June 2021 - AUA Public Policy Council Update for MAS
I am pleased to share updates from the AUA Public Policy Council that may benefit your Section members. Our updates include information on the AUA’s testimony and advocacy at the American Medical Association House of Delegates Annual Meeting and our Student, Resident, & Fellow Advocacy Night at Annual Urology Advocacy (AUA) Summit. We have also highlighted the AUA’s advocacy efforts to promote the urologic workforce.
Ashish Jha Highlights AUA Summit
We are very excited about the upcoming AUA Summit. During July, we will feature several advocacy-related events, including a Virtual Hill Day on July 21 that will provide direct opportunities to connect with key federal lawmakers and their staff on the topics impacting your practice and patients. The keynote speaker is Ashish Jha, MD, MPH – the Dean at Brown University’s School of Public Health. Featured on MSNBC and CNN, Dr. Jha is a world authority on the COVID-19 pandemic, so he brings unique insights to topics currently impacting healthcare and the future of healthcare in a post-COVID world.
Agency Visits Will Promote Strong Dialogue and Potential Wins on Key Issues
The AUA will meet with seven federal agencies in conjunction with this year’s AUA Summit.
This year, agency meetings will take place throughout the months of July and August.
The AUA has worked to build partnerships with key agencies in support of the important research needed to help patients with urologic diseases and conditions. Urologic research and the expanded role of telehealth will be topics of discussion during these events. Attendance is by invitation only for those with specialized backgrounds within the agency’s work. We will continue to keep you apprised of meeting outcomes as visits happen.
Student, Resident, & Fellow Advocacy Night
On July 19, in conjunction with the virtual 2021 AUA Summit, the AUA will be hosting a special two-hour event (7:00 – 9:00 p.m. EDT) for the next generation of urologic advocates. The evening will be made up of two separate sessions. The first session will feature a physician member of Congress keynote speaker to talk about their journey from clinic to congress, how to be an effective physician advocate, current health policy issues, and take live questions from the audience.
The second session will provide direct interaction with AUA advocacy leaders. It will include four break-out rooms focusing on four different topics in health advocacy, each led by a physician leader. The topics will include the following: patient and practice advocacy; research advocacy; workforce advocacy; and political advocacy. The rooms will be rotated every 15 minutes to allow all participants to meet with each advocacy leader. The event is free and open to any medical student, graduate student, resident, or fellow that are domestic AUA members and have registered for the 2021 AUA Summit.
The AUA Summit is free to all domestic AUA members. Register today!
American Medical Association (AMA) House of Delegates (HoD) Recap
Since June 11, AUA Delegates Drs. Terry Grimm and Hans Arora and Alternate Delegates Drs. James Gilbaugh and Jason Jameson have been representing the AUA at the 2021 AMA HoD Annual Meeting. Top issues include various physician workforce challenges and caring for patients in a pandemic and post-pandemic environment – particularly as it relates to telehealth. For a complete overview of the AUA’s advocacy and highlights of the meeting, visit our blogs.
Blog 1: https://community.auanet.org/blogs/policy-brief/2021/06/14/ama-house-of-delegates-recap
Blog 2: https://community.auanet.org/blogs/policy-brief/2021/06/15/ama-house-of-delegates-recap-june-14
Blog 3: https://community.auanet.org/blogs/policy-brief/2021/06/17/ama-house-of-delegates-recap-june-15-16
The next AMA HoD meeting will take place from November 13-16 in Orlando, Florida.
AUA Mobilizes Support for CONNECT for Health Act
On June 10, the AUA launched a Phone2Action campaign in support of the CONNECT for Health Act (S. 1512 and H.R. 2903). This bill expands access to telehealth services by eliminating the geographic area and originating site requirements and providing broad authority to HHS to waive all statutory restrictions on the use of telehealth in Medicare. This bill enables healthcare providers and patients in underserved communities with the ability to access the same telehealth services they have utilized during the public health emergency. The AUA urges members to participate in the Phone2Action campaign to request a Senate hearing on this bill and to urge their House Representatives to become a cosponsor of this important telehealth legislation. Read more about the AUA’s efforts in support of the CONNECT for Health Act here.
GAO Telehealth Report Highlights Telehealth Potential, AUA Input Included
A Government Accountability Office (GAO) report highlighted the potential for continuing telehealth usage at current levels following the public health emergency, but recommended caution on the part of lawmakers in maintaining some flexibilities due to concerns with fraud, waste and abuse.
