shortage and GME, addressing surprise billing, as well as fixing step therapy protocols and prior authorization policies. The AUA and the Alliance, which represents specialty medicine, met with 155 offices covering 33 states including meetings with Senators Ben Cardin (D-MD), Bill Cassidy (R-LA), and Phil Roe (R-TN) pictured below. Top to bottom: Past AUA Holtgrewe Fellow Dr. Kevin Koo (far right) was among a meeting with Dr. Cardin (third from right). Dr. Koo and LAC member Dr. Robert Bass (far left) met with Dr. Cassidy. Past Holtgrewe Scholar Dr. C.J. Stimson (far left) and LAC Chair Dr. Tom Rechtschaffen (far right) were among those who met with Dr. Phil Roe (second from the left).

Additional AUA attendees included Drs. James Cummings, Ron Davis, Mark Fallick, Daniel Frendl, Matt Gettman, Chris Gonzalez, John Henderson, Jason Jameson, Jeremy Shelton, and Kevan Sternberg.

Advocacy for Urologic Oncology: AUA Meets with National Cancer Institute

On June 17, AUA President John Lynch, MD, and key members of the AUA’s Research Advocacy Committee (RAC) met with National Cancer Institute (NCI) officials to advocate for urologic oncology research that advances treatments for bladder, kidney, and prostate cancers. The AUA provided a history about the Urology Care Foundation’s research programs and highlighted urology specific cancer statistics to raise awareness about the critical need for increased urology focused clinical trials. The AUA found several potential opportunities to continue future conversations with NCI including that because urologists are the primary point-of-care for urologic cancers, the AUA can facilitate communication to the urologic research community about NCI urologic research programs. This strategy aims to improve engagement from the urologic research community and expand funding sources for early stage diseases to prevent more advanced stage disease. The AUA plans to pursue additional meetings with NCI officials to ensure that urology is considered during program planning efforts.

AUA Representatives met with NCI officials on June 17. Sitting on the ride side of the table (left to right) are AUA Research Advocacy Committee Chair Toby Chai, MD;   RAC Chair-elect Michael Hsieh, MD, PhD; RAC NCI Liaison Gail Prins, PhD; AUA Director of Research Carolyn Best, PhD; RAC NCI Liaison Hyung Kim, MD; and AUA President John Lynch, MD.

U.S. Preventive Services Task Force Reform (USPSTF): Bill Reintroduced in the House

On June 27, Reps. Bobby Rush (D-IL-1), Phil Roe, MD (R-TN-1), Judy Chu (D-CA-27), and Neal Dunn, MD (R-FL-2) reintroduced the USPSTF Transparency and Accountability Act (H.R. 3534). This important bipartisan bill calls for reforms to the USPSTF and the process by which the group makes formal recommendations regarding preventive care services for Americans. Specifically, the bill calls for expanded research plans that account for subpopulations; requires the USPSTF to convene a stakeholders board to provide feedback on activity and to recommend topics and evidence for review; and mandates a 45-day minimum comment period for public comments. Additionally, the USPSTF would be required to respond to specific public comments on research plans and recommendations.

You can read the AUA’s press release on the reintroduction, with quotes from Public Policy Council Chair Dr. Chris Gonzalez, by clicking here. The joint press release from the four sponsors can be found here. The AUA also has a grassroots campaign supporting the USPSTF Transparency and Accountability Act. If you have not done so, please contact your representative (our Phone2Action system allows you to send both letters and customized tweets) and urge them to support the bill. We also ask that your colleagues do the same.

Read more about the AUA’s ongoing activities surrounding this issue by clicking here.

The following insurance carriers provide national coverage.

Aetna

Aetna has reviewed its Prostate Cancer Screening medical policy with the following changes:

  • Increased the age at which the prostate-specific antigen (PSA) screening is considered a medically necessary preventive service for men who are considered average-risk for prostate cancer, from 40 years of age and older to 45 years of age and older.
  • Increased age at which PSA screening is considered a medically necessary preventive service for men who are considered at high-risk for prostate cancer from under 40 years of age to 40 years of age and older.
  • Added note stating that routine prostate cancer screening for members 75 years of age or older is considered not medically necessary unless life expectancy is greater than or equal to 10 years.

Read the complete policy here.

Anthem Blue Cross Blue Shield

Anthem BlueCross Blue Shield has updated its Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions medical policy. Effective June 13, UroLift is now covered by Anthem for prostates less than 80ml when there is an image-confirmed absence of an obstructing middle lobe.

Read the complete update here.

UHC Community Plan

United Healthcare Community Plan has revised its Prolia/Xgeva pharmacy policy with the following changes:

  • Added that Xgeva may be considered medically necessary for the following indications (see the policy for the associated criteria):
    • Prevention of skeletal-related events in men with castration-resistant prostate cancer with bone metastases (refractory to intravenous bisphosphonate therapy)
      Osteopenia/osteoporosis for systemic mastocytosis with bone pain (not responding to bisphosphonates)

Read the complete update here.

United Healthcare Oxford

United Healthcare Oxford plan has revised its Prolia/Xgeva medical policy with the following changes to criteria:

  • Added statement to the coverage rationale indicating that Xgeva is proven for the prevention of skeletal-related events in men with castration-resistant prostate cancer who have bone metastases.
  • Added initial authorization and reauthorization criteria for Xgeva to be considered medically necessary for the prevention of skeletal-related events in men with castration-resistant prostate cancer who have bone metastases, including, but not limited to:
    • the member having a diagnosis of castration-resistant prostate cancer,
    • presence of metastatic disease, and
    • refractory, contraindication, or intolerance to treatment with intravenous bisphosphonate therapy.
  • Added the following ICD-10 diagnosis codes to applicable diagnosis codes for Xgeva:
    • C61 – Malignant neoplasm of prostate

Read the complete policy here.

