October 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 to Medicare payment cuts and AUAPAC giving activities.
Mark Your Calendars!
Registration for the 6th Annual Urology Advocacy Summit opens on November 1. The 2023 AUA Summit will be February 27 – March 1, 2023 at the Capital Hilton in Washington, DC. We look forward to seeing all of you next spring to advocate for the specialty of urology and urologic patients. Register at www.AUASummit.org this November!
Share With Your Trainees: Policy & Advocacy Resident Work Group Soliciting New Members
The AUA’s Policy & Advocacy Resident Work Group is soliciting applications for 2023 work group membership! Medical students, residents, and fellows are eligible to apply for the four remaining spots on the work group.
The Policy & Advocacy Resident Work Group aims to educate trainees on the inner workings of federal and state advocacy by presenting a behind-the-scenes look at the AUA’s policy and advocacy work.
The group is comprised of a mix of medical students, residents and fellows reports to the AUA’s Legislative Affairs Committee and meets quarterly to strategize trainee engagement in urologic advocacy. Historically, the group has also planned educational activities about urologic policy and advocacy and developed resources for trainees. In 2022, this included meeting with the AUA’s registered lobbyists and attending the 5th Annual Urology Advocacy Summit in Washington, DC.
To apply to the work group, please email a brief statement of interest and your CV to Juliana Nicolini at jnicolini@AUAnet.org by October 31, 2022. Applicants will be notified of the decision by December 9, 2022.
If you have any questions or concerns about the Policy & Advocacy Work Group, please do not hesitate to contact Juliana Nicolini via email.
AUA Fiercely Advocates to Mitigate Medicare Physician Fee Schedule Cuts
Every year the AUA analyzes the Medicare Physician Fee Schedule (MPFS) Proposed Rule for the upcoming calendar year and acts swiftly to provide comments to the Centers for Medicare & Medicaid Services (CMS) in an effort to protect reimbursement for urology. In addition, the AUA collaborates with coalitions and meets with Members of Congress and their staff to explore legislative solutions to the Medicare reimbursement system.
In September, the AUA joined with the Surgical Care Coalition, the Alliance of Specialty Medicine, and over 100 provider organizations to send letters to Representatives Ami Bera, MD, (D-CA-07) and Larry Bucshon, MD, (R-IN-08), commending them for introducing the Supporting Medicare Providers Act (H.R. 8800). The legislation would mitigate pending Medicare physician payment cuts by providing a 4.42% positive adjustment to the Medicare Physician Fee Schedule (MPFS) conversion factor for calendar year 2023.
On September 22, the AUA formally endorsed the Supporting Medicare Providers Act (H.R. 8800), led by Representatives Ami Bera, MD, (D-CA-07) and Larry Bucshon, MD (R-IN-08). The letter also calls on Congress to consider legislative and administrative changes to the MPFS to ensure stability, promote and reward value-based care, advance health equity and reduce disparities.
The AUA also participated in a Surgical Coalition meeting with staff in the office of Senator Debbie Stabenow (D-MI). Sen. Stabenow is the Chair of the Senate Finance Subcommittee on Health, which oversees the financing of the Medicare program. The discussion focused on Medicare payment cuts and subsequent structural reform and Sen. Stabenow’s staff expressed interest in introducing a Senate version of the Supporting Medicare Providers Act (H.R. 8800). However, Sen. Stabenow’s staff requested assistance from the coalition in finding a Republican lead on the Senate Finance Committee. The AUA will continue to partner with the Surgical Coalition to promote this important bill in both legislative chambers.
Promoting practice sustainability remains a top legislative and regulatory priority for the AUA. As a reminder, the need for permanent Medicare payment reform was one of the main congressional “asks” during the 2022 Annual Urology Advocacy Summit and is shaping up to be another featured session at the 2023 AUA Summit. The AUA is committed to working independently and with other like-minded physician groups to reduce the impact of payment cuts on the practice of urology and patient access.
