Network Management

Telemedicine for Preventative Services Reminder

As a friendly reminder, PreferredOne wants to encourage our provider partners to continue to see PreferredOne members in non face-to-face settings when appropriate including virtually, via telemedicine, or telephonically. This includes for preventative visits. PreferredOne does allow for codes 99381-99387 and 99391-99397 to be billed with a 95 modifier and a place of service of 11. The 95 modifier will assist us in identifying that the services were performed via telemedicine. For additional information on what services can be billed via telemedicine please see our Provider FAQ here.

Bind & PreferredOne network partnership to discontinue Jan. 1, 2021

Bind personalized health insurance was founded to change the way patients interact with the health care system—and as part of that mission, Bind is going through some changes itself. Beginning on January 1, 2021, Bind will no longer be a part of the PreferredOne network. Bind and PreferredOne have been partners since Bind's inception in 2016. PreferredOne contributed to Bind’s initial launch and both organizations are grateful for the partnership and joint success.

Bind has grown significantly since then and, as a result, effective 1/1/2021, Bind and PreferredOne will no longer pursue an operational partnership. Following that date, claims made to Bind through the PreferredOne network will be denied. Bind and PreferredOne will work together to ensure a smooth member and provider transition through 2020 on a client by client basis. Questions should be routed to the appropriate Bind or PreferredOne Account Partner.

Bind will continue to be a part of UnitedHealthcare’s Choice Plus network, so providers contracted through that network can still submit claims for Bind members.

However, providers should note that Bind only processes claims for Bind members that come directly to the company. This is true for all providers, those in the PreferredOne network (until Bind departs January 1, 2021 )and for UHC Choice Plus and Optum Behavioral Health providers

Providers should submit directly to Bind, electronically to Payer ID 25463 or by mail to:

Bind Benefits
PO Box 211758
Eagan, MN 55121

With headquarters in Minneapolis, and offices in New York City and San Francisco, Bind offers a unique coverage solution with no deductible or co-insurance to self-insured employers with 350+ employees and is ACA-compliant. Beginning in 2021, Bind will also offer a fully insured product.

For more information about Bind or its network affiliation, please visit yourbind.com/providers.

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).

Since the last newsletter, the following are the new, revised, or retired Medical Policy documents. Some of the more extensive Medical Policy updates are detailed for a few of the items below. 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.Hartwig-Caulley@PreferredOne.com

