November 2022 AUA Public Policy Council Update For Mas

From the Chair
MAAUA Chair 2020

I am pleased to share updates from the AUA Public Policy Council that may benefit your Section members. Our updates include information on the Calendar Year 2023 Medicare Physician Fee Schedule Final Rule and November’s American Medical Association House of Delegates meeting.

AUA Summit Registration is Open!

Registration is now open for the 6th Annual Urology Advocacy Summit taking place in Washington, D.C., February 27 – March 1, 2023. The dynamic conference includes a day of Capitol Hill meetings and features two days of in-person educational and trending policy sessions with an opportunity for attendees to earn continuing medical education credits.

AUAPAC Charitable Match Program Open

The American Urological Association’s Political Action Committee (AUAPAC) is dedicated to advancing urology’s top policy issues with lawmakers and your donation helps the us achieve changes that impact you and your patients. Non-partisan and representative of the entire urologic community, our goal is to work with and to help elect candidates to Congress who understand and can address the issues directly affecting our specialty.

Over the next few weeks, your contribution to AUAPAC will be matched by a dollar-for-dollar donation to a charity of your choice*! Whether it’s the Urology Care Foundation, AUA Section Education Funds, or another charity you feel passionately about – we know that urologists and urologic professionals around the country have many important philanthropic interests they support each year. Go to www.myAUAPAC.org to learn more and give.

CY 2023 Medicare Physician Fee Schedule Released by CMS

On November 1st, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS) final rule for CY 2023 (CMS-1770-F).  This rule updates payment policies and payment rates for Part B services furnished under the MPFS, as well as makes changes to the Quality Payment Program (QPP).  A pre-publication version of the rule can be found here. A press release and fact sheet are also available.

Conversion Factor: The CY 2023 Medicare conversion factor (CF) is set at $33.06, a decrease of 4.5% from the 2022 CF of $34.61. The decrease is mainly the result of the expiration of a 3% increase funded by Congress through 2022.  The other 1.6% decrease is the result of budget neutrality requirements due to changes in the inpatient E/M codes and hospital observation, emergency department, nursing facility, and home or residence services. The AUA has been lobbying Congress to avert this payment cut, as there is nothing the agency can do without an act of Congress.

Specialty Level Impact: Table 128 of the final rule outlines the financial impact of finalized policy. Urology is projected to see a decrease of 1% in Medicare payments. The impact amounts in Table 128 only includes changes to rate setting and changes to RVUs under the budget neutral system, not the impact of the conversion factor decrease. Note that the impact to individual or group practices varies based on practice type and mix of patients and services provides to those patients.

Code Level RVUs: In the 2023 rule, CMS accepted the Relative Value Scale Update Committee’s (RUC) recommended work and PE relative value units (RVUs) for laparoscopic simple prostatectomy procedures as reported by CPT codes 55821, 55831, 55866, and 55867. The AUA participated in the RUC survey for these codes and is pleased to see CMS finalized RUC recommended values.

Prior to release of the 2023 rule, the AUA submitted comments objecting to CMS’ proposed RVUs for percutaneous nephrolithotomy (50080 and 50081), which were lower values than the RUC recommended values for these services. CMS rejected the arguments of commenters that the RVUs proposed by RUC were not appropriate. The agency noted that in general, when the time for a service decreases, then the work RVU should have a corresponding decrease. The agency did, however, add in additional RVUs (0.30) for performing fluoroscopy, as this work was not accounted for in the proposed values.

Split/Shared Services: CMS continues to stand by its policy for billing split/shared services by time and has again reiterated that in 2024 a split/shared service is billed by the practitioner who provides a substantive portion of the visit using time as the determining factor. This policy applies only to services provided in the facility setting. However, CMS has delayed the implementation of this new policy for an additional year. The AUA advocated to the agency that using time rather than medical decision making to determine the substantive portion will undermine the agency’s efforts to move towards team-based care as physicians will be less likely to perform these visits.

Telehealth Services: The AUA advocated for CMS to add, on a permanent basis, telephone-only services (99441-99443) to the telehealth services list, however the agency has finalized its proposal to NOT add telephone-only services to the telehealth services list but will continue to pay for these services for 151 days after the PHE expires. At day 152 after the PHE ends the telephone-only E/M services will revert as unpayable and considered bundled under the MPFS.

Discarded/Wasted Drugs: In the proposed rule, CMS considered whether to use the authority granted by Congress to raise the applicable percentage of waste that triggers a refund for drugs with unique circumstances. Specifically, the agency considered drugs that must be reconstituted with hydrogel noting that a substantial amount adheres to the vial wall during preparation. The agency speculated 35 percent may be appropriate to account for the portion of the drug that adheres to the vial. The AUA commented that CMS should use its authority and finalize policy that raises the applicable percentage to 35 percent for wastage associated with drugs reconstituted with hydrogel. With this rule, CMS has finalized its proposal to allow for 35% wastage, and in this case, only one drug Jelmyto® (mitomycin for pyelocalyceal solution).