For a copy of any of the letters mentioned, please contact the AUA’s Vice President of Legislative & Political Affairs Brad Stine at BStine@AUAnet.org or our Director of Policy & Advocacy Ray Wezik at RWezik@AUAnet.org.
VA Prostate Cancer Legislation Likely Considered During Lame Duck Session
On September 28, the AUA met with staff in the office of Senator Jerry Moran (R-KS) to discuss progress on the Veterans’ Prostate Cancer Treatment and Research Act (S. 2720/H.R. 4880). H.R. 4880/S.2720 would establish a viable clinical pathway for prostate cancer within the Department of Veterans Affairs for those people who selflessly served this nation in uniform. The meeting was to ensure the legislation is on track for consideration this session. During the discussion, Sen. Moran’s staff explained that the bill is on track for inclusion in an end-of-year Veterans’ Affairs omnibus legislative package, which will be considered during the lame duck session following the mid-term elections. The AUA will continue working with committee staff during this legislative session to ensure the bill is enacted prior to the 117th Congress adjourning.
ICYMI: Updates from the AUA Policy & Advocacy Brief blog
AUA Urges Senate to Extend Telehealth Flexibilities
On September 13, the AUA signed onto a letter urging the Senate to pass a two-year extension for telehealth flexibilities enacted during the COVID-19 pandemic. The two-year extension will include provisions to waive provider and patient limitations, remove in-person requirements for telemental health, ensure continued access to clinically appropriate controlled substances, and increase overall telehealth services in the commercial market.
Virtual health care is a fundamental part of the U.S. healthcare system and helps to improve access to high quality care. The AUA continues to support telehealth efforts to ensure access to quality care. A copy of the letter is attached.
AUAPAC Supports Key Legislators to Advance Urologic Advocacy
In September, AUAPAC supported 12 Members of Congress who sit on key committees of jurisdiction or have demonstrated a commitment to advance health policy. The House Energy & Commerce Health Subcommittee is one of two committees with jurisdiction on various important measures, including prior authorization and physician workforce issues. The House Ways & Means Health Subcommittee has jurisdiction on all taxation and other revenue-raising measures, including the Medicare program. The Senate Health, Education, Labor, & Pensions Committee is one of two committees in the Senate with primary jurisdiction on health policy measures.
In September and October, AUAPAC supported: Representatives Ann Kuster (D-NH-02), Terri Sewell (D-AL-07), Brad Wenstrup (R-OH-02), Neal Dunn, MD, (R-FL-02), Michael Burgess, MD (R-TX-26), Vern Buchanan (R-FL-16), Cathy McMorris Rodgers (R-WA-05), John Joyce, MD (R-PA-13), Ami Bera, MD (D-CA-07), and Robin Kelly (D-IL-02); and Senators Maggie Hassan (D-NH) and Lisa Murkowski (R-AK).
Prior Authorization Legislation Passes House of Representatives
On September 14, the U.S. House of Representatives passed the Improving Seniors Timely Access to Care Act (H.R. 3173). As a reminder, H.R. 3173 reforms and expedites the prior authorization process within Medicare Advantage, including establishing an electronic prior authorization process and setting guidelines for prior authorization determinations. Reducing regulatory burdens, including prior authorization, consistently appear as a top issue for our members on the AUA’s Federal Legislative Priority Survey.
The House-passed prior authorization measure now moves to the U.S. Senate for further deliberation. Reforming prior authorization will remain an AUA priority, and the AUA will continue to advocate in support of this measure as it moves through Congress.
AUA Emphasizes Need for Specialists in Rural Area in Meetings on SPARC Act
On September 13-16, the AUA met with staff in the offices of Senators Martin Heinrich (D-NM), Bernie Sanders (I-VT) and Tim Cotton (R-AR) to discuss cosponsorship of the Specialty Physicians Advancing Rural Care (SPARC) Act (S. 4330). As a reminder, S, 4330 would establish a loan forgiveness program designed for specialty physicians who practice in a rural area for six years.
