November 2020 - AUA Public Policy Council Update for MAS
From the Chair
I am pleased to share updates from the AUA Public PolicyCouncil that may benefit your Section members. Our updates include information on advocating for expanded telehealth regulations, fundraising for veterans’ health legislation, as well as updates from the American Medical Association House of Delegates meeting.
American Medical Association (AMA) House of Delegates (HoD): AUA Physicians Participate in Virtual Interim Meeting
COVID-19-focused topics such as emergency and expanded telemedicine regulations, early vaccination policies for essential personnel, CARES Act equity and loan forgiveness in the Medicare Accelerated Payment Program and studying U.S. preparedness for future pandemics were among the hot topics discussed and passed during the November 13-17 AMA virtual HoD Interim Meeting.
Other issues considered revolved around co-pay accumulator policies, strengthening the accountability of health care reviewers and further lessening the prior authorization burdens on physicians. A total of 65 individual reports and resolutions covering clinical practice, payment, medical education, and public health topics were debated.
Delegates, Drs. Terry Grimm and Hans Arora; Alternate Delegates, Drs. Jason Jameson and James Gilbaugh; Resident & Fellow Section Delegate, Dr. Ruchika Talwar; and Young Physicians Section Representative, Dr. Clint Cary represented the AUA. The AUA delegation agreed to cosponsor two specific resolutions, 004 and 205, for the Interim Meeting. Resolution 004, “Nonconsensual Audio/Video Recording at Medical Encounters” establishes new AMA policy encouraging that any audio or video recording made during a medical encounter to require both physician and patient notification and consent. Resolution 205, “Telehealth Post SARS-COV-2”, among other things, directs the AMA to advocate to facilitate the widespread adoption of telehealth services in the practice of medicine for physicians or physician-led teams, post SARS-COV-2.
As a reminder, the AMA HoD is the principal policy-making body of the AMA. It represents the views and interests of a diverse group of member physicians from more than 170 societies. These delegates meet twice per year to establish policy on health, medical, professional and governance matters.
AUAPAC Update: AUA Participates in Fundraiser for California Congressman; Joins Virtual Conversation with AUAPAC Candidate
Last month, AUAPAC participated in a virtual fundraiser for Rep. Mark Takano (D-CA-41). Rep. Takano is Chairman of the House Veterans’ Affairs Committee. He has been a major champion for addressing disparities in health care regarding veterans. His committee had primary jurisdiction on H.R. 6092, the Veteran’s Prostate Cancer Treatment and Research Act, which unanimously passed the House of Representatives on September 22. AUAPAC remains hopeful that H.R. 6092 – and other veterans’ health legislation – will pass through the lame duck session of the Senate this fall.
AUAPAC also participated in a “fireside chat” with Rep. Robin Kelly (D-IL-02), who is seeking to be the vice chair of the House Democratic Caucus (a House leadership position). Rep. Kelly chairs the Congressional Black Caucus Health Braintrust, she is a member of the Energy & Commerce Subcommittee on Health and chairs the House Tech Accountability Caucus. She was one of the congressional speakers at the 2018 Annual Urology Advocacy Summit and AUAPAC has supported her in the past. For more information on AUAPAC and its activities, visit www.MyAUAPAC.org.
AUA Promotes Bladder Health Month!
The start of National Bladder Health Month began on Nov 1! The Urology Care Foundation’s Bladder Health Month Toolkit is available and includes weekly themes, downloadable images and fact sheets, and sample social media posts. Each week, the Urology Care Foundation will highlight different bladder conditions, follow #BladdersMatter on Twitter, Instagram, and Facebook to stay informed. The second annual “Social Media Day of Thanks” where those interested in bladder health can thank doctors, researchers, lawmakers, and others who support bladder health research, promote bladder health awareness, and care for those with bladder health conditions was held on November 12. Upcoming events include a focus on bedwetting and nocturia the week of November 22 and general bladder health to close out the month starting Nov 29. Check the toolkit for links to the weekly events.
