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

Prior Authorization Effective 9/1/2019

• Alpha-1 proteinase inhibitor, NOS (Prolastin, Zemaira) J0256
• Belrapzo (bendamustine) C9042, J9036
• Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) J9355

07/05/19 Infusions/Injections: added Alpha -1 proteinase inhibitor and newly effective HCPCS to Anti-hemophilia /blood clotting/coagulation factors, Gamifant, Triferic; Infusions/Injections - Antineoplastic/Chemotherapy /Immunotherapy/Radiopharmaceutical for Oncology Use - added Belrapzo and Herceptin Hylecta and newly effective HCPCS to Elzonris, Libtayo, Lumoxiti, Ogivir, Ontruzant, Truxima; Lab Tests – added Kidney transplant rejection; Maternity - revised entry to, “If LOS exceeds 2 days post vaginal delivery or 4 days post c-section delivery for mom or newborn”; Corrected CPT for Autologous Chondrocyte implantation entry.

06/14/19 Removed CT scan (computed tomography) for lung cancer screening (requesting coverage at no cost sharing [preventive] benefit G0297 – this no longer requires prior authorization.

05/22/19 Bariatric Surgery: added takedown; Cosmetic: Breast augmentation/implant – added removal to this entry: Genioplasty/mentoplasty – deleted, as this is always considered cosmetic and not subject to a M/N review: Revision of reconstructive procedures – deleted such as but not limited to retattooing of nipple. This will no longer require PA; Infusions/Injection: Botulinum toxin removed chemodenervation bladder, extremity, facial, larynx, neck, or trunk muscles as the PA for these drugs is not limited to these conditions; Evenity, Ixifi, and Zulresso added; Neurology: Neurostimulators – added neve blocking to this entry, Gastric – deleted eg VBLOC and added Enterra; Orthopedic: Arthrodesis, sacroiliac joint, minimally invasive aand Open osteochondral autograft, talus added, Hip resurfacing deleted; Other Procedures/Treatments: Fetal in-utero surgery added, Tonsillectomy and/or adenoidectomy - age for PA changed from 16 years or older to 12 years or older to correspond with the description of some of the CPT codes that are flagged: Ventricular restoration added. # has been added to all Comments related to INN or OON: A corresponding definition has been added at the bottom of the grid.

04/01/19 Eye: added Photrexa/riboflavin to the Collagen-cross linking for keratoconus entry; Home Health Care – added the following “(per diem S codes do not require prior authorization)”; Infusions/Injections - added Spravato; Antineoplastic/ Chemotherapy/ Immunotherapy/Radiopharmaceutical for Oncology use – added Trazimera (trastuzumab-qyyp); Infusions/Injections – Antineoplastic/ Chemotherapy/ Immunotherapy/ Radiopharmaceutical for Oncology Use: added an asterisk to drugs impacted by the Site of Care process and a reference at the end of the column and a hyperlink to a list including more detail.

03/22/19 Eye - Intravitreal/intraocular – removed Avastin; Infusions/Injections – Antineoplastic/ Chemotherapy/ Immunotherapy/Radiopharmaceutical for Oncology use – removed Avastin

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

REVISED

• MC/G002 Breast Reduction Surgery – Revised to reflect a separate indication for breast reduction, in support of the Women's Health and Cancer Rights Act.
• MC/I007 Cryoablation/Cryosurgery for Oncology Indications – Revised to reflect current recommendations for this treatment modality in prostate cancer and soft tissue sarcoma, as found in the National Comprehensive Cancer Network (NCCN) Guidelines.
• MC/L010 Genetic Testing for Hereditary Cancer Syndromes – Revised to reflect updated recommendations, as found in the National Comprehensive Cancer Network (NCCN) Guidelines.
• MC/L011 Insulin Infusion Pump – Revised to align with the American Association of Clinical Endocrinologists (AACE) recommendations and Continued Glucose Monitoring (CGM) criterion.
• MC/L012 Gene Expression Profiling – Revised to capture the National Comprehensive Cancer Network (NCCN) recommendation for use of Decipher, which is unique from the other 3 gene expression profile assays for prostate cancer.

Medical Policy

NEW

• MP/P014 Preventive Coverage for Colorectal Cancer Screening - This is a newly created policy, reflecting the position set-forth by the United States Preventive Services Task Force (USPSTF), one of the entities that describes ACA-required preventive coverage.
• MP/P016 Preventive Coverage for Osteoporosis Screening - This is a newly created policy, reflecting an updated position set-forth by the United States Preventive Services Task Force (USPSTF), one of the entities that describes ACA-required preventive coverage.
• MP/S014 Site of Care for Provider-Administered Medications – Created to provide coverage guidelines for the medically necessary and most cost-effective site of care for provider-administered drugs, infusions, and injectable therapies.

REVISED

• MP/M001 Molecular Testing Tumor/Neoplasm Biomarkers – Revised to reflect the use of the National Comprehensive Cancer Network (NCCN) Biomarkers Compendium as the sole resource for determination of the appropriate use of this form of testing.