The AUA provided input to the GAO in March highlighting the need for payment parity in order to maintain adoption of telehealth services by providers, as well as the crucial role audio-only visits played at the onset of the pandemic, and their continued importance for traditionally underserved populations. Public Policy Council Chair Eugene Rhee, MD; Urology Telehealth Task Force Chair Aaron Spitz, MD; and task force member Chad Ellimoottil met with GAO staff to discuss the AUA’s support for continuing telehealth flexibilities post-pandemic. That meeting helped form part of the GAO’s testimony to the Senate Finance Committee, which included AUA talking points on how telehealth services dramatically increased during the public health emergency. The GAO also shared the AUA’s feedback regarding barriers to telehealth utilization, such as lack of broadband access and technological literacy challenges.
In their report on telehealth utilization during the public health emergency, the GAO expressed concern regarding potential fraud and waste related to telehealth utilization. The AUA continues to address those concerns as part of our ongoing efforts around telehealth utilization post-public health emergency.
ICYMI: Updates from the AUA Policy & Advocacy Brief blog
AMA Prior Authorization Survey: 87% of Physicians Say PA interferes with Continuity of Care
In December 2020, the American Medical Association (AMA) surveyed 1,000 practicing physicians regarding their experience with prior authorization (PA). The survey revealed that PA still poses significant challenges for both physicians and patients at a time when our healthcare system faces unprecedented strains from the COVID-19 public health emergency. Moreover, the survey results showed health plans have yet to widely implement reforms suggested nearly three years ago through a consensus statement. The relevant portions of the consensus statement are listed below in line with the corresponding survey result.
| Consensus Statement Agreement | Survey results |
| Encourage the use of programs that selectively implement PA requirements based on stratification of health care providers’ performance and adherence to evidence-based medicine. | Only 11% of physicians report contracting with health plans that offer programs that exempt providers from PA. |
| Encourage revision of PA requirements, including the list of services subject to PA, based on data analytics and up-to-date clinical criteria. | A strong majority (83% and 83%*, respectively) of physicians report that the number of PAs required for prescription medications and medical services has increased over the last five years. |
| Encourage transparency and easy accessibility of PA requirements, criteria, rationale and program changes to contracted health care providers and patients/enrollees. | A majority (68% and 58%*, respectively) of physicians report that it is difficult to determine whether a prescription medication or medical service requires PA. |
| Encourage sufficient protections for continuity of care during a transition period for patients undergoing an active course of treatment when there is a formulary or treatment coverage change or change of health plan that may disrupt their current course of treatment. | An overwhelming majority (87%) of physicians report that PA interferes with continuity of care. |
| Encourage health care providers, health systems, health plans and pharmacy benefit managers to accelerate use of existing national standard transactions for electronic PA. | Physicians report phone and fax as the most commonly used methods for completing PAs. Moreover, under a quarter (24%) of physicians report that their EHR* system offers electronic PA for prescription medications. |
The AUA continues to advocate for restricted use of prior authorization as a means to reduce administrative burden and increase patient access. AUA efforts include meetings with the Center for Medicare and Medicaid Services’ Office of Burden Reduction and comments on agency rulemaking. For more information on the AUA’s advocacy and resources around PA, see our Prior Authorization page. Read more about the AMA’s PA survey, here.
AUA, Physician Organizations Seeks Bill Expanding Medicare Coverage of GME
On May 18, the AUA joined its colleagues in the GME Coalition in seeking expanded Medicare coverage of graduate medical education in the proposed infrastructure plan from the Biden administration. The letter (attached) discusses the physician shortage, how COVID-19 will impact the physician workforce, and how physicians are a critical part of our healthcare infrastructure.
The AUA also joined its colleagues in the Alliance of Specialty Medicine in submitting comments to the Senate Health, Education, Labor, and Pensions Committee for a physician workforce hearing held last week. On May 19, the Health Subcommittee held a hearing titled “A Dire Shortage and Getting Worse: Solving the Crisis in the Health Care Workforce.” The comment letter points out the growing number of specialty physicians as well as the extended length of time it takes to train those physicians over their primary care counterparts. The letter also provides the Alliance’s support of the Resident Physician Shortage Reduction Act (S.834), as well as the AUA-led legislation to create a student loan forgiveness program for specialty physicians that practice in a rural area (H.R. 944).
The AUA will continue to work with both the GME Coalition and the Alliance of Specialty Medicine on workforce legislation to address the shortage, diversity, and distribution issues in the physician workforce. For a copy of this comment letter, please contact AUA’s Director of Legislative & Political Affairs at BStine@AUAnet.org.
