May 2020 - AUA Public Policy Council Update for MAS

From the Incoming Chair

Over the past few months, we’ve all born witness to an existential worldwide health crisis. We, as urologists, rapidly ramped down, redeployed, and now are repatriating our practices. I’m inspired by our AUA and our healthcare personnel throughout this country, understanding the scope of our economic and personal recovery hinges on how the medical community leans in to create momentum.

I want to express my gratitude to Dr. Chris Gonzalez for modeling fortitude, commitment, and grace as the outgoing Chair of the AUA Public Policy Council. I’ve noted over the years his process of leadership, experience, and communication by example. He most certainly, like his predecessors, made this position immensely stronger upon departure as I transition to this role in June. I ask that at the end of your day, toast him, the urologists, providers, and the AUA staff who continue to advocate for this nation’s healthcare.

As the incoming Chair, I am pleased to share updates from the AUA Public Policy Council that may benefit your Section members. Our updates include information on more than a dozen virtual meetings with members of Congress on a wide range of topics, including top AUA legislative priorities like the need to expand additional medical liability protections for physicians and to better address physician workforce shortages. We also provide specific insurance updates regarding telehealth services in your geographic area.

Maryland Prostate Cancer Screening Bill Becomes Law in 2021

HB 852 Prostate Cancer Screening Coverage Services – Prohibiting Cost-Sharing, introduced by Maryland House Delegate Erek Barron (D), was enacted and will become law on January 1, 2021. HB 852 specifically requires the state of Maryland to cover a digital rectal exam and a PSA test for men between 40 and 75 years old and men who are at high risk of developing the disease. Since the AUA State Advocacy Committee began working on this important issue in 2018, Maryland is the second state (following New York) to pass legislation expanding access to screening services by prohibiting cost-sharing for certain individuals.

As a reminder, on February 13, AUA Mid-Atlantic Section President Dr. Benjamin Lowentritt testified in support of the bill in the Health and Governance Operations Committee. To listen to the hearing, click here (hearing begins at the 1:45:45 mark; Dr. Lowentritt’s testimony begins at the 1:54:44 mark). “This is about incorporating prostate cancer screening in a preventive measure in a well visit or physical exam that may be covered under a plan and not putting the patient at risk for even being concerned about the financial hardships that they might have from a bill,” he said in his testimony.

The AUA collaborated with ZERO – The End of Prostate Cancer , Chesapeake Urology and MedChi: The Maryland State Medical Society in formally endorsing the bill. The AUA sent support letters to the sponsors of the bill, committee hearing members and also to Governor Larry Hogan (R) urging his signature on the bill. The AUA also sent out a grassroots alert to more than 430 Maryland urologists – urging them to phone, tweet and write their state legislators to support HB 852.

Promoting prostate cancer screening coverage with no cost-sharing is a top priority for the AUA’s State Advocacy Committee. The AUA will continue to partner with stakeholders such as ZERO to urge other legislatures to introduce similar measures around the country (e.g., Illinois, Alabama – among others). For a copy of these letters or if you have any questions, please contact Andrea Oh at aoh@auanet.org

Congressional Outreach: AUA Participates in Various Virtual Meetings on COVID-19 Relief with Federal Lawmakers

The AUA joined other likeminded provider groups in meeting with members of Congress and their staff – from both sides of the aisle – to discuss numerous pressing issues impacting physicians and our health care delivery system around the country. A wide range of topics were mentioned, including top AUA legislative priorities like the need to expand additional medical liability protections for physicians and to better address physician workforce shortages. Other key areas involved telemedicine and the importance of streamlining both audio-only and visual services and improving the terms of the Medicare Accelerated and Advance Payment Programs that were enacted in March via the CARES Act (COVID III). These conversations were especially timely, as congressional efforts are now underway to eventually pass a fourth COVID-19 relief package.