United Healthcare

Effective Oct. 1, 2019, Optum Health will start managing prior authorization requests for certain medical benefit injectable medications for United Healthcare commercial plan members. Optum Health is an affiliate company of United Healthcare.  This includes the affiliate plans United Healthcare of Mid-Atlantic, Inc., Neighborhood Health Partnership and United Healthcare of the River Valley. Providers are asked to continue to request notification/prior authorization for United Healthcare Oxford, UMR, United Healthcare Community Plan and United Healthcare Medicare Advantage members through the existing processes until future notice. Providers will need to use a new process to request a prior authorization once the existing authorization expires or if there is a change in therapy. Changes in therapy include place of therapy, dose or frequency of administration. Active prior authorizations that were obtained through the current process will remain in place. The new process is designed to reduce the turnaround time for a determination. The system will document clinical requirements during the intake process and prompt providers to provide responses to the clinical criteria questions.

Read the complete update here.

Effective Aug. 1, 2019, United Healthcare is changing the name of a reimbursement policy that applies to United Healthcare Medicare Advantage and United Healthcare Community Plan “Evaluation and Management (E/M) Policy, Professional” to align with the Centers for Medicare & Medicaid Services (CMS). The new policy name will be M&R Observation and Discharge Policy, Professional.

This policy also will be changed to address reimbursement for discharge codes 99238 and 99239. According to CMS guidelines, “The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified non-physician practitioner even if the patient is discharged from the facility on a different calendar date. Only one hospital discharge day management service is payable per patient per hospital stay.” To be consistent with CMS guidelines, the policy is updated to allow only one hospital discharge day management service per patient per hospital stay regardless of tax ID number. This policy change applies to services reported using the CMS-1500 paper form, its successor form or the CMS-1500 form electronic equivalent.

Read the complete update here.

United Healthcare will require Prior Authorization for the following therapeutic radiopharmaceuticals:

  • Lutetium Lu 177 (Lutathera®)
  • Radium RA-233 dichloride (Xofigo®)

All therapeutic radiopharmaceuticals that have not yet received an assigned code and will be billed under a miscellaneous HCPCS code Therapeutic radiopharmaceuticals billed under the following HCPCS codes require prior authorization:

  • A9513 Lutetium Lu 177, dotatate, therapeutic, 1 mCi
  • A9606 Radium RA-223 dichloride, therapeutic, per microcurie
  • A9699 Radiopharmaceutical, therapeutic, not otherwise classified

If a member receives injectable chemotherapy drugs, or related cancer therapies in an outpatient setting between July 1, 2019 and Sept. 30, 2019, providers will not need to request prior authorization until administration of a new chemotherapy drug or related cancer therapy. United Healthcare will authorize the chemotherapy regimen the member was receiving prior to Oct. 1, 2019. The authorization will be effective until Sept. 30, 2020.

Read the complete update here.

Medicare Tips for billing for Urological Supplies

For the 2018 reporting period, the Medicare Fee-For-Service improper payment rate for urological supplies was 26.1 percent, representing a projected improper payment amount of approximately $72.2 million. Insufficient documentation accounted for 62.7 percent of improper payments for urological supplies. Additional types of errors for urological supplies were no documentation (2.6 percent) and for other reasons (32.3 percent).

How to prevent claim denials:

For DME items, remember to meet the following requirements:

  1. Have a Prescription (orders)
  2. Include Medical Record Information (including continued need if applicable)
  3. Ensure Correct Coding
  4. Maintain a proof of delivery (Suppliers are required to maintain proof of delivery documentation files)
  5. Have a detailed written order received by the supplier before a claim is submitted.

For more information regarding the specific criteria for urological supplies, see the article here

Centers for Medicare & Medicaid Services

Beginning on July 1, 2019, HCPCS code J9030 will be established and may be used in submitting claims under Medicare effective for claims with dates of service on or after July 1, 2019:

  • J9030 –
    • Short Descriptor- BCG live intravesical 1mg
    • Long Descriptor- BCG live intravesical instillation, 1 mg
    • TOS- 1, P

HCPCS code J9031 (BCG [intravesical] per instillation) is being discontinued effective July 1, 2019, and may not be used in submitting claims under Medicare effective for claims with dates of service on or after July 1, 2019. Please see AUA response below for more guidance on the use J9030 when billing for BCG.

Read the complete update here.

Dr. Jonathan Rubenstein, AUA Coding and Reimbursement Committee Chair, outlined some considerations for reporting BCG during the drug shortage. Read more here.

 

Local and Regional Updates

The following are updates in your Section. Please contact AUA Executive Vice President Kathleen Zwarick at kzwarick@AUAnet.org for more information on any of these issues.

 

Pennsylvania

The following coverage updates from Highmark includes Delaware, Pennsylvania, and West Virginia.

Highmark Blue Cross Blue Shield has revised its Urological Supplies medical policy, and has made the following revisions:

  • Added not medically necessary policy statement for use of catheter insertion trays for clean, non-sterile intermittent catheterization.
  • Added the following note for gloves in the list of non-covered supplies: these may be considered medically necessary for end-stage renal disease (refer to medical policy E-2).
  • Clarified that quantities in excess will be considered not medically necessary.
  • Clarified that any other indication not listed will be denied as not medically necessary.
  • Added the following CPT code:
    • A5105- Urinary suspensory, with leg bag, with or without tube, each

Read the complete policy here.

Highmark Blue Cross Blue Shield has revised its Treatment of the Prostate medical policy with the following changes to criteria:

  • Added Water Vapor Thermal Therapy (e.g., Rezum) may be considered medically necessary when prostate volume is less than 80 grams
  • Added Greenlight laser as an example of photoselective laser vaporization (PVP) in the list of procedures that may be considered medically necessary when criteria are met.
  • Revised required prostate size for prostatic urethral lift (UroLift) from “no greater than 80 grams” to “less than 80 grams.”
  • Updated covered diagnosis codes for CPT codes:
    • 53852
    • 53854

Read the complete policy here.

