Provider News 
April 2019 - In this issue:
      Resource
Provider Resources

Check out our Provider Resources webpage with important information for you and your staff. Access useful tools such as claims and authorization information. 
 
Stay Connected With Us
      survey
How Are We Doing?

On January 1, 2019, Neighborhood Health Plan became AllWays Health Partners. To ensure that we are providing you and your staff with the most effective information and support, we ask that you complete this brief survey. Your feedback will help us identify opportunities to better serve you. 

Providers who complete the survey before April 15, 2019 will be entered into a raffle drawing for a chance to win one of several prizes.

Thank you in advance for your participation. We appreciate the quality care you provide to our members. 

      Formulary
Formulary Updates

AllWays Health Partners regularly reviews and updates our formulary. Check out the latest updates effective 6/1/19.

For the latest information on our pharmacy programs, visit our online formulary today! 

      medpo
Medical Policy

The following medical policy updates are effective April 1, 2019: 
  • Assisted Reproductive Services/Infertility Services (Commercial Plans) - Annual review. Changed name of policy to Assisted Reproductive Services/Infertility Services. Clarified definition of infertility in women without exposure to sperm.Under General Eligibility Coverage Criteria, revised language under #2a to remove "These AI/IUI cycles with normal quality donor sperm and associated sperm processing and infertility medications are not covered because infertility has not been established until the AI/IUI cycles have been completed..." Changed language regarding immunity to rubella and varicella, lab testing and BMI. Clarified coverage criteria under Artificial Insemination (AI)/Intrauterine Insemination (IUI) section. Under Intra-Cytoplasmic Sperm Injection (ICSI) section, added language regarding documentation requirements for ICSI with authorized PGT cycle. Under Donor Egg Services for Infertility section, in #2, increased threshold to age 35. Under Donor Egg/Sperm Services When There is a Risk of Transmitting a Genetic Disorder. Increased threshold to age 35. Under Cryopreservation of Eggs/Embryos section, edited language under #3 adding "or surgical treatment". Under Exclusions, edited #1 to include "except for IUI as listed above", and #3 removed "AI/IUI cycles". Removed exclusion for IVF only requiring cryopreservation of embryos. Removed requirement of female to meet General Eligibility requirements for TESE and MESA. Updated references.
  • Neuromodulation for Overactive Bladder - Annual review. Under Initial Treatment Assessment with PTNS, revised criteria under #2b from two antimuscarinics to two oral medications. Under Permanent Implantation of SNS section, under item #1 changed criteria from greater than 50% symptom relief to greater than or equal to. 
  • Preimplantation Genetic Testing - Annual review without substantial changes in medically necessary indicators. Updated references.
  • Prostatic Urethral Lift - Annual review. Under Coverage Guidelines, revised medical therapy to clarify requirement; 3 months for alpha1-adrenergic antagonists or 5 alpha-reductase inhibitors for at least 6 months. Removed guidelines that member is a poor candidate for other surgical procedures for BPH using general anesthesia. Revised exclusion regarding urinary tract infection/prostatitis removing the one-year requirement. 
Click Here to view all medical policies.

      code
Code Updates

February 2019 Codes
The following code is covered; no prior authorization required, effective 2/1/19:
Code
Description
62273
Injection, epidural, of blood or clot patch

The following code is not covered for Commercial plans effective 4/1/19:
Code
Description
A7523
Tracheostomy shower protector, each

The following codes are covered with prior authorization effective 2/1/19:
Code
Description
S2066
Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral
S2067
Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral

The following service is not covered as it is not a medical benefit:
Description
Doulas

March 2019 Codes
The following codes/services  are covered without prior authorization:
Code
Description
Effective
S0189
Testosterone pellet, 75 mg
1/1/19
 N/A
Autologous Serum Eye Drops
 N/A

The following devices are not covered:
Description
Pregnancy Belt
Elvie Breast Pumps (not many other breast pumps are covered)

The following codes/services/implants are not covered as they are considered experimental/investigational:
Code
Description
Effective
N/A
Latera Absorbable Nasal Implant
6/1/19
N/A 
Reiki
N/A 
62263
Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days
6/1/19
62264
Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day
6/1/19