A strategic focus was placed on mainly educating lawmakers that sit on the committees overseeing U.S. health policy, which include the House Energy & Commerce and Ways & Means Committees and the Senate Finance and Health, Education, Labor & Pensions Committees, as well as others with a medical background. Those members included the following: Reps. John Katko (R-NY-24); Roger Marshall, MD (R-KS-01); Nanette Barragán (D-CA-44); Andy Harris, MD (R-MD-1); John Joyce, MD (R-PA-13); Joseph Morelle (D-NY-25); Donna Shalala (D-FL-27); Larry Bucshon, MD (R-IN-08); Nydia Velázquez (D-NY-7); Gus Bilirakis (R-FL-12); Bill Johnson (R-OH-06); Phil Roe, MD (R-TN-01); Nancy Pelosi (D-CA-12); Michael Burgess, MD (R-TX-26); Sens. Steve Daines (R-MT); John Boozman, OD (R-AR); Tammy Baldwin (D-WI); Bill Cassidy, MD (R-LA); John Thune (R-SD); and professional staff from the House Ways & Means Committee and the Senate Finance Committee.

National Insurance Updates

The following are national Medicare Administrative Contractor (MAC) and commercial insurance updates.

Aetna

Aetna reviewed its Homocysteine Testing Policy with the following changes to criteria, coding, and supporting information:

Revised criteria to indicate that:

  • The use of serum homocysteine as a biomarker for the development and/or progression of erectile dysfunction is considered experimental and investigational.

Added the following ICD-10 codes:

  • N52.01-N52.9 – Male erectile dysfunction

Read the update.

Aetna reviewed its Benign Prostatic Hyperplasia Policy with the following changes to criteria, coding, and supporting information:

  • Added experimental and investigational policy statement for CYP17 rs743572 polymorphism testing for estimating BPH susceptibility.
  • Revised the list of experimental and investigational treatment for BPH; clarified that temporary prostatic urethral stent includes implantable nitinol devices.
  • Revised the list of medically necessary treatment for BPH as alternatives to transurethral resection of the prostate; added language to state that usually 4 to 6 UroLift implants are placed into the prostate.
  • Added the following not covered HCPCS code:
    • C2625 – Stent, noncoronary, temporary, with delivery system [urethral stent]

Read the update.

Aetna reviewed its Electrical Stimulation for Pain Policy adding the following not covered CPT codes for electrical stimulation of posterior tibial nerve stimulation:

  • 0587T – Percutaneous implantation or replacement of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve.
  • 0588T – Revision or removal of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve.
  • 0589T – Electronic analysis with simple programming of implanted integrated neurostimulation system (e.g., electrode array and receiver), including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient-selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, when performed by physician or other qualified health care professional, posterior tibial nerve, 1-3 parameters.
  • 0590T – Electronic analysis with complex programming of implanted integrated neurostimulation system (e.g., electrode array and receiver), including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient-selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, when performed by physician or other qualified health care professional, posterior tibial nerve, 4 or more parameters.

Read the update.

Aetna reviewed its Erectile Dysfunction Policy with the following changes to criteria and supporting information:

  • Revised approval criteria for Xiaflex for Peyronie’s disease. Added the following initial approval criteria, among others: the member has stable Peyronie’s disease without clinical changes (e.g., worsening curvature) for at least three months; the member has intact erectile function (with or without medication); and the member is 18 years of age or older. Also added continuation criteria and updated dosing recommendations.

Read the update.

Aetna reviewed its Near-Infrared Vascular Imaging and Near-Infrared Fluorescence Imaging Policy adding delineation of the ureters during laparoscopy to the list of indications considered experimental and investigational for the use of near-infrared fluorescence (NIRF) imaging.

Read the update.

