network bulletinAn important message from UnitedHealthcare to health care professionals and facilities.

JANUARY 2018

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UnitedHealthcare respects the expertise of the physicians, health care professionals and their staff who participate in our network. Our goal is to support you and your patients in making the most informed decisions regarding the choice of quality and cost-effective care, and to support practice staff with a simple and predictable administrative experience. The Network Bulletin was developed to share important updates regarding UnitedHealthcare procedure and policy changes, as well as other useful administrative and clinical information.

Where information in this bulletin conflicts with applicable state and/or federal law, UnitedHealthcare follows such applicable federal and/or state law.

UnitedHealthcare Network Bulletin January 2018

2 | For more information, call 877-842-3210 or visit UHCprovider.com.

Table of ContentsFront & CenterStay up to date with the latest news and information.

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UnitedHealthcare CommercialLearn about program revisions and requirement updates.

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UnitedHealthcare Commercial Reimbursement PoliciesLearn about policy changes and updates.

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UnitedHealthcare Community PlanLearn about Medicaid coverage changes and updates.

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UnitedHealthcare Medicare AdvantageLearn about Medicare policy and guideline changes.

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UnitedHealthcare AffiliatesLearn about updates with our company partners.

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State NewsStay up to date with the latest state/regional news.

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UnitedHealthcare Network Bulletin January 2018 Table of Contents

3 | For more information, call 877-842-3210 or visit UHCprovider.com.

Front & CenterStay up to date with the latest news and information.

UnitedHealthcare Care Provider Administrative Guide for Commercial and Medicare AdvantageWe used your feedback to make changes to the UnitedHealthcare Provider Administrative Guide.

Tell Us What You Think of Our CommunicationsPlease take a few minutes to complete an online survey and give us your thoughts about the Network Bulletin and UnitedHealthcare Communications.

HEDIS® Season is HereBeginning in January 2018, you may see a request from us for Healthcare Effectiveness Data and Information Set (HEDIS) information. Because of the volume of records we need to collect, UnitedHealthcare is working with several health information organizations to coordinate the collection of records.

Pharmacy Update – Notice of Changes to Prior Authorization Requirements and Coverage Criteria for UnitedHealthcare Commercial and OxfordA Pharmacy Bulletin outlining upcoming new or revised clinical programs and implementation dates is now available online for UnitedHealthcare commercial.

Link Self-Service Updates and Enhancements We’ve made some changes to Link, your gateway to the online self-service tools for UnitedHealthcare.

Updates to Notification/Prior Authorization Requirements for Specialty Medications for UnitedHealthcare Commercial, Medicare Advantage and Community Plan MembersWe’re implementing these requirements because it’s important to provide our members access to care that’s medically appropriate as we work toward the Triple Aim of improving health care services, health outcomes and overall cost of care.

Review at Launch Drug Program for UnitedHealthcare Commercial and Community Plan Members – Effective Jan. 1, 2018As a reminder, please consider requesting pre-service coverage review for medications listed on UnitedHealthcare’s Review at Launch Commercial or Community Plan Medication List.

Reminder of Notification/Prior Authorization Requirement for Chimeric Antigen Receptor T-cell (CAR-T) TherapyWe’ve updated our coverage review requirement for transplants to add chimeric antigen receptor T-cell (CAR-T) therapy, including tisagenlecleucel (Kymriah™) and axicabtagene ciloleucel (Yescarta™).

Reminder: Clinical Laboratory Improvement Amendments Identification Requirements PolicyUnitedHealthcare has implemented a reimbursement policy that applies to all laboratory services to align with Centers for Medicare & Medicaid Services and Clinical Laboratory Improvement Amendments (CLIA) requirements.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

4 | For more information, call 877-842-3210 or visit UHCprovider.com.

Front & CenterStay up to date with the latest news and information.

Changes in Advance Notification and Prior Authorization RequirementsBeginning April 1, 2018, new codes will be added to prior authorization as a result of the American Medical Association 2018 annual CPT update for certain UnitedHealthcare Community Plan and commercial plans.

New Procedure Codes for Injectable Medications – Effective Jan. 1, 2018New procedure codes will become effective Jan. 1, 2018 due to updates from the Centers for Medicare & Medicaid Services.

UnitedHealthcare Community Plan Goes Live with a Dual Special Needs Program – UnitedHealthcare Dual Complete®On Jan. 1, 2018, UnitedHealthcare Community Plan will begin to serve eligible members in a new Dual Special Needs Plan (DSNP) – UnitedHealthcare Dual Complete,® a Medicare Advantage program – in several states. * Impacted states: Iowa, Michigan,

Missouri, Nebraska, North Carolina, Oklahoma and Virginia.

Dental Clinical Policy & Coverage Guideline Updates

Site of Service-Based Notification/Prior Authorization Requirements for Certain Procedures to Expand to Indiana and New Jersey – Effective April 1, 2018For dates of service on or after April 1, 2018, we’re expanding notification/prior authorization requirements for certain services to be covered in certain sites of care to include UnitedHealthcare commercial members in Indiana and New Jersey.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

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UnitedHealthcare Care Provider Administrative Guide for Commercial and Medicare AdvantageUnitedHealthcare is committed to making our provider guides easy for you to navigate. We have used your feedback to make changes to the guides.

Quick Reference to UnitedHealthcare Care Provider Administrative Guides Now AvailableA newly created Quick Reference to Provider Administrative Guides is now available on UHCprovider.com. We developed this resource based on care provider feedback. It contains information that you’re likely to need in your relationship with UnitedHealthcare.

Updated UnitedHealthcare Care Provider Administrative Guide Available Jan. 1, 2018*We’ll post this essential resource for physicians, hospitals, facilities and other health care providers on UHCprovider.com on Jan. 1, 2018. You can save the link to your favorites or download it.

Following are changes to the UnitedHealthcare Provider Administrative Guide:

Guide Retirements and Consolidations: UHC West Capitated Administrative Guide, the Preferred Care Partners and Medica HealthCare manuals are being retired as stand-alone publications. Beginning Jan. 1, 2018, you can find all the information from these guides in the 2018 UnitedHealthcare Care Provider Administrative Guide.

What’s New in the 2018 Guide: • Webpage layout: In addition to the PDF version of

the Guide available Jan. 1, 2018, in early January you may choose to view the 2018 Guide as a webpage. Both versions of the Guide are available on UHCprovider.com.

• New supplements: Previously separate provider guides and manuals are now incorporated as supplements:

– The UHC West Capitated Provider Administrative Guide is now a supplement in the UnitedHealthcare Care Provider Administrative Guide. The Capitation and Delegation Supplement applies to all care providers participating in a capitation and/or delegation agreement with us.

– The Preferred Care Partners and Medica HealthCare Provider manuals are part of the UnitedHealthcare Care Provider Administrative Guide as supplements by the same name (Preferred Care Partners and Medica Healthcare Provider). These health plans operate in certain counties in Florida.

• New chapters: Pharmacy and Credentialing and Re-Credentialing provide more details on these topics.

• Online resources: Use updated instructions and hyperlinks to find information located on our new provider portal, UHCprovider.com, and new or updated Link applications throughout the guide.

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UnitedHealthcare Network Bulletin January 2018 Table of Contents

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Note: Accessing the Provider Administrative Guide online offers the best experience due to the robust interactive features of the PDF document. You can print the PDF if you’d like, but preprinted copies will no longer be available to order.

Other notable changes:

• UnitedHealthcare Dual Complete® plans, a Medicare Advantage program: These plans follow the guidelines and policies outlined in the 2018 UnitedHealthcare Care Provider Administrative Guide, except for Arizona, Tennessee, Massachusetts, New Jersey and New York (which follow the respective Community and State Care Provider Manual).

• Fraud, Waste, and Abuse: New ways to report suspicious situations or concerns are in our ‘How to Contact Us’ table on page 4.

• Out-of-Network Laboratory Referrals: If a provider uses out-of-network labs and there is no written member consent authorizing the referral to the non-participating laboratory, the referring provider is financially responsible for any costs or expenses

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UnitedHealthcare Care Provider Administrative Guide for Commercial and Medicare Advantage

collected from a member by a non-participating laboratory. This includes non-covered services and balance bills. See page 48 for more information on Administrative Actions for Out-of-Network Laboratory Services Referrals.

• All Savers: Products offered off Exchange are no longer excluded from Chapter 6: Medical Management.

* Except as otherwise noted, the new guide is effective on April 1, 2018 for currently contracted care providers. It’s effective Jan. 1, 2018 for care providers newly contracted on or after Jan. 1, 2018. This guide applies to UnitedHealthcare Commercial and Medicare Advantage plans only.

Tell Us What You Think of Our CommunicationsAs a regular reader of The Network Bulletin, your opinion is important to us. We’d like to get your thoughts about The Bulletin and UnitedHealthcare communications related to network changes, quality initiatives and other issues. Please take a few minutes today to complete the survey online at uhcresearch.az1.qualtrics.com/jfe/form/ SV_08sAsRnUY2Kb153. Thank you for your time.

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UnitedHealthcare Network Bulletin January 2018 Table of Contents

7 | For more information, call 877-842-3210 or visit UHCprovider.com.

HEDIS® Season is Here Beginning in January 2018, you may receive a request from us for Healthcare Effectiveness Data and Information Set (HEDIS) information. HEDIS is a standardized set of measures developed by the National Committee for Quality Assurance (NCQA) to evaluate consumer health care. If you’re not familiar with the process, UnitedHealthcare collects HEDIS records from some of our participating care providers and NCQA analyzes the data to help improve the health care system. Ultimately, HEDIS medical record collection can support your care plans by helping our members manage their existing medical conditions and be more involved with their preventive health.

Due to the volume of records we need to collect, UnitedHealthcare is working with several health information organizations, including Advantmed, BACTES, Change Healthcare, Optum/CiOX and MRO, to coordinate collection. You may not be contacted, since our members are randomly selected for each HEDIS collection cycle.