Prior Authorization List

5/28/20 Infusions/injections: removed Vyondys 53 (golodirsen) (this has been added to the Investigative List), Yescarta - added HCPCS; lab Test: NIPT – added HCPCS.
04/28/20 Cosmetic (potentially):- addition of Lipoma removal if requesting general anesthesia ; Infusions/injections: Adakveo, Givlaari, addition of HCPCS; Herceptin Hylecta HCPCS revised; Hormone pellet implantation for males (estradiol and/or testosterone pellets) deleted; addition of Depo-estradiol, Estradiol, Estrogen, Firmagon, Goserlin, Histrelin, Leuprolide, Testosterone, and Triptodur when billed with F64.0,F64.1,F64.2,F64.8,F64.9,Z87.890 (F64.0 transsexualism, F64.1 dual role transvestism, F64.2 gender identify disorder of childhood, F64.8 other gender identity disorders, F64.9 gender identify disorder, unspecified, Z87.890 personal history of sex reassignment status); deleted Supprelin LA - implant (histrelin) - initial placement only (J9226) (captured in new histrelin entry); Neurology, Hypoglossal nerve stimulation – added CAT III code 0467T; Other Procedures/Treatments Gender reassignment: added surgical procedures for reassigning biological gender for all ages and the CPTs and diagnosis codes associated with this entry; Percutaneous Left Atrial Appendage Occlusion Closure and associated CPT added
03/10/20 Cosmetic (potentially) - added mastopexy/mammaplasty w/ or w/o implant, added implant material to the breast implant removal entry, added breast periprosthetic capsulectomy and associated CPTs, added breast reconstruction and associated CPTs, added or lipectomy to Excision entry, added breast to the revision of reconstructive procedures entry; Infusions/Injections… added Site of Care review asterisk designation (and HCPCS where they were missing), with a 4/6 effective date, to the currently listed drugs: Actemra, Aldurazyme, Benlysta, Berinert, Cerezyme, Cinqair, Cinryze, Crysvita, Elaprase, Elelyso, Exondys 51, Fabrazyme, Fasenra, Gattex, Glassia, Ilaris, Immune globulins, Kanuma, Krystexxa, Lumizyme, Mepsevii, Naglazyme, Nucala, Orencia, Ruconest , Soliris, Strensiq, Vimizim, VPriv; Newly added drugs also with a Site of Care review asterisk designation and a 4/6 effective date: Aralast NP, Flolan, Nulojix, Prolastin C, Remodulin, Xolair, Zemaira; Newly added drugs without Site of Care designation/no HCPCS: Adakveo, Avsola, Cablivi, Enhertu, Givlaari, Padcev, Reblozyl, Scenesse, Tepezza, Vyepti, Vyondys 53; Lab tests – added Comparative Genomic Hybridization and CPTs, heart transplant rejection added CPT 81595, added CPTs to the Non-invasive Pregnancy Testing (NIPT) entry; Orthognathic surgery – added CPTs; Other Procedure/Treatments – added Left Atrial Appendage Closure and CPT, added intraosseous basivertebral nerve to the Radiofrequency entry, deleted remote monitoring of physiologic parameters, added Septoplasty and Tracheostomy for sleep apnea, only.
01/21/20 Infusions/Injections – Zulresso – added HCPCS; Outpatient Therapy Services – removed Early Intensive Behavioral and Developmental Interventions / Therapy (EIBDI/ EIBDT/ABA), Autism

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies List

Various updates to HCPCS and quantity limits. Check PreferredOne.com for the most current version.

Medical Criteria

NEW

C011 Non-Surgical Treatments for Obstructive Sleep Apnea
L021 Whole Exome Sequencing

REVISED

F024 Radiofrequency Ablation (Neurotomy, Denervation, Rhizotomy) Cervical, Thoracic, Lumbosacral, Sacroiliac or Knee Pain – Revised to include additional indications and remove the requirement to provide evidence that the prior ablative treatment demonstrated an improvement in functional status and decreased use of analgesics
G002 Breast Reduction – Deleted Exclusion related to further reconstruction
I009 Deep Brain and Cortical Brain Stimulation – Revised to incorporate medically necessary indications for initial placement and replacement/revision of the use of this technology for partial-onset seizures
I010 Spinal Cord/Dorsal Column and Dorsal Root Ganglion Stimulation – Revised to incorporate medically necessary indications for initial placement and replacement/revision of the use of this technology in the dorsal root ganglion for lower limb pain due to complex regional pain syndrome
L012 Gene Expression Profiling – Revised to now allow Oncotype DX Breast Cancer Assay for Estrogen Receptor (ER) or Progesterone Receptor (PR) positive
L015 Comparative Genomic Hybridization (CGH) – Revised as evidence supports that testing should not be limited to children and to clarify the diagnosis which corresponds to the evidence in support of the use of this test and the recognized DSM diagnosis verbiage
M025 Transcranial Magnetic Stimulation (TMS) – Revised to no longer require evidence of treatment resistance during the current episode of major depressive disorder (MDD) when a previous episode of MDD was similar

Medical Policies

NEW

L004 Levels of Evidence and Evaluation of Health Care Services - Captures the types of scientific evidence that are reviewed, and the level of evidence rating that is required, to determine when a health care service is proven effective for our members. Note, only services with a high level of evidence showing safety, effectiveness and positive effects on health outcomes will be considered for coverage.
P015 Preventive Coverage for Prenatal Services - Reflects the ACA and MN State Statute required preventive/no-cost sharing coverage for prenatal services
P020 Preventive Coverage for Routine Immunizations – Reflects information that was previously found In MP/I003, just in a new format