Below are insurance updates from national insurance carriers. If you have questions about insurer issues, contact Keith Hawman at khawman@auanet.org
Aetna
Aetna reviewed its Urinary Incontinence (Commercial) Policy with the following changes:
- Added the following covered HCPCS code:
o C1820 – Generator, neurostimulator (implantable), with rechargeable battery and charging system
- Added the following not covered CPT codes:
o 0548T – Transperineal periurethral balloon continence device; bilateral placement, including cystoscopy and fluoroscopy;
o 0549T – Unilateral placement, including cystoscopy and fluoroscopy
o 0550T – Removal, each balloon
o 0551T – Adjustment of balloon(s) fluid volume
Aetna reviewed its Urological Supplies Policy adding the following:
- The inFlow device is considered medically necessary as an alternative to intermittent catheterization for members with permanent urinary retention (PUR) due to impaired detrusor contractility. Quantity limit is once every 29 days. Continuation beyond 3 months is considered medically necessary when criteria are met. See policy for full criteria.
- Covered HCPCS codes:
o 0596T – Temporary female intraurethral valve-pump (i.e., voiding prosthesis); initial insertion, including urethral measurement
o 0597T – replacement
Aetna reviewed its Pharmacogenetic and Pharmacodynamic Testing Policy, with the following changes:
- Revised criteria to add the following as medically necessary testing indications:
- Measurement of microsatellite instability (MSI-H) and mismatch repair (DMMR) for persons with metastatic colorectal cancer being considered for treatment with Yervoy or Opdivo;
- Revised criteria to add the following as not medically necessary testing indications:
- FoundationOne Liquid CDx for persons with prostate cancer being considered for treatment with Rubraca.
CGS Administrators
CGS Administrators reviewed its Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (MoIDX) (J15) (A58371) Local Coverage Article adding the following CPT code:
- 81541 – Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score
CGS Administrators reviewed its Urological Supplies (A52521) Supplemental Article with the following changes:
- Removed reference to code A4335 for inFLOW device from billing information stating suppliers must add a KX modifier to a code for the inFlow device, a catheter, an external urinary collection device, or a supply used with one of these items only if both 1 or 2 are met.
- Added billing information regarding inFLOW system for claims with dates of service on or after October 1 using HCPCS codes K1010, K1011, and/or K1012 to the coding guidelines section.
- Specified that billing for inFLOW intraurethral valve pump system using HCPCS code A4335 must be for claims with date of service July 26 through September 30 within the coding guidelines section.
CGS Administrators reviewed their Urological Supplies (JB, JC) (L33803) Local Coverage Determination (LCD) with the following changes:
- Added the following HCPCS codes:
o K1010 – Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each
o K1011 – Activation device for intraurethral drainage device with valve, replacement only, each
o K1012 – Charger and base station for intraurethral activation device, replacement only
- Removed reference to HCPCS code A4335 regarding inFLOW device due to new HCPCS codes within the coverage indications, limitations, and/or medical necessity section.
- Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates to add CMS HCPCS coding determinations.
Cigna
Cigna reviewed its Benign Prostatic Hyperplasia (BPH) Treatments Policy with the following changes:
- Changed age requirement for prostatic urethral lift from age 50 years or above to age 45 years or above.
- Revised criteria for prostatic urethral lift and water vapor thermal therapy (e.g., Rezūm System) regarding trial of conventional medical therapy to remove trial duration “at least three months.”
- Added the following experimental/investigational/unproven HCPCS codes:
o C9747 – Ablation of prostate, transrectal, high intensity focused ultrasound (HIFU), including imaging guidance
o C9769 – Cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor and incisional struts
- Removed the following experimental/investigational/unproven HCPCS code:
o C9734 – Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with magnetic resonance (MR) guidance
Humana
Humana reviewed its Urinary Incontinence Evaluation and Treatments Policy with the following changes:
- Revised coverage limitations section, updating the list of UI devices outside of a clinical setting to include external urine collection systems such as the PureWick Urine Collection System.
