May 2022 - 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 advocacy efforts to expand access to telehealth and bolster funding for urologic research. The AUA continues to conduct follow-up Hill meetings from the 2022 Annual Urology Advocacy (AUA) Summit. If you have any interest in continuing the dialogue from the AUA Summit with your federally elected officials, please do not hesitate to reach out to the AUA Legislative & Political Affairs Department at LegislativeAffairs@AUAnet.org for assistance.
Save the Date for the 6th AUA Summit: February 27 – March 1, 2023 at the Capital Hilton in Washington, DC!
AUA, AMA to CMS: Help Practices Stay Viable, Improve the Medicare Physician Payment System
On May 11, the AUA joined the American Medical Association (AMA) in a letter to the Centers for Medicare and Medicaid (CMS) asserting the goal of simplifying and aligning efforts between providers and CMS to improve financial viability of physician practices and alleviate administrative burdens. These efforts include promoting value-based care, ensuring financial stability and predictability, and safeguarding access to quality care. The current physician payment system fails to recognize increases in practice costs, resulting in systemic underfunding.
The AUA continues to support reforms to the Medicare physician payment system and will continue to seek ways to engage CMS on this issue. Please reach out to AUA Policy & Advocacy Director Ray Wezik at rwezik@AUAnet.org.
Rep. Brownley Sends Dear Colleague Letter in Support of Bladder Cancer Research Funding
For the third year, Representative Julia Brownley (D-CA-26) led a Dear Colleague letter in support of bladder cancer research funding within the Congressionally Directed Medical Research Programs (CDMRP). Rep. Brownley was joined by 35 members of Congress in urging Chairs and Ranking Members of the House Committee on Appropriations and House Defense Appropriations Subcommittee to consider the prevalence of bladder cancer in the veteran population and directly allocate $8 million in research funding within CDMRP.
The AUA has supported direct CDMRP funding for bladder cancer for several years and continues to advocate to members of Congress on behalf of bladder cancer patients and researchers. Each year the AUA also hosts a Congressional briefing on CDMRP for Hill staffers to learn more about the importance of urologic research within the programs. Please reach out to AUA Policy & Advocacy Director Ray Wezik at rwezik@AUAnet.org or visit the Policy & Advocacy Brief for a copy of the letter.
OIG Issues Report on Medicare Advantage’s Prior Authorization Denials
On April 28, the Department of Health and Human Services (DHHS) Office of Inspector General (OIG) issued a new report entitled “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns about Beneficiary Access to Medically Necessary Care,” which is attached. The OIG found that 13% of rejected prior authorization claims should have been covered under Medicare and 18% of payments were denied despite meeting Medicare coverage rules.
The OIG conducted this review due to concerns that Medicare Advantage Organizations (MAOs) were incentivized to deny beneficiaries access to services and payments to providers in an effort to increase MAO profits. Medicare Advantage plans have grown in popularity over recent years due to their perceived affordability and wider array of benefits than traditional Medicare. Currently, 28 million older Americans are enrolled in Medicare Advantage plans.
The denial of payment requests and services creates a burden on patients and providers while delaying or preventing patients from receiving medically-necessary care.
The OIG recommends that the Centers for Medicare and Medicaid Services (CMS):
- Issue new guidance on the appropriate use of MAO clinical criteria in medical necessity reviews.
- Update audit protocols to address MAO use of clinical criteria and examining particular types of medical services.
- Direct MAOs to take steps to identify and address vulnerabilities that lead to manual review and system errors.
The AUA previously made comments to CMS encouraging them to streamline the prior authorization process across health plan types, including Medicare Advantage, among other improvements. The AUA will continue to advocate for timely claims payment and approval on behalf of providers and urologic patients.
AUAPAC Participates in Fundraiser for Senate HELP and Finance Committee Member
On April 27, AUAPAC participated in a fundraiser for Senator Tim Scott (R-SC) —a member of the Senate Health, Education, Labor & Pensions (HELP) and Senate Finance Committees. Senator Scott is a champion of increasing access to telehealth and expanding access to life-saving pharmaceuticals through the Safe-Step Act, both of which the AUA strongly supports. During the fundraiser, the senator expressed his concern about the future of healthcare. He feels Congress needs to take the necessary steps to resolve underlying issues to increase access to healthcare and reduce costs – particularly in light of the numerous public health challenges this country witnessed at the height of the pandemic.
ICYMI: Updates from the AUA Policy & Advocacy Brief blog
AUA Meets with House Ways & Means Members on Workforce Shortages, Diversification of Clinical Trials, and More
Throughout April and May, the AUA met with staff in the offices of: Representatives Kevin Brady (R-TX-08), Ron Estes (R-KS-04), Darin LaHood (R-IL-18), Adrian Smith (R-NE-03), Jason Smith (R-MO-08), and Mike Thompson (D-CA-05) to reiterate the legislative asks from the 2022 Annual Urology Advocacy (AUA) Summit.