Investigative List

Deletion

• Sacroiliac (SI) Joint fusion, minimally invasive - This procedure is no longer investigative, has been removed from the Investigative List, and has been added to the Prior Authorization List. Open SI joint fusion remains investigative.

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.

NEW

• PP/T002 Therapeutic Equivalence - This newly created policy lays the foundation for preferring the use of a designated provider-administered medication/product over a non-preferred provider-administered medication/product. This policy also captures this process as it relates to formulary management of self-administered drugs.

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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.

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PreferredOne Partners with Angel Foundation

PreferredOne, in continued pursuit of providing additional value to quality member care, is proud to announce a partnership with Angel Foundation. Angel Foundation and PreferredOne know that with a cancer diagnosis life changes in an instant. We also understand that living with cancer can present an enormous financial challenge to individuals and families, and we want to help! That’s why we’re raising awareness of Angel Foundation and how they can support our patients. Angel Foundation provides Minnesota adults in active cancer treatment with financial assistance grants to help pay for daily living expenses. Although Angel Foundation is unable to pay for medical bills, they can help in the following ways and will pay for:

• Rent or mortgage payments
• Utility bills
• Food
• Fuel costs

The application process is fast, easy and online. Plus, grants are approved in just a few days.

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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:

1. Discuss with the patient the importance of communicating with other treating practitioners.
2. Obtain a signed release from the patient and file a copy in the medical record.
3. Document in the medical record if the patient refuses to sign a release.
4. Document in the medical record if you request a consultation.
5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
6. 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.

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Minnesota Community Measurement - Release of the 2018 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 2018 Health Care Quality Report on their website during the first quarter of 2019. The 2018 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 2018 Minnesota Health Care Quality Report at www.mncm.org.

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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.

PreferredOne's member and physician website will be updated in the near future to offer the following program documents:

• 2019 PreferredOne QM Program Description, Executive Summary
• 2018 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 email us at quality@preferredone.com

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2019 RADV/HHS Medical Record Request

PreferredOne has been notified by The Department of Health and Human Services (HHS) that we are required to participate in an Initial Validation Audit (IVA) for a sample of members both on and off the Health Insurance Exchange (HIX). This audit is not specific to you or your practice and is not designed to monitor your practice, your billing or coding patterns.

Cognisight, LLC is the IVA vendor selected to gather medical records on behalf of PreferredOne. Since this is a government mandated audit, it is your obligation to provide medical records or obtain records from your vendor and submit the requested medical records with no charge to PreferredOne or its IVA vendor, Cognisight. Please do NOT mail, fax, or email any invoice/pre-payment invoice requests. Thank you for your cooperation.

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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

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 2019 are accurate. Thank you!

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CODING

Code Updates for Select Preventive Services Effective July 1, 2019.

Colorectal Cancer Screening

PreferredOne® follows the United States Preventive Service Task Force (USPSTF) recommendation of screening for colorectal cancer starting at age 50 years and continuing until age 75 years. The frequency, procedure and diagnosis codes listed below will be followed.

Any services under the age of 50 years or greater than 76 years, will not be processed as a preventive benefit and member may incur cost sharing in the form of deductible, copay or coinsurance charges based on their benefit coverage. The same applies to any other diagnosis submitted with one of the below procedure codes or if the frequency is more often than listed below.

Procedure Code(s):

Barium Enema every 5 years:

• 74270, 74280, G0106, G0120, G0122

Colonoscopy every 10 years:

• 44389, 44392, 44394, 45378, 45380, 45381, 45384, 45385, 45388, G0105, G0121

CT Colonography every 5 years:

• 74263

Fecal Occult Blood every year:

• 82270, 82274, G0328

FIT DNA every 3 years;

• 81528

Sigmoidoscopy every 5 years:

• 44388, 45330, 45331, 45333, 45338, 45346, G0104

Pathology:

• 88304, 88305

Anesthesia/Sedation:

• 00812, 99152, 99153, 99156, 99157, G0500

Colonoscopy Consultation:

• 99201-99215

ICD‐10 Diagnosis Code(s):

• Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z12.13, Z80.0, Z83.71, Z83.79

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Mammography Screening

PreferredOne follows the United States Preventive Service Task Force (USPSTF) recommendation of screening mammography, with or without clinical breast examination (CBE), every 1-2 years for women and men aged 40 and older. PreferredOne® also follows criteria in MN statute 62A.30.

Frequency: every 1-2 years for women aged 40 and older. Any subsequent service will not be processed as a preventive benefit and member may incur cost sharing in the form of deductible, copay or coinsurance charges based on their benefit coverage. The same applies to any other diagnosis submitted with one of the below procedure codes.

Procedure Code(s):

• 77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)
• 77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed

ICD-10-CM Diagnosis Codes

• Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
• Z12.39 Encounter for other screening for malignant neoplasm of breast
• Z80.3 Family history of malignant neoplasm of breast

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Obesity Screening: Children and Adolescents

PreferredOne follows the United States Preventive Service Task Force (USPSTF) recommendation of clinicians screening for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status. PreferredOne® will allow up to 26 hours per year for any combination of the covered procedure codes listed below as a preventive benefit.