The AUA will publish a more thorough analysis, including final impact tables for commonly billed urologic codes, in the coming days as we continue to review the final rule. For questions or comments, please contact Bhavika Patel, Manager for Physician Payment and Reimbursement at bpatel@auanet.org

American Medical Association House of Delegates (HoD): Medicare Physician Reimbursement and Workforce Shortages Highlight Interim Meeting

On November 12-15, AUA Delegates – Hans Arora, MD; Jason Jameson, MD; Richard Pelman, MD; and AUA Resident/Fellow Section Delegate Ruchika Talwar, MD represented the AUA at the 2022 American Medical Association (AMA) House of Delegates (HoD) Interim Meeting. 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 a year to establish policy on health, medical, professional and governance matters.

The delegates first participated in a variety of specialty caucus pre-meetings, including those hosted by the Surgical Caucus organized by the American College of Surgeons, the Cancer Caucus organized by the American Society of Clinical Oncology, and the Specialty and Service Society Caucus.

In addition, the AUA delegation was active in six different reference committee meetings covering more than 150 distinct reports and resolutions relating to clinical practice, payment, medical education and public health topics. They provided testimony on multiple issues, including on Resolution 304 “Protecting State Medical Licensing Boards from External Political Influence” and Resolution 916 “Non-Cervical HPV Associated Cancer Prevention” to include the broad term genital cancers, rather than penile cancers,  to be more inclusive of various urologic cancers when promoting HPV vaccinations.

To read more about each day of the meeting, follow along on the Policy & Advocacy Brief:

Day 1: https://community.auanet.org/blogs/policy-brief/2022/11/12/2022-ama-house-of-delegates-interim-meeting-day-1

Day 2: https://community.auanet.org/blogs/policy-brief/2022/11/14/2022-ama-house-of-delegates-interim-meeting-day-2

Day 3: https://community.auanet.org/blogs/policy-brief/2022/11/15/2022-ama-house-of-delegates-interim-meeting-day-3

Day 4: https://community.auanet.org/blogs/policy-brief/2022/11/16/2022-ama-house-of-delegates-interim-meeting-day-4

ICYMI: Updates from the AUA Policy & Advocacy Brief  blog

AUA Urges Congress to Stabilize Medicare in MACRA Request for Information (RFI)

Representatives Ami Bera, MD (D-CA-7) and Larry Buschon, MD (R-IN-8), along with their colleagues, requested feedback from stakeholders on actions Congress should take to stabilize the Medicare payment system while ensuring successful value-based care incentives are in place. Specifically, the RFI asked that responses should address the effectiveness of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA); regulatory, statutory, and implementation barriers that need to be addressed for MACRA to fulfill its purpose of increasing value in the US health care system; how to increase provider participation in value-based payment models; and provide recommendations to improve the Merit –Based Incentive Payment System (MIPS) and Alternative Payment Models programs. The AUA submitted a letter in response on October 31.

The AUA states that Medicare physician payment, which has stagnated, cannot be stabilized without eliminating the budget neutrality requirement and implementing an inflationary adjustment like those included in other Medicare payment systems. Additionally, data utilized in determining cost components such as the Medicare Economic Index (MEI) or practice expense inputs are outdated; utilizing current data to update the MEI is critical to ensuring fair updates to physician payment.

The AUA urges Congress to revise the Quality Payment Program (QPP), which includes MIPS and APM, to support the delivery of value-based care and improved quality without creating administrative burden. CMS needs authority and resources to create programs that are meaningful to all providers and specialty types, while lowering the burden to participate in these programs. Therefore, it is important that CMS or other agencies are authorized to underwrite measures that are used in these programs.

For a copy of the final letter, please contact the AUA’s Policy & Advocacy Director Ray Wezik, JD at RWezik@AUAnet.org.

AUA Joins ZERO in Endorsement for The PSA for HIM Act (H.R. 1176)

On October 11, the AUA joined with ZERO – The End of Prostate Cancer, along with more than 20 patient advocacy organizations and other stakeholders from across the prostate cancer community, in sending a letter of support to Representatives Bobby Rush (D-IL-1) and Larry Buschon, MD (R-IN-8) for the Prostate Specific Antigen Screening for High-risk Insured Men Act (PSA) for HIM Act (H.R. 1176). The PSA for HIM Act waives deductibles, copayments and coinsurances for prostate cancer screenings for those with a family history of prostate cancer or who are African-American.