During the meetings, the AUA expressed support for such initiatives as easing the specialty physician workforce shortage, making telehealth expansion permanent, diversifying clinical trials and reforming the Medicare Physician Fee Schedule. The AUA also thanked Rep. Thompson’s office for being one of the primary sponsors of H.R. 2903, the CONNECT for Health Act. This bill would provide more equitable telehealth access by eliminating geographic restrictions for patients and expanding originating sites to include the home.
The AUA will continue to broaden interest and support for our top priorities among key policymakers during the second session of this 117th Congress. If you have any interest in continuing the dialogue from the AUA Summit with your federally elected officials, please do not hesitate to reach out to the AUA Legislative & Political Affairs Department at LegislativeAffairs@AUAnet.org for assistance.
AUA’s Prostate Cancer Impact Alliance (PCIA) Urges FCC to Increase Telehealth Coverage in Rural Areas
On April 14, the PCIA was joined by 10 other organizations and industry sponsors in providing comments to the Federal Communications Commission’s (FCC) proposed rule on promoting telehealth in rural America. The FCC seeks to revise the Rural Health Care Program by assisting rural healthcare providers with the cost of broadband and by building networks for healthcare providers to access broadband services.
In the letter, the PCIA strongly recommended that any data collection and analysis tools be evaluated through a health equity lens and agreed with the FCC’s plan to only apply an internal cap on multi-year commitments and upfront payments in the Healthcare Connect Fund when overall demand exceeds available funding.
The AUA remains committed to ensuring telehealth access for patients and providers alike and will continue to advocate for increased telehealth coverage with all stakeholders. Please reach out to AUA Policy & Advocacy Director Ray Wezik at rwezik@AUAnet.org or visit the Policy & Advocacy Brief for a copy of the letter.
AUA Discusses H.R. 4880 Outlook with House Veterans Affairs’ Committee Staff
On April 12, the AUA met with minority staff for the House Veterans’ Affairs Committee to discuss H.R. 4880 and its outlook for the remainder of the 117th Congress. During the meeting, committee staff expressed their interest in including H.R. 4880 in a larger bipartisan Veterans bill that they hope to have on the House floor this summer.
As you know, H.R. 4880 would establish a viable clinical pathway for prostate cancer within the Department of Veterans Affairs for those men who selflessly served this nation in uniform. The AUA will continue to promote and advance this important measure. You also can help this key initiative move forward in both chambers by logging onto the AUA’s grassroots alert system and urging your federally elected official to support this measure.
Below are insurance updates from national insurance carriers. If you have questions about insurer issues, contact Ray Wezik at rwezik@auanet.org.
Aetna
Aetna reviewed its Urinary Incontinence (Commercial) Policy with the following changes:
- Added codes 90912 and 90913
- Removed codes C9746 and 90911
Anthem
Anthem reviewed their Gene Expression Profiling for Bladder Cancer Policies, adding CPT code 81479.
BCBS Federal Employee Plan
BCBS Federal Employee Plan issued a new Besremi Policy stating Besremi may be considered medically necessary when criteria are met.
CGS Administrators
CGS Administrators reviewed its 4Kscore Assay (MolDX) (J15) (A56944) Local Coverage Article (LCA) issuing a new version of the document.
CGS Administrators reviewed its 4Kscore Assay (MolDX) (J15) (L36979) Local Coverage Determination (LCD) issuing a new version of the document, with the following changes:
- Under CMS National Coverage Policy added regulation CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80 and §80.1.1 and updated descriptions to regulations.
- Under Sources of Information moved sources 1-5 from to Bibliography. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were defined where appropriate throughout the LCD.
CGS Administrators reviewed its Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (J15) (L38378) Local Coverage Determination (LCD) issuing a new version of the document.
Issued a new version of its Urological Supplies (A52521) Supplemental Article. Under Requirements for Specific DMEPOS Items Pursuant To Final Rule 1713 (84 Federal Register Volume 217) added “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list, and removed “The link will be located here once it is available.”
CGS Administrators issued a new version of their Vacuum Erection Devices (VED) (JB, JC) (A52712) Local Coverage Article (LCA). Under Requirements For Specific DMEPOS Items Pursuant To Final Rule 1713 (84 Federal Register Volume 217) added “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list, and removed “The link will be located here once it is available.”
Cigna
Cigna reviewed its Multi-Source Brand Name Drugs Formulary Exception (CA Commercial) Prior Authorization (PA) Criteria adding Zytiga 250 mg and 500 mg tablets as applicable drugs.