Dean Health plan has updated its Prostate Treatment medical policy with the following changes to criteria:

  • Added transurethral incision of the prostate (TUIP); and laser based procedures including contact laser ablation of the prostate (CLAP), holmium laser procedures of the prostate (HoLAP, HoLEP, HoLRP) as additional interventions that do not require prior authorization and are considered medically necessary for the treatment of benign prostate hypertrophy (BPH) for members as an alternative to transurethral resection of the prostate.
  • Added criteria requirements for existing medically necessary procedure of prostatic urethral lift (e.g., UroLift) stating for the treatment of symptomatic BPH when all of the following criteria are met:
    • age 50 or above; and
    • estimated prostate volume <80 cc; and
    • no obstructive median lobe of the prostate identified on cystoscopy; and
    • failure contraindication, or intolerance to at least 3 months of conventional medical therapy for BPH.
  • Changed prior authorization status for Intensity-Modulated Radiotherapy (IMRT) and Stereotactic Radiosurgery from require prior authorization to do not require prior authorization through the Health Services Division.
  • Added experimental and investigational approaches for BPH stating temporary implantable nitinol device (TIND);
    • aquablation (water jet-hydrodissection);
    • bipolar plasma enucleation;
    • phytotherapy;
    • high-intensity, focused ultrasound (HIFU);
    • histotripsy;
    • prostatic arterial embolization (transcatheter embolization);
    • MRI-guided laser focal ablation.
  • Removed experimental and investigational approaches for BPH stating temporary prostatic urethral stent and botulinum toxin.
  • Changed experimental and investigational approach for BPH from “interstitial laser coagulation” to “interstitial laser coagulation of prostate (ILCP)”.
  • Added example for experimental and investigational approach for BPH of plasma kinetic vaporization stating PlasmaKinetic Tissue Management System.

Read the complete policy here.

Dean Health Plan has revised its Prostate Treatments medical policy with the following changes to criteria:

  • Added medically necessary policy statement for the use of MRI-TRUS fusion-guided prostate biopsy for the diagnosis of prostate cancer (prior authorization required) after one or more negative TRUS biopsies in members at high risk due to persistently elevated PSA and rising PSA
  • Added experimental/investigational policy statement for the use of MRI-TRUS fusion-guided prostate biopsy for all other indications
  • Added prior authorization requirement for intensity-modulated radiotherapy (IMRT) and stereotactic radiosurgery.

Read the complete policy here.

University of Pittsburgh Medical Center (UPMC) has revised its Sacral Nerve Stimulators medical policy with the following changes to criteria:

  • Added limitations for sacral nerve stimulation (SNS) for urinary indications, stating that SNS may not be considered medically necessary for urinary urge incontinence due to a neurologic condition, and any type of chronic voiding dysfunction other than those specified.
  • Added limitation stating that SNS may not be considered medically necessary for certain procedures for the treatment of incontinence that are considered experimental and investigational.
  • Added limitation stating that implantation of a neurostimulation system is contraindicated for members who have not demonstrated an appropriate response to test stimulation and members who are unable to operate the neurostimulator.
  • Added limitation stating that after implantation of any system component, shortwave diathermy, microwave diathermy, or therapeutic ultrasound diathermy may not be used on any member implanted with a neurostimulator system.
  • Added limitation stating that SNS device must be FDA approved.
  • Specified that the surgical therapies must be surgical corrective therapies, in criterion for urinary incontinence stating that other treatment modalities (e.g. documented behavioral interventions such as bladder or pelvic floor training, timed voiding, biofeedback, pharmacologic agents such as anticholinergics and beta-3 agonists, and/or surgical corrective therapies) must have been tried and failed for sacral nerve stimulation to be considered medically necessary, given that all other criteria have been met.
  • Added the following experimental and investigational codes:
    • L8605 – Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, anal canal, 1 ml, includes shipping and necessary supplies
    • 0377T – Anoscopy with directed submucosal injection of bulking agent for fecal incontinence
    • 53860 – Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence

Read the complete update here.

HB 64 – Medical Licensure

Representative Harry Readshaw (D) introduced HB 64 allowing professionals under the Bureau of Professional and Occupational Affairs, who are required to maintain continuing education, to accrue continuing education credits in excess of any continuing education credits required for biennial renewal.

The Senate Consumer Protection and Professional Licensure Committee passed the bill on June 12. The bill was referred to the Senate Appropriations Committee and awaits a hearing.

The bill is available here: https://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=PDF&sessYr=2019&sessInd=0&billBody=H&billTyp=B&billNbr=0064&pn=0068 (Due to technical difficulties, please copy and paste this link into your web browser).

New Jersey

AB 5665 – Medical Licensure

On June 24, Assemblymember Valerie Vainieri Huttle (D) introduced AB 5665 providing that maintenance of certification is not required for licensed physicians to perform specified professional activities in New Jersey. AB 5665 is the companion bill to SB 3821 to enter New Jersey into the Interstate Medical Licensure Compact. 

This measure has been referred to the Assembly Health and Senior Services Committee and awaits a hearing.

The bill is available here: 6/24/2019 Version

 

Horizon Blue Cross Blue Shield New Jersey has revised with the following changes to criteria:

  • Added marketed names for drugs.
  • Added statement that only physicians who have enrolled in the Plenaxis PLUS Program (Plenaxis User Safety Program), based on their attestation of qualifications and acceptance of prescribing responsibilities, may prescribe Plenaxis. Qualifications and acceptance of prescribing responsibilities may prescribe Plenaxis.
  • Added the following medically necessary off-label uses:
    • Prostate cancer.
  • Effective August 6, 2019, Horizon BCBSNJ will change the way we consider certain professional claims based on revisions to our medical policy, Gonadotropin-Releasing Hormone (GnRH) Receptor Antagonist [Degarelix (Firmagon™)].
  • Claims submitted for services provided on and after August 6, 2019 to patients enrolled in Horizon BCBSNJ commercial, Administrative Services Only (ASO) or Medicare Advantage (MA) plans will be processed as follows:

For services provided to patients 18 years of age or older:

  • Based on the submitted diagnosis code(s), information may be requested to help us determine the medical appropriateness of the services represented by HCPCS code J9155. Following our review of medical record information, the code above may be denied as an experimental/investigational, non-covered service.