- Added the following not covered HCPCS codes:
o K1006 – Suction pump, home model, portable or stationary, electric, any type, for use with external urine management system
o K1010 – Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each
o K1011 – Activation device for intraurethral drainage device with valve, replacement only, each
o K1012 – Charger and base station for intraurethral activation device, replacement only
Humana reviewed its Gene Expression Profiling Policy expanding investigational gene expression profiling (GEP) tests for bladder cancer to include 209-gene expression assay (i.e., Decipher Bladder TURBT); and genomic subtyping for management of locally advanced bladder cancer (i.e., Decipher Bladder).
Humana reviewed its Laboratory Analysis for Prostate Cancer Policy with the following changes:
- Revised criteria for BRCA1 and BRCA2 germline testing to specify applicable prostate cancer diagnoses for the individual being tested.
- Revised family history criteria for BRCA1 and BRCA2 germline testing to add indications for at least two close blood relatives diagnosed with breast cancer (includes invasive or DCIS) or prostate cancer (any grade); or brother, father or at least two family members (on the same side of the family) who died from prostate cancer.
- Added detailed criteria for confirmatory germline testing of BRCA1 and/or BRCA2.
- Added the following CPT code:
o 0228U – Oncology (prostate), multianalyte molecular profile by photometric detection of macromolecules adsorbed on nanosponge array slides with machine learning, utilizing first morning voided urine, algorithm reported as likelihood of prostate cancer
Humana reviewed its Benign Prostatic Hyperplasia (BPH) Treatments policy with the following changes:
- Revised the list of not eligible BPH treatments to clarify that temporary prostatic urethral stent is iTind.
- Added the following not covered HCPCS code (effective October 1):
o C9769 – Cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor and incisional struts
Noridian
Noridian reviewed its Prostate Cancer Genomic Classifier Assay for Men with Localized Disease Local Coverage Article (LCA) addressing billing and coding guidelines that complement the LCD for Prostate Cancer Genomic Classifier Assay for Men with Localized Disease.
Noridian reviewed their Urological Supplies (JB, JC) (L33803) Local Coverage Determination (LCD) with the following changes:
- Added the following HCPCS codes:
o K1010 – Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each
o K1011 – Activation device for intraurethral drainage device with valve, replacement only, each
o K1012 – Charger and base station for intraurethral activation device, replacement only
- Removed reference to HCPCS code A4335 regarding inFLOW device due to new HCPCS codes within the coverage indications, limitations, and/or medical necessity section.
- Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates to add CMS HCPCS coding determinations.
Palmetto
Palmetto reviewed its Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (MoIDX) (JJ, JM) (A58343) Local Coverage Article (LCA) adding the following CPT code:
- 81541 – Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score
United Healthcare
United Healthcare reviewed its Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions (UHC West) Policy adding the following CPT code:
- 0016M – Oncology (bladder), mRNA, microarray gene expression profiling of 209 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like).
Read the update (Community Plan).
United HealthCare reviewed its Omnibus Codes (UHC West) Policy, Coding Document with the following changes:
Added the following CPT code and associated criteria (see policy for specifics):
- 0596T – Temporary female intraurethral valve-pump (i.e., voiding prosthesis); initial insertion, including urethral measurement.
- 0597T – Temporary female intraurethral valve-pump (i.e., voiding prosthesis); replacement.
Added the following HCPCS codes and associated criteria (see policy for specifics):
- 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.
Removed the following CPT codes and associated criteria (see policy for specifics):
- 0443T – Real-time spectral analysis of prostate tissue by fluorescence spectroscopy, including imaging guidance (list separately in addition to code for primary procedure).
Local and Regional Updates
The following are updates in your Section. The AUA routinely monitors state legislative, regulatory, and insurance policytrends. For this month, there were several balance billing measures prefiled, meaning they will be considered during the 2021 legislative cycle. 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 policy adding the following HCPCS code:
- C9769 – Cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor and incisional struts
Highmark BCBS Delaware reviewed its Treatment of the Prostate policy with the following change to place of service:
- Removed the following statement from the place of service section: cryosurgical ablation of the prostate is considered an inpatient procedure.
