Serving Maryland, the District of Columbia and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (Used in VA by: First Care, Inc.). First Care, Inc., CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association.

CareFirst of Maryland, Inc. and The Dental Network underwrite products in Maryland only.

For more information, visit carefirst.com/bluelink

April 2019 I Volume 21 I Issue 2

What’s Happening? • Hospitals Must Attest to Patient Safety Standards

• U.S. Food and Drug Administration (FDA) Adds Boxed Warning to Uloric

• BlueLink Tip — Provider Self-Service Tools

Health Care Policy • Effective Dates, Current Procedural Terminology (CPT®) Codes and Policy Updates for April

• New Medical Technology Updates for April

Provider Reminders • Remember to Request a Prior Authorization for Genetic Tests

• Register Today for the CareFirst Pediatric Conference

• Federal Employee Program (FEP) Policy for Travel Vaccines

• Are You Up to Date on Best Practices and Quality Standards?

In Case You Missed It • Review The Latest Updates to The Institutional Provider Manual

• Do You Have A Claim To Refund? Open Now To Get The New Mailing Address

• Register Today For The CareFirst Pediatric Conference

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What’s Happening?

Hospitals Must Attest to Patient Safety Standards

Hospitals with 50 or more beds are now required to attest that their facility meets certain patient safety standards outlined in the Affordable Care Act (ACA). Affected providers were notified on March 1 of this change and asked to submit a signed attestation form within 30 days of notification. Additionally, to remain in compliance with the Centers for Medicare and Medicaid Services (CMS) as mandated by the ACA, these hospitals will be required to submit the form annually.

Completed forms should be sent to Janet Chavarria via email at Janet.Chavarria@carefirst.com. For questions or concerns, contact Donna Brohawn in the Provider Relations Department at 410-872-3571.

U.S. Food and Drug Administration (FDA) Adds Boxed Warning to Uloric

On February 21, the FDA added a boxed warning to Uloric (also known as febuxostat), a medication used to treat gout in adults, due to an increased risk of heart-related death and death from all causes compared to allopurinol, another gout medication.

A boxed warning is the FDA’s strictest warning and appears on a prescription drug label to alert prescribers and consumers of a serious or life-threatening risk.

It is recommended that health care professionals only prescribe Uloric for patients who have failed or cannot take allopurinol. Health care professionals should evaluate their patients who are taking Uloric and counsel them about the cardiovascular risks.

Patients should seek medical attention immediately if they experience any of the following symptoms:

• Chest pain • Shortness of breath • Rapid or irregular heartbeat • Numbness or weakness on one side of your body • Dizziness • Trouble talking • Sudden severe headache

Visit the FDA’s website to read the complete drug safety announcement.

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BlueLink Tip — Provider Self-Service Tools

Watch this issue’s BlueLink tip for details about how to use the provider self-service tools that are available to help you manage your practice.

Health Care Policy

Effective Dates, Current Procedural Terminology (CPT®) Codes and Policy Updates for April

Our Health Care Policy department continuously reviews medical policies and operating procedures as new, evidence-based information becomes available regarding advances on new or emerging technologies, as well as current technologies, procedures and services. The table below is designed to provide updates on changes to existing or new local policies and procedures during our review process. Each local policy or procedure listed includes a brief description of its status, select reporting instructions and effective dates. Policies from non-local accounts, such as NASCO and Federal Employee Program (FEP), may differ from our local determinations. Please verify member eligibility and benefits prior to rendering service through CareFirst on Call (Professional and Institutional) or CareFirst Direct. Note: The effective dates for the policies listed below represent claims with date of service (DOS) processed on and after that date.

Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

1.01.001

Durable Medical Equipment with Attached Table

Updated DME Companion Document Table. Report service with appropriate HCPCS code. Refer to policy for details.

Revision

Effective 01/28/19

1.01.051A

Seat Lift Mechanisms

Revised Policy Guidelines. Report service with appropriate HCPCS code. Refer to policy for details.

Revision

Effective 01/28/19

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

1.02.015

Therapeutic Shoes for Individuals with Diabetes

Revised Description, Benefit Applications, and Provider Guidelines. Report service with appropriate HCPCS code. Refer to policy for details.