The letter aims to show broad organizational support for the bill and stir new interest in advance of its reintroduction next year in the new congressional session. For a copy of the final letter, please contact the AUA’s Policy & Advocacy Director Ray Wezik, JD at RWezik@AUAnet.org.

Of Interest: Prior Authorization Cited as Largest Regulatory Burden for Group Practices

Eighty-two percent of group practice executives say prior authorization is very or extremely burdensome, according to the Medical Group Management Association’s “Annual Regulatory Burden Report.” The survey, released October 11, includes responses from executives representing more than 500 group practices. Read the full report here.

Below are insurance updates from national insurance carriers. If you have questions about insurer issues, contact Bhavika Patel at bpatel@AUAnet.org

Cigna

Cigna reviewed its Male Sexual Dysfunction Treatment (Non-pharmacologic) Policy with the following changes:

Added application of amniotic-derived allografts to nerve bundles during a radical prostatectomy to list of experimental, investigational, or unproven procedures for erectile dysfunction.

Updated experimental, investigational or unproven procedure regarding nerve grafting.

Added codes 64912, 64913, Q4100 as experimental/investigational/unproven.

Read the update.

Cigna reviewed its Oncology (Nubeqa) (CA Commercial) Prior Authorization (PA) Criteria with the following changes to FDA Indications:

Metastatic, Castration-Sensitive Prostate Cancer

Approve for 1 year if the individual meets the following criteria

Individual is > 18 years of age; AND

The medication is used concurrently with docetaxel; AND

Individual meets ONE of the following criteria

The medication is used concurrently with a gonadotropin-releasing hormone (GnRH) agonist; OR

The medication is used concurrently with Firmagon (degarelix subcutaneous injection); OR

Individual has had a bilateral orchiectomy

Non-Metastatic, Castration-Resistant

Approve for 1 year if the individual meets the following criteria

Individual is >18 years of age; AND

Meets one of the following criteria

The medication is used concurrently with a gonadotropin-releasing hormone (GnRH) agonist; OR

The medication is used concurrently with Firmagon (degarelix subcutaneous injection); OR

Individual has had a bilateral orchiectomy

Read the update.

Cigna reviewed its Oncology (Yonsa) (CA Commercial) Prior Authorization (PA) Criteria with the following changes:

The duration of approval was changed from 3 years to 1 year

Dexamethasone was also added as an option to the criteria requiring combination use with methylprednisolone

The criterion requiring trial of gonadotropin-releasing hormone “analog” was revised to “agonist”

An option that the medication is used in combination with Firmagon (degarelix subcutaneous injection) was added

Read the update.

Cigna reviewed its Oncology Medications Policy removing Xtandi from its Non-Covered list.

Read the update.

CGS Administrators

CGS Administrators reviewed its Prostate Cancer Detection with IsoPSA (J15) (A59066) Local Coverage Article (LCA). The article addresses billing and coding guidelines that complement the LCD for Prostate Cancer Detection with IsoPSA (L39284).

Read the update. (LCA)

Read the update. (LCD)

CGS Administrators reviewed its Urodynamics (J15) (L34056) Local Coverage Determination (LCD). At this time the 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

Read the update.

Humana

Humana released its new Eulexin Policy stating Eulexin may be considered medically necessary when criteria are met.

Read the update.

Noridian

Noridian reviewed its JW Modifier Billing Guidelines Local Coverage Article (LCA) stating SE1316 was removed under resources due to no longer being published. The article was replaced with JW Modifier: Drug/Biological Amount Discarded/Not Administered to Any Patient Frequently Asked Questions.

Read the update (A55932).

Read the update. (A53024)

National Government Services

National Government Services released its draft Water Vapor Thermal Therapy for LUTS/BPH (J6, JK) (DL37808) Local Coverage Determination (LCD). A synopsis of the draft: The patient must meet all enumerated indications and must not present any listed contraindications. ONE treatment for LUTS/BPH treatment is covered ONCE in patients with BOTH the following criteria:

The indications include the patient being 50 years old or more, a prostate volume of 30-120 cc and that they are symptomatic despite maximal medical management including meeting all the listed clinical benchmarks.

The contraindications include having a known or suspected prostate cancer (based on NCCN Prostate Cancer Early Detection guidelines) or a prostate specific antigen (PSA) >10 ng/mL, an active urinary tract infection, a history of bacterial prostatitis in the past three months, a history of prior prostate surgery, a diagnosis of neurogenic bladder or an active urethral stricture.

Read the update.

Palmetto

Palmetto has retired its Decipher Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease (MolDX) (A56325) Local Coverage Article (LCA).

Read the update.