If you are contacted by our health care organization, we will schedule a date for collection or explain the process for submitting records by mail, fax or electronically. We’ll send you a list of the requested medical records to help you prepare for the appointment or record submission. If you are contacted, please respond within five business days to indicate your preference for medical record collection.

You can find out more about HEDIS medical record collection by visiting UHCprovider.com > Menu > Resource Library > Patient Health and Safety Resources > HEDIS.

You can also contact us at uhc_hedis_help@uhc.com with questions. Thank you for working with us to fulfill these important annual requirements.

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Pharmacy Update – Notice of Changes to Prior Authorization Requirements and Coverage Criteria for UnitedHealthcare Commercial and OxfordA Pharmacy Bulletin outlining upcoming new or revised clinical programs and implementation dates is now available online for UnitedHealthcare commercial. Go to UHCprovider.com/pharmacy.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

8 | For more information, call 877-842-3210 or visit UHCprovider.com.

Link Self-Service Updates and Enhancements Link is the gateway to the online self-service tools for UnitedHealthcare. We’re continuously improving Link apps to better support your workflows. Here are some recent enhancements we’ve made:

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• eligibilityLink – Coverage dates added for termed policies Now, when you search for a member who is inactive, eligibilityLink will display previous coverage dates.

• Claim Estimator and OneNet PPO Pricing moved to Link These tools have been moved from UnitedHealthcare Online to the Link dashboard.

• referralLink Limited Use – More plans added The referralLink app can now be used for members of these plans:

– UnitedHealthcare Community Plan in Florida

– Dual Special Needs Plan (DSNP) in Florida, effective Jan. 1, 2018

– UnitedHealthcare Community Plan in Rhode Island

Please do not use referralLink to submit referrals for any other plans. To determine which online tool to use, look up the member in eligibilityLink. If referrals are required, you will be able to click on Referrals to open the appropriate tool. For more information, visit UHCprovider.com/referrals.

The UHCWest.com website will be retiring soon and will redirect you to UHCprovider.com, our new care provider website. Capitation, eligibility and patient management reports will transition to Document Vault on Link before UHCWest.com retires. Please refer to Information for UHCWest.com Users for the latest information.

An Optum ID is required to access Link and perform online transactions, such as eligibility verification, claims status, claims reconsideration, referrals, prior authorizations and more. To get an Optum ID, go to UHCprovider.com and click on New User to register for Link access.

For help with Link, call the UnitedHealthcare Connectivity Helpdesk at 866-842-3278, option 1, Monday through Friday, 8 a.m. to 10 p.m. Eastern Time.

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Updates to Notification/Prior Authorization Requirements for Specialty Medications for UnitedHealthcare Commercial, Medicare Advantage and Community Plan MembersWe’re making some updates to our coverage review requirements for certain specialty medications for many of our UnitedHealthcare commercial, Medicare Advantage and Community Plan members. We’re implementing these requirements because it’s important to provide our members access to care that’s medically appropriate as we work toward the Triple Aim of improving health care services, health outcomes and overall cost of care. These requirements will apply whether members are new to therapy or have already been receiving these medications.

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If you administer any of these medications without first completing the notification/prior authorization process, the claim may be denied. Members can’t be billed for services denied due to failure to complete the notification/prior authorization process.

What’s Changing for UnitedHealthcare Commercial PlansThe following requirement will apply to UnitedHealthcare commercial plans, including affiliate plans such as Mid Atlantic, UnitedHealthcare of the River Valley, UnitedHealthcare Oxford and Neighborhood Health Partnership.

For dates of service on or after April 1, 2018, we’ll require notification/prior authorization for the following medications:

• Fasenra™ (benralizumab) – The U.S. Food and Drug Administration (FDA) recently approved Fasenra as a treatment for severe asthma.

• Luxturna™ (voretigene neparvovec) – Recently approved by the FDA for the treatment of inherited retinal dystrophy caused by mutations in the RPE65 gene.

Luxturna (voretigene neparvovec) has been added to our Review at Launch program for UnitedHealthcare commercial plans. For both Luxturna and Fasenra, UnitedHealthcare will not deny any claims for lack of prior authorization until April 1, 2018, but care providers are encouraged to request a pre-determination coverage review for these new-to-market services prior to April 1, 2018. If no pre-determination is received, the services may be denied as not medically necessary.

For more information about the UnitedHealthcare commercial notification/prior authorization requirements for specialty medications, please refer to the Physician Health Care Professional, Facility and Ancillary Provider Administrative Guide at UHCprovider.com/guides.

What’s Changing for UnitedHealthcare Community PlanFor dates of service on or after April 1, 2018, we’ll require prior authorization for Fasenra (benralizumab), Luxturna (voretigene neparvovec) and Ilaris™ (canakinumab) for UnitedHealthcare Community Plan members in many states. Ilaris (canakinumab) is approved by the FDA for the treatment of several rare inflammatory diseases.

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Updates to Notification/Prior Authorization Requirements for Specialty Medications for UnitedHealthcare Commercial, Medicare Advantage and Community Plan MembersThe following chart outlines which specialty medication prior authorization requirements will become effective on April 1, 2018 for UnitedHealthcare Community Plan members in each state:

Prior Authorization Requirements – Effective April 1, 2018State Specialty MedicationArizonaCaliforniaFloridaHawaiiKansasLouisianaMississippiNebraskaNew JerseyNew MexicoNew YorkOhioPennsylvaniaRhode IslandTennesseeTexasVirginiaWashington

Ilaris (canakinumab)Luxturna (voretigene neparvovec)Fasenra (benralizumab)

IowaMaryland Ilaris (canakinumab)

Luxturna (voretigene neparvovec) has been added to our Review at Launch program for UnitedHealthcare Community Plan. Care providers are encouraged to request a pre-determination review for services prior to April 1, 2018.

Coverage of these products is also dependent on State Medicaid program decisions. Certain state Medicaid programs may choose to cover a drug through the state’s fee-for-service program and not the managed care organizations such as UnitedHealthcare, or they may provide other coverage guidelines and protocols.

We encourage you to verify benefits before submitting the prior authorization request or administering the medication.

The prior authorization requirement for Fasenra (benralizumab) and Ilaris (canakinumab) does not apply to UnitedHealthcare Dual Complete® plans.

What’s Changing for UnitedHealthcare Medicare Advantage PlansThe following requirements will apply to UnitedHealthcare Medicare Advantage plans, including UnitedHealthcare Dual SNP plans, and Medica and Preferred Care Partners of Florida groups.

For dates of service on or after April 1, 2018 we’ll require notification/prior authorization for the following medications:

• Radicava™ (edaravone) – FDA approved for the treatment of amyotrophic lateral sclerosis (ALS).

• Spinraza™ (nusinersen) – FDA approved for the treatment of spinal muscular atrophy.

• Luxturna (voreteigene neparvovec)

Care providers are encouraged to request a pre-determination review for services before April 1, 2018.

The UnitedHealthcare commercial and Community Plan medical benefit drug policies for these specialty medications are available at UHCprovider.com/en/policies-protocols. The Medications/Drug (Outpatient/Part B) – Medicare Advantage Coverage Summary is at UHCprovider.com/policies > Medicare Advantage Policies > Coverage Summaries for Medicare Advantage Plans.

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Review at Launch Drug Program for UnitedHealthcare Commercial and Community Plan Members – Effective Jan. 1, 2018As a reminder, please consider requesting pre-service coverage review for medications listed on UnitedHealthcare’s Review at Launch Commercial or Community Plan Medication List. We’ll add certain new drugs to the Review at Launch list and policy as soon as they’re approved by the Food and Drug Administration. Drugs will remain on the list until we communicate otherwise.

For medications on the list, we encourage you to request pre-service coverage reviews so you can check whether a medication is covered before providing services. Some benefit plans may not cover certain medications under the medical benefit or may not cover them right away. Clinical coverage reviews can also help avoid starting a patient on therapy that may later be denied due to lack of medical necessity. Your claims may be denied if a pre-service coverage review is not completed.

If you have any questions, call the Provider Services number on the member’s ID card.

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Reminder of Notification/Prior Authorization Requirement for Chimeric Antigen Receptor T-cell (CAR-T) TherapyWe’ve updated our coverage review requirement for UnitedHealthcare commercial, Medicare Advantage and Community Plan members for transplants to add chimeric antigen receptor T-cell (CAR-T) therapy, including tisagenlecleucel (Kymriah™) and axicabtagene ciloleucel (Yescarta™). CAR-T therapy is a form of adoptive cell transfer that’s shown promise in the treatment of certain hematologic malignancies.

For dates of service on or after Jan. 1, 2018, we’ll require notification/prior authorization for CAR-T therapy or related services, including outpatient or inpatient evaluation and the CAR-T outpatient or inpatient episode.

We’re implementing coverage reviews for CAR-T therapy to provide our members access to care that’s medically appropriate and because CAR-T therapy carries certain risks. Coverage reviews for CAR-T therapy will be managed by Optum Transplant Resource Services through the same process as the transplant of tissue or organs. Care providers must contract with Optum Transplant Resource Services to receive prior authorization and bill for CAR-T therapy.As with all notification/prior authorization requirements, if you provide any CAR-T services without first completing the notification/prior authorization process, the claim may be denied. Members can’t be billed for services denied due to failure to complete the notification/prior authorization process.

For more information, care providers may contact Optum Transplant Resources at 888-936-7246.

Coverage of these products is dependent on State Medicaid program decisions. Certain stateMedicaid programs may choose to cover a drug through the state’s fee-for-service program and not the managed care organizations such as UnitedHealthcare, or they may provide othercoverage guidelines and protocols. We encourage you to verify benefits before submitting theprior authorization request or administering the medication.