Humana
Humana reviewed its Xtandi Policy removing dosing information and quantity limits.
Humana reviewed its Yonsa Policy removing dosing information and quantity limits.
Humana reviewed its Zytiga Policy removing dosing information and quantity limits.
Noridian
Noridian issued a new version of their Vacuum Erection Devices (VED) (JB, JC) (A52712) Local Coverage Article (LCA). Under Requirements For Specific DMEPOS Items Pursuant To Final Rule 1713 (84 Federal Register Volume 217) added “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list, and removed “The link will be located here once it is available.”
Noridian issued a new version of its Botulinum Toxin Types A and B (JE) (A57185) Local Coverage Article (LCA) with the following changes:
- Under Article Text added: Added anatomic to bullet “A complete anatomic description of the site(s) injected”.
- Added after last paragraph: Due to the short life of Botulinum toxin, Medicare will reimburse the unused portion of these drugs. (R3538CP-1) Therefore, scheduling of more than one patient, where possible, is allowed to prevent wastage of Botulinum toxin.
- In all cases, the documentation must show the exact dosage of the drug given to the patient, the reason for unavoidable wastage, and the amount of the discarded portion of the drug.
- If a single dose vial is split between multiple patients, Medicare will allow payment only for the portion used for the beneficiary plus a pro rata amount for wastage. Note that if non-Medicare patients are treated with a portion of the same vial, it would be expected that those non-Medicare patients be billed for their pro rata share of wastage.
- Bill Medicare patients for wastage using the – JW modifier on a separate line and the appropriate number of units, rounded to the nearest unit such that the total billed does not exceed the contents of the vial.
- For split vials, for example, if patient 1 received 30 units and patient 2 received 60 units from a 100 unit vial, wastage billed with -JW would be:
- Patient 1: 3 units [(30 units used for the patient/90 total units used) * 10 units of wastage = 3.33 rounded to 3]
- Patient 2: 7 units [(60 units used for the patient/90 total units used) * 10 units of wastage = 6.66 rounded to 7]
- If additional vials are needed to address the needs of a set of patients, pro-rata wastage should be calculated over the total vial volume for that session. Furthermore, it is expected that a provider will use the most economical combination of vials that will meet the needs of a set of patients should multiple sizes be available.
- If the HCPCS code for the administered drug represents other than 1 unit of the drug (e.g., 100 units of the drug could be 1 HCPCS “unit”) rounding should be in relation to the nearest full HCPCS unit for the administered drug (rounded down) and any reported wastage (rounded up, but not to exceed the total contents of the vial).
- Added after last paragraph: Due to the short life of Botulinum toxin, Medicare will reimburse the unused portion of these drugs. (R3538CP-1) Therefore, scheduling of more than one patient, where possible, is allowed to prevent wastage of Botulinum toxin.
Noridian reviewed its Botulinum Toxin Types A and B (L35172) Local Coverage Determination (LCD) with the following changes under Coverage Indications, Limitations and/or Medical Necessity:
- Deleted 17. Due to the short life of Botulinum toxin, Medicare will reimburse the unused portion of these drugs only when vials are not split between patients.
- Use modifier JW to code for drug wastage on a separate line of the claim form.
- The documentation must show in the patient’s medical record the exact dosage of the drug given, exact amount and reason for unavoidable wastage, and the exact amount of the discarded portion of the drug. 18.
- Scheduling of more than one patient is encouraged to prevent wastage of Botulinum toxins.
- If a vial is split between two patients, the billing in these instances must be for the exact amount of Botulinum toxin used on each individual patient. Medicare would not expect to see billing for the full fee amount for Botulinum toxin on each beneficiary when the vial is split between two or more patients.
United Healthcare
United Healthcare reviewed its Yonsa (Commercial) Step Therapy (ST) Criteria removing no disease progression criterion for prostate cancer.
United Healthcare reviewed its Self-Administered Medications List (Commercial) Policy adding Besremi to the self-administered medications list.
United Healthcare reviewed its Yonsa (Notification) Prior Authorization (PA) Criteria with the following changes:
- Added initial authorization criterion for external beam radiation therapy
- Removed initial authorization criterion for disease progression
WPS Government Health Administrators
WPS Government Health Administrator issued a new version of its Botulinum Toxin Type A & Type B (J05, J08) (A57474) Local Coverage Article (LCA) adding N39.46 to ICD-10 Codes that Support Medical Necessity Group 3 Paragraph Group 3 codes 52287.
Local and Regional Updates
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.
Legislative session ended for the following states: Maryland (April 11).
The following state is in special session: Virginia (April 4 – May 31).