REVISED

C008 Clinical Trials - Revised to state that all costs associated with the clinical trial protocol are not eligible for coverage
D004 Durable Medical Equipment – Revised to add information regarding allowing a second, different type of ventilator if medically necessary
D009 Dental Services, Hospitalization, and Anesthesia for Dental Services Covered Under the Medical Benefit – Revised to further support the position regarding when hospitalization and/or MAC/general anesthesia for dental care is appropriate
D010 Drug Testing in Substance Abuse Treatment and Chronic Pain Management Settings – Revised to reflect that definitive drug testing must meet the same medical necessity requirements as presumptive testing and that it should be employed only when the member is disputing the results of the presumptive testing; Decreased the annual allowed number of presumptive tests from 24 to 16
G001 Genetic Testing for Heritable and Somatic Conditions – Revised to include “somatic”, ie, it is also applicable to requests for genetic testing that are not inherited, and to reflect that testing of embryos for PGD is in scope for this policy
H006 Hearing Devices – Revised to remove the exclusion for partially implantable bone conduction hearing systems using magnetic coupling for acoustic transmission
I001 Investigative Services - Addition of statement that new FDA-approved drugs and clinical indications for provider-administered medications may be designated as excluded, until PreferredOne has determined if reliable evidence permits conclusions concerning its safety, effectiveness, or effect on health outcomes
I002 Infertility Treatment – Revised to expand Exclusions
L002 Lipoma Removal – Revised to include additional required documentation on the pre-operative surgical plan and expanded symptom of pain at rest
P013 – Addition of newly approved companion diagnostic tests in support of new FDA-approved drugs and/or indications; revised the Exclusions list and Attachment A to revise appropriate indications
R002 Reconstructive Surgery - Addition of the new language associated with requests for reconstructive surgery that would not otherwise be covered, but are being requested due to the presence of DSM mental health disorder diagnosis causing clinically significant distress or impairment
W001 Physician Directed Weight Loss Programs – Revised to further define weight loss medications

Investigative List

Based on a full review of all items currently on the PreferredOne Investigative List, and newly assessed technology/codes, the following revisions have been made to the List.

Added

Heart transplant rejection testing - My TAI
Whole genome sequencing (WGS)

Deleted

Alternative/Holistic Therapies – this is excluded in Plan language
Alternative /Holistic Laboratory Testing: Micronutrient Testing in absence of specific symptoms related to malnourishment – this is excluded in Plan language and is also considered non-standard laboratory testing
Alternative /Holistic Laboratory Testing: NutrEval in absence of specific symptoms related to malnourishment – this is excluded in Plan language and is also considered non-standard laboratory testing
Bone conduction hearing systems, partially implantable, using magnetic coupling for acoustic transmission
Cardiac devices and procedures for occlusion of left atrial appendage
Coronary Artery Calcium Scoring
Dynamic Graciloplasty
EROS device – coverage of this is subject to plan language for treatment of sexual dysfunction
Tumor Necrosis Factor (TNF) antagonist testing
6-thioguanine nucleotide (6-TGN) & 6-methylmercaptopurine nucleotide (6-MMPN) enzyme activity measurements