AUAPAC Hosts Virtual Fundraisers for Physician Workforce and Research Champions
On May 27, AUAPAC hosted a virtual fundraiser for Representative Peter Welch (D-VT-At Large). Rep. Welch is a member of the House Energy & Commerce Health Subcommittee, is the Democratic lead on AUA-led legislation to create a student loan forgiveness program for specialty physicians that practice in a rural area (H.R. 944), and champions the continued use of telemedicine beyond the current public health emergency. The event was attended by nine other physician groups within the medical and dental community, allowing the conversation to be focused entirely on health policy issues.
On June 8, AUAPAC participated in a fundraiser for Representative Rosa DeLauro (D-CT-03). She serves as Chair of the House Appropriations Committee, which overseas our nation’s investment in biomedical research at agencies such as the National Institutes of Health (NIH) and the continued funding of the Congressionally Directed Medical Research Programs (CDMRP) Prostate Cancer Research Program and Kidney Cancer Research Program. During the event, AUAPAC raised the issue of proportionate funding across the NIH, as urologic conditions are present in many disease states where NIH research is conducted. As a reminder, promoting and protecting funding for urologic research remains a top legislative priority for the AUA during this 117th Congress.
AUA Supports Private Contracting in Medicare Bills
On June 3, the AUA joined its colleagues in the Alliance of Specialty Medicine to support the reintroduction of the Medicare Patient Empowerment Act (H.R. 3322/S. 826). The bill would establish a Medicare payment option for patients and eligible professionals to freely contract, without penalty, for Medicare fee-for-service items and services, while allowing Medicare beneficiaries to use their Medicare benefits. The endorsement letters were sent to the corresponding bill sponsors, Rep. Pete Sessions (R-TX-17) and Sens. Rand Paul, MD (R-KY) and Lisa Murkowski (R-AK). For a copy of these letters, please contact AUA’s Director of Legislative & Political Affairs at BStine@AUAnet.org
Below are insurance updates from national insurance carriers. If you have questions about insurer issues, contact Ray Wezik at rwezik@auanet.org
CGS Administrators
CGS Administrators released its Androgen Receptor Variant (AR-V7) Protein Test (MoIDX) (J15) (A57158) Local Coverage Article (LCA). This LCA is now in effect, beginning, May 9.
CGS Administrators released its Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC) (MolDX) (J15) (L37836) Local Coverage Determination (LCD). This LCD is now in effect, beginning, May 9.
CGS Administrators reviewed its Urological Supplies (A52521) Supplemental Article with the following changes to billing guidelines:
- Added billing guidelines for inFlow under HCPCS A4335 for dates of service on or after April 1.
- Added charging base to the following guidelines: code A4335 is billed as 1 unit of service at initial issue and is all inclusive (catheter, activator, charging base); code A4335 must also be used on separate claim lines for replacement of any individual components of the inFlow intraurethral valve pump system (catheter, activator, charging base).
- Revised billing guidelines regarding initial sizing and insertion of inFlow replacement to replace codes K1011, K1011, and K1012 with product information.
CGS Administrators reviewed its Urological Supplies (JB, JC) (L33803) Local Coverage Determination (LCD) removing the following HCPCS codes:
- K1010 – Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each
- K1011 – Activation device for intraurethral drainage device with valve, replacement only, each
- K1012 – Charger and base station for intraurethral activation device, replacement only
Humana
Humana reviewed its Erectile Dysfunction and Peyronie’s Disease Treatments Policy with the following changes:
- Added the following criteria for penile arterial revascularization surgery:
- Member must be nicotine-free for six weeks prior to the date of the anticipated surgery (unless the surgical procedure is emergent); and
- Members who have been nicotine users prior to the anticipated surgery must provide documentation of nicotine cessation, as evidenced by negative lab test report for nicotine and cotinine, to have been performed within two weeks of the planned surgical procedure
- Removed the following criterion for penile arterial revascularization surgery:
- Member is not currently cigarette smoking
Humana reviewed its Laboratory Analysis for Prostate Cancer Policy with the following changes:
- Added criteria for BRCA1 and BRCA2 germline testing for individual with a first-degree relative diagnosed with:
- Metastatic prostate cancer by biopsy and/or radiography; or
- Prostate cancer with intraductal/cribriform histology; or
- Prostate cancer stratified as high-risk group (see policy for details); or
- Prostate cancer stratified as very-high-risk group (see policy for details)
- Revised criteria for BRCA1 and BRCA2 germline testing including:
- Clarified characteristics of prostate cancer stratified as very-high-risk group by listing applicable high-risk features (two required);