Sen. Heinrich’s staff were responsive to a program that operates parallel to the National Health Services Corps (NHSC) and focuses on providing specialty care in rural areas of America, especially New Mexico. They also felt the SPARC Act establishes a program that not only increases access to specialists but also helps bolster the idea of localized medicine.
Similarly, Sen. Sanders’ staff expressed a general concern about the impending physician workforce shortage, specifically in rural areas with limited access to any medical services. They were also empathetic to the level of student loan debt specialists have and understand that it contributes to the disparity in the number of physicians who practice in rural America.
As for Sen. Cotton’s staff, they acknowledged that specialty physicians’ exclusion from the NHSC needs a remedy and they see the SPARC Act as a viable solution. They also understood that the program would help strengthen care in rural areas without access to specialists. However, they do have concerns about the viability of the legislation from an appropriations perspective, given Congress’ current appetite for loan forgiveness programs.
You can help advocate for the SPARC Act by contacting your U.S. Senators to ask them to cosponsor this legislation. Take Action Now!
AUA Prostate Cancer Impact Alliance Hosts Impact Series: Men Who Have Sex with Men Webinar
The AUA/Urology Care Foundation’s Prostate Cancer Impact Alliance hosted the Impact Series: Men Who Have Sex with Men Webinar. The purpose of this webinar was to address the needs of men who have sex with men who have prostate cancer as they undergo treatment from their urologists and other healthcare providers. This webinar also aimed to make patient advocacy groups and physicians more aware of the challenges and barriers that men who have sex with men face in fighting prostate cancer.
The esteemed panel included Hugh McBride; Lee Newell and Rich Radocchia, LCSW as patient speakers and AUA members LaMont J. Barlow, MD; Tomas L. Griebling, MD and Jordan Bilbrew, MD. A special thank you to Darryl Mittendorf, LCSW, of Malecare for moderating the webinar.
Access a recording of the webinar here: https://www.youtube.com/watch?v=lU-9JmL8pt4
Below are insurance updates from national insurance carriers. If you have questions about insurer issues, contact Bhavika Patel at bpatel@AUAnet.org.
Aetna reviewed its Erectile Dysfunction (Commercial) Policy with the following changes:
Experimental and investigational treatment for erectile dysfunction, platelet-rich plasma injection
Criteria note for semi-rigid or inflatable penile prostheses regarding exceptions to normal prolactin, thyroid hormone, and serum testosterone levels
CPT code 0232T
Criteria for Xiaflex for Peyronie’s disease regarding administration by an experienced healthcare provider
Dosage and administration
Aetna reviewed its Benign Prostatic Hyperplasia Policy adding transperineal laser ablation of the prostate or transperineal percutaneous laser ablation, including imaging guidance, as experimental and investigational for the treatment of BPH.
BCBS Federal Employee Plan
BCBS Federal Employee Plan issued a new version of its Nubeqa Prior Authorization (PA) Rationale document.
Cigna reviewed its Benign Prostatic Hyperplasia (BPH) Treatments Policy with the following changes:
Added transperineal laser ablation (e.g., SoracteLite) as experimental, investigational, or unproven
Removed medically necessary criteria for urethral lift (e.g., UroLift), water vapor thermal therapy (e.g., Rezūm System), and waterjet tissue ablation (e.g., AquaBeam System)
Added code 0714T (experimental/investigational/unproven)
Humana reviewed its Intensity Modulated Radiation Therapy Policy with the following changes:
Added SpaceOAR Vue as an example of a transperineal biodegradable spacer for which members may be eligible
Added Barrigel transperineal biodegradable spacer as experimental/investigational
Updated listed of contraindications to placement of a transperineal biodegradable spacer in coverage limitations section
Added “not covered if used to report any procedure outlined in coverage limitations section” for CPT code 55874
National Government Services
National Government Services issued a new version of its Biomarker Testing for Prostate Cancer Diagnosis (J06, JK) (A56609) Local Coverage Article (LCA) adding the following language to the CPT/HCPCS Codes section – Group 1: Paragraph: “The CPT codes in Group 1 are considered medically necessary when ordered by a physician or other qualified health care professional.”