Aetna reviewed its Urinary Incontinence Policy with the following changes to criteria, coding, and supporting information:

  • Added that genetic testing for stress urinary incontinence is considered experimental and investigational because its clinical value for this indication has not been established.
  • Added that FemiLift (CO2 laser) for the treatment of urinary incontinence is considered experimental and investigational because its effectiveness has not been established.
  • Added that the Adjustable Transobturator Male System for the treatment of stress urinary incontinence (SUI) is considered experimental and investigational because its effectiveness has not been established.
  • Added that magnetic stimulation for the treatment of women with SUI is considered experimental and investigational because the effectiveness of this approach has not been established.
  • Removed cancer as a contraindication for the use of the Interstim Continence Control System.

Read the update.

Cap Blue Cross

Cap Blue Cross reviewed its Treatments of the Prostate Policy to include the following chases to coding:

  • Added the following CPT and HCPCS codes:
    • 0582T – Transurethral ablation of malignant prostate tissue by high-energy water vapor thermotherapy, including intraoperative imaging and needle guidance
  • Added the following HCPCS code:
    • C2596 – Probe, image-guided, robotic, waterjet ablation

Read the update.

Centers for Medicare and Medicaid Services (CMS)

CMS revised its Sacral Nerve Stimulation NCD and added the following HCPCS code effective January 1, 2020:

  • C1820 – Generator, neurostimulator (implantable), with rechargeable battery and charging system

Read the update.

CGS Administrators

CGS Administrators reviewed its Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia – LCD (J15) (L38378) revising the notice period from March 31, 2020 to now be extended until May 31, 2020 and adding the policy will not be effective until June 1.

Read the update.

CGS Administrators reviewed with the Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia – LCA (J15) (A57926) making the following change to coding:

  • Added the following CPT code to coding information under article text and CPT/HCPCS group 1 paragraph:
    • 0421T – Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed).
  • Removed the ICD-10 code N40.1 from ICD-10 codes that support medical necessity group 1, as the code was added in error.
  • Created the coding information subsection under article text; Added information stating that CPT code 0421T is considered not medically necessary and will automatically be denied as a non-covered procedure.

Read the update.

Cigna

Cigna revised its Prolia, Xgeva Pharma Policy criterion for the indication of bone loss in non-metastatic prostate cancer regarding the definition of high risk for fractures, updating the bone mineral density T-score to less than or equal to -2.5 in the lumbar spine, femoral neck, total hip, and/or 33% (one third) radius [wrist].

Read the update.

Highmark Inc.

Highmark reviewed its Lab Management Code List, with the following changes to coding:

  • Added the following CPT codes:
    • 81277 – Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number and loss-of-heterozygosity variants for chromosomal abnormalities.
    • 81542 – Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score.
    • 0113U – Oncology (prostate), measurement of PCA3 and TMPRSS2-ERG in urine and PSA in serum following prostatic massage, by RNA amplification and fluorescence-based detection, algorithm reported as risk score.
    • 0133U – Hereditary prostate cancer-related disorders, targeted mRNA sequence analysis panel (11 genes) (List separately in addition to code for primary procedure).
  • Removed the following CPT codes:
    • 0057U – Oncology (solid organ neoplasia), mRNA, gene expression profiling by massively parallel sequencing for analysis of 51 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as a normalized percentile rank.

Read the update.

Humana

Humana revised its Erleada policy criteria for prostate cancer (non-metastatic castration-resistant) by removing the criterion that the member has a prostate-specific antigen doubling time (PSADT) of less than or equal to 10 months.

Read the update.

Humana reviewed its Xtandi Policy with the following changes to the list of indications, criteria, and supporting information:

  • Revised the description section by adding the indication of metastatic castration-sensitive prostate cancer.
  • Added criteria for the indication of metastatic castration-sensitive prostate cancer with the following criteria:
    • The member has a diagnosis of metastatic castration-sensitive prostate cancer.
  • The member will use Xtandi in combination with androgen deprivation therapy (e.g., previous bilateral orchiectomy or GnRH analog).
  • The member has intolerance or contraindication to Erleada (apalutamide).
  • Revised criteria for prostate cancer (non-metastatic castration-resistant) by removing the criterion that the member has a prostate-specific antigen doubling time (PSADT) of less than or equal to 10 months.