The Centers for Medicare & Medicaid Services (CMS) has not issued coverage guidance forCAR-T therapy.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

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Reminder: Clinical Laboratory Improvement Amendments Identification Requirements PolicyUnitedHealthcare has implemented a reimbursement policy that applies to all laboratory services to align with Centers for Medicare & Medicaid Services (CMS) and Clinical Laboratory Improvement Amendments (CLIA) requirements. The effective date for the policy was Nov. 1, 2016 for participating providers and Aug. 1, 2016 for non-participating providers. The reimbursement policy applies to UnitedHealthcare commercial and Medicare Advantage members claims submitted on either a CMS 1500 claim form or HIPAA 5010 837 P claim file.

The policy requires that all claims for laboratory services include the CLIA number for the servicing care provider. The lab servicing provider’s physical address also will be required if the address differs from the billing provider’s address noted on the claim. The billing or servicing provider’s address must match the address associated with the CLIA ID number. CLIA regulatory requirements vary by the kind of test each laboratory conducts. Tests are categorized as waived, moderate complexity or high complexity. CLIA requires all lab testing sites to have one of the following certificates to legally perform clinical laboratory testing.

Types of CLIA Certificates:

• Certificate of Waiver

• Certificate of Registration

• Certificate of Accreditation

• Certificate for Physician-Performed Microscopy

• Certificate of Compliance

Claims for laboratory services may be denied if the CLIA information is missing, invalid or not within the scope of the awarded CLIA certificate per the CLIA ID number reported on the claim. Reporting of the modifier QW when billing for CLIA waived tests also may be required based on the level of CLIA certification the lab has obtained. Claims denied for missing information may be resubmitted with the required information. Please refer to the reimbursement policy for additional information, including the claims submission process.

For more information on CLIA requirements and test complexity categories, go to CLIA website at cms.hhs.gov/clia/.

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For dates of service on or after April 1, 2018, we’re expanding notification/prior authorization requirements for certain services to be covered in certain sites of care to include UnitedHealthcare commercial members in Indiana and New Jersey, including members enrolled in the following benefit plans:

• UnitedHealthcare

• Golden Rule Insurance Company (group 902667)

• Mid-AtlanticMD Healthplan Individual Practice Association, Inc. (M.D. IPA) or Optimum Choice, Inc. plans

• UnitedHealthcare Oxford*

• Neighborhood Health Plan

• UnitedHealthcare of the River Valley

• UnitedHealthcare Life Insurance Company (group 755870)

• UnitedHealthcare Community Plan benefit plans, excluding Dual-SNP benefit plans

* UnitedHealthcare Oxford plans require prior authorization requests to evaluate medical necessity for procedures provided in any setting other than a physician’s office. Site of service will now be reviewed as part of the existing prior authorization review process for these procedures to be performed in an outpatient hospital setting.

Site of service medical necessity reviews are part of our prior authorization process that supports member benefit plans requiring care to be medically necessary as well as cost-effective. These requirements are already in place in most other states. Following are more details on what’s new for Indiana and New Jersey.

Site of Service-Based Notification/Prior Authorization Requirements for Certain Procedures to Expand to Indiana and New Jersey – Effective April 1, 2018

• Certain procedures will require notification/prior authorization to be covered in an outpatient hospital setting, while others will require notification/prior authorization to be covered in any setting other than a physician’s office.

• These requirements, which are already in place in other states, will apply to UnitedHealthcare commercial members in Indiana and New Jersey beginning April 1, 2018.

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Procedures Requiring Notification/Prior Authorization in an Outpatient Hospital SettingThe following procedures will require notification/prior authorization to be covered in an outpatient hospital setting for UnitedHealthcare commercial members in Indiana and New Jersey:

Carpal Tunnel 64721

Cataract 66821 66982 66984

Cosmetic and Reconstructive 13101 13132 14040 14060 14301 21552 21931

Ear, Nose and Throat 21320 30140 30520 69436 69631

Gynecology 57522 58353 58558 58563 58565

Hernia Repair 49505 49585 49587 49650 49651 49652 49653 49654 49655

Liver Biopsy 47000

Ophthalmology 65426 65730 65855 66170 66761 67028 67036 67040 67228 67311

67312

Tonsillectomy & Adenoidectomy 42820 42821 42825 42826 42830

Upper & Lower Gastrointestinal Endoscopy

43235 43239 43249 45378 45380 45384 45385

Urology 50590 52000 52005 52204 52224 52234 52235 52260 52281 52310

52332 52351 52352 52353 52356 54161 55040 55700 57288

Miscellaneous 20680

Notification/prior authorization is not required for these services to be covered in a network ambulatory surgery center. We encourage physicians to review network ambulatory surgery centers in their area and obtain privileges with those centers that best meet their needs and their patients’ needs.

For more information, please go to UHCprovider.com/policies > Protocols > Prior Authorization for Outpatient Surgical Procedures FAQ.

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Procedures Requiring Notification/Prior Authorization in Any Setting Other Than a Physician’s OfficeThe following procedures will require notification/prior authorization to be covered in any setting other than the physician’s office for UnitedHealthcare commercial plan members in Indiana and New Jersey:

Dermatologic 10120 10140 11400 11401 11402 11403 11404 11406 11420 11421 11422 11423 11424 11426 11442

Gastroenterology 45300 45330 46922

General Surgery 19000

Neurologic 62270 62320 62321 62322 62323 64633 64635

Muscular/Skeletal 27096 64479 64483 64490 64493 64520

Obstetrics/Gynecology 57460

Respiratory 31579

Urology 55250

Vascular 36473 36475 36478

While notification/prior authorization is not required for these procedures to be covered in a physician’s office, if you bill for a site of service other than a physician’s office without following the notification/prior authorization process, claims will be denied. For more information, please go to UHCprovider.com/policies > Protocols > Notification Prior Authorization Requirement for Certain Office-Based Procedures to be Covered in Other Sites of Service.

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Site of Service-Based Notification/Prior Authorization Requirements for Certain Procedures to Expand to Indiana and New Jersey – Effective April 1, 2018

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How Our Notification/Prior Authorization Process Will Work for These Procedures

When we receive notification/prior authorization requests for these procedures, we’ll work with the requesting care provider to determine if an alternate site of care may be medically appropriate and may offer patients more convenient care experiences, as well as meaningful savings on out-of-pocket costs compared with other sites of service. Coverage determinations will take into account the availability of a participating facility, specialty requirements, physician privileges and whether a member has individual needs that require more intensive services.

Standard prior authorization processes and protocols apply. If the prior authorization process is not completed before performing a procedure that is on one of the above prior authorization lists, claims will be denied and the member can’t be billed for the service. If prior authorization is denied due to lack of medical necessity, members can be billed for the service to be performed in an outpatient hospital setting if the physician obtains adequate written consent from the member per our protocols.

To save time, we encourage you to take advantage of our online notification process, available through UHCprovider.com/priorauth. Or call the number on the member’s health plan ID card.

As health care continues to evolve and consumers increasingly demand a wider range of quality, cost effective options for their health care services, we anticipate a continued focus on place of service. If you have questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s ID card.

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Site of Service-Based Notification/Prior Authorization Requirements for Certain Procedures to Expand to Indiana and New Jersey – Effective April 1, 2018

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Changes in Advance Notification and Prior Authorization RequirementsCode Additions to Prior AuthorizationEffective for dates of service on or after April 1, 2018, new codes will be added to prior authorization as a result of the American Medical Association (AMA) 2018 annual update to the CPT for these plans: UnitedHealthcare commercial plans (UnitedHealthcare Mid Atlantic Health Plan, Navigate, Neighborhood Health Partnership, UnitedHealthOne, UnitedHealthcare Commercial, UnitedHealthcare of the River Valley and UnitedHealthcare West) and UnitedHealthcare Community Plan.

Category CodesFunctional Endoscopic Sinus Surgery (FESS) 31253 31257 31259

Sinuplasty 31298

Effective for dates of service on or after April 1, 2018, the following procedure codes will require prior authorization for UnitedHealthcare Mid Atlantic Health Plan (Commercial Plan):

Category CodesArthroplasty 24370

Injectable Medications J7320 J7322

Effective for dates of service on or after April 1, 2018, the following procedure codes will require prior authorization for UnitedHealthcare Community Plan of Florida (Medicaid Plan):

Category CodesNon-Emergent Air Ambulance Transport A0430 A0431 A0435 A0436

Circumcision 54161 (Code requires prior authorization based on site of service today. Effective April 1, 2018 this will require prior authorization in all places of service.)

Effective for dates of service on or after April 1, 2018, the following procedure codes will require prior authorization for UnitedHealthcare Community Plan of Virginia (Medicaid Plan):

Category CodesEnteral Services B9004 B9006 E0791

Home Health Care S5170 (limit is 14 meals in 7 days upon member discharge from a facility into the community)

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Changes in Advance Notification and Prior Authorization Requirements

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Effective for dates of service on or after April 1, 2018, the following procedure codes will require prior authorization for Neighborhood Health Partnership. These procedure codes were removed from prior authorization in error effective Oct. 1, 2017 and are being re-implemented:

Category CodesInjectable Medications J0178 J0490 J0585 J0586 J0587 J0588 J0596 J0597

J0598 J0881 J0882 J0885 J0887 J0888 J0890 J1290J1726 J1729 J2503 J2778 J3358 J7320 J7321 J7322 J7323 J7324 J7325 J7326 J7327 J7328 J9035* J9310*

*for non-oncology indication only

Effective for dates of service on or after April 1, 2018, the following procedure codes will require prior authorization for UnitedHealthcare of the River Valley. These procedure codes were removed from prior authorization in error effective Oct. 1, 2017 and are being re-implemented:

Category CodesInjectable Medications 90378 J0490 J0585 J0586 J0587 J0588 J0596 J0597

J0598 J1290 J1726 J1729 J3358 J7320 J7321 J7322 J7324 J7326 J7327 J7328 J9035** J9310*

*for non-oncology indication only** for oncology indications only

The most up-to-date Advance Notification lists are available online:

• UnitedHealthcare Medicare and UnitedHealthcare commercial plans – UHCProvider.com/priorauth > Advance Notification and Plan Requirement Resources > Plan Requirement Resources

• UnitedHealthcare Community Plan – UHCCommunityPlan.com > For Health Care Professionals > Select your state.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

20 | For more information, call 877-842-3210 or visit UHCprovider.com.