- Revised criterion denoting individual to be tested who has an affected first-, second-or third-degree relative with a pathogenic or likely pathogenic variant in BRCA1or BRCA2 genes (test known familial variant);
- Revised language to replace “close blood relative(s)” with “first-, second-or third-degree relative(s)” and specified “on the same side of the family” where applicable
Noridian
Noridian released its draft Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (MoIDX) Local Coverage Determination (LCD) on May 20. A teleconference only open meeting and presentation of this policy is scheduled on June 24. The comment period begins on May 20 and ends on July 3. A synopsis of the draft is as follows:
- Limited coverage for prostate biomarker diagnostic tests that help differentiate men who may or may not benefit from a prostate biopsy when all of the following conditions are met: The member is a candidate for prostate biopsy or repeat prostate biopsy, according to a consensus guideline; the member has not had a prostate biopsy or has a had a previous negative or non-malignant but abnormal histopathology finding; the member would benefit from treatment of prostate cancer; the member is within the population for which the test was developed and validated and the lab providing the test is responsible for clearly indicating to treating clinicians the population and indication for test use; if the test relies on an algorithm, the algorithm must be validated in a cohort that is not a development cohort for the algorithm; the analytes measured have demonstrated clinical validity and clinical utility in the peer reviewed published literature, establishing a clear and significant biological/molecular basis for stratifying members and subsequently selecting their clinical management decision within a clearly defined population; the test is ordered by a physician specialist in the management of prostate cancer, such as urologist or oncologist.
Read the update (JF) (DL39007).
Read the update (JE) (DL39005).
Palmetto
Palmetto released its draft Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (MolDX) (JJ, JM) (DL38985) Local Coverage Determination (LCD) on May 20. A teleconference only open meeting and presentation of this policy is scheduled on June 28. The comment period begins on May 20 and ends on July 3. A synopsis of the draft is as follows:
- Prostate biomarker diagnostic tests that help differentiate beneficiaries who may benefit from a prostate biopsy may be considered medically necessary when all criteria are meant, which includes the following: beneficiary is a candidate for prostate biopsy or repeat prostate biopsy, according to a consensus guideline; beneficiary has not had a prostate biopsy or has had abnormal histopathology findings despite previous negative tests; the beneficiary is within the population for which the test was developed and validated and would benefit from the treatment of prostate cancer; that the tests be ordered by an approved physician with proper algorithm validation; and that the analytes measured have demonstrated clinical validity and clinical utility.
Palmetto reviewed its Transurethral Waterjet Ablation of the Prostate (JJ, JM) (A58008) Local Coverage Article (LCA) removing the following codes from CPT/HCPCS code group 1:
- K1010 – Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each
- K1011 – Activation device for intraurethral drainage device with valve, replacement only, each
- K1012 – Charger and base station for intraurethral activation device, replacement only
United Healthcare
United Healthcare reviewed its Clinical Diagnostic Laboratory Services (Medicare) Policy Removed CPT codes including:
- 0011M – Oncology, prostate cancer, mRNA expression assay of 12 genes (10 content and 2 housekeeping), RT-PCR test utilizing blood plasma and/or urine, algorithms to predict high-grade prostate cancer risk
- 0012M – Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), utilizing urine, algorithm reported as a risk score for having urothelial carcinoma
Local and Regional Updates
The AUA is joining the American Medical Association (AMA) and other national physician organizations (e.g., American College of Emergency Physicians, American Academy of Family Physicians, American Society of Clinical Oncology) to oppose the American Academy of PA’s (AAPA) decision to change their title from “physician assistant” to “physician associate”. The decision to take this position was unanimous among the State Advocacy Committee’s membership and aligns with the AUA Current State of Advanced Practice Providers in Urologic Practice White Paper.
The following are updates in your Section. The AUA routinely monitors state legislative, regulatory, and insurance policy trends. Please contact AUA State Advocacy Manager Catherine Hendricks at chendricks@AUAnet.org for more information on any of these issues.
Delaware
Highmark BCBS Delaware
Highmark BCBS Delaware reviewed its Treatment of the Prostate (Commercial) Policy adding HCPCS codes C9769, C9740, C9739.
H.B. 21 – Nurse Practitioner
Introduced by Representative Mimi Minor-Brown (D), H.B. 21 seeks to make Delaware part of the nursing compact. The bill passed the House and is in the Senate Legislative Oversight and Sunset Committee for consideration. Read the bill.