Read the update.

Humana reviewed its Xtandi Policy with the following changes to the list of indications, criteria, and supporting information:

  • Revised description section by adding the indication of metastatic castration-sensitive prostate cancer.
  • Added criteria for the indication of metastatic castration-sensitive prostate cancer with the following criteria:
    • The member has a diagnosis of metastatic castration-sensitive prostate cancer.
  • The member will use Xtandi in combination with androgen deprivation therapy (e.g. previous bilateral orchiectomy or GnRH analog).

Read the update.

Humana reviewed its Erective Dysfunction Medications Policy revising the list of indications for Cialis by adding the treatment of the signs and symptoms of benign prostatic hyperplasia (BPH), ED, and signs and symptoms of BPH with ED (ED/BPH).

Read the update.

National Government Services

National Government Services rescheduled its multijurisdictional Care Advisory Committee meeting regarding facet joint and medial nerve branch procedures due to COVID-19 pandemic. The new meeting will be held via teleconference only on May 28 from 2 p.m. to 4 p.m. ET/1 pm to 3 p.m. CT.

Read the update.

National Government Services reviewed its Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) LCS (J6, JK) (A56874) with the following changes to coding and administrative information:

  • Corrected the ICD-10 code range C79.32-C79.52 to add ICD-10 code C79.31 to ‘Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation’ section.
  • Corrected the ICD-10 code range C00.01-C10.9 to add ICD-10 code C00.0 to ‘Group 2 Medical Necessity ICD-10 Codes Asterisk Explanation’ section.
  • Added note stating that “the ‘ICD-10 Codes that Support Medical Necessity’ section has been revised to correct the ICD-10 code range C79.32- C79.52 to include ICD-10 code C79.31 under section ‘Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation’ and to correct the ICD-10 code range C00.1-C10.9 to include ICD-10 code C00.0 under ‘Group 2 Medical Necessity ICD-10 Codes Asterisk Explanation’ section”.

Read the update.

National Government Services reviewed its Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH) LCD (L38367) revising the notice period from March 31, 2020 to now be extended until May 31, changing the effective date to June 1.

Read the update.

Noridian

Noridian reviewed its Decipher Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease (MoIDX) LCA (JF) (A57646) with the following changes to coding.

  • Added the following CPT code to article text and CPT/HCPCS group 1:
    • 81542 – Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as metastasis risk score.
  • Removed the following CPT code from article text and CPT/HCPCS group 1:
    • 81479 – Unlisted molecular pathology procedure.

Read the update.

Noridian reviewed its Decipher Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease (MoIDX) LCA (JE) (A57645) with the following changes to coding:

  • Added the following CPT code to article text and CPT/HCPCS codes group 1:
    • 81542 – Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as metastasis risk score.
  • Removed the following CPT code from article text and CPT/HCPCS codes group 1:
    • 81479 – Unlisted molecular pathology procedure.

Read the update.

Noridian reviewed its Sacral Nerve Stimulation for Urinary and Fecal Incontinence LCA (A53017) with the following change to coding:

  • Added the following HCPCS code to group 2 ancillary codes:
    • C1820 – Generator, neurostimulator (implantable), with rechargeable battery and charging system.

Read the update.

Noridian reviewed its Sacral Nerve Stimulation for Urinary and Fecal Incontinence LCA (A53359) with the following change to coding:

  • Added the following HCPCS code to group 2 ancillary codes:
    • C1820 – Generator, neurostimulator (implantable), with rechargeable battery and charging system.

Read the update.

Noridian updated its MSI-H and dMMR Biomarker for Unresectable or Metastatic Solid Tumors – LCA (JE) (A56103) article, moving the following CPT code from group 1 to group 2:

  • 81301 – Microsatellite instability analysis (e.g., hereditary non-polyposis colorectal cancer, lynch syndrome) of markers for mismatch repair deficiency (e.g., bat25, bat26), includes comparison of neoplastic and normal tissue, if performed.