Revision

Effective 01/01/19

1.03.001

Orthotic Devices & Orthopedic Appliance

Updated Policy Guidelines. Report service with appropriate HCPCS code. Refer to policy for details.

Revision

Effective 01/01/19

2.01.021

Temporomandibular Joint (TMJ)

Revised Policy Guidelines. Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

Revision

Effective 01/01/19

2.01.045

Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid

Description and Policy statements updated to reflect not medically necessary statements. Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

Periodic review and update

Effective 01/28/19

2.03.004

Hyperthermia in the Treatment of Cancer

Under Description, Policy, and Policy Guidelines, updated statements. Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review and update

Effective 01/28/19

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

2.03.009

Antineoplaston A Therapy

Under Description, added no further review statement. Under Policy Guidelines, added experimental / investigational criteria and updated 2018 rationale statement. Report service using appropriate category I CPT code. Refer to policy for details.

No further review scheduled

Effective 01/28/19

2.03.010

Genetic Testing for Inherited Susceptibility to Colon Cancer

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

4.01.005

Lactation Consultations

Policy placed in archived status. Replaced by new policy 4.01.010. Report service using appropriate category I code or HCPCS code. Refer to policy for details.

Revision

Effective 01/27/19

4.01.010

Lactation Consultations

New Policy replacing policy 4.01.005. Lactation Consultations refer to comprehensive breastfeeding education, support, counseling, clinical management and interventions provided to women during the antenatal, perinatal, and postpartum period. Lactation Consultations are considered medically necessary for women who plan to breastfeed or who are breastfeeding. Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

New Policy

Effective 01/28/19

6.01.042 Under Policy Guidelines, added updated 2018 rationale statement. Report service using

Periodic review and update

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

Dual X-Ray Absorptiometry (DEXA scan) for Determining Body Composition

appropriate category I CPT code. Refer to policy for details.

Effective 01/28/19

7.01.025

Spinal Cord and Deep Brain Stimulation

Under Policy statement, added medically necessary criteria. Under Policy Guidelines, updated deep brain stimulation utilization specification and added 2018 rationale statement. Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

Revision

Effective 01/28/19

7.01.074

Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code or category III CPT code. Refer to policy for details.

Periodic review and update

Effective 01/28/19

7.01.094

Mechanical Embolus Retrieval for Acute Ischemic Stroke

Description updated. Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review and update

Effective 01/28/19

7.01.100

Cervical Vertebral Disc Replacement

Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code or category III CPT code. Refer to policy for details.

Periodic review and update

Effective 01/28/19

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

7.03.001

Human Organ Transplants

Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

Periodic review and update

Effective 01/28/19

7.03.003

High Dose Chemotherapy / Radiation Therapy with Allogeneic Stem Cell Support

Under Policy Guidelines, added experimental / investigational criteria and updated 2018 rationale statement. Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

Periodic review and update

Effective 01/28/19

10.01.014A

Preventable Adverse Events

Under Policy Guidelines, added updated 2018 rationale statement. Refer to policy for details.

Periodic review and update

Effective 01/28/19

11.01.002

Genetic Testing for Inherited BRCA1 or BRCA2 Mutations

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.004

Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT or HCPCS code. Refer to policy for details.

Revision

Effective 01/31/19

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

11.01.007

Genetic Testing for Germline Mutations of the RET Proto-Oncogene in Medullary Carcinoma of the Thyroid

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT or HCPCS code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.025

Genetic Testing for Cystic Fibrosis

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.026

Testing for Tay-Sachs Disease

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.027

Genetic Testing for Canavan Disease

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.031

Pharmacogenomic and Serologic Metabolite Markers for Inflammatory Bowel Disease Patients Treated with Azathioprine

Policy placed in archived status. Replaced by new policy 11.01.075, Serologic Metabolite Markers for Inflammatory Bowel Disease Patients Treated with Azathioprine. For Pharmacogenomic Testing, please refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

11.01.032

Assays of Genetic Expression in Tumor Tissue to Determine Prognosis in Breast Cancer Patients

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.033

Cytochrome P450 Genotyping

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.034

Molecular Genetic Expression Test for Identification of Heart Transplant Rejection

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.035

Genetic Testing for Celiac Disease

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.038

Pharmacogenomic Testing for Warfarin Sensitivity

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

11.01.039

Genetic Testing for Cardiac Channel Mutations

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT or HCPCS code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.040

Topographic Genotyping, Quantitative Mutational Analysis

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.041

KRAS Mutation Analysis in Metastatic Colorectal Cancer

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.042

Genomic Analysis for Cancer of Unknown Primary Origin

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.044

Genetic Expression Profiling for Coronary Artery Disease

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code.