New Jersey
Horizon BCBS New Jersey
Horizon BCBS New Jersey reviewed its Lab Management Codes (eviCore) Coding Document adding the following CPT code:
- 0016M – Oncology (bladder), mRNA, microarray gene expression profiling of 209 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like)
Independence Blue Cross
Independence Blue Cross reviewed its Lab Management Codes (eviCore) Coding Document adding the following CPT codes:
- 0016M – Oncology (bladder), mRNA, microarray gene expression profiling of 209 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like)
- 0228U – Oncology (prostate), multianalyte molecular profile by photometric detection of macromolecules adsorbed on nanosponge array slides with machine learning, utilizing first morning voided urine, algorithm reported as likelihood of prostate cancer
Independence Blue Cross reviewed its Durable Medical Equipment (DME) Policy Attachment A2 (Medicare) Supporting Coverage Document adding the following HCPCS Code:
- K1006 – Suction pump, home model, portable or stationary, electric, any type, for use with external urine management system
Telemedicine
On October 27, the New Jersey (NJ) Senate Health, Human Services and Senior Citizens Committee heard testimony from the public and various health care providers, health care insurers, and other stakeholders concerning the provision of telemedicine and telehealth services during the COVID-19 pandemic. Jefferson Health, the New Jersey Psychiatric Association, an oncologist from Sloan Kettering, the American Health Insurance Plans, and the NJ Association of Health plans testified.
Health care providers reported telemedicine offering greater access to patients with a lower cancellation rate and is helpful for follow-up care. The insurance plans voiced concern regarding required equivalent in-person and telehealth payment rates, as this eliminates the cost-saving aspect of telehealth. They also believe the state should not interfere with or require certain payment models. The committee will use the testimony as they consider future telemedicine legislation. Listen to the full testimony here.
S.B. 2465 – Medical Licensure
In June, Senator Stephen Sweeney (D) introduced S.B. 2465 requiring any advertisement of health care professionals include the type of professional license and professional degree the professional received. Advertisements may not include deceptive or misleading information. On October 29, the Assembly passed S.B. 2465, the Senate concurred, and the bill was sent to Governor Phil Murphy for signature. Read the bill.
S.B. 3145 – Medical Licensure
On November 5, Sen. Linda Greenstein (D) introduced S.B. 3145 requiring applications for a professional license to include a separate line allowing an individual to list a professional name, a line for a legal name, and the ability for the individual to choose which name is to appear on the license. This bill is similar to A.B. 2308 introduced by Assemblymember Valerie Vainieri Huttle (D) earlier this year. S.B. 3145 was referred to the Senate Commerce Committee for further consideration. Read the bill.
Pennsylvania
Cap Blue Cross
Cap Blue Cross reviewed its Experimental and Investigational Procedures policy adding the following HCPCS codes:
- C9768 – Endoscopic ultrasound-guided direct measurement of hepatic portosystemic pressure gradient by any method (list separately in addition to code for primary procedure)
- 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
Cap Blue Cross reviewed its Miscellaneous Genetic Tests and Molecular Diagnostics Test policy adding the following CPT code:
- 0016M – Oncology (bladder), mRNA, microarray gene expression profiling of 209 genes, utilizing formalinfixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like)
Cap Blue Cross reviewed its Treatments of the Prostate Policy adding the following HCPCS codes:
- C9761 – Cystourethroscopy, with ureteroscopy and/or pyeloscopy, with lithotripsy (ureteral catheterization is included) and vacuum aspiration of the kidney, collecting system and urethra if applicable
- C9769 – Cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor and incisional struts
Highmark Pennsylvania
Highmark Pennsylvania reviewed its Treatment of the Prostate policy adding the following HCPCS code:
- C9769 – Cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor and incisional struts
Highmark Pennsylvania reviewed its Treatment of the Prostate policy with the following change to place of service:
- Removed the following statement from the place of service section: cryosurgical ablation of the prostate is considered an inpatient procedure.
West Virginia
Highmark West Virginia
Highmark West Virginia reviewed its Treatment of the Prostate policy adding the following HCPCS code:
- C9769 – Cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor and incisional struts
Highmark West Virginia reviewed its Treatment of the Prostate policy with the following change to place of service:
- Removed the following statement from the place of service section: cryosurgical ablation of the prostate is considered an inpatient procedure.
