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

Cosmetic - Breast Reduction, Mammoplasty – added CPT 19366

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies List

Revisions: None
Deletions: None

Medical Clinical Policies

New: None

Revised (substantive clinical revisions)

Breast Reconstruction (MC/G004) - Added a statement, under implant removal/reinsertion, requiring that the original implant placement was for medically necessary indications (not cosmetic)
Durable Medical Equipment, Orthotics and Supplies (DMEPOS) (MP/D004) – added a statement regarding timeframe for replacement of a DME item meeting reasonable useful lifetime of 5 years (unless otherwise noted)
DMEPOS, Lower Limb Prostheses (MC/D005) – Added Ottobock 4R57 Rotation Adapter and indications for use
DMEPOS, Pneumatic Compression Devices and Heat/Cold Therapy Units (MC/D006) - Revised to allow non-segmental home model or segmental home model without calibrated gradient pressure for members with contraindications to pharmacologic prophylaxis
DMEPOS, Wheelchairs and Mobility Assistive Equipment (MC/D003) - Added indication requiring that the standing system is primarily needed to support ADLs
Levels of Evidence (LOE) and the Evaluation of Health Care Services (MP/L004)
- Revised to reflect the development, classification and approval pathways for drug and device development under the FDA
- Revised the statement regarding peer-reviewed medical journal articles, clarifying that it must include a systematic review and either a traditional or network meta-analysis
- Added a statement regarding randomized controlled trials
Neurostimulation, Sacral Nerve (MC/I008)
- Revised the statement regarding trial of conservative treatment by removing “failure” (hard to define)
- Combined all behavioral type therapies into one entry
- Added a note to clarify that stress incontinence does not include mixed incontinence
Nuclear Medicine, Cardiac Positron Emission Tomography (PET), Cardiac PET/Computed/Tomography (CT) (MC/L023) – Replaced the hyperlink to the ACR SPR STR Practice Parameter guidelines with specific indications, broken out by each type of technology
Rhinoplasty (MC/C001) - Revised to match specific indications to each type of surgical procedure
Special Coverage for the COVID-19 Pandemic policies - revised to incorporate coverage for the newest FDA-approved treatments and vaccinations

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies List

Revisions: None
Deletions: None

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.

PIC Member Rights and Responsibilities

PAS 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.
Golden Valley, MN 55416

Blood Pressure Readings for Controlling High Blood Pressure

In 2022 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 2022 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 2021 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, www.culturecareconnection.org.

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PHARMACY

Access to Criteria and Policies
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 and policy documents developed for provider administered drugs are available at PreferredOne.com by clicking on Coverage and Benefits then choosing Pharmacy Policy.

ClearScript Formulary Changes
Effective January 1, 2022 some medications may now be excluded from the ClearScript formulary. Alternatives can be found on the formulary, as detailed above, by searching for the excluded drug then clicking Show Formulary Alternatives at the bottom of the screen. If it is medically necessary for a member to have coverage of a formulary excluded drug, a Pharmacy Medication Request can be submitted for a formulary exception review.

Formulary Exceptions Policy for ClearScript
In conjunction with the ClearScript Formulary changes mentioned above, the PreferredOne Pharmacy and Therapeutics Committee approved an updated version of the Formulary Exceptions Policy, PC/F002. You can click here to view the policy. This policy applies to drugs that are not included in the ClearScript formulary.

Investigative List Additions
On December 8, 2021, The PreferredOne Pharmacy and Therapeutics Committee approved two additions to our Pharmacy Investigative List.

Intralipid infusion for infertility (and associated services)
Ketamine infusion for treatment of depression

These services are considered investigative and therefore, are not eligible for reimbursement based on the enrollee’s Certificate of Coverage (COC) or Summary Plan Description (SPD).