New Procedure Codes for Injectable Medications – Effective Jan. 1, 2018New procedure codes will become effective Jan. 1, 2018 due to updates from the Centers for Medicare & Medicaid Services (CMS). Correct coding rules dictate that assigned and permanent codes should be used when available. The following injectable medications that may be subject to prior authorization and/or Administrative Guide Protocols will have new codes:

For UnitedHealthcare Commercial PlansAfstyla – J7210

Cuvitru – J1555

Exondys 51 – J1428

Gelsyn-3 – J7328

Kovaltry – J7211

Kymriah – Q2040

Ocrevus – J2350

Spinraza – J2326

For UnitedHealthcare Community PlanBrineura – C9014

Cuvitru – J1555

Exondys 51 – J1428

Kymriah – Q2040

Makena / Hydroxyprogesterone Caproate – J1726, J1729

Ocrevus – J2350

Spinraza – J2326

Front & Center

If you have questions, please contact Provider Services at the number on the member’s ID card.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

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Front & Center

UnitedHealthcare Community Plan Goes Live with a Dual Special Needs Program – UnitedHealthcare Dual Complete®On Jan. 1, 2018, UnitedHealthcare Community Plan will begin to serve eligible members in a new Dual Special Needs Plan (DSNP) – UnitedHealthcare Dual Complete,® a Medicare Advantage program – in Iowa, Michigan, Missouri, Nebraska, North Carolina, Oklahoma and Virginia.

UnitedHealthcare Dual Complete® State Provider ServicesIowa 844-368-6883

Michigan 844-368-6885

Missouri 844-368-6886

North Carolina 844-368-7151

Nebraska 844-368-7149

Oklahoma 844-368-7150

Virginia 844-368-7151

UnitedHealthcare Network Bulletin January 2018 Table of Contents

22 | For more information, call 877-842-3210 or visit UHCprovider.com.

Dental Clinical Policy & Coverage Guideline UpdatesFor complete details on the policy updates listed in the following table, please refer to the December 2017 UnitedHealthcare Dental Policy Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Dental Clinical Policies and Coverage Guidelines > Dental Policy Update Bulletins.

Front & Center

Policy Title Policy Type

TAKE NOTE

Annual CDT Code Updates

UPDATED/REVISED (Effective Jan. 1, 2018)

Application of Medicaments and Desensitizing Resins Clinical Policy

Full Mouth Debridement Coverage Guideline

Implants Coverage Guideline

Medically Necessary Orthodontic Treatment Coverage Guideline

Miscellaneous Diagnostic Procedures Coverage Guideline

National Standardized Dental Claim Utilization Review Criteria Utilization Review Guideline

Oral Surgery: Miscellaneous Surgical Procedures Clinical Policy

Oral Surgery: Orthodontic Related Procedures Clinical Policy

Note: The inclusion of a dental service (e.g., procedure or technology) on this list does not imply that UnitedHealthcare provides coverage for the dental service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail.

December 2017 UnitedHealthcare Dental Policy Update Bulletin

UnitedHealthcare Network Bulletin January 2018 Table of Contents

23 | For more information, call 877-842-3210 or visit UHCprovider.com.

On-Line Chemotherapy Prior Authorization System to Display Outcome FindingsUnitedHealthcare is adding a new feature to our on-line chemotherapy prior authorization tool.

This information on outcomes of cancer treatment regimens in our members is intended to supplement data obtained from clinical trials.

Jan. 1, 2018 Coding Update to the UnitedHealthcare Facility Outpatient Procedure Grouper MappingOn Jan. 1, 2018, code updates will be made to the current UnitedHealthcare 2017 Outpatient Procedure Grouper (OPG) mapping.

UnitedHealthcare CommercialLearn about program revisions and requirement updates.

UnitedHealthcare NexusACO® Benefit Plans are Growing in 2018Membership in the UnitedHealthcare NexusACO benefit plans is growing. Starting Jan. 1, 2018, more members will have access to the UnitedHealthcare NexusACO product.

UnitedHealthcare Genetic and Molecular Testing Prior Authorization/Notification UpdatesStarting April 1, 2018, UnitedHealthcare will require prior authorization/notification for additional codes as part of the online prior authorization/notification program for genetic and molecular testing performed in an outpatient setting for our fully insured UnitedHealthcare Commercial Plan members.

UnitedHealthcare Shared Services Updates for Government Employees Health Association MembersOn Jan. 1, 2018, GEHA members will be able to access the UnitedHealthcare Options PPO network of care providers in Illinois, Kansas and Missouri. On Jan. 1, 2018, GEHA members in Texas will be able to access the Choice Plus network.

UnitedHealthcare Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline Updates

UnitedHealthcare Network Bulletin January 2018 Table of Contents

24 | For more information, call 877-842-3210 or visit UHCprovider.com.

UnitedHealthcare Commercial

UnitedHealthcare NexusACO® Benefit Plans are Growing in 2018 We’re excited to let you know that membership in the UnitedHealthcare NexusACO benefit plans is growing. Starting Jan. 1, 2018, more members will have access to the UnitedHealthcare NexusACO product.

UnitedHealthcare NexusACO is an accountable care organization (ACO) focused tiered product that builds on the strength of local ACO partnerships and the UnitedHealth Premium® program. Nationally, ACOs in certain markets have been selected to be included in Tier 1 for the UnitedHealthcare NexusACO benefit plan.

While UnitedHealthcare NexusACO members can receive benefits for services from all care providers who participate in UnitedHealthcare NexusACO, there may be higher out-of-pocket costs when getting care from care providers who are not in Tier 1.

Tier 1 providers for UnitedHealthcare NexusACO are:

• ACO care providers, supplemental care providers and selected oncologists in markets where there’s a featured ACO

• Physicians who are rated as a Premium Care Physician in the Premium program and oncologists in areas without a featured ACO

Tier 1 providers are identified in the UnitedHealthcare NexusACO care provider directory. If you’re not sure if you’re Tier 1 for NexusACO, you can check at UHCprovider.com > Menu > Find a Care Provider > NexusACO Care Provider Directory. If you’re Tier 1 for NexusACO, you’ll see the Tier 1 graphic by your name.

Health Plan Key FeaturesUnitedHealthcare NexusACO includes two benefit plans – NexusACO R and NexusACO OA. For both of these benefit plans, members choose a primary care physician (PCP) to help them navigate the complex health care system. NexusACO R requires referrals while NexusACO OA does not. Standard prior authorization and notification requirements apply.

For More InformationIf UnitedHealthcare NexusACO is available in your area, you can find more information at UHCprovider.com > Menu > Health Plans by State > Choose your state > UnitedHealthcare NexusACO.

For an on-demand video, go to the UHC On Air app on your Link dashboard and select the UHC News Now channel. To access Link apps, go to UHCprovider.com and use the Link button in the upper right corner to sign in with your Optum ID.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

25 | For more information, call 877-842-3210 or visit UHCprovider.com.

UnitedHealthcare Commercial

UnitedHealthcare Genetic and Molecular Testing Notification/Prior Authorization UpdatesEffective April 1, 2018, UnitedHealthcare will require notification/prior authorization for additional codes as part of the online notification/prior authorization process program for genetic and molecular testing performed in an outpatient setting for UnitedHealthcare commercial benefit plan members when UnitedHealthcare is the primary payer.*

New CPT codes included in the notification/prior authorization requirement:

• G9840 Kras gene mutation testing performed before initiation of anti-egfr moab

• G9843 Kras gene mutation

• 81520 ONC Breast MRNA Gene Expression Profile Hybrid 58 Genes

• 81521 ONC Breast MRNA MicroRNA Gene Expression Profile Hybrid 70 Genes

* UnitedHealthcare Commercial fully insured members in Florida (excluding Neighborhood Health Partnership members) participate in the Laboratory Benefit Management Program pilot and are not subject to these requirements.

We previously announced the Genetic and Molecular Testing Notification/Prior Authorization Program requirement effective Nov. 1, 2017. At the time, we said that UnitedHealthcare Mid-Atlantic was excluded from the requirement.

We want to clarify which UnitedHealthcare commercial plans in Maryland will require genetic and molecular testing notification/prior authorization effective April 1, 2018. Beginning April 1, 2018, members in the following plans will require notification/prior authorization for genetic and molecular testing:

• UnitedHealthcare of the Mid-Atlantic, Inc.

Members in the following plans do NOT require notification/prior authorization for genetic and molecular testing:

• MD-Individual Practice Association, Inc. (MD-IPA) and Optimum Choice, Inc.

• MAMSI Life and Health Insurance Company

UnitedHealthcare Network Bulletin January 2018 Table of Contents

26 | For more information, call 877-842-3210 or visit UHCprovider.com.

UnitedHealthcare Commercial

On-Line Chemotherapy Prior Authorization System to Display Outcome FindingsUnitedHealthcare is adding a new feature to our on-line chemotherapy prior authorization tool. Beginning in January 2018, the following outcome data will be available to practices that request prior authorization for cancer treatment regimens:

• Median duration of treatment (in months)

• Hospitalization rate

• Average monthly cost of care (while on treatment)

• Selection frequency for treatment regimen (by cancer and line of therapy)

The only way to view the outcome data is by completing a prior authorization process on UHCprovider.com. The data will be visible within the online prior authorization tool to the right of the corresponding chemotherapy regimen. Additional details about the outcomes data are also available by clicking the “Help” link on this same screen. At this time, outcomes are only available for adjuvant breast cancer and metastatic breast cancer with first line therapy. Outcomes data for other types of cancer will be available in the future.