ICYMI: Updates from the AUA Policy & Advocacy Brief blog
Osteopathic Physicians: AUA Signs onto Letter Supporting DOs
On October 21, the AUA joined with 44 other medical societies by signing onto a public letter from the Council of Medical Specialty Societies (CMSS). The joint statement denounces recent mischaracterizations of osteopathic physicians by the media when covering President Trump’s treatment for coronavirus. The letter highlights the education, training and clinical work required of both MDs and DOs.
As background, the CMSS was created to provide an independent forum for the discussion by medical specialists of issues of national interest and mutual concern, and consists of 45 societies with more than 800,000 U.S. physician members.
For a copy of this letter, please contact AUA Legislative & Political Affairs Director Brad Stine at bstine@AUAnet.org.
New Evaluation and Management Guidelines: Registration for Webinar is Open
On January 1, 2021 the new Evaluation & Management Guidelines will become active and there are a number of updates providers and practices need in order to understand and comply with the new Guidelines. During this live, interactive webinar on December 1, 2020, expert faculty will introduce and explain the new guidelines and how they compare to the previous guidelines.
All attendees will receive a complimentary “Evaluation & Management: CPT Code and Guideline Changes” digital brochure, developed by the Policy & Advocacy Department and the Coding & Reimbursement Committee, to reinforce the 2021 changes and provide a handy reference tool.
REGISTER TODAY to attend this webinar so you and your practice are informed, ready and able to accurately submit reimbursements according to the 2021 E/M Guidelines, as well as maintain billing and reimbursement efficiencies.
AUA State Advocacy Committee Meets
On October 29, the AUA’s State Advocacy Committee (SAC) held its second virtual meeting in 2020. The committee primarily focused on setting the AUA’s 2021 state advocacy initiatives, which used data from the federal/state legislative priorities survey that was disseminated several months ago to all domestic AUA members. There was lengthy discussion on physician contracts/restrictive covenants, the Interstate Medical Licensure Compact and utilization management protocols such as step therapy and prior authorization.
The SAC also voted to focus on Men’s Health Awareness Month in 2021 by working with different legislators and governors to submit proclamations making this important designation – particularly focusing on health care disparities when it comes to men’s health.
Division Overview
With the recent hiring of new team members and redesign of the AUA’s Public Policy and Advocacy Division, here is an overview of which staff oversee which pieces of political, policy, and advocacy work:
| Topic | Staff | Primary Contact Info |
| AUAPAC | Brad Stine | bstine@auanet.org |
| Coding & Reimbursement Committee | Ray Wezik, Keith Hawman | khawman@auanet.org |
| CPT Editorial Panel | Keith Hawman, Carrie Renner | khawman@auanet.org |
| Insurance | Keith Hawman, Carrie Renner | crenner@auanet.org |
| Legislative Affairs Committee | Josh Webster | jwebster@auanet.org |
| Lobbying (federal) |
Brad Stine, Quardricos Driskell Josh Webster |
bstine@auanet.org |
| Lobbying (state) | Catherine Hendricks | chendricks@auanet.org |
| National Insurance Advisory Workgroup | Carrie Renner | crenner@auanet.org |
| Patient Advocacy | Ray Wezik, Kimberly Serota | rwezik@auanet.org |
| Public Policy Council | Kathy Shanley, Camille Chilcoat | cchilcoat@auanet.org |
| Regulatory Workgroup | Ray Wezik | rwezik@auanet.org |
| Research Advocacy | Ray Wezik, Kimberly Serota | rwezik@auanet.org |
| Research Advocacy Committee | Ray Wezik, Kimberly Serota | kserota@auanet.org |
| Residency Advocacy Workgroup | Josh Webster | jwebster@auanet.org |
| RUC | Keith Hawman, Carrie Renner | khawman@auanet.org |
| State Advocacy Committee | Catherine Hendricks | chendricks@auanet.org |
| Urology Telehealth Task Force | Ray Wezik | rwezik@auanet.org |
| Veterans Health Workgroup | Quardricos Driskell | qdriskell@auanet.org |
| Workforce Workgroup | Josh Webster | jwebster@auanet.org |