PreferredOne does not specifically reward practitioners or other individuals for issuing denials of coverage or service care. Financial incentives for utilization management decision-makers do not encourage decisions that result in underutilization. Utilization management decision making is based only on the appropriateness of care and service and existence of coverage.
The Chiropractic, Integrated Health, and Pharmacy and Therapeutics Quality Management Subcommittees approve new criteria sets and clinical policy bulletins for use in their respective areas of Integrated Healthcare Services. Quality Management Subcommittee approval is not required when there has been a decision to retire a PreferredOne criteria document or when medical polices are created or revised; approval by the Chief Medical Officer is required. The Quality Management Subcommittees are informed of these decisions.
For the most current versions of the Medical Policy documents, please access the Medical Policy section on the PreferredOne website. (Click on Benefits and Tools then choose Medical Policy, Precertification, Prior Authorization.) Medical Policy documents are available on the PreferredOne website to members and to providers without prior registration.
Since the last newsletter, the following are the new, revised, or retired Medical Policy documents. Some of the more extensive Medical Policy updates are detailed for a few of the items below. If you wish to have paper copies of these documents, or you have questions, please contact the Medical Policy Department telephonically at (763) 847-3386 or online at Heather.Hartwig-Caulley@PreferredOne.com.
- 002 Plain Film X-rays
- 003 Passive Treatment
- 004 Experimental, Unproven, or Investigational Services
- 006 Active Procedures in Physical Medicine
- 007 Acute and Chronic Pain Administration Policy
- 011 Infant Care Policy ‐ Chiropractic
- 012 Measurable Progressive Improvement ‐ Chiropractic
- 014 Plan of Care
- 015 Advanced Imaging
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies List
- Breast Prosthesis, custom, post mastectomy: added as eligible
- Compression Garments: revisions were made regarding HCPCS, coverage, and quantities
- CPAP: available as purchase or rent to purchase
- CPAP accessories/supplies/humidifiers: available as purchase
- Electrical stimulation of sacral anterior nerve roots: added as requiring prior authorization
- Functional Electrical Stimulation: added medical necessity indications for the Parastep I system added; added examples of FES equipment that is considered exercise equipment excluded from coverage
- Haberman Feeder: added to the list as excluded
- Incontinence Supplies: added HCPCS A4337 to column of non-covered items
- Iontophoresis: added purchase under claims processing column
- Mechanical Stretch Devices: covered as rental only
- Nerve stimulator, peroneal nerve: added new entry and examples of devices
- Neuromuscular Electrical Stimulation (NMES): added specific contraindications and a note regarding usage, and examples of devices
- Neuromuscular Electrical Stimulation form-fitting garment: added to list with specific HCPCS and medical necessity indicatio
- NMES/TENS combination devices: added to list and examples of devices
- Positional Devices: added HCPCS E0190 to column of non-covered items
- Respiratory Equipment: replaced the deleted HCPCS for 2016 (E0450, E0460, E0461, E0463, E0464) with the new HCPCS E0465, E0466
- Safety Equipment: added additional information to the examples of non-covered equipment
- Standing frame/standers: deleted the three separate entries and combined into one with separate M/N indications by HCPCS code
- TENS Unit Supplies: added information regarding HCPCS and quantity limits
- Wedges for Infant GERD: added coverage information
- New Criteria
- MC/I012 Hypoglossal Nerve Stimulation
- MC/N008 Skilled Private Duty/Extended Hours Home Health Care
- New Policies
- MP/F007 Free-Standing Birth Centers
- MP/L002 Lipoma Removal
- Revised Criteria
- MC/G003 Excision Redundant Tissue
- MC/I008 Sacral Nerve Stimulation
- MC/I010 Spinal Cord/Dorsal Column Stimulation
- MC/L008 Continuous Glucose Monitoring Systems for Long-Term Use
- MC/L009 Intensity Modulated Radiation Therapy (IMRT) - In June of 2016, the Subcommittee approved a revised version of the MC/L009 Intensity Modulated Radiation Therapy (IMRT) criteria document. The review of and updates to the criteria were undergone in partnership with a local radiation oncology group, allowing PreferredOne to acquire expert opinion and guidance throughout the revision process. Substantial revisions were made to the criteria, such as including more detailed medical necessity requirements for different indications and removal of other indications previously addressed in the criteria document. One major update is the need to complete an IMRT Prior Authorization Form when submitting a request for the service, especially for indications in which PreferredOne requires documentation of both 3D CRT and IMRT plans, to ensure that all relevant clinical information is submitted. Failure to complete the IMRT Prior Authorization Form on a pre-service basis will result in an inability to complete the prior authorization process.