This information on outcomes of cancer treatment regimens in our members is intended to supplement data obtained from clinical trials, which include selected patients and may not reflect the patients in your practice. We hope you find the additional information useful as you select the best treatment options for your patients and that you share this data and its impact on your decision-making process with your patients.

If you have any questions, send an email to unitedoncology@uhc.com.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

27 | For more information, call 877-842-3210 or visit UHCprovider.com.

UnitedHealthcare Commercial

Jan. 1, 2018 Coding Update to the UnitedHealthcare Facility Outpatient Procedure Grouper Mapping

On Jan. 1, 2018, the following code updates will be made to the current UnitedHealthcare 2017 Outpatient Procedure Grouper (OPG) mapping:

• Expired codes - 20 OPG 0-10 codes expire on Dec. 31, 2017. The codes will be deleted from the UnitedHealthcare OPG Exhibit on Jan. 1, 2018. An additional 16 OPG unlisted codes expire and will be deleted as well.

• Newly Published codes – 34 OPG 0-10 codes will be added to the UnitedHealthcare OPG Exhibit on Jan. 1, 2018. An additional 28 OPG unlisted codes will be added as well.

There are no other grouper level assignment changes to existing codes. For reimbursement under the OPG, UnitedHealthcare requires the appropriate line level CPT/Healthcare Common Procedure Coding System (HCPCS) code, in addition to the revenue code, when billing for outpatient procedures.

The updated 2017 UnitedHealthcare OPG Exhibit is available at UHCprovider.com/claims under the Outpatient Procedure Grouper Exhibits section.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

28 | For more information, call 877-842-3210 or visit UHCprovider.com.

UnitedHealthcare Commercial

UnitedHealthcare Shared Services Updates for Government Employees Health Association MembersThrough a shared services administrative arrangement, UnitedHealthcare provides access to the UnitedHealthcare’s Networks of care providers to Government Employees Health Association (GEHA) members in 29 states: Alabama, Arkansas, Colorado, Washington D.C., Delaware, Hawaii, Idaho, Indiana, Iowa, Louisiana, Maryland, Mississippi, Montana, Minnesota, Nebraska, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin and Wyoming.

On Jan. 1, 2018, GEHA members also will be able to access the UnitedHealthcare Options PPO network of care providers in Illinois, Kansas and Missouri. Access will be terminated to the UnitedHealthcare Options PPO network of providers in Alaska.

On Jan. 1, 2018, GEHA members in Texas will be able to access the Choice Plus network. Previously, these members had access to Options PPO network.

For GEHA members using the Options PPO network contracts, Conifer Health Solutions provides inpatient medical and mental health utilization management. UnitedHealthcare has delegated these inpatient utilization management services for Options PPO membership (e.g., notification, initial determination, inpatient care management and appeals) to Conifer Health Solutions. Conifer Health Solutions uses Milliman Care Guidelines® and is URAC-accredited in health utilization management.

For GEHA members in Texas who use the Choice Plus network of providers, UnitedHealthcare Clinical Services and Optum provides inpatient medical and mental health utilization management (e.g., notification, initial determination, inpatient care management and appeals).

GEHA is one of the largest national health benefit providers for civilian federal employees. Please check the back of the member’s ID card for contact information. For eligibility, summary of benefits, pre-certification requirements and claim status, call the provider dedicated self-service line at 877-343-1887 or send an email to uhss@umr.com.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

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UnitedHealthcare Commercial

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UnitedHealthcare Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline UpdatesFor complete details on the policy updates listed in the following table, please refer to the December 2017 Medical Policy Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Commercial Policies > Commercial Medical & Drug Policies and Coverage Determination Guidelines > Medical Policy Update Bulletins.

Policy Title Policy Type Effective Date

TAKE NOTE

Annual CPT® and HCPCS Code Updates

NEW

Alpha1-Proteinase Inhibitors Drug Feb. 1, 2018

Ilaris® (Canakinumab) Drug Jan. 1, 2018

Review at Launch for New to Market Medications Drug Jan. 1, 2018

UPDATED/REVISED

Balloon Sinus Ostial Dilation Medical Jan. 1, 2018

Blepharoplasty, Blepharoptosis and Brow Ptosis Repair CDG Jan. 1, 2018

Breast Reduction Surgery CDG Dec. 1, 2017

Cardiovascular Disease Risk Tests Medical Jan. 1, 2018

Clinical Trials CDG Dec. 1, 2017

Cosmetic and Reconstructive Procedures CDG Jan. 1, 2018

Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements CDG Jan. 1, 2018

Electrical and Ultrasound Bone Growth Stimulators Medical Jan. 1, 2018

Epidural Steroid and Facet Injections for Spinal Pain Medical Jan. 1, 2018

Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography Medical Jan. 1, 2018

Femoroacetabular Impingement Syndrome Medical Dec. 1, 2017

UnitedHealthcare Network Bulletin January 2018 Table of Contents

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UnitedHealthcare Commercial

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UnitedHealthcare Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline Updates

Note: The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail.

Policy Title Policy Type Effective Date

Functional Endoscopic Sinus Surgery (FESS) Medical Jan. 1, 2018

Gynecomastia Treatment CDG Dec. 1, 2017

Habilitative Services for Essential Health Groups CDG Jan. 1, 2018

Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable

Medical Jan. 1, 2018

Home Health Care CDG Dec. 1, 2017

Infertility Services CDG Jan. 1, 2018

Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions

Medical Jan. 1, 2018

Occipital Neuralgia and Headache Treatment Medical Jan. 1, 2018

Omnibus Codes Medical Jan. 1, 2018

Orthognathic (Jaw) Surgery CDG Dec. 1, 2017

Preventive Care Services CDG Jan. 1, 2018

Prolotherapy for Musculoskeletal Indications Medical Jan. 1, 2018

Proton Beam Radiation Therapy Medical Jan. 1, 2018

Rehabilitation Services (Outpatient) CDG Jan. 1, 2018

Site of Service Guidelines for Certain Outpatient Surgical Procedures URG Jan. 1, 2018

Somatostatin Analogs Drug Feb. 1, 2018

Specialty Medication Administration – Site of Care Review Guidelines URG Jan. 1, 2018

Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins

Medical Feb. 1, 2018

Transcatheter Heart Valve Procedures Medical Feb. 1, 2018

Vagus Nerve Stimulation Medical Jan. 1, 2018

UnitedHealthcare Network Bulletin January 2018 Table of Contents

31 | For more information, call 877-842-3210 or visit UHCprovider.com.

Notice on Claim Project for Code 77014 – Intensity Modulated Radiation Therapy PolicyImage guidance code 77014 may be separately reimbursed even after IMRT planning when done in conjunction with image-guided radiation therapy (IGRT), either codes G6015-G6016 or 77385-77386.

UnitedHealthcare Commercial Reimbursement PoliciesLearn about policy changes and updates.

Unless otherwise noted, the following reimbursement policies apply to services reported using the 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent or its successor form. UnitedHealthcare reimbursement policies do not address all factors that affect reimbursement for services rendered to UnitedHealthcare members, including legislative mandates, member benefit coverage documents, UnitedHealthcare medical or drug policies, and the UnitedHealthcare Care Provider Administrative Guide. Meeting the terms of a particular reimbursement policy is not a guarantee of payment. Once implemented, the policies may be viewed in their entirety at UHCprovider.com > Menu > Policies and Protocols > Commercial Policies > Reimbursement Policies for Commercial Plans. In the event of an inconsistency between the information provided in the Network Bulletin and the posted policy, the posted policy prevails.

Reimbursement Policy for Oxford Multiple Diagnostic Imaging Reductions – Effective April 1, 2018UnitedHealthcare/Oxford is implementing a new reimbursement policy to apply the Multiple Diagnostic Imaging Reductions (MDIR) for diagnostic radiology for commercial products.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

32 | For more information, call 877-842-3210 or visit UHCprovider.com.

Reimbursement Policy for Oxford Multiple Diagnostic Imaging Reductions – Effective April 1, 2018UnitedHealthcare/Oxford is implementing a new reimbursement policy to apply the Multiple Diagnostic Imaging Reductions (MDIR) for diagnostic radiology for commercial products. This will allow us to better align with Centers for Medicare & Medicaid Services (CMS) requirements and UnitedHealthcare commercial plans. This policy will replace the current Multiple Imaging Rules policy.

Beginning April 1, 2018, UnitedHealthcare/Oxford will apply a MDIR when multiple procedures within the same diagnostic family, assigned a Multiple Procedure Indicator (MPI) of 4, are performed during the same patient session by the same physician, health care professional or multiple physicians in the same group practice reporting under the same federal tax identification number (TIN). Services will be ranked by the CMS Total Non-Facility Relative Value Unit (RVU). The services with the highest RVU will be considered primary and services with the lower RVU will be considered second and subsequent. These changes will apply to all codes that have a CMS MPI of 4 on the National Physician Fee Schedule (NPFS).

• For the Technical Component (TC) of Radiology services (MPI 4), services ranked as primary will be allowed at 100% of the allowable amount. Second and subsequent services will be reduced by 50% of the allowable amount.

• For the Professional Component (PC) of Radiology services (MPI 4), services ranked as primary will be allowed at 100% of the allowable amount. Second and subsequent services will be reduced by 5% of the allowable amount.

• For globally billed services, for two or more procedures subject to MDIR, for a patient at the same session, the charge for the Global Procedure Codes will be divided into the PC and TC (indicated by modifiers 26 and TC) using Oxford’s standard Professional/Technical percentage splits. The RVUs assigned to each component (26 or TC) will determine which code will be ranked as primary, with no reduction applied, and those that will be ranked as secondary or subsequent, with reductions applied in accordance with this policy. The components (26 or TC) will be ranked independently of each other utilizing the CMS Non-Facility Total RVUs.

The new commercial reimbursement policy titled Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging Policy, published in January 2018, will indicate that the reductions will become effective on April 1, 2018.