The updated article reflects a title change indicating its status as billing and coding document.

Read the update.

Palmetto

Palmetto reviewed its Procedure Codes That Require Additional Documentation – Coding Document with the following changes to coding:

  • Added CPT codes, including, but not limited to the following:
    • 0582T – Transurethral ablation of malignant prostate tissue by high-energy water vapor thermotherapy, including intraoperative imaging and needle guidance.

Read the update.

Tufts Health Plan

Tufts Health Plan reviewed its policies with the following changes to criteria:

  • Removed specific language indicating that Tufts Health Plan will hold the member harmless from a financial perspective when using an out-of-network (OON) provider.
  • Revised telemedicine section to indicate that plans which require referrals and/or authorizations to see OON specialists continue to require referrals and/or authorizations for telehealth services, unless services are related to the following: COVID-19; inpatient care; post-acute care, including inpatient rehab, skilled nursing facilities, long-term acute care (LTAC), and/or home care following an inpatient admission; primary care or outpatient behavioral health services.

Read the update.

United Healthcare

United Healthcare published a Provider Bulletin announcing:

  • Prior authorization extensions for Medicare, Medicaid, Individual, and Group market health plans due to COVID-19.
  • A 90 day extension for certain prior authorization requests with an end date of service between March 24 and May 31.

Read the update.

United Healthcare reviewed its Clinical Diagnostic Laboratory Services Policy with the following changes to coding.

  • Added the following CPT codes:
    • 0154U – Oncology (urothelial cancer), RNA, analysis by real-time RT-PCR of the FGFR3 (fibroblast growth factor receptor 3) gene analysis (i.e., p.R248C [c.742C>T], p.S249C [c.746C>G], p.G370C [c.1108G>T], p.Y373C [c.1118A>G], FGFR3-TACC3v1, and FGFR3-TACC3v3) utilizing formalin-fixed paraffin-embedded urothelial cancer tumor tissue, reported as FGFR gene alteration status.
  • Removed notation indicating the following CPT code is not covered when submitted with screening diagnosis; added reference to related policy on molecular pathology/molecular diagnostics/genetic testing:
  • 0133U – Hereditary prostate cancer–related disorders, targeted mRNA sequence analysis panel (11 genes) (List separately in addition to code for primary procedure).

Read the update.

United Healthcare reviewed its Discarded Drugs and Biologicals Policy, Professional Payment Policy with the following changes to criteria, coding, and supporting information:

  • Revised reimbursement guideline for Examples of wastage of single use vials from “HCPCS code J0585 is defined as onabotulinumtoxinA, per unit” to “HCPCS code J0585 is defined as per unit.”
  • Revised reimbursement guideline for Per Unit Example, Single Patient from “HCPCS code J0585 is defined as onabotulinumtoxinA, per unit” to “HCPCS code J0585 is defined as per unit.”
  • Revised reimbursement guideline example for Multi-use vials are not subject to payment for discarded amounts of drug or biological.
  • Removed the following HCPCS codes from the policy:
    • J0120-J9999 – Drugs and biologicals.
  • Removed the following coding modifier from the policy:
    • JW – Drug or biological amount discarded/not administered to any patient.

Read the update.

United Healthcare reviewed its Sterilization (NCD 230.3) Policy removing the following CPT code:

  • 55450 – Ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure).

Read the update.

United Healthcare reviewed its Category III CPT Codes Policy adding the following CPT codes as non-covered:

  • 0590T – Electronic analysis with complex programming of implanted integrated neurostimulation system (e.g., electrode array and receiver), including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient-selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, when performed by physician or other qualified health care professional, posterior tibial nerve, 4 or more parameters.
  • Added note to criteria section stating, “Once a Category III CPT code is replaced by a Category I CPT code, the item, service, or procedure should not be presumed to be medically necessary.”