National Government Services added a tracking sheet for its draft Biomarker Testing for Prostate Cancer Diagnosis (J6, JK) (L37733) Local Coverage Determination (LCD). The Final LCD Notice Period ends October 31. The Final LCD Effective Date is November 1.
National Government Services (NGS) issued a new version of its Biomarker Testing for Prostate Cancer Diagnosis (J6, JK) (L37733) Local Coverage Determination (LCD). Based on a request for Reconsideration, the LCD was revised to allow a physician or other qualified health care professional to order the EPI test as well as other biomarkers as discussed in the LCD. NGS added two additional biomarkers: the MyProstateScore and the isoPSA test. NGS clarified which biomarker tests are recommended for use prior to prostate biopsy and what tests are recommended for use after biopsy of the prostate. The language concerning biomarker testing was updated and the information in the Rationale for Determination section was clarified.
National Government Services issued its Response to Comments: Biomarker Testing for Prostate Cancer Diagnosis (J6, JK) (A59220) Local Coverage Article (LCA). This comment/response article is published for L37733 Biomarker Testing for Prostate Cancer Diagnosis.
Noridian issued a new version of its Molecular Diagnostic Tests (MDT) (MolDX) (JF) (A57527) Local Coverage Article (LCA). Under CPT/HCPCS Codes Group#1: Codes the description was revised for 0016M, 0229U, and 0306U. Under CPT/HCPCS Codes Group 1: Codes added 0323U, 0326U, 0329U, 0330U, 0331U. This revision is due to the Q3 2022 CPT/HCPCS Code Update and was effective on July 1.
Noridian issued a new version of its Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer (MoIDX) Local Coverage Article (LCA) deleting 81162 from CPT/HCPCS Codes Group 2 as it was added in error during revision 1.
Palmetto released a draft of its Transurethral Waterjet Ablation of the Prostate (JJ, JM) (DL38549) Local Coverage Determination (LCD). Synopsis of draft:
Treatment for LUTS/BPH treatment will be considered reasonable and necessary when performed ONCE in patients and only treatment using an FDA approved/cleared device will be considered reasonable and necessary. The listed indications must all be included, which include prostate volume of 30-150 cc by transrectal ultrasound (TRUS) and persistent moderate to severe symptoms despite maximal medical management including all the criteria described.
The LCD also lists limitations that render the procedure not reasonable and necessary, which include having a body mass index ≥ 42kg/m2; Bladder cancer, neurogenic bladder, bladder calculus or clinically significant bladder diverticulum; Active urinary tract or systemic infection; Treatment for chronic prostatitis; And the inability to safely stop anticoagulants or antiplatelet agents preoperatively.
Palmetto reviewed its Bladder Tumor Marker (FISH) (JJ, JM) (A53095) Local Coverage Article (LCA) removing verbiage regarding instructions on how to submit a DEX Z-code on claims and how to register a test for a DEX Z-code identifier.
United Healthcare reviewed its Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/ Orthotics (Non-Foot Orthotics), Nutritional Therapy and Medical Supplies Grid (Medicare) Policy replacing vacuum pump or device coverage criteria with non-covered criterion and LCD reference. The revision indicated vacuum pump or devices as non-covered DME.
United Healthcare reviewed its Co-Surgeon and Team Surgeon Reimbursement & Billing Document updating modifier 62 and modifier 66 guidelines to specific for the same date of service.
United Healthcare retired its Bladder Stimulators (Pacemakers) Policy.
WPS Government Health Administrators
WPS Government Health Administrators retired its ConfirmMDx Epigenetic Molecular Assay (MolDX) (J05, J08) (A57561) Local Coverage Article (LCA), effective August 20. This article is being retired since the associated LCD L37005 MolDX: ConfirmMDx Epigenetic Molecular Assay is retiring as it has been incorporated into our new MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (L39042) LCD.