UnitedHealthcare Commercial Reimbursement Policies

UnitedHealthcare Network Bulletin January 2018 Table of Contents

33 | For more information, call 877-842-3210 or visit UHCprovider.com.

UnitedHealthcare Commercial Reimbursement Policies

Notice on Claim Project for Code 77014 – Intensity Modulated Radiation Therapy PolicyOn June 1, 2017, the UnitedHealthcare commercial Intensity Modulated Radiation Therapy (IMRT) policy was revised to no longer allow separate reimbursement for seven radiation therapy services (codes 77014, 77295, 77306, 77307, 77321, 77331 and 77370) when billed 30 days before or after IMRT plan code 77301. The seven additional codes are considered included in the reimbursement for code 77301.

However, it later was determined that image guidance code 77014 may be separately reimbursed even after IMRT planning when done in conjunction with image-guided radiation therapy (IGRT), either codes G6015-G6016 or 77385-77386.

Specifically, code 77014 may be separately reimbursed when reported on a CMS-1500 claim form or its electronic equivalent on the same date of service as:

• Codes G6015 or G6016 in a non-facility place of service.

• Codes 77385 or 77386, when reported with modifier 26, in a non-facility place of service.

In addition, code 77014 is separately reimbursable on a CMS-1500 claim form or its electronic equivalent when reported with modifier 26 in a facility place of service, when the hospital reports the correct IMRT code and the physician reports the professional component of IGRT.

UnitedHealthcare made revisions to the IMRT policy to stop denials of 77014 on Oct. 8, 2017. A national claim adjustment project is being conducted to overturn applicable denials for claims processed from June 1, 2017 to Oct. 8, 2017. Code 77014 may still be subject to other reimbursement policy edits, coverage and/or benefit determinations.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

34 | For more information, call 877-842-3210 or visit UHCprovider.com.

UnitedHealthcare Community PlanLearn about Medicaid coverage changes and updates.

UnitedHealthcare Community Plan Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline Updates

UnitedHealthcare Community Plan Preferred Drug List Updates for First Quarter 2018UnitedHealthcare Community Plan’s Preferred Drug List is updated quarterly by our Pharmacy and Therapeutics Committee.

Update to Prior Authorization Requirements for Polysomnography and Portable Monitoring for Sleep-Related Breathing Disorders for Members The prior authorization requirements for UnitedHealthcare Community Plan have changed for many states that participate in the Polysomnography and Portable Monitoring for Sleep-Related Breathing Disorders program.

* Impacted states: New Jersey, New York, Rhode Island and Delaware.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

35 | For more information, call 877-842-3210 or visit UHCprovider.com.

UnitedHealthcare Community Plan

UnitedHealthcare Community Plan Preferred Drug List Updates for First Quarter 2018 UnitedHealthcare Community Plan’s Preferred Drug List (PDL) is updated quarterly by our Pharmacy and Therapeutics Committee. Please review the changes and update your references as necessary.

You may also view the changes at: UHCCommunityPlan.com > For Health Care Professionals > State> Pharmacy Program.

We provided a list of available alternatives to UnitedHealthcare Community Plan members whose current treatment includes a medication removed from the PDL. Please provide affected members with a prescription for a preferred alternative in one of the following ways:

• Call or fax the pharmacy

• Use e-Script

• Write a new prescription and give it directly to the member

If a preferred alternative is not appropriate, call 800-310-6826 for prior authorization for the member to remain on their current medication.

Changes will be effective Jan. 1, 2018 for UnitedHealthcare Community Plan in these states: Arizona, California, Florida for Florida Health Kids, Hawaii, Louisiana, Maryland, Nevada, New Jersey, New Mexico, New York, Ohio, Pennsylvania, Rhode Island and Virginia.

These changes don’t apply to UnitedHealthcare Community Plans in Delaware, Florida Medicaid, Iowa, Kansas, Michigan, Mississippi, Nebraska, Texas and Washington.

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UnitedHealthcare Community Plan Preferred Drug List Updates for First Quarter 2018

PDL Additions

Brand Name Generic Name Comments Notes

Austedo Deutetrabenazine tabletIndicated for treating Huntington's disease and tardive dyskinesia. Prior authorization required.

Zejula Niraparib capsuleIndicated for treating recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer. Prior authorization required. Available through specialty pharmacy.

Alunbrig Brigatinib tabletIndicated for treating anaplastic lymphoma kinase (ALK)-positive metastatic non-small cell lung cancer (NSCLC). Prior authorization required. Available through specialty pharmacy.

Eldepryl* Selegiline capsule Indicated for treating Parkinson's disease.Already preferred for Arizona.

Rilutek* Riluzole tablet Indicated for treating amyotrophic lateral sclerosis (ALS).

Isentress HD Raltegravir tabletIndicated for treating human immunodeficiency virus (HIV) infection.

Does not apply to Maryland or California. Already preferred for Arizona.

Selzentry Maraviroc oral solutionIndicated for treating human immunodeficiency virus (HIV) infection.

Does not apply to Maryland or California

Rydapt Midostaurin capsuleIndicated for treating acute myelogenous leukemia (AML) and systemic mastocytosis. Prior authorization required. Available through specialty pharmacy.

MavyretGlecaprevir/Pibrentasvir tablet

Indicated for treating chronic hepatitis C infection genotypes 1, 2, 3, 4, 5, or 6. Prior authorization required. Available through specialty pharmacy.

Does not apply to Rhode Island.

Otezla Apremilast tabletIndicated for treating plaque psoriasis and psoriatic arthritis. Prior authorization required. Available through specialty pharmacy.

Does not apply to Arizona, Virginia or Rhode Island.

Eucrisa Crisaborole 2% ointment Indicated for treating atopic dermatitis. Step therapy applies.Does not apply to Virginia or Rhode Island.

Vyvanse Chewable

Lisdexamfetamine chewable tablet

Indicated for treating attention deficit hyperactivity disorder and binge eating disorder. Diagnosis required.

Applies to Louisiana only.

Nuvigil* Armodafinil tabletIndicated for treating narcolepsy, obstructive sleep apnea, and shift work sleep disorder. Diagnosis required.

Applies to Louisiana only.

*Only generics are covered.

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UnitedHealthcare Community Plan

UnitedHealthcare Network Bulletin January 2018 Table of Contents

37 | For more information, call 877-842-3210 or visit UHCprovider.com.

PDL Modifications

Brand Name Generic Name Comments Notes

Provigil Modafinil tabletTherapeutic alternative required. A history of failure, contraindication or intolerance to armodafinil is required.

Applies to Louisiana only.

PDL Deletions

Brand Name Generic Name Comments Notes

ZepatierElbasvir-grazoprevir tablet

An alternative agent is available, including Mavyret. Current users will be grandfathered through the duration of their regimen.

Does not apply to Arizona, Rhode Island or Virginia.

EpclusaSofosbuvir-velpatasvir tablet

An alternative agent is available, including Mavyret. Current users will be grandfathered through the duration of their regimen.

Does not apply to Arizona, Rhode Island or Virginia.

Sovaldi Sofosbuvir tabletAn alternative agent is available, including Mavyret. Current users will be grandfathered through the duration of their regimen.

Does not apply to Arizona, Rhode Island or Virginia.

DuleraMometasone/formoterol inhaled

Alternative agents are available, including Fluticasone/Salmeterol (generic AirDuo RespiClick) and Breo Ellipta. Dulera will continue to be available for any patient less than age 12.

Applies to Ohio only.

*Only generics are covered.

If you have questions, call UnitedHealthcare Community Plan’s Pharmacy Department at 800-310-6826.

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UnitedHealthcare Community Plan Preferred Drug List Updates for First Quarter 2018

UnitedHealthcare Community Plan

UnitedHealthcare Network Bulletin January 2018 Table of Contents

38 | For more information, call 877-842-3210 or visit UHCprovider.com.

Update to Prior Authorization Requirements for Polysomnography and Portable Monitoring for Sleep-Related Breathing Disorders for Members in Certain StatesThe prior authorization requirements for UnitedHealthcare Community Plan have changed for many states that participate in the Polysomnography and Portable Monitoring for Sleep-Related Breathing Disorders program.

Which states participate in the prior authorization requirements for sleep studies?

• New Jersey

• New York

• Rhode Island

• Delaware

What are the prior authorization requirements for sleep studies?

• UnitedHealthcare Community Plan members are required to obtain a prior authorization request for attended sleep studies in a health care facility, lab, sleep clinic, etc.

• However, UnitedHealthcare Community Plan customers are NOT required to obtain a prior authorization for unattended sleep studies in the member’s home.

What are the procedure codes for attended sleep testing that require prior authorization?

Procedure codes for attended sleep testing that require prior authorization include CPT 95805, 95807, 95808, 95810 and 95811.

For more Information, contact your local Network Management representative or Provider Services at 877-842-3210.

UnitedHealthcare Community Plan

UnitedHealthcare Network Bulletin January 2018 Table of Contents

39 | For more information, call 877-842-3210 or visit UHCprovider.com.

UnitedHealthcare Community Plan

UnitedHealthcare Community Plan Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline UpdatesFor complete details on the policy updates listed in the following table, please refer to the December 2017 Medical Policy Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Community Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines > Medical Policy Update Bulletins.