Read the update.

United Healthcare released a new Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid policy with the following coding and supporting information:

  • Replaced state-specific policies with a comprehensive policy for Oklahoma, Oregon, Texas, and Washington, with the following changes to criteria.
  • Revised coverage guidelines for the following for Oregon and Washington:
    • Pumps, including medications and necessary supplies
  • Revised coverage guidelines for the following for Washington only:
    • Vacuum pump or device (e.g., ErecAid)

Read the update.

United Healthcare reviewed its Biofeedback Therapy for the Treatment of Urinary Incontinence (NCD 30.1.1) Policy adding the following CPT codes:

  • 90912 – Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient.
  • 90913 – Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure).

Read the update. 

Local and Regional Updates

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

Delaware

Highmark BCBS Delaware reviewed its Sacral Nerve Neuromodulation Policy with the following changes to criteria, coding, and supporting information:

  • Removed a criterion for treatment of urinary incontinence which required presence of symptoms for at least one year’s duration resulting in significant disability.
  • Revised conventional therapy requirement for treatment of urinary incontinence to require two of the following: behavioral training, pharmacological treatment, or surgical corrective therapy (previously required both pharmacological and behavioral treatment).
  • Changed title from “Sacral Nerve Neuromodulation/Stimulation” to “Sacral Nerve Neuromodulation”.

Read the update.

Highmark BCBS Delaware reviewed its Tumor Markers Policy with the following changes to criteria and coding:

  • Added the following to indications for which prostate specific antigen (PSA) may be considered medically necessary: members with palpable abnormal prostate gland; members with lower urinary tract signs and symptoms (i.e. hematuria, slow urine stream, hesitancy, urgency, frequency, nocturia, incontinence).

Read the update.

Maryland

Maryland Resumes Elective Surgeries

Maryland Governor Larry Hogan (R) announced, elective and non-urgent medical procedures and appointments could resume on May 7 if medical facilities met certain requirements. These requirements include the following:

  • Adequate supplies of personal protective equipment;
  • Continued social distancing;
  • Enhanced sanitation measures; and
  • COVID-19 symptom screening.

HB 858 – Medical Malpractice
On March 13, Delegate Susan McComas (R) introduced HB 858. This bill amends Courts and Judicial Proceedings Law and allows for a defendant in a malpractice claim to motion for a protective order that limits the disclosure of evidence that can cause annoyance, embarrassment, oppression or undue burden or expense to the defendant.

On May 8, this measure was enacted without Governor Hogan’s (R) signature and will become law on October 1, 2020. Read the bill.

New Jersey

Horizon BCBS New Jersey reviewed its Jevtana Policy with the following changes to criteria, supporting information, and language:

  • Added criterion stating that for medical necessity to be indicated for Jevtana, in the treatment of hormone-refractory metastatic prostate cancer in adult members, in addition to all other criteria being met, Jevtana must not be used with other chemotherapy agents.
  • Changed criterion stating that for medical necessity to be indicated for Jevtana, in the treatment of hormone-refractory metastatic prostate cancer, Jevtana must be prescribed by the treating physician to now state that the prescriber must be a specialist in the area of the member’s diagnosis (e.g., oncologist) or must have consulted with a specialist in the area of the member’s diagnosis.

Read the update.

Horizon BCBS New Jersey reviewed its Proleukin policy removing criterion stating that Proleukin must be considered investigational in the treatment of other malignancies (e.g., lung cancer, colorectal cancer, acute myeloid leukemia, bladder cancer, neuroblastoma, pancreatic cancer, endometriomas) and pre-malignancies (e.g., myelodysplastic syndromes).

Read the update. 

Horizon BCBS New Jersey reviewed its Image Guided Radiation Therapy (IGRT) with the following additions to the Medicare coverage section:

  • There is no National Coverage Determination (NCD) for IGRT.
  • In the absence of an NCD, coverage decisions must be left to the discretion of local Medicare carriers.
  • The LCD: Intensity Modulated Radiation Therapy (IMRT) (L36711) and Local Coverage Article: Billing and Coding: Intensity Modulated Radiation Therapy (IMRT) (A56725) can be referred to.