Refer to policy for details.

Revision

Effective 01/31/19

11.01.046

Genetic Testing for Predicting Progression of

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service

Revision

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

Adolescent Idiopathic Scoliosis

using appropriate category I CPT code. Refer to policy for details.

Effective 01/31/19

11.01.047

PCA3 Genetic Assay for Prostate Cancer

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.048

Gene Expression Assay for Risk Assessment in Colon Cancer

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.049

Noninvasive Prenatal Testing for Fetal Aneuploidy

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.050

Genetic Testing for Familial Cardiomyopathies

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.054

BRAF Gene testing for Predicting Response to

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service

Revision

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

BRAF inhibitor Therapy in Malignant Melanoma

using appropriate category I CPT code. Refer to policy for details.

Effective 01/31/19

11.01.055

Genetics-based testing of thyroid nodule biopsy for malignancy

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.056

Next Generation Sequencing Panels for Cancer Risk Prediction

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.057

KRAS Mutation Analysis in Non-small cell Lung Cancer

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.058

Epigenetic Assay for Detection and / or Management of Prostate Cancer (ConfirmMDx)

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.059

General Approach to Genetic Testing

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

11.01.060

General Approach to Evaluating the Utility of Genetic Panels

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.062

Blood Testing for Genetic Biomarkers as Screening for Colorectal Cancer

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.063

Molecular Genetic Panel Testing for Guiding Cancer Therapies

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.064

Gene Expression Assays for Managing Prostate Cancer

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.065

Genetic Testing for Age-Related Macular Degeneration

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

11.01.066

Whole Exome and Genome Sequencing for Cancerous and Non-cancerous Conditions

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.067

DecisionDx-UM Assay for Stratifying Risk of Metastatic Uveal Melanoma

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.070

Urine Exosome Assay to Predict High-grade Prostate Cancer at Initial Biopsy, ExoDx® Prostate (IntelliScore)

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.071

Pharmacogenomic Assay for the Management of Major Depressive Disorder (GeneSight® Psychotropic)

Policy placed in archived status. Refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

11.01.073

Genetic Testing

Genetic tests are laboratory tests or studies that identify changes in human deoxyribonucleic acid (DNA), chromosomes, genes or proteins, and can confirm or rule out a suspected genetic condition and identify a person’s chance of developing and

New Policy

Effective 02/01/19

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

passing on a genetic disorder. Refer to policy for details.

11.01.074

Biochemical Markers for the Diagnosis of Alzheimer's Disease

New Policy replacing archived policy 11.01.004. For Genetic Testing for Alzheimer’s Disease, please refer to new policy 11.01.073, Genetic Testing. Measurement of cerebrospinal fluid biomarkers and urinary biochemical markers of Alzheimer's Disease are considered experimental / investigational. Report service using appropriate category I CPT code. Refer to policy for details.

New Policy

Effective 02/01/19

11.01.075

Serologic Metabolite Markers for Inflammatory Bowel Disease Patients Treated with Azathioprine

New Policy replacing archived policy 11.01.031. For Pharmacogenomic Testing, please refer to new policy 11.01.073, Genetic Testing. Serologic Metabolite Marker testing of Azathioprine is proposed to assist clinicians to identify drug metabolite levels that may lead to toxicities. Analysis of azathioprine serologic metabolite markers and 6-mercaptopurine (6-MP), including 6-thioguanine nucleotide (6-TGN) and 6-methyl mercaptopurine nucleotide (6-MMP), is considered experimental / investigational. Report service using appropriate category I CPT code. Refer to policy for details.

New Policy

Effective 02/01/19

11.01.076

Circulating Tumor Cell Detection in Management

New Policy replacing archived policy 11.01.069. For Circulating Tumor DNA, please refer to new policy 11.01.073, Genetic Testing. Circulating tumor cells (CTC) are malignant cells found in the

New Policy

16 April 2019 I Volume 21 I Issue 2

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

of Cancer Patients (liquid biopsy)

peripheral blood originating from a primary or metastatic tumor. Detection and quantification of circulating tumor cells is considered experimental / investigational. Report service using appropriate category I CPT code. Refer to policy for details.