- MC/L010 Genetic Testing for Hereditary Cancer Syndromes ‐ In June of 2016, the Subcommittee approved a revised version of MC/L010 Genetic testing for Hereditary Cancer Syndromes that incorporated revisions based on the most current versions of the applicable National Comprehensive Cancer Network (NCCN) Guidelines. These revisions include the addition of medical necessity requirements for testing of the CDH1 gene.
- MC/L012 Gene Expression Profiling - In March of 2016, the Subcommittee approved a revised version of the MC/L012 Gene Expression Profiling criteria document. The revisions include the specification that the criteria for gene expression profiling for breast cancer also apply to men.
- MC/L014 Laboratory Testing for Detection of Heart Transplant Rejection
- MC/L015 Comparative Genomic Hybridization (CGH, aCGH)
- MC/N007 Skilled Intermittent Home Health Care
- Revised Policies
- MP/C001 Court-Ordered Mental Health Services
- MP/C002 Cosmetic Treatments
- MP/C008 Clinical Trials
- MP/C011 Court-Ordered Substance Use Related Disorders
- MP/G002 Gender Reassignment
- MP/H006 Hearing Devices
- MP/H007 Hospice Care
- MP/H008 Humanitarian Use Devices
- MP/M001 Molecular Testing ‐ Multiple revisions to capture PreferredOne’s positions regarding coverage of and when appropriate, the medical necessity of molecular tests used in oncology. Attachment A lists tests, conditions, and indications that are covered if the member meets the medical necessity criteria.
- MP/N002 Nutritional Counseling
- MP/P010 UVB Phototherapy for Skin Disorders
- MP/P013 Pharmacogenetic/Pharmacogenomic testing and Serologic Testing for Inflammatory Conditions ‐ Multiple revisions have been made to Attachment A of the MP/P013 document. Attachment A lists the pharmacogenetic/pharmacogenomic tests, conditions, and indications that are covered if the member meets the medical necessity criteria.
- Retired Criteria
- MC/K002 Bronchial Thermoplasty
- Retired Policies
- Bone conduction hearing systems, intra-oral (eg, SoundBite™ Hearing System)
- Bone conduction hearing systems, partially implantable, using magnetic coupling for acoustic transmission (EG, BAHA® Attract System and the Sophono®/Otomag™ Alpha bone conduction hearing system)
- Bronchial thermoplasty for asthma and other indications
- Deep Brain Stimulation for multiple indications
- Humira (adalimumab) serum drug concentration and antibody testing (eg, PROMETHEUS® Answer ADA™)
- Multi-biomarker disease activity (MBDA) test for Rheumatoid Arthritis (RA) (eg, Vectra® DA)
- Spinal cord/dorsal column stimulation for multiple indications
- To now allow gene expression profiling for prostate cancer using gene hypermethylation of gene regions GSTP1, APC, and RASSF1 (ConfirmMDx™) to further define the probability of high-grade cancer in members after a negative biopsy
- To now allow molecular testing for prostate cancer using percent free PSA, 4Kscore®, Prostate Health Index (PHI), and PCA3 assay to further define the probability of high-grade cancer in members who have never undergone a biopsy or have negative biopsy results.
Pharmacy and Therapeutics
- New Criteria
- New Policy
- PP/Q003 Quantity Limits
- Revised Criteria
The following Pharmacy and Therapeutics criteria documents have all undergone extensive revisions since the last newsletter. Briefly summarizing the revisions made to these documents on this newsletter may not be sufficient.