For services provided to patients under 18 years of age:

  • Regardless of the submitted diagnosis code(s), the administration of drugs represented by HCPCS code J9155 will be denied as an experimental/investigational, non-covered service.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been canceled or postponed, the changes will be applied to claims for dates of service on and after August 6, 2019.

Read the complete policy here by clicking on the G in the Alphabet and searching Gonadotropin Releasing Hormone Analogs to review this medical policy content.

Horizon Blue Cross Blue Shield NJ has reviewed and updated its Provenge medical policy with the following changes to criteria:

  • Sipuleucel-T (Provenge®) is medically necessary for the FDA-approved treatment of prostate cancer in members who meet all of the following criteria:
    • Adult men(18 years or older);
    • Androgen-independent (hormone refractory) prostate cancer has been confirmed by histology;
    • Serum testosterone less than 50 ng/dL in men who have not undergone prior surgical castration;
    • Radiological evidence of peripheral metastases (see Informational Note A);
    • Evidence of progressive disease based on successive radiographic studies or prostate specific antigen (PSA) progression as defined by PSA Consensus Criteria (see Informational Note B);
    • Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1 (see Informational Note C);
    • Asymptomatic or minimally symptomatic (see Informational Note D); and
    • Member has no hepatic metastases.

Read more here by clicking on the link, and searching for “Sipuleucel-T (Provenge®).”

ICYMI: Updates from the AUA Policy & Advocacy Brief blog

Advocacy on Capitol Hill: PCORI Reauthorization, Spinal Cord Injury Awareness, and Cancer Prevention among Top Priorities

The AUA joined more than 115 spinal cord injury/disorder advocates from 37 states and jointly participated in 215 meetings with Congressional offices during United Spinal’s Roll on Capitol Hill event. The AUA met with staff in the offices of Sens. Jim Inhofe (R-OK), Mike Enzi (R-WY), James Lankford (R-OK) and John Thune (R-SD), and Representatives Glenn Grothman (R-WI-6), Marcy Kaptur (D-OH-9), and Kendra Horn (D-OK-5) to discuss autonomous vehicles (AV), the Air Carrier Access Amendment Act and the Protecting Access to Wheelchairs Act (HR 2293). Additionally, the AUA attended a briefing hosted by Research!America entitled, “Improvements to Rural Health Care Through Patient-Centered Research.” The briefing aimed to explore advances in patient-centered research to improve delivery of care in rural areas. Senator Chris Van Hollen (D-MD) provided opening remarks that addressed the need to continue working in a bipartisan effort towards reauthorization for the Patient Centered Outcomes Research Institute (PCORI) prior to the funding expiration date of September 30.

Read more!

Practice Management:  Join the Practice Management Network, Evaluation & Management Auditing Service

For a limited time, Practice Managers’ Network (PMN) subscriptions are available at a discounted rate. Find out why you should subscribe your practice to the PMN. Are you looking for support with your administrator duties and wish you had a network of peers to keep you updated on current urology management trends and issues? Would your staff benefit from professional coding reviews on denials and tough billing questions? Let the Practice Managers’ Network (PMN) provide the support your practice needs for the rest of 2019 at a discounted $199 (regular $349). With a PMN subscription, you receive: Unlimited Expert Coding Advice through the AUA Coding Hotline operated by CPC and ICD-10-CM certified staff, Practice Managers’ Network Online Community, PMN E-News monthly email newsletter, PM Coding Chat, PMN Podcast Series, and discounts on PM conferences, seminars and products. If you are not yet a part of this valuable network, this is an ideal opportunity to take advantage of and set your practice up for success! Discounted rates will only be available for a limited time! Please contact pracman@auanet.org or subscribe Practice Mangers’ Network .

Would you like to improve the financial health of your practice? If so, the AUA’s Evaluation & Management Audit Service is an essential option for your team. Designed for evaluation and management (E&M) services and minor procedures only, the Evaluation & Management Audit Service provides a mechanism for educating providers on documentation guidelines, ensuring all services are supported, and all appropriate revenue is captured.  There are multiple benefits to participating in this program:

  • Our audit service is urology-specific and is being performed by experts in the field.
  • All auditing is done at the AUA. No medical records are outsourced to a third party.
  • The service also offers your practice an opportunity to identify reimbursement deficiencies and increase revenue by spotting under-coding and unbilled services.

Slots for this program are limited and will be filled based on submission date and availability. Visit the AUA’s Evaluation & Management Service page to learn more about using this service for your practice.

Updates: First Friday Clinician Outreach Meeting, July 12, 2019

The Centers for Medicare & Medicaid Services (CMS) July 12 Clinician Outreach Meeting focused on the newly published Open Payments 2018 Data, the Inpatient Rehabilitation Facility (IRF) Appeals Settlement Initiative, and the Electronic Health Record (EHR) Reporting Program.

Read more!

Quality Payment Program: Urology Participation by State in MIPS 2017

Check out the MIPS reporting statistics for your state in 2017.

Read more!

U.S. Election News: North Carolina Urologist Greg Murphy Advances to General Election!

Congratulations to AUA member Dr. Greg Murphy for his win on July 9 in North Carolina’s special primary election for the open seat to represent the state’s 3rd District in the U.S. House of Representatives. Dr. Murphy, a urologic surgeon in Pitt County, defeated Dr. Joan Perry in a bid to fill the seat formerly held by Walter B. Jones, who passed away in February 2019.

Dr. Murphy has represented State District 9 in the North Carolina General Assembly since 2015. If elected, he would join Dr. Neal Dunn (R-FL-02) as the only urologists currently serving in the U.S. Congress. He will now face one final opponent in a special general election on September 10.

AUAPAC was supportive of his campaign during the primary election, and will continue to do so over the next months.