Effective 02/01/19

1.01.017

Pulsed Electrical Stimulation Device for Osteoarthritis of the Knee

Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate HCPCS code. Refer to policy for details.

Periodic review and update

Effective 02/25/19

1.01.018

Neuromuscular Electrical Stimulation (NMES) Devices

Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate HCPCS code. Refer to policy for details.

Periodic review and update

Effective 02/25/19

2.01.002

Dynamic Posturography

Under Policy Guidelines, added experimental / investigational criteria and updated 2018 rationale statement. Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review and update

Effective 02/25/19

2.02.003

Thoracic Electrical Bioimpedance Measurement

Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review and update

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

Effective 02/25/19

3.01.016

Dialectical Behavior Therapy

Dialectical Behavior Therapy (DBT) consists of multiple components, including individual psychotherapy, skills training, telephone coaching, and a therapist consultation team. Dialectical behavior therapy is considered medically necessary for a defined patient population. Report service using appropriate HCPCS code. Refer to policy for details.

New Policy

Effective 01/01/19

4.02.001

Assisted Reproductive Technology (ART)

Procedures:

In Vitro Fertilization (IVF)

Gamete Intrafallopian Transfer (GIFT)

Zygote Intrafallopian Transfer (ZIFT)

Under Description, updated Related ART and Laboratory Procedures. Under Policy Guidelines, added updated 2018 rationale statement. Revised Benefit Applications statements. Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

Periodic review and update & revision

Effective 02/25/19

6.01.019

Charged-Particle (Proton or Helium Ion) Radiation Therapy

Policy placed in archived status and replaced by a new policy 6.01.048, Proton Beam Therapy. Updated Description and Policy statements. Under Policy Guidelines, updated rationale with experimental / investigational statement and added 2018 rationale. Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

Revision

Effective 02/24/19

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

6.01.048

Proton Beam Therapy

Proton beam therapy (PBT) is a technology for delivering conformal external beam radiation with positively charged atomic particles to a well-defined treatment volume. Proton Beam Therapy is considered medically necessary. Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

New Policy

Effective 02/25/19

7.01.029

Thermal Capsulorrhaphy for Joint Instability

Under Description, added no further review statement. Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

Periodic review and update

No further review scheduled

Effective 02/25/19

7.01.037

Electrophrenic Pacemaker

Description updated. Under Policy, revised the experimental / investigational indication statement. Under Policy Guidelines, added experimental / investigational criteria and updated 2018 rationale statement. Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review and update

Effective 02/25/19

7.01.047

Functional Neuromuscular Stimulation

Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

Periodic review and update

19 April 2019 I Volume 21 I Issue 2

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

Effective 02/25/19

7.01.075

Vagus Nerve Stimulation

Updated Description. Revised Policy statements and added “Transcutaneous (nonimplantable) vagus nerve stimulation devices (HCPCS E1399) are considered experimental / investigational for all indications.” Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

Periodic review and update

Effective 02/25/19

7.01.090

Pulmonary Vein Ablation / Isolation for Atrial Fibrillation

Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review and update

Effective 02/25/19

7.01.118

Minimally Invasive Interventions for Fecal Incontinence

Under Policy, revised statement.

Under Policy Guidelines, added updated 2018 rationale statement. Report service using appropriate category I CPT code or category III CPT code. Refer to policy for details.

Periodic review and update

Effective 02/25/19

7.01.124

Minimally Invasive Sacroiliac Joint Fusion

Updated Description. Revised Policy experimental / investigational and medically necessary statements for minimally invasive sacroiliac joint fusion / stabilization. Updated Policy Guidelines and added 2018 rationale statement. Added statements for Benefits Applications and Provider Guidelines sections. Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review, update and revision

Effective 01/01/19

20 April 2019 I Volume 21 I Issue 2

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

11.01.069

Circulating Tumor DNA and Circulating Tumor Cell Detection in Management of Cancer Patients (liquid biopsy)

Policy placed in archived status. Replaced by new policy 11.01.076, Circulating Tumor Cell Detection in Management of Cancer Patients. For Circulating Tumor DNA/ Cell-Free DNA, please refer to new policy 11.01.073, Genetic Testing. Report service using appropriate category I CPT code. Refer to policy for details.