Any services beyond the 26 hours per year or for children less than 6 years of age, will not be processed as a preventive benefit and member may incur cost sharing in the form of deductible, copay or coinsurance charges based on their benefit coverage.

Procedure Code(s):

Medical Nutrition Therapy - diagnosis specific (at least one from below)

• 97802, 97803, 97804

Preventive Medicine Individual Counseling – diagnosis specific (at least one from below)

• 99401, 99402, 99403, 99404

Behavioral Counseling or Therapy - not diagnosis specific

• G0447, G0473

ICD‐10 Diagnosis Code(s):

Body Mass Index 30.0 – 39.9:

• Z68.30, Z68.31, Z68.32, Z68.33, Z68.34, Z68.35, Z68.36, Z68.37, Z68.38, Z68.39

Body Mass Index 40.0 and over:

• Z68.41, Z68.42, Z68.43, Z68.44, Z68.45

Obesity:

• E66.01, E66.09, E66.1, E66.8, E66.9

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Osteoporosis Screening

PreferredOne follows the United States Preventive Service Task Force (USPSTF) recommendation of screening for;

• osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool;
• osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older.

The frequency is one screening service per lifetime. Any subsequent service will not be processed as a preventive benefit and member may incur cost sharing in the form of deductible, copay or coinsurance charges based on their benefit coverage. The same applies to any other diagnosis submitted with one of the below procedure codes.

Procedure Code(s):

• 77078 Computed tomography, bone mineral density study, 1 or more sites, axial skeleton (eg, hips, pelvis, spine)
• 77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)
• 77085 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment

ICD-10-CM Diagnosis Codes

• Z00.00 Encounter for general adult medical examination without abnormal findings
• Z00.01 Encounter for general adult medical examination with abnormal findings
• 13.820 Encounter for screening for osteoporosis
• Z82.62 Family history of osteoporosis

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Visual Screening: Children
(Primary Care Practitioner, not Optometry or Ophthalmology)

PreferredOne follows United States Preventive Service Task Force (USPSTF) recommendation of vision screening at least once in all children ages 3 to 5 years to detect amblyopia or its risk factors.

The service will process as preventive benefit once in children ages 3 to 5 years when submitted with the following procedure and diagnosis codes when submitted by child’s primary care practitioner;

• Z01.00 Encounter for examination of eyes and vision without abnormal findings
• Z01.01 Encounter for examination of eyes and vision with abnormal findings
• 99173 Screening test of visual acuity, quantitative, bilateral
• 99174 Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with remote analysis and report

When the above services are submitted more than once or outside the recommended age criteria, the service will not be processed as a preventive benefit and member may incur cost sharing in the form of deductible, copay or coinsurance charges based on their benefit coverage.

Please see Medical Policy MP/V001, Vision Care, Pediatric for services rendered by an optometrist or ophthalmologist.

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Billing Information

Mental Health Partial Hospitalization - H0035

Healthcare Common Procedure Coding System (HCPCS) code H0035 (Mental health partial hospitalization, treatment, less than 24 hours) is not designated as a multiple unit eligible code and should not be reported with multiple units. Claims will be denied as exceeding unit maximum when submitted with multiple units.

Anesthesia for Cesarean Delivery - 01961, 01967, 01968

Current Procedural Terminology (CPT®) code 01961 is not to be reported with add-on code 01968 per CPT® guidance. Continuous epidural anesthesia for labor and delivery services should be reported using either code 01967 or codes 01967 and 01968. Code 01968 is an add-on code to 01967 only and both codes are expected to be on the same claim with the same date of service.

General anesthesia for vaginal delivery is coded with 01961.

• 01961 Anesthesia for cesarean delivery only
• 01967 Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor)
• 01968 Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed)

Anesthesia Modifiers

It is important to append the appropriate anesthesia modifier to the procedure code to further identify the provider of service.

Modifiers:

• AA Anesthesia services performed personally by anesthesiologist
• QK Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals
• QX CRNA service: with medical direction by a physician
• QY Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist
• QZ CRNA service: without medical direction by a physician

Claim Appeal Form vs Attachment Form

Please see the MN AUC website for the correct form to submit, https://www.health.state.mn.us/facilities/auc/guides/index.htm.

Under the “Quick Links” in the upper right hand corner are four documents, one for any attachment(s) that will accompany a claim form submission. This IS NOT the form to use for denied claim appeals. The second document is the instructions for the ATTACHMENT Cover Sheet.

The third document in this link is for denied claim appeals to be sent to the Coding Department for adjustment consideration. Please be sure to use this document only for denied claim appeals. The fourth document is the instructions for the APPEAL Form. This completed appeal form may be sent to directly to the Coding Department at 763-847-4957.

There is also a PreferredOne Coding Appeal Adjustment Form on our website - https://www.health.state.mn.us/facilities/auc/guides/index.htm., that can be sent directly to the Coding Department at 763-847-4957.

Completion of either Appeal Form requires a complete description of the code(s) denied and why the appeal is being requested. Please also include a copy of the remittance advice received and any corrected claim. Additional references or resources are acceptable to submit with either form.

In order to reduce administrative burden for both the provider and PreferredOne, only the type(s) of document(s)/record(s) requested is/are necessary to send.

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