Revised

Adoptive Immunotherapy – entry revised to also include “or Adoptive Cell Transfer AND Cellular Therapy (ACT), includes Tumor Infiltrating Lymphocytes (TILs), T cell receptors (TCRs), Lymphokine Activated Killers (LAKs) and Chimeric Antigen Receptors (CARs)”: the following also added under Comments/definition: Adoptive Immunotherapy or Adoptive Cell Transfer involves collecting and using the patients’ own immune cells to treat their cancer. This does not apply to Provenge (sipuleucel-T) which is FDA approved for prostate cancer (see Prior Authorization List), Kymriah (Tisagenlecleucel) which is FDA approved for leukemia and lymphoma, Yescarta (Axicabtagene ciloleucel) FDA approved for non-Hodgkin Lymphoma and Imlygic (Talimogene laherparepvec) which is FDA approved for melanoma.
Carbogen Inhalation Therapy entry has been revised and is investigative for any use (previous position was investigative for Treatment of Hearing Loss, only)
Circulating tumor cells/markers or cell-free tumor DNA for the management of all cancers has been revised to Circulating tumor cells/markers or circulating tumor DNA for the management of all cancers
Deep brain stimulation (DBS) for treatment of other movement disorders and neurologic disorders – is now allowed for seizure disorders
Extracranial/Intracranial Arterial Bypass (anastomosis) – revised to state except for treatment of Moyamoya
High Intensity Focused Ultrasound (HIFU) - “except for prostate cancer” has been removed: this is now investigative for all indications
Home Monitoring of Pulmonary Function Using Home Spirometry has been revised to allow for use after lung transplantation
Hyperthermia Treatment for cancer conditions – revised to allow for Goblet cell carcinoid tumor
Inflammatory Bowel Disease Testing – removed Fecal Calprotectin from this entry
Implantable subcutaneous target stimulator – added peripheral subcutaneous field stimulation (PSFS)/ peripheral nerve field stimulation (PNFS) to this entry and the specific position for PNFS for back pain due to FBSS
Photodynamic Therapy for Dermatologic Conditions – revised by the addition of “refractory” to actinic keratosis (an allowed diagnosis)
Procuren moved to a new entry, Platelet Derived Growth Factors – comments added, “Examples in include Procuren and Regranex. Can allow Regranex for non-healing diabetic neuropathic ulcers/diabetic foot ulcers”
Spinal cord stimulation (SCS) - addition of dorsal column stimulation (DCS) to these entries

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

Pharmacy

Pharmacy criteria documents for coverage of drug requests under the Pharmacy benefit are available at PreferredOne.com by clicking on Coverage and Benefits, choosing Pharmacy Information, then choosing Formulary. Pharmacy criteria documents developed for provider administered drugs are found in the Medical Policy section on PreferredOne.com.

Pharmacy Policy documents developed for provider administered drugs are found in the Medical Policy section on PreferredOne.com.

Pharmacy Criteria

NEW

IC-0057 Trastuzumab
IC-0449 Trastuzumab Hylecta

REVISED

A011 Altered Bone Homeostasis Treatment Medications – Revised to reflect additional off-label use and clinical indications that support refractory to treatment with pamidronate or Zometa
B003 Botulinum Toxin – Revised to incorporate additional first line treatments and include an indication for use in Tardive Dyskinesia
B004 Biologics for Rheumatoid Arthritis - Addition of Avsola, a biosimilar to Remicade, as second line
B005 Biologics for Plaque Psoriasis - Addition of Avsola, a biosimilar to Remicade, as second line
B006 Biologics for Crohn’s Disease – Revised to reflect preferred infliximab products before the use of Entyvio or non-preferred infliximab products; addition of Avsola, a biosimilar to Remicade, as second line
B010 Biologics for Juvenile Idiopathic Arthritis and Juvenile Rheumatoid Arthritis - Addition of Avsola, a biosimilar to Remicade, as second line
B011 Biologics for Psoriatic Arthritis - Addition of Avsola, a biosimilar to Remicade, as second line
B012 Biologics for Ankylosing Spondylitis - Addition of Avsola, a biosimilar to Remicade, as second line
B013 Biologics for Ulcerative Colitis - Revised to require use of a preferred infliximab products a self-administered anti-TNF agent, and Stelara before Entyvio or a non-preferred infliximab product; addition of Avsola, a biosimilar to Remicade, as second line
B016 Biologics for Multiple Sclerosis – Removed the language regarding lifetime limited use of Lemtrada
R004 Rituximab Prior Authorization – Revised to incorporate use in Myasthenia Gravis and SLE; request for use in NMO no longer requires failure of other treatment; revised entry for use in antibody mediated heart transplant rejection
S008 Spinal Muscular Atrophy Treatment Medications – revised Continuation indications
V001 Vascular Endothelial Growth Factor Antagonists for Intravitreal Use – Revised to include Avastin biosimilars Mvasi and Zirabev as preferred medications; addition of Beovu; revisions to reflect that each non-preferred product is allowed for its FDA-approved indication, only