Prior Authorization: AUA Signs AMA Letter in Support of H.R. 3107

On July 8, the AUA signed onto a letter orchestrated by the American Medical Association (AMA) in support of the Improving Seniors’ Timely Access to Care Act (H.R. 3107). The bill was introduced by Reps. Suzan DelBene (D-WA-1), Mike Kelly (R-PA-16), Roger Marshall, MD (R-KS-1) and Ami Bera, MD (D-CA-7) to streamline prior authorization processes in Medicare Advantage plans. In addition, the AUA has launched a grassroots campaign urging lawmakers to cosponsor this bill. Please consider contacting your Representative and asking your physician colleagues to do the same.

Read more!

A main highlight from the meeting occurred on June 11, when AMA leadership election results were shared with the full house. Former AUA Legislative Affairs Committee member and current AUA Public Policy Council member Dr. Underwood won a seat on the AMA Board of Trustees. This is the first time since 1984 that a urologist will serve on the AMA Board. His four-year term starts on July 1 and is renewable once.

While at the meeting, the AUA convened separately with state and national medical societies —including Connecticut State Medical Society, MedChi, Nevada State Medical Association, and New Hampshire Medical Society— to discuss and strategies on policy issues such as compounding, patient data, telemedicine, shared decision making, scope of practice, and organ transplants.

View our updates from the meeting here:

Patient & Research Advocacy: Patient-Centered Outcomes Research Institute (PCORI) Legislation Officially Introduced

Reps. Diana DeGette (D-CO-01) and Don Beyer (D-VA-08) introduced H.R. 3030, the “Patient-Centered Outcomes Research Extension Act of 2019.” The bill would reauthorize PCORI (without any changes) for another decade. The bill was introduced quickly so that it could be considered in the House Energy & Commerce hearing on health program extenders, which occurred earlier this week. As a reminder, PCORI reauthorization was part of the research “ask” at the 2019 AUA Summit. In addition, the AUA has plans to meet with additional members of Congress, specifically republicans, to gain bipartisan support for the bill.

Prior Authorization: Bill Introduced and Grassroots Alert  

On June 5, the AUA, together with the Regulatory Relief Coalition, announced support for H.R. 3107, the Improving Seniors’ Timely Access to Care Act of 2019. As previously reported, this bill would protect patients from unreasonable Medicare Advantage plan requirements that needlessly delay or deny access to medically necessary care. The AUA has launched a grassroots campaign urging lawmakers to cosponsor this bill. Please consider contacting your Representativeand asking your physician colleagues to do the same. To date, over 210 responses have been sent to elected officials.

The following insurance updates are from national coverage providers.

Anthem Blue Cross

Anthem Blue Cross has updated the way providers are to file for Timely Filing. Effective July 1, 2019, the timeframe for filing will move from 18 months, to 12 months for correcting claims. This gives providers less time to correct their claims.

Read the complete policy here.

In addition, Anthem Blue Cross has a new policy for Prostate Multiparametric Magnetic Resonance Imaging.  This policy has been created to address the use of multiparametric magnetic resonance imaging (mpMRI). This technology is a “fusion biopsy system” in which mpMRI images are fused with real-time high definition prostate ultrasound images through the use of specialized equipment and software. This enables the ability to target and biopsy areas suspicious for prostate cancer.

The use of mpMRI fusion with rectal ultrasound for targeted biopsy of the prostate is considered medically necessary for individuals with:

  • A persistently elevated or rising prostate specific antigen, and
  • negative or Gleason score less than or equal to 6, International Society of Urological Pathology (ISUP) Grade Group 1, prostate biopsy(s), and
  • an mpMRI with at least one Likert scale equal to or greater than 3 lesions according to the Prostate Imaging Reporting and Data System (PI-RADS

Read the complete policy here.

Last, Anthem Blue Cross has created a new Denosumab Agents policy. This is a combination policy combining Prolia and Xgeva.  When a drug is being reviewed for coverage under a member’s medical benefit plan or is otherwise subject to clinical review (including prior authorization), Anthem will use its criteria (please see policy hyperlinked below) to determine whether the drug meets any applicable medical necessity requirements for the intended/prescribed purpose.

Anthem advises to use the HCPCS code:

  • J0897- Injection, denosumab, 1 mg [Prolia, Xgeva]

Read the complete policy here.

Aetna

Aetna has revised its Erectile Dysfunction medical policy with the following changes to criteria:

  • Added measurement of serum melatonin levels and shear wave elastography to the list of workup/laboratory tests, which are considered experimental or investigational for the diagnosis of erectile dysfunction.
  • Added homocysteine to the examples of serum biomarkers on the list of workup/laboratory tests.
  • Added acoustical wave therapy, epalrestat, gene therapy, and tacrolimus to the list of treatments considered experimental and investigational for erectile dysfunction.
  • Reformatted medically necessary criteria for implantable devices with no change to intent.
  • Added the following non-covered CPT codes:
    • 76981 – Ultrasound, elastography; parenchyma (e.g., organ) [shear wave]
    • 80197 – Tacrolimus
    • 83090 – Homocysteine
    • 91200 – Liver elastography, mechanically induced shear wave (e.g., vibration), without imaging, with interpretation and report
  • Added the following non-covered HCPCS codes:
    • J7503 – Tacrolimus, extended release, (envarsus xr), oral, 0.25 mg
    • J7507 – Tacrolimus, immediate release, oral, 1 mg
    • J7508 – Tacrolimus, extended release, (astagraf xl), oral, 0.1 mg
    • J7525 – Tacrolimus, parenteral, 5 mg
  • Added a statement indicating there is no specific non-covered CPT code for gene therapy.
  • Updated background section to add information on several subjects including, but not limited to, acoustical wave therapy, measurement of serum melatonin levels for the diagnosis of erectile dysfunction, and shear wave elastrography for the diagnosis of erectile dysfunction.

Read the complete policy here.

