Medical Management

Medical Policy

Medical Policy documents are available on the PreferredOne website to members and to providers without prior registration. The most current version of Medical Policy documents are accessible under the Medical Policy section on the PreferredOne website (PreferredOne.com). (Click on Coverage & Benefits then choose Medical Policy).

If you wish to have paper copies of these documents, or you have questions, please contact the Medical Policy Department telephonically at (763) 847-3386 or online at Heather.Thompson@PreferredOne.com.

Prior Authorization List

  • Laboratory Testing: deleted CPT codes 0236U, 0333U, 0338U, and 0012U; added CPT codes 81404, 81599, 0070U, 0173U, and S3842; replaced separate entries with “Genetic, molecular, and pharmacogenetic/ pharmacogenomic testing” – all CPT codes requiring prior authorization added

  • Cardiovascular: Total Artificial Heart - CPT code 33929 replaced with 33928

  • Cosmetic (potentially) and/or Reconstructive Procedures: Excision/removal of excessive/redundant tissue - revised to reflect “(includes lipectomy, panniculectomy)” and CPT codes 15830 and 15837 added

Medical Clinical Policies

  • New: None

  • Revisions (substantive clinical revisions)

    • Bariatric Surgery for Obesity (MC/H003) – revised to align with the current expert professional practice and specialty society standards and clinical practice guidelines
    • DMEPOS, Wheelchairs and Mobility Assistive Equipment (MC/D003) – revised to increase age for eligibility for coverage of the attendant control (joystick)
    • Gender Reassignment, Surgical Treatment for Gender Dysphoria (MC/G019) – deleted the age requirement for breast or chest gender reassignment surgery
    • Genetic Testing, Whole Exome and Whole Genome Sequencing (MC/L021)
      • added autism as a specific diagnosis related to developmental delay (DD) or intellectual disability (ID)
      • deleted the indication regarding Family history strongly suggestive of a genetic etiology, including consanguinity
    • Molecular Testing, Tumor Neoplasm Biomarkers (MC/L012)
      • revised to reflect the updated NCCN position regarding the use of Oncotype DX Prostate in low, favorable intermediate, unfavorable intermediate, or high-risk prostate cance
      • revised to reflect indications for the appropriate use of post-biopsy diagnostic molecular testing for cutaneous melanoma (as supported by NCCN)
    • Pharmacogenetics/Pharmacogenomics (MC/P013) - revised Attachment A to match the current FDA Companion Diagnostic List
    • Special Coverage for COVID-19 Pandemic – addition of CPT codes for the vaccinations that have recently received authorization by the FDA for emergency use
    • Speech Therapy (MC/N004) – added medical necessity indications for speech therapy for feeding disorders
  • Retired: None

Medical/Surgical and Behavioral Health Services Investigative List

  • Addition: Molecular testing, circulating tumor cells/markers (ctDNA) or cell-free DNA (cfDNA) testing – added HelioLiver Test 0333U and CELLSEARCH HER2 Circulating Tumor Cell (CTCHER2) Test 0338U as other examples of investigative testing
  • Deletions
    • Fetal in-utero surgery - deleted fetal tracheal occlusion for congenital diaphragmatic hernia (FETO)
    • Molecular testing, pre-biopsy gene expression profiling for indeterminate cutaneous lesions, such as but not limited to, Pigmented Lesion Assay - deleted of DecisionDX Diff DX-Melanoma 0314U
  • Revisions
    • Balloon dilation: under Comments, added NuVent Eustachian as another example of an investigative device
    • Molecular testing, circulating tumor cells/markers (ctDNA) or cell-free DNA (cfDNA) - under Comments, added Tempus xF Liquid Biopsy (this is a cell-free DNA test)
    • Photodynamic Therapy - added CPT 96574

DMEPOS List

  • Addition: ROMTech PortableConnect Adaptive Telemed – added under Physical Therapy equipment, as excluded for rental or purchase for use in the home
  • Deletion: None
  • Revision: None

Reminder: Pharmacogenetic Panel testing for Anti-depressant and Anti-Psychotic Medications We are seeing an increased number of requests for panels that do not fall within our criteria or include investigative services. Please note that the panel must be 15 genes or less and include CYP2C19 and CYP2D6. Separate testing for MTHFR will be denied as investigative.

Please visit www.preferredone.com for the most current version.