Revision

Effective 01/31/19

1.01.012

Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders

Revised Policy statement. Under Policy Guidelines, added experimental / investigational criteria and updated 2019 rationale statement. Report service with appropriate HCPCS code. Refer to policy for details.

Periodic review, update and revision

Effective 03/25/2019

2.01.049

Xenon Chloride Excimer Laser Therapy for Treatment of Psoriasis and Vitiligo

Under Policy Guidelines, added updated 2019 rationale statement. Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review and update

Effective 03/25/19

2.03.014

Electric Tumor Treatment Fields

Revised Benefits Applications statement. Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

Revision

Effective 03/25/19

21 April 2019 I Volume 21 I Issue 2

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

3.01.011A

Autism Spectrum Disorders (Virginia Mandate)

Revised Provider Guidelines. Report service using appropriate category I CPT code, category III CPT code, or HCPCS code. Refer to policy for details.

Revision

Effective 03/25/19

3.01.015

Autism Spectrum Disorder(s)

Revised Provider Guidelines. Report service using appropriate category I CPT code or category III CPT code. Refer to policy for details.

Revision

Effective 03/25/19

5.01.003

Colony Stimulating Factors (CareFirst)

Under Policy Guidelines, added updated 2019 rationale statement. Report service using appropriate HCPCS code. Refer to policy for details.

Periodic review and update

Effective 03/25/19

5.01.016

Zoster Vaccine (Oka/Merck) (Zostavax®), (GlaxoSmithKline) Shingrix®

Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review and update

Effective 03/25/19

6.01.003

Electron Beam Computed Tomography to Detect Coronary Artery Calcification

Under Policy Guidelines, added updated 2019 rationale statement. Report service using appropriate I CPT code. Refer to policy for details.

Periodic review and update

Effective 03/25/19

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

6.01.010

Stereotactic Radiosurgery and Stereotactic Body Radiotherapy with 3-D Conformal Radiation Therapy

Revised Description. Under Policy Guidelines, added updated 2019 rationale statement. Report service using appropriate I CPT code. Updated Cross References to Related Policies and Procedures section. Refer to policy for details.

Periodic review and update

Effective 03/25/19

6.01.043

Stereotactic Radiosurgery Using Gamma Rays

Under Policy Guidelines, added experimental / investigational criteria and updated 2019 rationale statement. Report service using appropriate I CPT code. Updated Cross References to Related Policies and Procedures section. Refer to policy for details.

Periodic review and update

Effective 03/25/19

7.01.032

Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty

Under Policy Guidelines, added updated 2019 rationale statement. Report service using appropriate I CPT code. Refer to policy for details.

Periodic review and update

Effective 03/25/19

7.01.036

Obesity and Morbid Obesity

Revised Description. Report service using appropriate category I CPT code or HCPCS code. Refer to policy for details.

Revision

Effective 01/29/19

7.01.067

Prolotherapy (Proliferative Therapy)

Under Policy Guidelines, added experimental / investigational criteria and updated 2019 rationale statement. Report service using

Periodic review and update

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

appropriate HCPCS code. Refer to policy for details.

Effective 03/25/19

7.01.084

Spinal Manipulation Under Anesthesia

Under Description, added no further review statement. Under Policy Guidelines, added updated 2019 rationale statement. Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review and update

No further review scheduled

Effective 03/25/19

7.01.102

Bronchial Thermoplasty for Control of Asthma

Under Policy Guidelines, added updated 2019 rationale statement. Report service using appropriate I CPT code. Refer to policy for details.

Periodic review and update

Effective 03/25/19

8.01.011A

Habilitative Services (MD and DC Mandates)

Revised Provider Guidelines. Report service using appropriate category I CPT code or category III CPT code. Refer to policy for details.

Revision

Effective 03/25/19

11.01.029

Serum Antibody Marker Testing for Inflammatory Bowel Disease

Under Policy Guidelines, added updated 2019 rationale statement. Report service using appropriate category I CPT code. Updated Cross References to Related Policies and Procedures section. Refer to policy for details.