United Healthcare

United Healthcare has updated its medical policy for Discarded Drugs and Biologicals. Reimbursement may be made when a physician, hospital, or other provider or supplier must discard the remainder of a single use/dose vial (SDV) or other single use/dose package after administering a dose of the drug or biological. The reimbursement may be made for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label.

When billing drugs, units of service must be billed in multiples of the dosage specified in the full CPT/HCPCS descriptor. This descriptor does not always match the dose given. The units billed must correspond with the smallest dose (vial) available for purchase from the manufacturer(s) that could provide the appropriate dose for the patient, while minimizing any wastage.

  • Example of vial size selection, the CPT/HCPCS code for Drug A indicates 1 unit = 30 mg. Drug A is available from the manufacturer in 60mg and 90 mg vials. The amount prescribed for the patient is 48 mg. If the provider uses a 90 mg vial to administer the dose, the provider may only submit 2 units (rather than 3 units) as the doses available from the manufacturer allow the prescribed amount to be administered with a 60 mg vial.

The JW modifier is only permitted to be used to identify discarded amounts from a single vial or single package drug or biological. It is inappropriate to append JW modifier to a multi-dose vial (MDV).

Read the complete policy here. 

In addition, United Healthcare has revised criteria for its Prolia and Xgeva pharmacy policy. They have added castration-resistant prostate cancer with bone metastases (prevention of skeletal-related events), and osteopenia/osteoporosis in members with systemic mastocytosis with bone pain note responding to bisphosphonates, as medically necessary indications for Xgeva. 

The member must be refractory (within past 30 days), have contraindication (including renal insufficiency), or intolerance to treatment with intravenous bisphosphonate therapy (e.g. pamidronate, zoledronic acid).

Read the complete policy here.

Local and Regional Updates

The following are updates in your Section. Please contact AUA Executive Vice President Kathleen Zwarick at kzwarick@AUAnet.org for more information on any of these issues.

Delaware

Highmark BCBS of Delaware updated its Oncologic Genetic Testing medical policy. Oncologic genetic testing may be considered when criteria, including, but not limited to, the following, are met:

  • All genetic testing panels must be performed in a Clinical Laboratory Improvement Amendment (CLIA) licensed lab Genetic testing panels are to be ordered by or recommended by a physician specialist such as hematology, oncology, and a physician with expertise in the treatment of the targeted disease or geneticist. The ordering provider must not be employed or contracted by a commercial genetic testing laboratory

Read the complete policy here.

New Jersey

Horizon Blue Cross Blue Shield (BCBS) has changed its coverage decision in its Radiation Treatment of Bladder Cancer medical policy. Horizon has changed the coverage decision from “will be considered on a case-by-case basis” to “is considered medically necessary” for the use of radiation therapy in the preoperative setting (i.e., prior to planned cystectomy) for muscle-invasive bladder carcinoma (stages T2-T4).  

Horizon has removed policy statement for non-muscle invasive bladder carcinoma (stages Ta, Tis, T1) stating that in the treatment of recurrent non-muscle invasive bladder carcinoma in members who are medically inoperable, the use of radiation therapy will be considered on a case-by-case basis. In addition, they have removed the policy statement for muscle-invasive bladder carcinoma (stages T2-T4) stating that the use of intensity-modulated radiation therapy (IMRT) will be considered on a case-by-case basis. 

Read the complete update here. (Click on the Radiation for Bladder Cancer Policy.) 

Horizon Blue Cross Blue Shield of New Jersey has reviewed and revised its Firmagon medical policy with the following changes to the policy:  

  • Added medically necessary policy statement for Firmagon for annual renewal when member meets all of the following criteria: tumor response with stabilization of disease or decrease in the size of the tumor or tumor spread; and absence of unacceptable toxicity from the drug (i.e. hypersensitivity reactions, QTc prolongation).
  • Added medically necessary off-label use option for Firmagon stating prostate cancer when used for progressive castration-naïve disease in combination with abiraterone and prednisone for M1 disease.
  • Added medically necessary off-label use option for Firmagon stating prostate cancer when used for progressive castration-naïve disease as a single agent for M0 disease.
  • Added medically necessary off-label use options for Firmagon for prostate cancer for androgen deprivation therapy for PSA persistence/recurrence stating positive digital rectal examination (DRE) following EBRT if biopsy negative and no distant metastases as single-agent therapy; or positive DRE following EBRT in patients who are not candidates for local therapy and have a positive bone scan as single-agent therapy or with abiraterone and prednisone.
  • Revised medically necessary policy statement for the FDA-approved indication of advanced prostate cancer to add age requirement of 18 years and older.
  • Revised medically necessary policy statement for Firmagon at the FDA-recommended dose to add approval duration of 1 year.
  • Removed medically necessary off-label uses for Firmagon including but may not be limited to:
    • prostate cancer for adjuvant treatment with or without external beam radiation therapy (EBRT) if positive lymph nodes were found during pelvic lymph node dissection;
    • prostate cancer for initial treatment for locally advanced (T3b-4) or metastatic disease;
    • prostate cancer for salvage therapy following radiation therapy in patients with rising prostate-specific antigen levels or positive digital rectal examination with a negative biopsy and no distant metastatic disease who are not candidates for local therapy.
  • Removed some medically necessary criteria for off-label use of prostate cancer regarding androgen deprivation therapy for various risk levels (see policy).
  • Removed medically necessary criterion option for off-label use of prostate cancer for androgen deprivation therapy as a single agent for biochemical failure stating following radical prostatectomy in combination with external beam radiation therapy (EBRT) for disease without distant metastatic disease.
  • Revised medically necessary off-label use for Firmagon for prostate cancer when used for progressive castration-naïve disease to now state used in combination with Taxotere (docetaxel) with concurrent steroid for M1 disease; changed “with docexatel with or without prednisome” to “with docetaxel with concurrent steroid”.
  • Revised medically necessary off-label use for Firmagon for prostate cancer to now state used for M0 or M1 castration-recurrent disease to maintain castrate levels of serum testosterone (<50ng/dL); added M0 or M1 specification, and added <50ng/dL requirement.
  • Revised medically necessary off-label use for Firmagon for prostate cancer to now state androgen deprivation therapy for PSA persistence/recurrence with or without abiraterone and prednisone following radical prostatectomy in combination with or without external beam radiation therapy (EBRT) for distant metastatic disease; added with or without abiraterone and prednisone requirement.
  • Revised medically necessary off-label use for Firmagon for prostate cancer to now state androgen deprivation therapy for PSA persistence/recurrence or positive DRE following EBRT in patients who are not candidates for local therapy (especially if bone scan positive) as single-agent therapy; changed “radiation therapy” to “EBRT” and added that this applies especially if bone scan positive and it’s used as single-agent therapy.
  • Added Medicare coverage section stating:
    • There is no National Coverage Determination (NCD) or Local Coverage Determination (LCD) for jurisdiction JL for Gonadotropin-Releasing Hormone (GnRH) Receptor Antagonist [Degarelix (Firmagon)];
    • Gonadotropin-Releasing Hormone (GnRH) Receptor Antagonist [Degarelix (Firmagon)] is administered subcutaneously;
    • Per Local Coverage Article A53127, Drugs administered subcutaneously are considered to be usually self-administered;
    • If a drug is self-administered by more than 50 percent of Medicare beneficiaries, the drug is excluded from coverage under Medicare Part B;
    • For Medicare Advantage Products, Gonadotropin-Releasing Hormone (GnRH) Receptor Antagonist [Degarelix (Firmagon)] is non-covered;
    • and for members with a Medicare drug plan (Part D) Gonadotropin-Releasing Hormone (GnRH) Receptor Antagonist [Degarelix (Firmagon) may be covered under that plan.