Affirmative Statement About Incentives

PreferredOne does not specifically reward practitioners or other individuals for issuing denials of coverage or service care. Financial incentives for utilization management decision-makers do not encourage decisions that result in under-utilization. Utilization management decision making is based only on appropriateness of care and service and existence of coverage

Member’s Rights and Responsibilities

PreferredOne presents the Member Rights & Responsibilities with the expectation that observance of these rights will contribute to high quality patient care and appropriate utilization for the patient, the providers, and PreferredOne. PreferredOne further presents these rights in the expectation that they will be supported by our providers on behalf of our members and an integral part of the health care process. It is believed that PreferredOne has a responsibility to our members. It is in recognition of these beliefs that the following rights are affirmed and presented to PreferredOne members.

PAS Member Rights and Responsibilities

PIC Member Rights and Responsibilities

Adverse Determination – To Speak to a Physician Reviewer

PreferredOne Integrated Healthcare Services Department attempts to process all reviews in the most efficient manner. We look to our participating practitioners to supply us with the information required to complete a review in a timely fashion. We then hold ourselves to the timeframes and processes dictated by the circumstances of the case and our regulatory bodies. Practitioners may, at any time, request to speak with a peer reviewer at PreferredOne regarding the outcome of a review by calling 763-847-4488, option 2 and the Intake Department will facilitate this request. You or your staff may also make this request of the nurse reviewer with whom you have been communicating about the case and she/he will facilitate this call. If, at any time, we do not meet your expectations and you would like to issue a formal complaint regarding the review process, criteria or any other component of the review, you may do so by calling or writing to our Customer Service Department.

Phone number: (763) 847-4488, Option 3.
(800) 379-7727, Option 3
Address: PreferredOne, Grievance Department
6105 Golden Hills Dr.

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Quality Management

Blood Pressure Readings for Controlling High Blood Pressure
 In 2023 PreferredOne will once again be focusing on an initiative to control high blood pressure among our members diagnosed with hypertension. Controlling blood pressure is a HEDIS measurement specified by NCQA and is also reported by Minnesota Community Measurement. We value this project and deem it as important to our members because hypertension is the most treatable form of cardiovascular disease and medication compliance is a significant factor that contributes to the overall success of treatment. As part of this initiative in 2023 we are asking for provider’s assistance by conducting a secondary reading of your patient’s blood pressure if it is high following the initial reading and ensuring that the patient’s medical records reflects both of the measurements taken.

MY 2022 HEDIS Medical Record Review
PreferredOne’s HEDIS Medical Record Review Vendor (CIOX Health on behalf of Optum) will be contacting clinics in the coming weeks to coordinate medical record review for PreferredOne members seen at your clinics. As a contracted provider you are obligated to allow PreferredOne and its vendor to conduct this review. HEDIS measures are nationally used by all accredited health plans and PreferredOne also has an obligation to the Minnesota Department of Health to collect HEDIS data on an annual basis. Medical record review is an important component of the HEDIS compliance audit. It ensures that medical record reviews performed by our vendor meet audit standards for sound processes and that abstracted medical data are accurate. We would appreciate your cooperation with collecting medical record review information at your clinic site(s). We appreciate your clinic’s assistance in making this a smooth process.

Serving a Culturally and Linguistically Diverse Membership
Cultural and linguistic competence is the ability of health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought by their patients/consumers to the health care encounter. Cultural and linguistically appropriate services lead to improved outcomes, efficiency, and satisfaction.
Culture Care Connection is an online learning and resource center, developed by Stratis Health, aimed at supporting health care providers, staff, and administrators in their ongoing efforts to provide culturally-competent care in Minnesota.
For more information regarding Stratis Health’s resource center, click on the following link, http://www.culturecareconnection.org/ .

NETWORK MANAGEMENT

***Addition as of 3/22/2023 - Important Update to CPT codes 11200 – 11201

CPT codes 11200 and 11201 have been deemed cosmetic in nature and claims billed for those services will deny to provider liability. In the event a contracted PreferredOne provider partner wishes to bill a member for those services, the member must first sign a financial liability waiver prior to services being rendered indicating the services are not covered by insurance and that the member agrees to be financially liable for those services. An approximate dollar amount the member will owe must also be indicated on the wavier. In the event a provider does obtain a financial liability waiver prior to services being rendered please be sure to include the GA modifier when billing codes 11200 and 11201 on claims to indicate a signed waiver is on file. Should you have any questions on this update please reach out to your assigned Provider Relations Representative.