Retired: B015 Breast Cancer Risk Reduction Medications Step Therapy – this process is managed by the PBMs

Pharmacy Policy

Revised

C003 Compounded Drug Products – Revised to capture that a compounded product may be allowed when it is a therapeutically equivalent and more cost-effective than the commercially available product.
PP/F001 Formulary Exception - Revised to reflect addition of new language applicable to all Essential Health Benefit (EHB) plans
PP/S001 Step Therapy – Addition under Coverage to reflect new state statute language re: step therapy and stage IV advanced metastatic cancer.

Pharmacy Investigative List

Addition of varicose vein treatment with micronized purified flavonoid fraction and Vyondys 53

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.

Quality Management

Exchange of information

Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral. PreferredOne would like to take this opportunity to stress the importance of communicating with your patient’s other health care practitioners. This includes primary care physicians and medical specialists, as well as behavioral health practitioners. While we realize in this age of electronic medical records, many records are available to other practitioners in the same care system, currently across systems there is not this coordination of information about your patients.

Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner. PreferredOne urges all its practitioners to obtain the appropriate permission from these patients to coordinate care between behavioral health and other health care practitioners at the time treatment begins.

We encourage all health care practitioners to:

Discuss with the patient the importance of communicating with other treating practitioners.
Obtain a signed release from the patient and file a copy in the medical record.
Document in the medical record if the patient refuses to sign a release.
Document in the medical record if you request a consultation.
If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:
- Diagnosis
- Treatment plan
- Referrals
- Psychopharmacological medication (as applicable)

We appreciate your efforts to provide coordinated care among our membership population and ensuring your patients and their entire medical team is informed about patients’ medical treatment plans and outcomes.

Minnesota Community Measurement - Release of the 2019 Health Care Quality Report

Minnesota Community Measurement (MNCM) is a collaboration among health plans and provider groups designed to improve the quality of medical care in Minnesota. MNCM’s mission is to accelerate the improvement of health by publicly reporting health care information. MNCM has three goals:

Reporting the results of health care quality improvement efforts in a fair and reliable way to medical groups, regulators, purchasers and consumers.
Providing resources to providers and consumers to improve care.
Increasing the efficiencies of health care reporting in order to use our health care dollars wisely.

PreferredOne is one of seven founding health plan members of MNCM. The state medical association, medical groups, consumers, businesses and health plans are all represented on the organization's board of directors. Data is supplied by participating health plans on an annual basis for use in developing their annual Health Care Quality Report.

MNCM released their 2019 Health Care Quality Report on their website during the first quarter of 2020. The 2019 Health Care Quality report features comparative provider group performance on depression care, preventive health screening, and chronic disease care. One of the primary objectives of this report is to provide information to support provider group quality improvement. Provider groups will find this report useful to improve health care systems for better patient care. Sharing results with the public provides recognition for provider groups that are doing a good job now and motivates other groups to work harder. The report will allow provider groups to track their progress from year-to-year and to set and measure goals for future health care initiatives. The MNCM website also provides consumers with information regarding their role as active participants in their own care. Visit the MNCM website site to view the 2019 Minnesota Health Care Quality Report at www.mncm.org.

Quality Management (QM) Program

The mission of the QM Program is to identify and act on opportunities that improve the quality, safety and value of care provided to PreferredOne members, both independently and/or collaboratively, with contracted practitioners and community efforts, and also improve service provided to PreferredOne members and other customers.