Periodic review and update

Effective 03/25/19

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Medical Policy and/or Procedure

Actions, Comments, and Reporting Guidelines Policy Status and Effective Date

11.01.045

Proteomics-Based Testing for Evaluation of Ovarian Masses

Updated Description with a second generation OVA1 test, Overa™. Under Policy Guidelines, added updated 2019 rationale statement. Updated Provider Guidelines with reporting statement for Overa™ (CPT code 0003U). Report service using appropriate category I CPT code. Refer to policy for details.

Periodic review and update

Effective 03/25/19

New Medical Technology Updates for April

Our technology assessment unit evaluates new and existing technologies to apply to our local indemnity and managed care benefit plans. The unit relies on current scientific evidence published in peer-reviewed medical literature, local expert consultants and physicians to determine whether those technologies meet CareFirst criteria for coverage. Policies for non-local accounts like NASCO and FEP may differ from our local determinations.

Please verify member eligibility and benefits prior to rendering services via CareFirst on Call (Professional or Institutional) or CareFirst Direct. The technology assessment unit recently made the following determinations:

Technology Description CareFirst and CareFirst BlueChoice Determination

Artificial Pancreas Device Systems

Artificial Pancreas Device Systems are proposed to improve glycemic control in patients with insulin-dependent diabetes especially control of nocturnal hypoglycemia; and is a system of devices that according to the Food and Drug Administration, closely mimics the function of the pancreas in regulating glucose. System components include a

Medically necessary for qualifying systems when criteria are met.

HCPCS reporting code(s) S1034, S1035, S1036, S1037

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Technology Description CareFirst and CareFirst BlueChoice Determination

continuous glucose monitor, computer-controlled algorithm and an insulin pump. Systems come in a variety of designs and include low glucose suspend systems (LGS), control-to-range systems, and more complex bi-hormonal control-to-target systems.

Intravenously administered ketamine for chronic pain

Intravenously administered ketamine for the treatment of chronic pain.

Considered experimental / investigational

HCPCS reporting code(s) J3490

Serum Biomarker Panel testing for Systemic Lupus Erythmatosus (e.g. AVISE® panel tests)

Diagnostic panel tests (e.g. AVISE® CTD & AVISE® Lupus) that use proprietary algorithms and/or index scores to aid in the diagnosis of autoimmune disorders such as systemic lupus erythematosus (SLE), Rheumatoid Arthritis and Sjögren’s syndrome; and panels (e.g. AVISE® SLE Prognostic) that predict the risk for complications.

Considered experimental / investigational

There is no specific CPT code for these panel tests.

CPT reporting code(s) include but may not be limited to the following: 0039U, 0062U, 81599, 83520, 84999, 86038, 86039, 86146, 86147, 86200, 86225, 86235, 86376, 86800, 88184, 88185, 88187, 88188, 88189

Vectra DA Vectra DA is a rheumatoid arthritis disease activity blood test that measures twelve biomarkers and uses proprietary algorithms to generate a score that corresponds to three risk categories (low, moderate and high) for radiographic progression.

Considered experimental / investigational

CPT reporting code(s) 81490

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Provider Reminders

Remember to Request a Prior Authorization for Genetic Tests

Check out our tip sheet before submitting an order for genetic testing, it will walk you through the necessary steps. You may also want to review the provider overview and frequently asked questions that appeared in the February 4 Provider News & Updates.

Register Today for the CareFirst Pediatric Conference

Register for CareFirst’s Pediatric Conference where you can earn up to 4.5 AMA PRA Category 1 Credits™. Attendees will hear from leading experts who will share their knowledge about a wide range of pediatric topics. This free conference takes place at our Canton Conference Center on Friday, September 13 from 8 a.m. to 2:30 p.m. and is open to pediatricians, family practitioners, nurse practitioners and physician assistants. Space is limited. Please visit www.carefirst.com/pedsconference to learn more and register.

Federal Employee Program (FEP) Policy for Travel Vaccines

Did you know that FEP member benefits cover vaccinations required for international travel? In situations where a member may have been exposed to a disease or may be traveling to an area where he or she is at higher risk for contracting the disease, FEP will review the service under the patient’s medical benefits.