Read the complete policy here. Once you click on the link, click on the alphabetical list, and click the Gs.  Then continue to click the Gonadotropin-Releasing Hormone (GnRH) Receptor Antagonist [Degarelix (Firmagon™)].

SB 3821 – Medical Licensure

Senator Joseph Vitale (D) introduced SB 3821 to enter New Jersey into the Interstate Medical Licensure Compact. A license issued under the Compact for a member state constitutes a full and unrestricted license to practice medicine in that member state. Specifically, SB 3821 requires a physician, to qualify for licensure, to be a graduate of an accredited medical school, have passed the licensing examination within three attempts, successfully have completed graduate medical education, hold a specialty certification, possess a full and unrestricted license in the origin state of licensure, have never had a controlled substance license or permit suspended or revoked, have never been subject to a license related disciplinary action, and may not be under investigation by a licensing or law enforcement agency.

SB 3821 has been referred to the Senate Health, Human Services and Senior Citizens Committee.

The bill is available here: 5/30/2019 Version 

Maryland

HB 931 – Certificate Of Need

Delegate Nicholaus Kipke (R) introduced HB 931 that would have altered a provision of law exempting offices from certificate of need requirements. Specifically, it would have provided that a certificate of need is required before the type or scope of any health care service is changed if the health care service results in a change in operating room capacity in a hospital. It would have repealed the circumstances under which a certificate of need is required before certain capital expenses are made by or on behalf of a certain health care facility.

Governor Larry Hogan (R) vetoed the bill on May 24.

The bill is available here: 3/15/2019 Version

Pennsylvania

HB 64 – Medical Licensure

Representative Harry Readshaw (D) introduced HB 64 allowing professionals under the Bureau of Professional and Occupational Affairs who are required to maintain continuing education to accrue continuing education credits in excess of any continuing education credits required for biennial renewal.

The House passed HB 64 in March. The Senate Consumer Protection and Professional Licensure Committee passed the bill on June 12. It now awaits further consideration by the full Senate.

The bill is available here: 3/28/2019 Version

Virginia

Premier Health has revised its Luteinizing Hormone Releasing Agents medical policy. They have updated clinical criteria for the use of luteinizing hormone releasing hormone (LHRH) drugs for prostate cancer, adding that the member must have a documented hypersensitivity to any of the components of Eligard for coverage. 

Premier has also added transgender services to the clinical criteria section with a statement to refer to the transgender services policy for coverage criteria. 

A plan design summary to the procedure section, which includes a table on luteinizing hormone releasing hormone drugs, also has been added.

Read the complete policy here.

West Virginia
HB 133 – Medical Malpractice
Delegate Roger Hanshaw (R) introduced HB 133 providing that in an action brought against a health care facility or health care provider alleging inappropriate staffing or inadequate supervision, if the facility or provider demonstrates compliance with the minimum staffing requirements under state law, the facility or provider is entitled to a rebuttable presumption that appropriate staffing and adequate supervision of patients to prevent accidents were provided.

Under this measure, in any action alleging inappropriate staffing or inadequate supervision, if staffing is less than the minimum staffing requirements under state law, then there is a rebuttable presumption that there was inadequate supervision of patients and that inadequate staffing or inadequate supervision was a contributing case of the patient’s fall and injuries or death.

Governor Jim Justice (R) signed the bill into law on May 28.

The bill is available here: 5/28/2019 Final Version

ICYMI: Updates from the AUA Policy & Advocacy Brief blog

Veterans’ Healthcare: AUA Joins Veterans Health Council to Share Advocacy Priorities

On June 13, the AUA attended a partnership and advocacy meeting hosted by the Veterans Health Council of Vietnam Veterans of America. This meeting brought together more than 20 advocacy organizations to discuss opportunities to improve veterans’ healthcare. Several AUA advocacy partners were in attendance, including Prostate Health Education Network, RetireSafe, Caregiver Action Network, and ZERO. Through initial introductions of participants, common priorities included work on suicide prevention, post-traumatic stress disorder, women veterans, toxic exposures (i.e., Agent Orange), improving access to care through the VA system, PCORI reauthorization and access to infertility care for wounded warriors and veterans. Future meetings will focus further on these shared priorities and strategies to partner for improved access to healthcare, information and education for veterans, and support for families and caregivers.