Services Through eviCore
The following codes are covered with prior authorization through eviCore effective 2/11/19:
Code
Description
0501T
Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission, analysis of fluid dynamics and simulated maximal coronary hyperemia, generation of estimated FFR model, with anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report
0502T
Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; data preparation and transmission
0503T
Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; analysis of fluid dynamics and simulated maximal coronary hyperemia, and generation of estimated FFR model
0504T
Noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed tomography angiography data using computation fluid dynamics physiologic simulation software analysis of functional data to assess the severity of coronary artery disease; anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report

Drug Coverage Updates 
The following code is covered with prior authorization effective 3/1/19:
Code
Description
C9038
Injection, mogamulizumab-kpkc, 1 mg

April 2019 HCPCS Codes
The following codes effective 4/1/19 are non-covered:
Code
Description
G2001
Brief (20 minutes) in-home visit for a new patient post-discharge. For use only in a Medicare-approved CMMI model. (Services must be furnished within a beneficiary's home, domiciliary, rest home, assisted living and/or nursing facility within 90 days following discharge from an inpatient facility and no more than 9 times.)
G2002
Limited (30 minutes) in-home visit for a new patient post-discharge. For use only in a Medicare-approved CMMI model. (Services must be furnished within a beneficiary's home, domiciliary, rest home, assisted living and/or nursing facility within 90 days following discharge from an inpatient facility and no more than 9 times.)
G2003
Moderate (45 minutes) in-home visit for a new patient post-discharge. For use only in a Medicare-approved CMMI model. (Services must be furnished within a beneficiary's home, domiciliary, rest home, assisted living and/or nursing facility within 90 days following discharge from an inpatient facility and no more than 9 times.)
G2004
Comprehensive (60 minutes) in-home visit for a new patient post-discharge. For use only in a Medicare-approved CMMI model. (Services must be furnished within a beneficiary's home, domiciliary, rest home, assisted living and/or nursing facility within 90 days following discharge from an inpatient facility and no more than 9 times.)
G2005
Extensive (75 minutes) in-home visit for a new patient post-discharge. For use only in a Medicare-approved CMMI model. (Services must be furnished within a beneficiary's home, domiciliary, rest home, assisted living and/or nursing facility within 90 days following discharge from an inpatient facility and no more than 9 times.)
G2006
Brief (20 minutes) in-home visit for an existing patient post-discharge. For use only in a Medicare-approved CMMI model. (Services must be furnished within a beneficiary's home, domiciliary, rest home, assisted living and/or nursing facility within 90 days following discharge from an inpatient facility and no more than 9 times.)
G2007
Limited (30 minutes) in-home visit for an existing patient post-discharge. For use only in a Medicare-approved CMMI model. (Services must be furnished within a beneficiary's home, domiciliary, rest home, assisted living and/or nursing facility within 90 days following discharge from an inpatient facility and no more than 9 times.)
G2008
Moderate (45 minutes) in-home visit for an existing patient post-discharge. For use only in a Medicare-approved CMMI model. (Services must be furnished within a beneficiary's home, domiciliary, rest home, assisted living and/or nursing facility within 90 days following discharge from an inpatient facility and no more than 9 times.)
G2009
Comprehensive (60 minutes) in-home visit for an existing patient post-discharge. For use only in a Medicare-approved CMMI model. (Services must be furnished within a beneficiary's home, domiciliary, rest home, assisted living and/or nursing facility within 90 days following discharge from an inpatient facility and no more than 9 times.)
G2013
Extensive (75 minutes) in-home visit for an existing patient post-discharge. For use only in a Medicare-approved CMMI model. (Services must be furnished within a beneficiary's home, domiciliary, rest home, assisted living and/or nursing facility within 90 days following discharge from an inpatient facility and no more than 9 times.)
G2014 (changed from G0074)
Limited (30 minutes) care plan oversight. For use only in a Medicare-approved CMMI model. (Services must be furnished within a beneficiary's home, domiciliary, rest home, assisted living and/or nursing facility within 90 days following discharge from an inpatient facility and no more than 9 times.)
G2015
Comprehensive (60 mins) home care plan oversight. For use only in a Medicare-approved CMMI model. (Services must be furnished within a beneficiary's home, domiciliary, rest home, assisted living and/or nursing facility within 90 days following discharge from an inpatient facility.)

      hosp
Hospital Inpatient Utilization Report

The latest quarterly hospital inpatient utilization report is now available. To review this report, click on the Reports tab in the Provider Portal and select Clinical Reports. If you do not have access to the Provider Portal, you may register online at allwaysprovider.org




AllWays Health Partners includes AllWays Health Partners, Inc. and AllWays Health Partners Insurance Company.