- PC/A005 Antidepressant Medications Step Therapy
- PC/B004 Biologics for Rheumatoid Arthritis
- PC/B005 Biologics for Plaque Psoriasis
- PC/B006 Biologics for Crohn’s Disease
- PC/B009 Bisphosphonates and Osteoporosis Prevention and Treatment Medications
- PC/B010 Biologics for Juvenile Idiopathic Arthritis and Juvenile Rheumatoid Arthritis
- PC/B011 Biologics for Psoriatic Arthritis
- PC/B012 Biologics for Ankylosing Spondylitis
- PC/B013 Biologics for Ulcerative Colitis
- PC/G001 Growth Hormone Medications
- PC/M001 Multiple Sclerosis Medications
- Revised Policies
- PP/B002 Biosimilar Products
- PP/C002 Cost Benefit Program
- PP/F001 Formulary Exceptions
- PP/O001 Off-Label Drug Use
- PP/T001 Tobacco Cessation Medications
- Retired Criteria
- PC/O001 Overactive Bladder Medications Step Therapy
- Retired Policies
- PP/Q001 Express Scripts Quantity Limits
- PP/Q002 ClearScript Quantity Limits
Synagis (palivizumab) is a vaccination to prevent lung disease in children at high risk of developing the disease caused by respiratory syncytial virus (RSV). The RSV season typically lasts from November to March, and Synagis is given as an injection once a month during the RSV season. PreferredOne will require prior authorization, including the submission of a completed Synagis Prior Authorization Form, at the start of the upcoming RSV season, beginning November 2016. Synagis is available in 50mg and 100mg vials and dosing is calculated based on the child’s weight. Therefore, PreferredOne will follow the Minnesota Department of Human Services Dosing Allowance policy when authorizing requests for Synagis.
As mentioned above, requests for authorization of IMRT currently require the submission of an IMRT Prior Authorization Form for the request to be processed. Requests for Synagis beginning around the upcoming RSV season will also require the submission of a Prior Authorization Form. Failure to submit the appropriate authorization forms will result in unprocessed authorization requests for services that require prior authorization. The following are other PreferredOne forms available on the PreferredOne website that need to completed and submitted to PreferredOne, when applicable.
- Gene Expression Profiling Prior Authorization Form
- Genetic Testing for Heritable Conditions Authorization Form
- Minnesota’s Universal Outpatient Mental Health/Chemical Health Authorization Form
- Orthodontic Service Salzmann Evaluation Index Form
- Orthognathic Surgery Authorization Form
- PreferredOne Precertification/Prior Authorization Concurrent Review Fax
- Radiofrequency Ablation Prior Authorization Form
- Substance Related Disorder Authorization Form
- Universal Health Plan/Home Health Agency Prior Authorization Request Form
Remember to check the Pre-certification/Prior Authorization List posted on the PreferredOne website. The list can be found with the other Medical Policy documents on the PreferredOne internet home page. The list will be fluid, as we see opportunities for impact driven by, but not limited to, new FDA-approved devices, medications, technologies, or changes in standard of care. Please check the list regularly for revisions.
Minnesota Community Measurement (MNCM) is a collaboration among health plans and provider groups designed to improve the quality of medical care in Minnesota. MNCM’s mission is to accelerate the improvement of health by publicly reporting health care information. MNCM has three goals:
- Reporting the results of health care quality improvement efforts in a fair and reliable way to medical groups, regulators, purchasers and consumers.
- Providing resources to providers and consumers to improve care.
- Increasing the efficiencies of health care reporting in order to use our health care dollars wisely.
PreferredOne is one of seven founding health plan members of MNCM. The state medical association, medical groups, consumers, businesses and health plans are all represented on the organization's board of directors. Data is supplied by participating health plans on an annual basis for use in developing their annual Health Care Quality Report.
MNCM released their 2015 Health Care Quality Report on their website during the first quarter of 2016. The 2015 Health Care Quality report features comparative provider group performance on preventive care screening and chronic disease care. One of the primary objectives of this report is to provide information to support provider group quality improvement. Provider groups will find this report useful to improve health care systems for better patient care. Sharing results with the public provides recognition for provider groups that are doing a good job now and motivates other groups to work harder. The report will allow provider groups to track their progress from year-to-year and to set and measure goals for future health care initiatives. The MNCM website also provides consumers with information regarding their role as active participants in their own care. Visit the MNCM website site to view the 2015 annual report at www.mncm.org.
The mission of the QM Program is to identify and act on opportunities that improve the quality, safety and value of care provided to PreferredOne members, both independently and/or collaboratively, with contracted practitioners and community efforts, and also improve service provided to PreferredOne members and other customers.
PreferredOne's member and physician website will be updated in the near future to offer the following program documents:
- 2016 PreferredOne QM Program Description, Executive Summary
- 2015 Year-End QM Program Evaluation, Executive Summary
To access these documents, log into the Provider site, and then click on the Quality Management Program link under the Information heading.
If you would like to request a paper copy of either of these documents please contact Heather Clark at 763-847-3562 or e-mail us at firstname.lastname@example.org.
We would like to thank all of our provider groups for their cooperation and collaboration during our recent HEDIS medical record review process. We realize that this process is burdensome to clinics and staff and appreciate your willingness in working with our vendor to ensure our HEDIS results for 2016 are accurate. Thank you!