“Surprise” Billing: AUA Meets with Main Senate Office Sponsor

The AUA recently met with staff in Sen. Maggie Hassan’s (D-NH) office who, along with Sens. Michael Bennet (D-CO), Bill Cassidy, MD (R-LA), Todd Young (R-IN), Lisa Murkowski (R-AK), and Tom Carper (D-DE), introduced the Stopping the Outrageous Practice (STOP) of Surprise Medical Bills Act of 2019 aimed at addressing the issue of surprise medical billing that usually occurs after a patient receives emergency care from a physician or hospital that is not part of their insurance network. Sen. Hassan is supportive of arbitration to resolve the medical bill issue. Arbitration provides an alternative for providers but may add regulatory complexity and cost. Her office is currently working with Sen. Lamar Alexander (R-TN), chairman of Senate Health, Education, Labor and Pensions (HELP) Committee, on the arbitration approach.

As mentioned in last week’s Policy Blog, the AUA cosigned an Alliance of Specialty Medicine letter sent to the Senate HELP Committee providing feedback on the surprise billing issue, which is part of a larger draft healthcare bill entitled the Lower Healthcare Cost Act of 2019.

AUA Advocacy Efforts to Support Research Funding, Women’s Health Needs, and Access to Infertility Treatment 

The AUA played an active role on Capitol Hill by participating in events and fly-ins that supported research funding, women’s health, and access to infertility treatments. Through collaborations with AUA advocacy partners One Voice Against Cancer, Bolder Women’s Coalition, and Resolve: The National Infertility Association, the AUA met with legislative offices to discuss the critical need for an increase in funding for the National Institute of Health funding to $41.6 billion for Fiscal Year (FY) 2020 and for the National Cancer Institute (NCI) to $6.5 billion for FY 2020. Additionally, the AUA supported the Access to Infertility Treatment and Care Act legislation that would insure insurance coverage for infertility treatments. You can read the full recap of these meetings and events here.

AUA, along with Physician Clinical Registry Coalition, Alliance of Specialty Medicine and Other Advocacy Groups, Respond to CMS and ONC Proposed Rules on Interoperability and Information Blocking Policies

The AUA has joined the Physician Clinical Registry Coalition (PCRC) and the Alliance of Specialty Medicine in urging the Office of the National Coordinator for Health Information Technology (ONC) to implement the information blocking provisions as a response to the ONC proposed rule entitled “21st Century Cures Act: Interoperability, Information Blocking and the ONC Health IT Certification Program.” The PCRC and Alliance issued their concerns in a letter responding to the ONC proposed rule entitled “21st Century Cures Act: Interoperability, Information Blocking and the ONC Health IT Certification Program.”  The goal is to allow the use of registries to grow and ultimately result in even greater improvements in the quality of patient care.

In addition, the PCRC and the Alliance also responded to Centers for Medicare & Medicaid Services proposed rule “Patient Protection and Affordable Care Act: Interoperability and Patient Access for Medicare Advantage. “This rule supports innovation aimed at minimizing errors, improving care coordination, reducing clinician burden, lowering costs, and enhancing consumer experience.” This rule focuses largely on patient access to health care data. Both rules want to advance interoperability among health care providers, payers, and patients and help patients become more engaged partners in their care by having access to their data.

The AUA also signed onto a letter with several advocacy organizations in response to the CMS Patient Protection and Affordable Care Act: Interoperability and Patient Access for Medicare Advantage proposed rule. The focus of this letter was to provide specific recommendations and action items for shared decision-making between provider and patient that ensure patients are truly making informed decisions. The letter emphasizes that Shared Decision Making should be a defined concept and urges CMS to prioritize implementation of the National Quality Partners Playbook: Shared Decision-Making in Healthcare (Playbook).

In 2018, the AUA supported a letter to CMS from many of these same organizations again calling on CMS to advance the recommendations included in the National Quality Partners Playbook on Shared Decision-Making.

Practice Management: Register Today for The AUA’s Regional Coding Seminar, Join the Practice Management Network, Evaluation & Management Auditing Service

The AUA is returning to The Westin Las Vegas for our annual Las Vegas Coding Seminar, to be held  July 19-20. Registration for this event is officially open. The seminar will feature experts in the field of urology, who will provide updates on coding changes, discussions of common coding questions and payment denials gathered from the AUA Coding Hotline. Our event is widely-praised by its attendees, with one suggesting that they “highly-recommend that physicians, managers, coders & billers of any level should attend.” The seminar will offer practical exercises to hone the skills of anyone in the practice who is involved with CPT, HCPCS, or ICD coding. Our seminar also will feature coding workshops to educate attendees on coding basics and discuss surgical coding challenges, as well as our auditing workshop, which will show our attendees how to face the challenges of E&M documentation head on.

Visit our website to view the seminar schedule for each day and register for the AUA Coding Seminar.

Does your practice needs access to valuable coding resources and updates on current urology management trends and issues? If so, you need to join the AUA’s Practice Management Network. The Practice Managers Network (PMN) is a vibrant hub of education and interaction. Our network allows its members to engage in a variety of ways, from discussing important matters in our online community, to receiving essential coding guidance from our AUA Coding Hotline. Let PMN give your practice the tools it needs to succeed. Join the Practice Managers’ Network and optimize your practice today.

Would you like to improve the financial health of your practice? If so, the AUA’s Evaluation & Management Audit Service is an essential option for your team. Designed for evaluation and management (E&M) services and minor procedures only, the Evaluation & Management Audit Service provides a mechanism for educating providers on documentation guidelines, ensuring all services are supported, and all appropriate revenue is captured.  There are multiple benefits to participating in this program:

  • Our audit service is urology-specific and is being performed by experts in the field.
  • All auditing is done at the AUA. No medical records are outsourced to a third party.
  • The service also offers your practice an opportunity to identify reimbursement deficiencies and increase revenue by spotting under-coding and unbilled services.

Slots for this program are limited and will be filled based on submission date and availability. Visit the AUA’s Evaluation & Management Service page to learn more about using this service for your practice.