Delaware
S.B. 265 – Insurance
Introduced by Senator Spiros Mantzavinos (D), S.B. 265 requires that third-party cost sharing utilized by enrollees is applied toward the enrollee’s deductibles and any out-of-pocket limits. The bill was referred to the Senate Banking, Business and Insurance Committee.
S.B. 267 – Insurance
Introduced by Senator Spiros Mantzavinos (D), S.B. 267 requires a third-party cost-sharing assistance utilized by patients to be applied toward the enrollee’s health insurance deductibles and any out-of-pocket limits. Additionally, the bill defines what constitutes a “cost-sharing requirement” as well as how to calculate the assistance when applying to patient’s deductibles and out-of-pocket limits. The bill was referred to the Senate Banking, Business and Insurance Committee.
H.B. 415 – Medical Licensure
Introduced by Representative David Bentz (D), H.B. 415 provides the process for a health care provider licensed in another state to provide health care services in the state with a temporary license. The bill was referred to the House Health and Human Development Committee.
District of Columbia
DC B 24-0684 – Medical Business ENACTED
Introduced by Councilmember Elissa Silverman (I), DC B 24-0684 amends when the ban on non-compete agreements applies from March 16, 2021 to October 1, 2022. Mayor Muriel Bowser signed the bill into law on May 3.
Pennsylvania
Independence Blue Cross
Independence Blue Cross reviewed its Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (Commercial) Policy with the following changes:
- Changed coverage decision for water-jet hydrosection (Aquablation) for the treatment of urinary outlet obstruction due to benign prostatic hyperplasia from experimental/investigational to medically necessary when criteria are met
- Changed coverage decision for water vapor thermotherapy (Rezum) for the treatment of urinary outlet obstruction due to benign prostatic hyperplasia in members 45 years or older from experimental/investigational to medically necessary when criteria are met
- Updated medically necessary criteria for prostatic urethral lift
- Added “of prostate” to high-intensity focused ultrasound in experimental/investigational section
- Changed coverage decision for codes 0421T, 53854, C2596 from experimental/investigational to medically necessary when criteria are met (see policy history)
Maryland
S.B. 386 – Interstate Medical Licensure Compact ENACTED
Introduced by Senator Pam Beidle (D), S.B. 386 would extend the interstate medical licensure compact until 2027. Governor Larry Hogan (R) signed the bill into law on May 12.
New Jersey
Horizon BCBS New Jersey
Horizon BCBS New Jersey reviewed its Intravesical Transurethral Electrical Bladder Stimulation (ITEBS) Policy updating Medicare coverage information.
- 4032 – Insurance
Introduced by Representative Craig Coughlin (D), A. 4032 amends the out-of-network consumer protection law, including revising sections of the arbitration process extending the time the health insurer has to negotiate a settlement from 30 days to 60 days. The bill language is not available.
- 1177 – Insurance
Introduced by Senator Joseph Lagana (D), S. 1177 amends the out-of-network consumer protection law, including revising sections of the arbitration process extending the time the health insurer has to negotiate a settlement from 30 days to 60 days. The bill was referred to the Senate Commerce Committee.
Virginia
H.B. 264 – Telehealth ENACTED
Pre-filed for 2022 by Delegate Chris Head (R), H.B. 264 seeks to allow the Board of Medicine to allow a physician licensed in good standing in another state to provide telehealth services during a Board of Health emergency order when the purpose is to provide continuity of care to a patient in the state through telehealth. This applies if the patient and provider have an established patient-physician relationship. Governor Glen Youngkin signed the bill into law on April 27.
S.B. 148 – Medical Business ENACTED
Introduced by Senator Thomas Norment, Jr. (R), S.B. 148 seeks to provide limited immunity to healthcare professionals during a disaster or local emergency under specific circumstances. Governor Glenn Youngkin (R) signed the bill into law on April 11.
H.B. 81 – Telehealth ENACTED
Pre-filed for 2022 by Delegate Terry Kilgore (R), H.B. 81 would require the Board of Health to consult with the Virginia Telehealth Network to develop and maintain the statewide telehealth plan. Governor Glenn Youngkin (R) signed the bill into law on May 9.
S.B. 369 – Telehealth ENACTED
Introduced by Senator Richard Stuart (R), S.B. 369 seeks to permit the Board of Medicine to allow a physician licensed in good standing in another state to provide telehealth services during a Board of Health emergency order. This applies when the purpose is to provide continuity of care to a patient in the state through telehealth if the patient and provider have an established patient-physician relationship. Governor Glenn Youngkin (R) signed the bill into law on May 9.
Best regards,
Kathy and the AUA Public Policy & Advocacy Team