If a member is traveling to an area known to be prevalent for a specific disease, and it is reasonable to assume that without the vaccine, the member would be at high risk to contract the disease, regular medical benefits may be provided for the vaccine. This means that the patient may be responsible for deductible, coinsurance and/or a copayment. Further, these services should be treated as any other covered service.

FEP patients should never be charged in full upfront for travel vaccines and as a provider in the network, you must file a claim with CareFirst on behalf of the patient. Refusal to take this action on the patient’s behalf is a direct violation of the provider network contract. Keep in mind this benefit is not specifically stated in the FEP service benefit brochure as the brochure is a summary or overview of benefits provided. Medical benefits encompass a wide variety of services and due to the size of the brochure, it is not possible to capture every time.

Information regarding the vaccinations required for certain areas of travel have been provided by the Center for Disease Control and is available for viewing at wwwnc.cdc.gov/travel. You may also contact the FEP Provider Service line for more information on travel vaccines for FEP patients.

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Please note that risks for diseases in certain countries change from time to time, so it is a good idea to review the list periodically for any updates.

For any questions or concerns, please use the following FEP Provider Services phone numbers:

FEP Provider Services for DC: 800-842-5975 or 202-488-4900 FEP Provider Services for MD: 800-854-5256 or 410-581-3568

Are You Up to Date on Best Practices and Quality Standards? From recommending preventive care options to your patients or managing day-to-day office operations, the clinical resources on our provider website can be valuable, time-saving tools to help support your treatment plan for patients with chronic diseases. CareFirst’s Quality Improvement Council annually reviews the clinical resources and adopts nationally recognized guidelines and best practices to make sure you are informed when information changes. Click on the links below for details on topics that can help you improve the care you provide to patients in your practice.

Quality Standards and Best Practices

General Guidelines and Survey Results Topic Website Link PDF Available CareFirst’s Quality Improvement Program Includes processes, goals and outcomes.

carefirst.com/qualityimprovement

Clinical Practice Guidelines Includes evidence-based clinical practice guidelines for medical and behavioral conditions.

carefirst.com/clinicalresources

Preventive Health Guidelines Includes evidence-based preventive health guidelines for perinatal care, children, adolescents and adults.

carefirst.com/clinicalresources

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Accessibility and Availability of Appointments Includes medical and behavioral health accessibility and availability standards for routine care appointments, urgent care appointments and after-hours care.

carefirst.com/clinicalresources

Care Coordination Programs Topic Website Link PDF Available Access to Complex Care Coordination Includes instructions for making referrals for both medical and behavioral health; or call 800-245-7013.

carefirst.com/providermanualsandguides

Practitioner Referrals for Disease Management Includes information on how to use the services, how a member becomes eligible and how to opt in or opt out.

carefirst.com/clinicalresources

Pharmaceutical Management Topic Website Link PDF Available Pharmaceutical Management Includes the formulary, restrictions/ preferences, guidelines/policies and procedures.

carefirst.com/rx

Utilization Procedures Topic Website Link PDF Available Utilization Management Criteria Includes information on how to obtain Utilization Management criteria for both Medical and Behavioral Health.

carefirst.com/bluelink > February 2019

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Physician Reviewer Includes instructions on how to obtain a physician reviewer to discuss utilization management decisions for both medical and behavioral health.

carefirst.com/bluelink > February 2019

Decisions about Medical and Mental Health, and Pharmacy Includes affirmative statement for anyone making decisions regarding utilization management.

carefirst.com/bluelink > February 2019

Member Related Resources Topic Website Link PDF Available Quality of Care Complaints Includes policies and procedures for complaints involving medical issues or services given by a provider in our network.

carefirst.com/qoc

How to File an Appeal Includes policies and procedures for members to request an appeal of a claim payment decision.

carefirst.com/appeals

Member’s Privacy Policy Includes a description of our privacy policy and how we protect our members health information.

carefirst.com/privacy

Member’s Rights and Responsibilities Statement Outlines responsibilities to our members.

carefirst.com/myrights

To request a paper copy of any documents listed above, please call 800-842-5975

In Case You Missed It

April 1, 2019 — Review The Latest Updates To The Institutional Provider Manual

April 1, 2019 — Do You Have A Claim To Refund? Open Now To Get The New Mailing Address

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March 28, 2019 — Register Today for the CareFirst Pediatric Conference