H.B. 141 – Nurse Practitioner
Introduced by Representative Mimi Minor-Brown (D), H.B. 141 seeks to amend the state nursing law to remove the definition of “independent practice” and replace it with “full practice authority” and grants full practice authority in conjunction with licensure. The bill was passed by the House and is now in the Senate Oversight and Sunset Committee. Read the bill.
New Jersey
- 4559 – COVID/Medical Liability
Introduced by Assemblymember Joann Downey (D), A. 4559 provides certain civil immunities granted to for-profit healthcare facilities and healthcare systems during the state of emergency and public health emergency are to expire at the end of the public health emergency. The bill was referred to the Assembly Health Committee. Read the bill.
- 5602 – Prostate Cancer
Introduced by Assemblymember John Burzichelli (D), A. 5602 seeks to designate September as “Prostate Cancer Awareness Month.” Under current law, the month of June in each year is designated as “Prostate Cancer Awareness Month” in New Jersey. This bill amends current law to move “Prostate Cancer Awareness Month” from June to September. The bill was referred to the Assembly Health Committee. Read the bill.
- 1771 – Pelvic Exam
Introduced by Senator Fred Madden, S. 1771 seeks to prohibit an invasive exam of an unconscious patient without the patient’s prior informed consent. The bill was referred to the Senate Health, Human Services and Senior Citizens Committee. Read the bill.
- 3731 – COVID/Medical Liability
Introduced by Senator Nia Gill (D), S. 3731 seeks to end civil immunity provided to certain health care professionals and health care facilities related to COVID-19 response. The bill was referred to the Senate Judiciary Committee. Read the bill.
- 3745 – Prostate Cancer
Introduced by Senators Stephen Sweeney (D) and Troy Singleton (D), S. 3745 seeks to make every September Prostate Cancer Awareness Month, instead of June. The bill was referred to the Senate health, Human Services and Senior Citizens Committee. Read the bill.
Pennsylvania
Cap Blue Cross
Cap Blue Cross reviewed its Erectile Dysfunction Policy with the following changes:
- Added the following CPT codes:
- 36245 – Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family
- 36246 – Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family
- 36247 – Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family
- 36248 – Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (list in addition to code for initial second or third order vessel as appropriate)
- 75736 – Angiography, pelvic, selective or supraselective, radiological supervision and interpretation
- Added the following HCPCS codes:
- J0270 – Injection, alprostadil, 1.25 mcg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)
- J0275 – Alprostadil urethral suppository (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)
- L7902 – Tension ring, for vacuum erection device, any type, replacement only, each
- Removed the following CPT codes:
- 54230 – Injection procedure for corpora cavernosography
- 54231 – Dynamic cavernosometry, including intracavernosal injection of vasoactive drugs (e.g., papaverine, phentolamine)
Independence Blue Cross
Independence Blue Cross reviewed its Urological Supplies (Medicare Advantage) Policy with the following changes:
- Removed the following HCPCS codes:
- K1010 – Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each
- K1011 – Activation device for intraurethral drainage device with valve, replacement only, each
- K1012 – Charger and base station for intraurethral activation device, replacement only
- Indicated that A4335 is used to represent the INFLOW Device.
New Jersey
- 4559 – COVID/Medical Liability
Introduced by Assemblymember Joann Downey (D), A. 4559 provides certain civil immunities granted to for-profit healthcare facilities and healthcare systems during the state of emergency and public health emergency are to expire at the end of the public health emergency. The bill was referred to the Assembly Health Committee. Read the bill.
- 5602 – Prostate Cancer
Introduced by Assemblymember John Burzichelli (D), A. 5602 seeks to designate September as “Prostate Cancer Awareness Month.” Under current law, the month of June in each year is designated as “Prostate Cancer Awareness Month” in New Jersey. This bill amends current law to move “Prostate Cancer Awareness Month” from June to September. The bill was referred to the Assembly Health Committee. Read the bill.
- 1771 – Pelvic Exam
Introduced by Senator Fred Madden, S. 1771 seeks to prohibit an invasive exam of an unconscious patient without the patient’s prior informed consent. The bill was referred to the Senate Health, Human Services and Senior Citizens Committee. Read the bill.
- 3731 – COVID/Medical Liability
Introduced by Senator Nia Gill (D), S. 3731 seeks to end civil immunity provided to certain health care professionals and health care facilities related to COVID-19 response. The bill was referred to the Senate Judiciary Committee. Read the bill.
- 3745 – Prostate Cancer
Introduced by Senators Stephen Sweeney (D) and Troy Singleton (D), S. 3745 seeks to make every September Prostate Cancer Awareness Month, instead of June. The bill was referred to the Senate health, Human Services and Senior Citizens Committee. Read the bil