Read the update.

SB 2465 – Medical Licensure
On May 11, Senator Stephen Sweeney (D) introduced SB 2465. This bill creates the “New Jersey Health Care Transparency Act” to require health professionals to display information about their license in advertisements and place of practice. SB 2465 also requires health care professionals to wear name tags with the professional’s: full name, licensed profession, license expiration, and recent picture. SB 2465 was introduced and referred to the Senate Health, Human Services and Senior Citizens Committee. This measure is eligible for consideration. Read the bill.

SB 2435 – Provider Contracts
On May 7, Senator Vin Gopal (D) introduced SB 2435. This bill deems void and unenforceable any covenant in a contract or agreement that restricts the ability of a physician or nurse to practice in a geographic area for any period of time after termination of the partnership, employment, or professional relationship. SB 2435 does not apply to restrictive covenants that prohibit a physician from leaving a hospital system or a group practice comprising 30 or more physicians to join any other hospital system or group practice comprising 30 or more physicians within a given geographic area. SB 2435 was introduced and referred to the Senate Health, Human Services and Senior Citizens Committee. This measure is eligible for further consideration. Read the bill.

AB 4018 – Medical Licensure
On May 4, Assemblymember Ronald Dancer (R) introduced AB 4018. This bill requires certain physicians to provide patients with written notification explaining how to obtain medical records. AB 4018 applies to physicians who anticipate ending the operations of their practice for more than three months. This bill also requires such physicians to provide written notification to all patients whom the physician has treated in the previous seven years. AB 4018 was introduced and referred to the Assembly Health Committee. This measure is eligible for consideration. Read the bill.

Pennsylvania

Highmark Pennsylvania reviewed its Sacral Nerve Neuromodulation Policy with the following changes to criteria, coding, and supporting information:

  • Removed a criterion for treatment of urinary incontinence which required presence of symptoms for at least one year’s duration resulting in significant disability.
  • Revised conventional therapy requirement for treatment of urinary incontinence to require two of the following: behavioral training, pharmacological treatment, or surgical corrective therapy (previously required both pharmacological and behavioral treatment).
  • Changed title from “Sacral Nerve Neuromodulation/Stimulation” to “Sacral Nerve Neuromodulation”.

Read the update.

Highmark Pennsylvania reviewed its Tumor Markers Policy with the following changes to criteria and coding:

  • Added the following to indications for which prostate specific antigen (PSA) may be considered medically necessary: members with palpable abnormal prostate gland; members with lower urinary tract signs and symptoms (i.e., hematuria, slow urine stream, hesitancy, urgency, frequency, nocturia, incontinence).

Read the update.

West Virginia

Highmark West Virginia reviewed its Sacral Nerve Neuromodulation Policy with the following changes to criteria, coding, and supporting information:

  • Removed a criterion for treatment of urinary incontinence which required presence of symptoms for at least one year’s duration resulting in significant disability.
  • Revised conventional therapy requirement for treatment of urinary incontinence to require two of the following: behavioral training, pharmacological treatment, or surgical corrective therapy (previously required both pharmacological and behavioral treatment).
  • Changed title from “Sacral Nerve Neuromodulation/Stimulation” to “Sacral Nerve Neuromodulation”.

Read the update.

Highmark West Virginia reviewed its Tumor Markers Policy with the following changes to criteria and coding:

  • Added the following to indications for which prostate specific antigen (PSA) may be considered medically necessary: members with palpable abnormal prostate gland; members with lower urinary tract signs and symptoms (i.e. hematuria, slow urine stream, hesitancy, urgency, frequency, nocturia, incontinence).

Read the update.