Policy Title Policy Type Effective Date

TAKE NOTE

Annual CPT® and HCPCS Code Updates

NEW

Alpha1-Proteinase Inhibitors Drug Feb. 1, 2018

Exondys 51™ (Eteplirsen) (for Pennsylvania Only) Drug Jan. 1, 2018

Ilaris® (Canakinumab) Drug Feb. 1, 2018

Review at Launch for New to Market Medications Drug Jan. 1, 2018

UPDATED/REVISED

Actemra® (Tocilizumab) Injection for Intravenous Infusion Drug Jan. 1, 2018

Ambulance Services CDG Jan. 1, 2018

Attended Polysomnography for Evaluation of Sleep Disorders Medical Jan. 1, 2018

Breast Reconstruction Post Mastectomy CDG Jan. 1, 2018

Breast Repair/Reconstruction Not Following Mastectomy CDG Jan. 1, 2018

Cardiovascular Disease Risk Tests Medical Jan. 1, 2018

Clinical Trials CDG Dec. 1, 2017

Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements CDG Jan. 1, 2018

Emergency Health Care Services and Urgent Care Center Services (Maryland Only) CDG Jan. 1, 2018

Enzyme Replacement Therapy Drug Jan. 1, 2018

Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography

Medical Jan. 1, 2018

Femoroacetabular Impingement Syndrome Medical Dec. 1, 2017

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UnitedHealthcare Network Bulletin January 2018 Table of Contents

40 | For more information, call 877-842-3210 or visit UHCprovider.com.

Policy Title Policy Type Effective Date

Functional Endoscopic Sinus Surgery (FESS) Medical Jan. 1, 2018

Gynecomastia Treatment CDG Dec. 1, 2017

Hip Resurfacing and Replacement Surgery (Arthroplasty) Medical Jan. 1, 2018

Home Health Care CDG Dec. 1, 2017

Hospice Care (for Florida, Louisiana, Mississippi and Tennessee) CDG Feb. 1, 2018

Orthognathic (Jaw) Surgery CDG Dec. 1, 2017

Probuphine® (Buprenorphine) Drug Jan. 1, 2018

Prolotherapy for Musculoskeletal Indications Medical Jan. 1, 2018

Repository Corticotropin Injection (H.P. Acthar Gel®) (for Pennsylvania Only) Drug Feb. 1, 2018

Site of Service Guidelines for Certain Outpatient Surgical Procedures URG Jan. 1, 2018

Vagus Nerve Stimulation Medical Jan. 1, 2018

REPLACED

Hip Replacement Surgery (Arthroplasty) Medical Jan. 1, 2018

Note: The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail.

UnitedHealthcare Community Plan

UnitedHealthcare Community Plan Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline Updates

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UnitedHealthcare Network Bulletin January 2018 Table of Contents

41 | For more information, call 877-842-3210 or visit UHCprovider.com.

UnitedHealthcare Medicare AdvantageLearn about Medicare policy and guideline changes.

Reminder on Coverage of Annual Wellness Visits and Routine PhysicalsUnitedHealthcare offers the Medicare-covered annual wellness visit to all UnitedHealthcare Medicare Advantage Plan members and an additional annual routine physical exam to many plan members.

Outpatient Injectable Chemotherapy Notification for UnitedHealthcare Medicare Advantage Plans: Florida, Georgia and WisconsinBeginning March 1, 2018 participating care providers who are located in Florida and Georgia and administer outpatient injectable chemotherapy for a cancer diagnosis must submit notification before rendering services to UnitedHealthcare Medicare members. Beginning April 1, 2018 participating care providers who are located in Wisconsin and administer outpatient injectable chemotherapy for a cancer diagnosis must submit notification before rendering services to UnitedHealthcare Medicare members.

UnitedHealthcare Medicare Advantage Policy Guideline Updates

UnitedHealthcare Medicare Advantage Coverage Summary Updates

UnitedHealthcare Network Bulletin January 2018 Table of Contents

42 | For more information, call 877-842-3210 or visit UHCprovider.com.

UnitedHealthcare Medicare Advantage

Reminder on Coverage of Annual Wellness Visits and Routine PhysicalsThe annual wellness visit (or personalized prevention plan services) is a yearly visit covered by Original Medicare to develop or update the member’s personalized prevention plan. UnitedHealthcare offers the Medicare-covered annual wellness visit to all UnitedHealthcare Medicare Advantage Plan members and an additional annual routine physical exam to many plan members.

Because UnitedHealthcare Medicare Advantage plan enrollment is based on a calendar year, UnitedHealthcare covers both the annual wellness visit and the routine physical (when covered) once every calendar year and the visits do not need to be 12 months apart. For example, if a member gets their annual wellness visit and/or routine physical in June 2017, they do not need to wait until June 2018 for their next visit but can get one again anytime in 2018.

For more information on determining the appropriate submission codes for these wellness visits and other preventive services, go to UHCprovider.com/content/dam/provider/docs/public/reports/path/2017-Medicare-Advantage-Preventive-Screening-Guidelines.pdf.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

43 | For more information, call 877-842-3210 or visit UHCprovider.com.

Outpatient Injectable Chemotherapy Notification for UnitedHealthcare Medicare Advantage Plans: Florida, Georgia and WisconsinBeginning March 1, 2018 participating care providers who are located in Florida and Georgia and administer outpatient injectable chemotherapy for a cancer diagnosis must submit notification before rendering services to UnitedHealthcare Medicare members, including AARP® MedicareComplete®, Care Improvement Plus®, UnitedHealthcare Dual Complete® and UnitedHealthcare® Group Medicare Advantage plans.

UnitedHealthcare Medicare Advantage

Beginning April 1, 2018 participating care providers who are located in Wisconsin and administer outpatient injectable chemotherapy for a cancer diagnosis must submit notification before rendering services to UnitedHealthcare Medicare members.

This is part of our effort to continually improve health care experiences and outcomes for our members. We have contracted with eviCore to provide a web-based application to review chemotherapy regimens.

Notification will be required for:• Chemotherapy injectable drugs (J9000 - J9999),

Leucovorin (J0640) and Levoleucovorin (J0641)

• Chemotherapy injectable drugs that have a Q code

• Chemotherapy injectable drugs that haven’t received an assigned code and will be billed under a miscellaneous Healthcare Common Procedure Coding System (HCPCS) code

• All outpatient injectable chemotherapy drugs started after the notification effective date

• Adding a new injectable chemotherapy drug to a regimen

Notification will not be required for:• Radio-therapeutic agents (e.g., Zevalin and Xofigo)

• Oral chemotherapy drugs, which are covered under a member’s pharmacy benefit plan

• Growth factors including: J2505 (neulasta), J1442, (neupogen), J2820 Leukine® (sargramostim), Q5101, (Filgrastim–biosimilar Zarxio), J1447 Granix (tbofilgrastim)

• Use of chemotherapy drugs for non-cancer diagnosis

How to Submit NotificationTo submit an online notification request for injectable chemotherapy, go to UHCprovider.com.

• Sign in to Link by clicking on the Link button in the top right corner of UHCprovider.com. Use your Optum ID and select the Prior Authorization and Notification app.

• If you don’t have an Optum ID, click the New User button in the top right corner of UHCprovider.com.

Please complete all notifications online. If you have questions or need assistance with your online request, call 866-889-8054, 7 a.m. to 7 p.m., Central Time, Monday through Friday.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

44 | For more information, call 877-842-3210 or visit UHCprovider.com.

UnitedHealthcare Medicare Advantage

UnitedHealthcare Medicare Advantage Policy Guideline UpdatesThe following UnitedHealthcare Medicare Advantage Policy Guidelines have been updated to reflect the most current clinical coverage rules and guidelines developed by the Centers for Medicare & Medicaid Services (CMS). The updated policies are available for your reference at UHCprovider.com > Menu > Policies and Protocols > Medicare Advantage Policies > Policy Guidelines.

Policy Title

NEW (Approved on Nov. 8, 2017)

Biomarkers in Cardiovascular Risk Assessment

UPDATED/REVISED (Approved on Nov. 8, 2017)

Cardiointegram (CIG) as an Alternative to Stress Test or Thallium Stress Test (NCD 20.27)

Challenge Ingestion Food Testing (NCD 110.12)

Chelation Therapy for Treatment of Atherosclerosis (NCD 20.21)

Diagnostic Endocardial Electrical Stimulation (Pacing) (NCD 20.12)

Displacement Cardiography (NCD 20.24)

Electrocardiographic (EKG) Services (NCD 20.15)

Epidural Injection

Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions (NCD 110.21)

Erythropoietin Stimulating Agent (ESA)

Ethylenediamine-Tetra-Acetic (EDTA) Chelation Therapy for Treatment of Atherosclerosis (NCD 20.22)

External Electrocardiographic Recording

Hair Analysis (NCD 190.6)

HIS Bundle Study (NCD 20.13)

Home Use of Oxygen in Approved Clinical Trials (NCD 240.2.1)

Hyperbaric Oxygen Therapy (NCD 20.29)

Infrared Therapy Devices (NCD 270.6)

Infusion Pumps (NCD 280.14)

Intravenous Histamine Therapy (NCD 30.6)

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UnitedHealthcare Network Bulletin January 2018 Table of Contents

45 | For more information, call 877-842-3210 or visit UHCprovider.com.

UnitedHealthcare Medicare Advantage

UnitedHealthcare Medicare Advantage Policy Guideline Updates

Policy Title

Lymphocyte Immune Globulin, Anti-Thymocyte Globulin (Equine) (NCD 260.7)

Peridex CAPD Filter Set (NCD 230.13)

Plethysmography (NCD 20.14)

Routine Costs in Clinical Trials (NCD 310.1)

Screening for Hepatitis C Virus (HCV) in Adults (NCD 210.13)

Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy) (NCD 70.2.1)

Transfer Factor for Treatment of Multiple Sclerosis (NCD 160.20)

Transportation Services

Ultrafiltration Monitor (NCD 230.14)

Ultrafiltration, Hemoperfusion, and Hemofiltration (NCD 110.15)

Vagus Nerve Stimulation (VNS) (NCD 160.18)

Note: The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail.

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UnitedHealthcare Network Bulletin January 2018 Table of Contents

46 | For more information, call 877-842-3210 or visit UHCprovider.com.

UnitedHealthcare Medicare Advantage

UnitedHealthcare Medicare Advantage Coverage Summary UpdatesFor complete details on the policy updates listed in the following table, please refer to the December 2017 Medicare Advantage Coverage Summary Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Medicare Advantage Policies > Coverage Summaries > Coverage Summary Update Bulletins.