2020 PreferredOne QM Program Description, Executive Summary

2019 Year-End QM Program Evaluation, Executive Summary

To access these documents, log into the Provider site, and then click on the Quality Management Program link under the Information heading.

If you would like to request a paper copy of either of these documents please contact Heather Clark at 763-847-3562 or e-mail us at quality@preferredone.com.

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents HEDIS Technical Specifications

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. This measure is a hybrid measure, which means, it can be collected both from administrative data and chart information. What you may not realize is that the burden of collecting this information from your clinic records could be lessened if practitioners were to use appropriate codes when submitting their billing statements. This measure has appropriate codes that would assist PreferredOne in collecting this information administratively through claims data.

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents:

This measure examines the percentage of members 3-17 years of age who had an outpatient office visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity.

Description	CPT	ICD-10-CM Diagnosis	HCPCS
BMI Percentile		Z68.51-Z68.54
Counseling for nutrition	97802-97804	Z71.3	S9470, S9452, S9449, G0270-G0271, G0447
Counseling for physical activity		Z02.5, Z71.82	S9451, G0447

We encourage practitioners to use the above coding specifications to reduce the burden of chart review that will need to be performed at your clinic in the following year. If you have questions about these measures you may visit NCQA’s website at www.ncqa.org or contact us at quality@preferredone.com.

HEDIS Data

We would like to thank all of our provider groups for their cooperation and collaboration during our recent HEDIS medical record review process. We realize that this process is burdensome to clinics and staff and appreciate your willingness in working with our vendor to ensure our HEDIS results for 2020 are accurate. Thank you!

PHARMACY

Continuous Glucose Monitor Coverage Change

Effective September 1, 2020, Continuous Glucose Monitors and supplies will be moved from coverage under the medical benefit to the prescription drug benefit.

Continuous Glucose Monitors and supplies will be covered under the pharmacy benefit for members diagnosed with Type 1 or Type 2 diabetes and receiving Insulin. They will no longer be covered under the medical DME benefit. For continued coverage of CGM supplies, affected members will be required to receive them through an in-network pharmacy. A new prescription may be needed. Members and providers will receive a letter from PreferredOne in advance of this change taking effect.

If members have any questions about their prescription coverage, they may contact PreferredOne Customer Service at 763.847.4477 or 800.997.1750.

New Prior Authorization Criteria for Rituximab Products

Effective 10/01/2020, PreferredOne will implement new Prior Authorization criteria for rituximab products (Rituxan, Ruxience, and Truxima). The full criteria is available for review here.

Patients currently on treatment will not be affected by this change. For patients new to treatment , Ruxience (Q5119) and Truxima (Q5115) are the preferred products and will be allowed before Rituxan (J9312). For exceptions, the patient must have a contraindication, intolerance, or failure to both Ruxience (Q5119) AND Truxima (Q5115). Additionally, patients who are receiving rituximab treatment for a cancer diagnosis will now have immediate review and subsequent approval as long as they are requesting one of the preferred products, Ruxience (Q5119) or Truxima (Q5115).

Please reach out to your PreferredOne Network Management Representative if you have any questions or concerns.

CODING

Drug Testing for Controlled Substance Payment and Reimbursement Guidelines

Beginning 10/1/2020, PreferredOne will be following CMS guidelines on billing for definitive and presumptive drug testing of controlled substances.

Consistent with CMS guidelines, PreferredOne considers CPT codes 80320-80377 as non-reimbursable. The appropriate HCPCS G0480-G0483 and G0659 should be reported based on the number of drug classes tested. The appropriate PLA codes can be reported based on the number of drugs tested. Only one code from either of these code ranges may be reported per date of service.

For PreferredOne coverage guidelines, please refer Clinical Policy MC/L002 Drug Testing in Substance Abuse Treatment and Chronic Pain Management Settings.