ICYMI: Updates from the AUA Policy & Advocacy Brief blog

AUAPAC: AUA Hosts Virtual Meeting for Urologist Candidate

On April 28, the AUA hosted a virtual meet and greet with urologist and AUA member William Figlesthaler, MD. Dr. Figlesthaler, of Naples, FL, is running for Congress in Florida’s 19th Congressional District—a seat currently held by Rep. Francis Rooney (R), who will retire at the end of the year. The meet and greet was attended by 10 of the AUA’s colleagues in MaDPAC.

Since announcing his candidacy this past November, Dr. Figlesthaler has raised and self-funded more than $500,000 for his campaign.

Research Advocacy: AUA Participates in Virtual Meetings with Congressional Offices to discuss Fiscal Year 2021 Department of Defense Appropriations

On May 5 and 6, the AUA met with the offices of Betty McCollum (D-MN-4) and Rep. Dutch Ruppersberger (D-MD-2) to discuss funding for the Congressionally Directed Medical Research Programs (CDMRP), housed within the Department of Defense (DoD) budget. The meetings were led by the Defense Health Research Consortium (DHRC), a diverse group of patient and provider advocacy organizations that work together to support vital medical research programs at the DoD, which totals nearly $1 billion each year. As a coalition, the DHRC is advocating for a 5 percent increase, plus inflation, for the CDMRP program as a whole in fiscal year 2021. Additionally, the AUA is advocating for the dedication of a $10 million line item for Bladder Cancer within the CDMRP and increase the Kidney Cancer line item from $40 million to $50 million in fiscal year 2021.

Telehealth: CMS Releases New Waivers and Rule Changes to Expand Telehealth Services

The new round of COVID-19-related regulatory waivers and rule changes includes multiple telehealth changes, including an increase in reimbursement rates for audio-only telephone evaluation and management (E/M) services. This is a major win for medicine. On April 30, the Centers for Medicare & Medicaid Services issued another round of sweeping regulatory waivers and rule changes to deliver expanded care to the nation’s seniors and provide flexibility to the healthcare system as the country reopens after weeks of closure due to the COVID-19 pandemic. Additional changes in this rule for telehealth include the following:

  • The addition of new telehealth services on a sub-regulatory basis and will consider requests by practitioners for new services;
  • Increased telehealth access for patients in rural and medically underserved areas.

More details about the changes in the rule can be found here.

AUA Urology Telehealth Task Force: Retaining Telehealth Services Post-COVID-19

On a related topic, the AUA Urology Telehealth Task Force is strategizing on how we might preserve pieces of the current telehealth waivers in a post-pandemic era. After a conference call with the CMS last week, one agency official signaled that “the silver lining in the COVID pandemic is the use of telehealth services.” However, CMS is concerned about fraud, patient safety and costs of telehealth services and will be looking at the current changes and what services might be retained post-pandemic.

The AUA task force is collecting anecdotal stories and data in preparation to advocate for retention of telehealth services. If there is information your practice is experiencing and would like to share, please email Stephanie Storck at sstorck@AUAnet.org.

COVID-19: Congress Approves Additional $484 Billion Relief Bill

On April 23, Congress gave final approval to H.R. 266, the Paycheck Protection Program and Health Care Enhancement Act, to provide roughly $484 billion in coronavirus relief for small businesses, hospitals and expanded medical testing. This package essentially serves as an extension of the Coronavirus Aid, Relief, and Economic Security (CARES) Act of 2020, the $2.2 trillion bill enacted in late March that provided loans and financial support to major industries (such as airlines) and small businesses alike, as well as direct payments to individuals and families. Federal response to the global pandemic now stands at $2.8 trillion – by far the largest emergency relief effort in modern U.S. history. The following day, this legislation President Trump signed this bill into law.

The AUA has been working closely with other provider groups to advocate for additional relief for physicians during this crisis, particularly those that have seen a dramatic reduction in revenue/caseloads since most elective surgeries have been restricted during the pandemic.

With my warmest wishes for your good health,

Kathy