United Healthcare

United Healthcare reviewed its Jevtana Policy with the following changes:

Removed reference link to the United Healthcare Medicare Advantage Policy Guideline titled “Coverage of Drugs and Biologicals for Label and Off-Label Uses”

Removed language describing compendia ratings and recommendation systems

Added ICD-10 diagnosis codes C7A.1 and C7A.8

Read the update.

WPS Government Health Administrators

WPS Government Health Administrators released its draft Prognostic and Predictive Molecular Classifiers for Bladder Cancer (MolDX) (J5, J8) (DL38684) Local Coverage Determination (LCD).

A Synopsis of the draft:

This draft LCD presents a revision of L38684 “MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer” and includes additional information and clarification added to the coverage Indications.

This contractor will cover molecular diagnostic tests for use in a beneficiary with bladder cancer when all of the following conditions are met:

The beneficiary is being actively managed for bladder cancer.

The beneficiary is within the population and has the indication for which the test was developed and is covered.

At least 1 of the 2 criteria are met:

The patient is a candidate for multiple potential treatments, which could be considered to have varied or increasing levels of intensity based on a consensus guideline, and the physician and patient must decide among these treatments. OR

The patient is a candidate for multiple therapies, and the test has shown that it predicts response to a specific therapy among accepted therapy options based on nationally recognized society consensus guidelines.

The test demonstrates analytical validity including both analytical and clinical validations. If the test relies on an algorithm (which may range in complexity from a threshold determination of a single numeric value to a complex mathematical or computational function), the algorithm must be validated in a cohort that is not a development cohort for the algorithm.

The test has demonstrated clinical validity and utility, establishing a clear and significant biological/molecular basis for stratifying patients and subsequently selecting (either positively or negatively) a clinical management decision.

The test successfully completes a Molecular Diagnostic Services Program (MolDX®) technical assessment that ensures the test is reasonable and necessary as described above.

Read the update.

WPS retired its Decipher Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease (MolDX) (A56403) Local Coverage Article (LCA), effective October 27.

Read the update.

WPS retired its Government Health Administrators Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MolDX) (A56234) Local Coverage Article (LCA), effective October 27.

Read the update.

WPS retired its Government Health Administrators Response to Comments: MolDX: Prolaris Prostate Cancer Genomic Assay for Men with Favorable Intermediate Risk Disease [DL37226] (A55645) Policy, effective October 27.

Read the update.

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.

Delaware

H.B. 334 – Telemedicine ENACTED

Introduced by Representative Dave Bentz (D), H.B. 334 permits health care professionals who are licensed in another state to deliver health-care services by telemedicine by applying for an interstate telehealth registration. Telemedicine is subject to the same standard of care as an in-person encounter. Prescriptions are prohibited based on an internet questionnaire. Governor John Carney (D) signed the bill on October 21.

S.B. 267 – Insurance ENACTED

Introduced by Senator Spiros Mantzavinos (D), S.B. 267 requires that a third-party cost-sharing assistance – utilized by patients – is 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. Governor John Carney (D) signed the bill on October 26.

Pennsylvania

  1. B. 2884– Insurance

Introduced by Representative Dan Frankel (D), H.B. 2884 addresses concerns surrounding Integrated Delivery Networks (IDNs), where a health system charges its own health plan for health care service(s) at a lower rate than it charges competing health insurance companies. The bill was referred to the House Insurance Committee.

S.B. 225 – Insurance ENACTED

Introduced by Kristin Phillips-Hill (R), S.B. 225 seeks to provide direction concerning the use review and appeals process, the right to receive continuous care from a non-participating provider under certain circumstances and the prompt payment of claims. Governor Tom Wolfe (D) signed the bill into law on November 3.

New Jersey

Horizon BCBS New Jersey

Horizon BCBS New Jersey reviewed its Benign Prostatic Hyperplasia Procedures: Prostatic Urethral Lift, Transurethral Water Vapor Thermal Therapy and Transurethral Waterjet Ablation Policy stating that each procedure is medically necessary when criteria are met.

Read the update.

Horizon BCBS New Jersey reviewed its Radiation Therapy with Pluvicto Policy indicating Pluvicto or 177Lu-PSMA given every 6 weeks for 4-6 cycles is considered medically necessary for individuals with progressive metastatic castration-resistant prostate cancer when criteria are met.

Read the update.

  1. 3216– Insurance

Introduced by Senator Paul Sarlo (D), S. 3216 requires health insurance carriers to provide an adequate network of physicians to ensure covered persons reside no more than: a 20 minute drive or 10 miles from a primary care provider; 30 minute drive or 15 miles from at least three hospital based medical specialists within each specialty; and 45 minute drive or 20 miles from at least three hospital based medical specialists and within the geographic boundaries of the state. The bill was referred to the Senate Commerce Committee.

Best regards,

Maureen and the AUA Public Policy & Advocacy Team