WPS Government Health Administrators retired its 4Kscore Assay (DL37013) Local Coverage Determination (LCD), effective October 17. This LCD is retiring this LCD as this test is no longer in the Moldx program. WPS is not receiving claims for this service.
WPS Government Health Administrators issued a new version of its Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer (MolDX) (J5, J8) (A58756) Local Coverage Article (LCA), deleting CPT code 81162 from CPT/HCPCS Codes Group 2, as the addition of this code in Revision 1 was done in error.
WPS Government Health Administrators issued a new version of its Prognostic and Predictive Molecular Classifiers for Bladder Cancer (MolDX) (JJ, JM) (A58211) Local Coverage Article (LCA). Under the CPT/HCPCS Codes Group 1 the code description was revised for 0016M, due to the Quarter 3 CPT/HCPCS Code Update.
WPS Government Health Administrators published its response to comments on its 4Kscore Assay (J05, J08) (A59230) Local Coverage Article (LCA).
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.
Independence Blue Cross
Independence Blue Cross reviewed its Oncology Agents (Commercial) Policy with the following changes:
Updated criteria for Yonsa and Zytiga to remove Erleada
Updated criteria for Yonsa and Zytiga regarding inadequate response to other drugs
H.B. 2824 – Insurance
Introduced by Representative Pamela DeLissio (D), H.B. 2824 seeks to create a single payer universal healthcare insurance plan in the state, the Pennsylvania Health Care Plan (PHCP). The PHCP would administer a plan to provide cost-effective healthcare services ranging from wellness and preventative care to catastrophic care. The bill was referred to the House Health Committee.
H.B. 2842 – Prostate Cancer
Introduced by Representative Jeanne McNeill (D), H.B. 2842 seeks to amends state insurance law to require coverage for prostate cancer screening. The bill was referred to the House Insurance Committee.
The Pennsylvania Supreme Court has reversed a longstanding rule that required medical malpractice lawsuits to be filed in the county where the alleged negligent care was given. The decision clears the way for plaintiffs to file medical malpractice cases in any county where the healthcare provider regularly conducts business. The new rule, which goes into effect on January 2, 2023, will be reexamined in two years.
A.J.R. 186 – Alliance Topics
Introduced by Assemblymember Angela McKnight (D), A.J.R. 186 would designate the second week of November each year as “Urinary Incontinence Awareness” week. The bill was referred to the Assembly Health Committee.
- 4485– Insurance
Introduced by Assemblymember Herb Conaway (D), A. 4485 requires health insurance carriers to provide an adequate network of physicians. Under the bill, an insurer must ensure there is a sufficient number of physicians within a 20 minute drive or 10 miles, whichever is less, from three primary care physicians and a 30 minute drive or 15 miles from at least three office-based medical specialists within each specialty. The network will be required to have a sufficient number of physicians to: meet the health needs of covered persons, provide an appropriate choice of physicians to provide services covered under the plan and reasonably ensure covered persons have access to in-network facilities. The bill requires the Commissioner of Banking and Insurance and the Commissioner of Human Services to establish a system where a covered person may file a formal complaint concerning network adequacy with the respective Departments. The bill was referred to the Assembly Financial Institutions and Insurance Committee on September 15.
- 4619– Medical Licensure
Introduced by Assemblymember Lou Greenwald (D), A. 4619 makes permanent certain forms of temporary licensure for health care providers in other states. Temporary licensees will be authorized to practice up to one year in New Jersey without holding a permanent license. They also will not be required to pay any fees or complete a criminal history background check as a condition of the temporary authorization to practice. If the individual applies for full licensure within one year of obtaining temporary authorization, the temporary authorization will remain in place until a final determination is made on the application for full licensure. The bill amends the telemedicine and telehealth laws to allow the use of telemedicine and telehealth by out-of-state practitioners authorized to practice under the bill. The bill was referred to the Assembly Regulated Professions Committee.
Maureen and the AUA Public Policy & Advocacy Team