Policy Title

TAKE NOTE

Annual CPT® and HCPCS Code Updates

UPDATED/REVISED (Approved on Nov. 20, 2017)

Family Planning (Birth Control)

Foot Care Services

Hearing Aids, Auditory Implants and Related Procedures

Hyperbaric Oxygen Therapy

Ostomy Supplies

Positron Emission Tomography (PET)/Combined PET-CT (Computed Tomography)

Prostate: Services and Procedures

Radiologic Therapeutic Procedures

Services While Confined/Incarcerated

Spine Procedures

Vertebral Artery Surgery

Vision Services, Therapy and Rehabilitation

Note: The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

47 | For more information, call 877-842-3210 or visit UHCprovider.com.

UnitedHealthcare AffiliatesLearn about updates with our company partners.

Oxford® Medical and Administrative Policy Updates

SignatureValue/UnitedHealthcare Benefits Plan of California Benefit Interpretation Policy Updates

SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guideline Updates

UnitedHealthcare Network Bulletin January 2018 Table of Contents

48 | For more information, call 877-842-3210 or visit UHCprovider.com.

Policy Title Policy Type Effective Date

TAKE NOTE

Annual CPT® and HCPCS Code Updates

NEW

Acupuncture Reimbursement Feb. 1, 2018

Alpha1-Proteinase Inhibitors Clinical Feb. 1, 2018

Ilaris® (Canakinumab) Clinical Jan. 1, 2018

Review at Launch for New to Market Medications Clinical Jan. 1, 2018

UPDATED/REVISED

Attended Polysomnography for Evaluation of Sleep Disorders Clinical Jan. 1, 2018

Breast Reconstruction Post Mastectomy Clinical Jan. 1, 2018

Breast Repair/Reconstruction Not Following Mastectomy Clinical Jan. 1, 2018

Cardiovascular Disease Risk Tests Clinical Jan. 1, 2018

Cosmetic and Reconstructive Procedures Clinical Jan. 1, 2018

Dialysis Services Administrative Dec. 1, 2017

Drug Coverage Criteria - New and Therapeutic Equivalent Medications Clinical Jan. 1, 2018

Drug Coverage Guidelines Clinical Jan. 1, 2018

Drug Testing Reimbursement March 1, 2018

Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements

Administrative Jan. 1, 2018

Electric Tumor Treatment Field Therapy Clinical Dec. 1, 2017

Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography

Clinical Jan. 1, 2018

Functional Endoscopic Sinus Surgery (FESS) Clinical Jan. 1, 2018

UnitedHealthcare Affiliates

Oxford® Medical and Administrative Policy UpdatesFor complete details on the policy updates listed in the following table, please refer to the December 2017 Policy Update Bulletin at OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Policy Update Bulletin.

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UnitedHealthcare Network Bulletin January 2018 Table of Contents

49 | For more information, call 877-842-3210 or visit UHCprovider.com.

Policy Title Policy Type Effective Date

Hip Resurfacing and Replacement Surgery (Arthroplasty) Clinical Jan. 1, 2018

Hospice Care Administrative Dec. 1, 2017

Inpatient Maternity Stay and Subsequent Home Nursing Administrative Dec. 1, 2017

Lyme Disease Clinical Dec. 1, 2017

Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions

Clinical Jan. 1, 2018

Omnibus Codes Clinical Jan. 1, 2018

Preventive Care Services Clinical Jan. 1, 2018

Prolotherapy for Musculoskeletal Indications Clinical Jan. 1, 2018

Site of Service Guidelines for Certain Outpatient Surgical Procedures Clinical Jan. 1, 2018

Specialty Medication Administration - Site of Care Review Guidelines Clinical Jan. 1, 2018

Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins

Clinical Feb. 1, 2018

Transcatheter Heart Valve Procedures Clinical Feb. 1, 2018

Vagus Nerve Stimulation Clinical Jan. 1, 2018

REPLACED

Hip Replacement Surgery (Arthroplasty) Clinical Jan. 1, 2018

UnitedHealthcare Affiliates

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Oxford® Medical and Administrative Policy Updates

Note: The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that Oxford provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail.

Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

50 | For more information, call 877-842-3210 or visit UHCprovider.com.

UnitedHealthcare Affiliates

Policy Title Applicable State(s)

UPDATED/REVISED (Effective Jan. 1, 2018)

Cosmetic, Reconstructive, or Plastic Surgery All (California, Oklahoma, Oregon, Texas, & Washington)

Family Planning: Birth Control Oklahoma, Oregon, Texas, & Washington

Habilitative Services All

Hearing Services Oklahoma, Oregon, Texas, & Washington

Member Initiated Second and Third Opinion All

Pain Management All

Pervasive Developmental Disorder and Autism Spectrum Disorder All

Services While Confined/Incarcerated Oklahoma, Oregon, Texas, & Washington

Vision Care and Services Oklahoma, Oregon, Texas, & Washington

SignatureValue/UnitedHealthcare Benefits Plan of California Benefit Interpretation Policy UpdatesFor complete details on the policy updates listed in the following table, please refer to the December 2017 SignatureValue/UnitedHealthcare Benefits Plan of California Benefit Interpretation Policy Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Commercial Policies > UnitedHealthcare SignatureValue/UnitedHealthcare Benefits Plan of California Benefit Interpretation Policies > Benefit Interpretation Policy Update Bulletins.

Note: The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail.

UnitedHealthcare Network Bulletin January 2018 Table of Contents

51 | For more information, call 877-842-3210 or visit UHCprovider.com.

UnitedHealthcare Affiliates

SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guideline UpdatesFor complete details on the policy updates listed in the following table, please refer to the December 2017 SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guidelines Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Commercial Policies > UnitedHealthcare SignatureValue/ UnitedHealthcare Benefits Plan of California Medical Management Guidelines > Medical Management Guideline Update Bulletins.

Policy Title Effective Date

TAKE NOTE

Annual CPT® and HCPCS Code Updates

UPDATED/REVISED

Balloon Sinus Ostial Dilation Jan. 1, 2018

Blepharoplasty, Blepharoptosis and Brow Ptosis Repair Jan. 1, 2018

Breast Reconstruction Post Mastectomy Jan. 1, 2018

Breast Repair/Reconstruction Not Following Mastectomy Jan. 1, 2018

Cardiovascular Disease Risk Tests Jan. 1, 2018

Cosmetic and Reconstructive Procedures Jan. 1, 2018

Electrical and Ultrasound Bone Growth Stimulators Jan. 1, 2018

Emergency Health Care Services and Urgent Care Center Services Dec. 1, 2017

Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography Jan. 1, 2018

Femoroacetabular Impingement Syndrome Dec. 1, 2017

Functional Endoscopic Sinus Surgery (FESS) Jan. 1, 2018

Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable Jan. 1, 2018

Intensive Behavioral Therapy for Autism Spectrum Disorder Dec. 1, 2017

Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions Jan. 1, 2018

Occipital Neuralgia and Headache Treatment Jan. 1, 2018

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UnitedHealthcare Network Bulletin January 2018 Table of Contents

52 | For more information, call 877-842-3210 or visit UHCprovider.com.

Policy Title Effective Date

Omnibus Codes Jan. 1, 2018

Orthognathic (Jaw) Surgery Dec. 1, 2017

Preventive Care Services Jan. 1, 2018

Prolotherapy for Musculoskeletal Indications Jan. 1, 2018

Proton Beam Radiation Therapy Jan. 1, 2018

Pulmonary Rehabilitation Jan. 1, 2018

Specialty Medication Administration – Site of Care Review Guidelines Jan. 1, 2018

Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Feb. 1, 2018

Transcatheter Heart Valve Procedures Feb. 1, 2018

Vagus Nerve Stimulation Jan. 1, 2018

Note: The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail.

UnitedHealthcare Affiliates

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SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guideline Updates

UnitedHealthcare Network Bulletin January 2018 Table of Contents

53 | For more information, call 877-842-3210 or visit UHCprovider.com.

State NewsStay up to date with the latest state/regional news.

Site of Service-Based Notification/Prior Authorization Requirements for Certain Procedures to Expand to Indiana and New Jersey – Effective April 1, 2018For dates of service on or after April 1, 2018, we’re expanding notification/prior authorization requirements for certain services to be covered in certain sites of care to include UnitedHealthcare commercial members in Indiana and New Jersey.

UnitedHealthcare Community Plan Goes Live with a Dual Special Needs Program – UnitedHealthcare Dual Complete®On Jan. 1, 2018, UnitedHealthcare Community Plan will begin to serve eligible members in a new Dual Special Needs Plan (DSNP) – UnitedHealthcare Dual Complete,® a Medicare Advantage program – in several states.

* Impacted states: Iowa, Michigan, Missouri, Nebraska, North Carolina, Oklahoma and Virginia.

Update to Prior Authorization Requirements for Polysomnography and Portable Monitoring for Sleep-Related Breathing Disorders for Members The prior authorization requirements for UnitedHealthcare Community Plan have changed for many states that participate in the Polysomnography and Portable Monitoring for Sleep-Related Breathing Disorders program.

* Impacted states: New Jersey, New York, Rhode Island and Delaware.

Outpatient Injectable Chemotherapy Notification for UnitedHealthcare Medicare Advantage Plans: Florida, Georgia and WisconsinBeginning March 1, 2018 participating care providers who are located in Florida and Georgia and administer outpatient injectable chemotherapy for a cancer diagnosis must submit notification before rendering services to UnitedHealthcare Medicare members. Beginning April 1, 2018 participating care providers who are located in Wisconsin and administer outpatient injectable chemotherapy for a cancer diagnosis must submit notification before rendering services to UnitedHealthcare Medicare members.

Doc#: PCA-1-009011-12052017_12122017

Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Texas, Inc., UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc. OptumRx, OptumHealth Care Solutions, Inc. or its affiliates. Behavioral health products are provided by U.S. Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates.