Network Bulletin: February 2016
network bulletin
Important updates from UnitedHealthcare to health care professionals and facilities
enter
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.
Table of Contents
Front & Center •
Site of Service Guidelines for Select Outpatient
Surgical Procedures Expanding to Include
UnitedHealthcare Community Plan in Certain
States and Additional Procedures
•
Prior Authorization for Functional
Endoscopic Sinus Surgery
•
UnitedHealthcare Dental Clinical Policies and Dental
Coverage Guidelines - Effective April 1, 2016
•
Changes in Advance Notification and
Prior Authorization Requirements
•
Special Needs Plan Updates
•
New Initiative Examines Costs of High-Impact Devices
•
National Ancillary Provider Updates
UnitedHealthcare Commercial
•
New Helicobacter Pylori Serology Testing Medical Policy
•
Changes to 2016 Out-of-Pocket Maximum Limits
•
UnitedHealthcare Medical Policy, Drug Policy and
Coverage Determination Guideline (CDG) Updates
UnitedHealthcare Community Plan
•
UnitedHealthcare Community Plan Medical Policy
& Coverage Determination Guideline Updates
•
Injectable Chemotherapy Prior Authorization
Program for UnitedHealthcare Community
Plans in Maryland and Washington
UnitedHealthcare Medicare Solutions
•
The Centers for Medicare & Medicaid Services
Local Coverage Determinations for DME
UnitedHealthcare Affiliates
•
Discontinuation and Limitation of OneNet PPO Products
•
Oxford Medical and Administrative Policy Updates
•
UnitedHealthcare of the River Valley Preauthorization
List and Coverage Policy Updates
•
SignatureValue/UnitedHealthcare Benefits Plan of
California Benefit Interpretation Policy Updates
•
SignatureValue/UnitedHealthcare Benefits Plan of
California Medical Management Guideline Updates
UnitedHealthcare Commercial
Reimbursement Policies
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2
•
Revision to Bilateral Procedures Policy
for Payment of Bilateral Codes
•
Replacement Codes Policy Implementation
•
Revision to Supply Policy – Denial in Nonfacility
Places of Service – Effective Q2
Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
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Front & Center
Site of Service Guidelines for Select
Outpatient Surgical Procedures Expanding to
Include UnitedHealthcare Community Plan in
Certain States and Additional Procedures
Providing access to medically necessary care while improving cost
efficiencies for the overall health care system is critical as we work
toward achieving the Triple Aim to improve care experiences, health
outcomes and total cost of care for UnitedHealthcare members.
In support of that work, for dates of service on or after
May 2, 2016, we will expand site of service-based prior
authorization guidelines to include UnitedHealthcare
Community Plan Medicaid members in a number of states,
excluding Medicare Dual Special Needs Plans (DSNPs)
and Medicare Medicaid Plans (MMPs). Additionally, for
dates of service on or after May 2, we are also adding some
tonsillectomy, adenoidectomy and gynecology codes.
Under these guidelines, prior authorization is required to perform
certain surgical procedures in an outpatient hospital setting. No prior
authorization is required for these procedures if they are performed
at a network ambulatory surgery center. Coverage determinations
take into consideration the availability of a participating network
facility, specialty requirements, physician privileges and whether a
patient has an individual need for access to more intensive services.
As a reminder, site of service prior authorization reviews are
already in place for certain surgical procedures to be performed
in an outpatient hospital setting in most states for members of the
following UnitedHealthcare Commercial plans, including Exchange
plans:
•
Golden Rule Insurance Company (group 902667)
•
Mid-AtlanticMD Healthplan Individual Practice Association,
Inc. (M.D. IPA) or Optimum Choice, Inc. plans
•
Neighborhood Health Partnership
•
UnitedHealthcare of the River Valley
•
UnitedHealthcare Oxford*
•
UnitedHealthcare
•
UnitedHealthcare Life Insurance Company (group 755870)
Continued >
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< Continued
*UnitedHealthcare Oxford previously required prior authorization for these procedures when provided in
a setting other than a physician’s office. The site of service will now be reviewed for medical necessity
as part of that prior authorization review process before these procedures can be performed in an
outpatient hospital setting.
Front & Center
Site of Service
Guidelines for Select
Outpatient Surgical
Procedures Expanding to
Include UnitedHealthcare
Community Plan in
Certain States and
Additional Procedures
We are expanding the site of service prior authorization requirement to apply to Medicaid
members enrolled in UnitedHealthcare Community Plan, excluding Medicare Dual Special
Needs Plans (DSNPs) and Medicare Medicaid Plans (MMPs), in the following states,
effective May 2, 2016, unless otherwise noted:
•
Arizona
•
Rhode Island
•
New Mexico (effective July 1, 2016)
•
Tennessee
•
New York
•
Washington
To align with site of service guidelines that are already in place for many UnitedHealthcare
commercial plans, these UnitedHealthcare Community Plans will require physicians to submit
prior authorization requests to perform the following procedures in an outpatient hospital
setting:
Procedures & Services
CPT Codes
Abdominal Paracentesis
49083
Carpal Tunnel
64721
Cataract
66821 66982 66984
Hernia Repair
49585 49587 49650 49651 49652 49653 49654 49655
Liver Biopsy
47000
Tonsillectomy & Adenoidectomy
42821 42826
Upper & Lower Gastrointestinal
Endoscopy
43235 43239 43249 45378 45380 45384 45385
Urologic
50590 52000 52005 52204 52224 52234 52235 52260
52281 52310 52332 52351 52352 52353 52356 57288
At the same time, the following codes will be added to the list of procedures requiring site
of service-based prior authorization for all included UnitedHealthcare commercial plans and
UnitedHealthcare Community Plans.
Procedures & Services
CPT Codes
Gynecology
57522 58353 58558 58563 58565
Tonsillectomy & Adenoidectomy
42820 42825 42830
Continued >
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< Continued
All of the codes noted above will be in scope for site of service-based prior authorization
for included UnitedHealthcare commercial and UnitedHealthcare Community Plans for
dates of service on or after May 2, 2016, in most states.
Front & Center
For UnitedHealthcare commercial plans in Illinois and for UnitedHealthcare Community
Plan in New Mexico, the requirement applies for dates of service on or after July 1, 2016.
To help ease this transition, we encourage you to familiarize yourself with network
ambulatory surgery centers in your area and obtain privileges to perform procedures in
those settings, if you do not already have them.
Site of Service
Guidelines for Select
Outpatient Surgical
Procedures Expanding to
Include UnitedHealthcare
Community Plan in
Certain States and
Additional Procedures
Prior authorization requests can be filed in multiple ways:
• For UnitedHealthcare commercial plans, go to UnitedHealthcareOnline.com
> Notifications/Prior Authorizations > Notification/Prior Authorizations
Submission. This is the recommended option for the simplest experience.
•
For UnitedHealthcare Community Plan, follow the plan-specific prior authorization
request submission process outlined at UHCCommunityPlan.com > For Health
Care Professionals.
•
Call the Provider Services number on the back of the member’s health care ID card.
If you do not complete the prior authorization process before performing these procedures
in an outpatient hospital setting, claims will be denied. Members cannot be billed for
services that are denied due to lack of prior authorization.
For more information on this requirement, please see the answers to frequently asked
questions at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and
Guides > Protocols > Site of Service for Outpatient Surgical Procedures FAQ.
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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Network Bulletin: November 2013 - Volume 58
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Front & Center
Prior Authorization for Functional
Endoscopic Sinus Surgery
Beginning May 2, 2016, some functional endoscopic sinus surgery procedures will be added to our prior authorization list
for many UnitedHealthcare commercial plans and UnitedHealthcare Community Plans (Medicaid), excluding Medicare Dual
Special Needs Plans (DNSPs) and Medicare Medicaid Plans (MMPs).
This is part of our ongoing responsibility to regularly evaluate our medical policies, clinical programs and health benefits
against the latest scientific evidence and specialty society guidance, as our member benefit plans require care to be medically
appropriate. Using evidence-based medicine to guide coverage decisions supports quality patient care and reflects our shared
commitment to the Triple Aim: better care, better health and lower costs.
The prior authorization requirement for these procedures applies to the following UnitedHealthcare plans, including Health Care
Exchange plans, beginning with dates of service on and after May 2, 2016, in most states*:
•
UnitedHealthcare
•
Golden Rule Insurance Company (group 902667)
•
Mid-AtlanticMD Healthplan Individual Practice Association, Inc. (M.D. IPA) or Optimum Choice, Inc.
•
Neighborhood Health Partnership (These plans already require prior authorization for these procedures.)
•
UnitedHealthcare of the River Valley
•
UnitedHealthcare Oxford
•
UnitedHealthcare Life Insurance Company (group 755870)
•
UnitedHealthcare West/Signature Value (not including California members)
•
UnitedHealthcare Community Plan (Medicaid)
*For UnitedHealthcare commercial members in Illinois and Iowa, and for UnitedHealthcare Community Plan (Medicaid) members in New
Mexico, these guidelines apply to dates of service on or after July 1, 2016.
Medical necessity reviews will be required for all UnitedHealthcare Community Plan (Medicaid) and commercial members for
these procedures in all states. For some members, the medical necessity review will include a review for the appropriate site of
services when the procedure is requested to be performed in an outpatient hospital setting.
For more information about which plans are in scope for site of service reviews, go to UnitedHealthcareOnline.com > Tools &
Resources > Policies, Protocols and Guides > Protocols > Site of Service for Outpatient Surgical Procedures FAQ.
Continued >
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< Continued
Prior authorization will be required for the following functional endoscopic sinus surgery
procedures:
Front & Center
Prior Authorization for
Functional Endoscopic
Sinus Surgery
CPT Codes
Description
31237
Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement
31238
Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage
31239
Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy
31240
Nasal/sinus endoscopy, surgical; with concha bullosa resection
31254
Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior)
31255
Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior)
31256
Nasal/sinus endoscopy, surgical, with maxillary antrostomy;
31267
Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus
31276
Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from
frontal sinus
31287
Nasal/sinus endoscopy, surgical, with sphenoidotomy
31288
Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus
Prior authorization requests can be submitted multiple ways:
•
For UnitedHealthcare commercial plans, go to UnitedHealthcareOnline.com
> Notifications/Prior Authorization > Notification/Prior Authorizations
Submission. Using UnitedHealthcareOnline.com is the easiest way to initiate prior
authorization and is recommended.
•
For UnitedHealthcare Community Plan, follow the plan-specific prior authorization request
submission process outlined at UHCCommunityPlan.com > For Health Care
Professionals.
•
Call the Provider Services number on the back of your patient’s member health care
ID card.
Claims submitted without completion of the prior authorization process will be denied, and the
member cannot be billed for the service. Per our standard protocols, members can opt to be
billed for services that are denied due to lack of medical necessity, but only with knowledge of
the coverage determination and written consent to be held responsible for the cost of the service
per our standard protocols. For more information, go to UnitedHealthcareOnline.com > Clinician
Resources > Advance and Admission Notification Requirements.
For details, please see the answers to frequently asked questions at
UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides >
Protocols > Prior Authorization for Functional Endoscopic Sinus Surgery FAQ. If you have
questions, please contact your local Network Management representative or call the provider
services number on the back of the member’s UnitedHealthcare ID card.
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Network Bulletin: November 2013 - Volume 58
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or visit UnitedHealthcareOnline.com
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Front & Center
UnitedHealthcare Dental Clinical Policies and Dental
Coverage Guidelines — Effective April 1, 2016
Effective April 1, 2016, UnitedHealthcare will begin publishing dental clinical policies and coverage guidelines to help administer
dental plan benefits. These policies and guidelines will apply to all UnitedHealthcare dental plans except UnitedHealthcare
Community Plan and certain custom groups. They will serve as the clinical foundation for making dental coverage determinations
and support our clinical dental programs.
The policies and guidelines will be available at
UnitedHealthcareOnline.com > Tools & Resources >
Policies, Protocols and Guides > Dental Clinical Policies
& Coverage Guidelines.
The dental policies and guidelines will not replace the current
National Standardized Commercial Dental Claim Utilization
Review Criteria located at UnitedHealthcare Dental Benefit
Providers (DPB).com > Resources > Clinical Guidelines.
As policies and guidelines are developed or modified, the
National Standardized Commercial Dental Claim Utilization
Review Criteria will be updated in the corresponding dental
policy or guideline document.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
On March 1, 2016, UnitedHealthcare will begin publishing
monthly editions of the Dental Policy Update Bulletin, an
online resource that provides notices of new and updated
dental clinical policies and coverage guidelines. A new
edition of the bulletin will be published on the first day of
each month at UnitedHealthcareOnline.com > Tools &
Resources > Policies, Protocols and Guides > Dental
Clinical Policies & Coverage Guidelines. Recently approved,
revised and/or retired dental policies and coverage guidelines
also will be published in the Network Bulletin.
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
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Front & Center
Changes in Advance Notification and Prior
Authorization Requirements
As of Jan. 1, 2016, certain procedures were added or removed from the Prior Authorization and Advance Notification Lists for
UnitedHealthcare Commercial, UnitedHealthcare Medicare Solutions, UnitedHealthcare Community Plan and UnitedHealthcare
Connected (MMP) plans. These changes are based on 2016 national coding updates published by the Centers for Medicare &
Medicaid Services (CMS).
Note: Servicing providers with approved prior authorizations for the eliminated codes are advised to request new authorizations under the
replacement codes due to a more intricate definition of service being defined. Interim processes have been implemented for dates of service
until March 1, 2016 to address the transitional implementation of these codes.
Service Category
Eliminated
Codes
Applies to
Replacement
Codes
Home Health Care
UnitedHealthcare Medicare Solutions, UnitedHealthcare Community Plan,
UnitedHealthcare Connected (MMP)
G0154
G0299, G0300
Experimental &
Investigational
UnitedHealthcare Community Plan, UnitedHealthcare Connected (MMP),
UnitedHealthcare Commercial
0262T
33477*
Durable Medical Equipment
(DME): with billable dollar
threshold
UnitedHealthcare Medicare Solutions, UnitedHealthcare Community Plan,
UnitedHealthcare Connected (MMP)
E0450, E0463
E0465
DME: with billable dollar
threshold
UnitedHealthcare Medicare Solutions, UnitedHealthcare Community Plan,
UnitedHealthcare Connected (MMP)
E0461, E0464
E0466
UnitedHealthcare Commercial
Q9979
J0202
Injectable Medications
*Effective for dates of service May 1, 2016 and after, procedure code 33477 will be added to the Prior Authorization and
Advance Notification Lists for UnitedHealthcare Community Plan in Michigan, Ohio, Tennessee and Texas.
Effective for dates of service May 1, 2016 and after, certain procedures will be added to the Prior Authorization and Advance
Notification Lists for UnitedHealthcare Commercial, UnitedHealthcare Medicare Solutions, UnitedHealthcare Community Plan
and UnitedHealthcare Connected.
These changes are based on requirements from CMS:
Service Category
BRCA Genetic Testing
(breast cancer susceptibility)
Injectable Medications
Applies to
Added Codes
UnitedHealthcare Commercial, UnitedHealthcare Community Plan,
UnitedHealthcare Connected (MMP)
81162, 81432, 81433
UnitedHealthcare Community Plan, specific to states:
AZ, CA, DE, FL, IA, LA, MD, MI, MS, NE, NJ, NY, OH, PA, RI, TN, TX, WA
J1575
Continued >
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< Continued
For dates of service May 1, 2016 and after, procedure codes E0601 (Continuous airway
pressure (CPAP) device) and E0470, E0471, and E0472 (Respiratory assist device, bi-level
pressure capability devices) will require prior authorization, regardless of the billed amount
on the Prior Authorization and Advance Notification Lists for UnitedHealthcare Medicare
Solutions plans and UnitedHealthcare Connected (MMP) plans.
Front & Center
Changes in Advance
Notification and
Prior Authorization
Requirements
The most up-to-date Advance Notification lists are available online:
•
UnitedHealthcare Medicare Solutions plans: UnitedHealthcareOnline.com >
Clinician Resources > Advance & Admission Notification Requirements.
•
UnitedHealthcare Community Plan and UnitedHealthcare Connected plans:
UHCCommunityPlan.com > For Health Care Professionals > Select your state.
Special Needs Plan Updates
Annual Model of Care Training for Special Needs Plan Care Providers
The Centers for Medicare and Medicaid Services (CMS) requires annual Model of Care training
for care providers who care for Special Needs Plan (SNP) members. The 2016 Model of Care
training will soon be released.
Provider Access to Health Risk Assessment and Individual Care Plan for Special
Needs Care Providers
UnitedHealthcare provides access to patient Health Risk Assessments (HRAs) and Individual
Care Plans (ICP) for SNP care providers in a variety of ways, including the following: mailing,
faxing, website postings to UnitedHealthcareOnline.com or placing in the physical and/or
electronic chart. Care providers are encouraged to review plans of care and participate with the
SNP Interdisciplinary Care Team (ICT) when updates are necessary.
For more information please visit UnitedHealthcareOnline.com.
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Front & Center
New Initiative Examines Costs of High-Impact Devices
UnitedHealthcare and Dignity Health co-founded SharedClarity
to change how hip and knee implants, stents, surgical mesh and
dozens of other high-impact, devices are evaluated, selected
and sourced. The effort also promotes improved patient
outcomes and provides significant savings for health care
providers.
UnitedHealthcare plays a critical role in the success of the
program, from providing access to its expansive health provider
network to sharing data, claims history and other clinical
information from its 46 million active members.
SharedClarity clinical review teams analyze studies, sciencebased information, quality reporting, physician input and
other data on medical device performance to make clinical
recommendations. SharedClarity also has the capability to
deploy a customized study using third-party data aggregation
resources if consensus is not reached.
National Ancillary Provider Updates
UnitedHealthcare received notification that Empi Inc. left
the consumer market on Dec. 18, 2015. Empi provided
Transcutaneous Electrical Nerve Stimulation units
(TENS) and Neuromuscular Stimulation units (NMES)
for rental and purchase, along with supporting supplies.
We have alternative contracts with Kinex, Electrostim
Medical Services, Inc. (EMSI) and Zynex for TENS
and Neuromuscular Stimulator devices. All compatible
consumable supplies will be available through Kinex.
We also were notified that Target Corp. no longer supplies
breast pumps through its pharmacies as of Dec. 1, 2015.
National suppliers of breast pumps are Byram Healthcare,
Edgepark Medical Supplies, McKesson Patient Care
Solutions, Medline Industries Inc., and Walmart (mail order).
Contracts are established for the selected devices and provide
market-leading prices for health system member-owners —
Advocate Health Care, Baylor Scott and White Health, Dignity
Health and McLaren Health Care.
In addition to a lower purchase price, a device that experiences
fewer issues and reduces readmissions helps health insurers,
health providers and, most importantly, patients.
For more information, please visit the SharedClarity
website at SharedClarity.net or contact SharedClarity
national sales consultant Shay Damaske by email at
sdamaske@sharedclarity.net.
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UnitedHealthcare Commercial
New Helicobacter Pylori Serology Testing
Medical Policy
UnitedHealthcare introduced a new medical policy, effective
Jan. 1, 2016 for UnitedHealthcare Commercial health plan
members regarding Helicobacter pylori (H. pylori) serology testing.
The new medical policy describes the American
Gastroenterological Association guidelines for the testing,
evaluation and management of dyspepsia and peptic ulcer disease
(PUD). The guidelines state that serology testing (CPT code
86677), which does not test for an active Helicobacter pylori (H.
pylori) infection, should no longer be used. The guidelines state that
stool antigen test or urea breath test should be used rather than
serology testing to both diagnose and confirm eradication of an
active H. pylori infection.
H. pylori is a class I carcinogen linked as a causative agent in PUD
gastric adenocarcinoma and mucosa-associated lymphoid tissue
(MALT) lymphoma. The medical policy reflects a “test, treat, retest
and confirm eradication” policy in cases of H. pylori infection, which
has been linked to the development of PUD, gastric malignance
and dyspeptic symptoms, instead of moving directly to proton
pump inhibitor (PPI) therapy. UnitedHealthcare developed the
H. pylori testing policy from guidelines issued by the American
Gastroenterological Association and the American College of
Gastroenterology that emphasize:
•
Eliminating serology use because studies show that about
50 percent of patients with a positive H. pylori serology do not
actually have an active infection
•
Testing, treating and retesting for active H. pylori infection
before prescribing PPI
UnitedHealthcare’s medical policy and information on the tests at
issue can be found can be found at UnitedHealthcareOnline.com >
Tools & Resources > Policies, Protocols and Guides > Policies >
Medical & Drug Policies and Coverage Determination Guidelines –
Commercial > Helicobacter Pylori Serology Testing.
If you have any questions, please contact your Provider Advocate.
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UnitedHealthcare Commercial
Changes to 2016 Out-of-Pocket Maximum Limits
Updates have been made to annual out-of-pocket maximum limits for 2016 for UnitedHealthcare Commercial members in fully
insured and self-insured plans.
Out-of-pocket maximum is the total amount a member will spend for health care, after which the member’s benefit plan pays for
all covered medical expenses until the year ends. It does not include premiums and is not offset by employer contributions.
In May 2015, the Department of Health and Human Services imposed a ceiling on individual and family out-of-pocket maximums.
The requirement is applicable for plans with coverage starting in 2016 and after.
New 2016 Out-of-Pocket Maximum Limits for
Fully Insured and Self-insured Plans:
New 2016 Out-of-Pocket Maximum Limits for
HSA plans:
Plan Type
Non-Health Saving Account (non-HSA) Plans
Plan Type
HSA Plans
Individual
$6,850
Individual
$6,550
Family
$13,700
Family
$13,100
Inclusions: The above limits apply to in-network out-of-pocket maximum limits for all plans that include a funded account for
medical expenses, including high-deductible health plans.
Exclusions: Grandfathered plans and 1-50 transitional relief groups* are excluded.
Some UnitedHealthcare Commercial Members May Have Multiple Out-of-Pocket Maximum Limits
Seven employers who offer UnitedHealthcare commercial benefit plans will allow calculation and accumulation of a new copay
maximum and a new out-of-pocket maximum for those benefit plans.
Those employers include:
1. Employee Retirement System for the State of Texas
2. State of Maryland
3. State of Florida
4. Kohler
5. Caterpillar
6. MetLife
7. AT&T
Continued >
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< Continued
Starting Jan. 1, 2016, when a care provider accesses member eligibility/benefits information
on UnitedHealthcareOnline.com for the seven listed employers’ benefit plans, the new
individual/family new out-of-pocket maximum limits will be displayed under Patient Eligibility
& Benefits along with the following message:
UnitedHealthcare
Commercial
Changes in Advance
Notification and
Prior Authorization
Requirements
“This patient’s plan design has multiple out of pocket maximums, please review the benefit
plan documents or contact the customer service member number on the member’s ID card
for important benefit information.”
In March 2016, the individual/family new out-of-pocket maximum limits will be displayed as
two new fields as:
•
Copay Maximum
•
Out of Pocket Maximum 2
The fields for the out-of-pocket maximum limits will be separate for those members with
individual coverage and those with family coverage.
If you have questions, please call Provider Services at 877-842-3210.
* Under the Centers for Medicare & Medicaid Services’ extended transitional relief policy,
small group employers with up to 100 employees may renew their non-compliant coverage
for a policy year beginning on or before Oct 1, 2016. Transitional Relief only applies to
groups that do not offer Affordable Care Act-compliant small group plans. Insurers will
allow employer groups to modify their anniversary date or elect a short plan year in order
to ultimately have an Oct. 1, 2016 anniversary date. Certain restrictions may apply to each
insurer.
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UnitedHealthcare Commercial
UnitedHealthcare Medical Policy, Drug Policy and
Coverage Determination Guideline (CDG) Updates
For complete details on the policy updates listed in the following table, please refer to the January 2016 Medical Policy
Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medical & Drug
Policies and Coverage Determination Guidelines > Medical Policy Update Bulletin.
Policy Title
Policy Type
Effective Date
Abnormal Uterine Bleeding and Uterine Fibroids
Medical
Jan. 1, 2016
Attended Polysomnography for Evaluation of Sleep Disorders
Medical
Jan. 1, 2016
Bariatric Surgery
Medical
Jan. 1, 2016
Breast Imaging for Screening and Diagnosing Cancer
Medical
Jan. 1, 2016
Cardiovascular Disease Risk Tests
Medical
Jan. 1, 2016
Cochlear Implants
Medical
Jan. 1, 2016
Cosmetic and Reconstructive Procedures
CDG
Jan. 1, 2016
Emergency Health Services and Urgent Care
CDG
Jan. 1, 2016
Fecal DNA Testing
Medical
Jan. 1, 2016
Gastrointestinal Motility Disorders, Diagnosis and Treatment
Medical
Jan. 1, 2016
Gene Expression Tests
Medical
Jan. 1, 2016
Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC)
Medical
Jan. 1, 2016
Glaucoma Surgical Treatments
Medical
Jan. 1, 2016
Hepatitis Screening
Medical
Jan. 1, 2016
Home Health Care
CDG
Jan. 1, 2016
Implanted Electrical Stimulator for Spinal Cord
Medical
Jan. 1, 2016
ANNUAL CPT/HCPCS CODE UPDATES
Continued >
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< Continued
UnitedHealthcare
Commercial
UnitedHealthcare
Medical Policy, Drug
Policy and Coverage
Determination Guideline
(CDG) Updates
Policy Title
Policy Type
Effective Date
Macular Degeneration Treatment Procedures
Medical
Jan. 1, 2016
Molecular Profiling to Guide Cancer Treatment
Medical
Jan. 1, 2016
Occipital Neuralgia and Headache Treatment
Medical
Jan. 1, 2016
Omnibus Codes
Medical
Jan. 1, 2016
Preventive Care Services
CDG
Jan. 1, 2016
Sodium Hyaluronate
Medical
Jan. 1, 2016
Transcatheter Heart Valve Procedures
Medical
Jan. 1, 2016
Alemtuzumab
Drug
Feb. 1, 2016
Anemia Drugs: Darbepoetin Alfa, Epoetin Alfa, and
Methoxy Polyethylene Glycol-Epoetin Beta
Drug
Feb. 1, 2016
Clotting Factors and Coagulant Blood Products
Drug
Feb. 1, 2016
Deep Brain Stimulation
Medical
Jan. 1, 2016
Electrical Stimulation and Electromagnetic Therapy
for Wounds
Medical
Jan. 1, 2016
Entyvio (Vedolizumab)
Drug
Feb. 1, 2016
Genetic Testing for Hereditary Breast and/or Ovarian
Cancer Syndrome (HBOC)
Medical
Jan. 1, 2016
Hereditary Angioedema (HAE), Treatment and Prophylaxis
Drug
Feb. 1, 2016
Hysterectomy for Benign Conditions
Medical
Jan. 1, 2016
Immune Globulin (IVIG and SCIG)
Drug
Feb. 1, 2016
Implantable Beta-Emitting Microspheres for Treatment of
Malignant Tumors
Medical
Jan. 1, 2016
Infertility Diagnosis and Treatment
Medical
Jan. 1, 2016
Intensity-Modulated Radiation Therapy
Medical
Feb. 1, 2016
Lupron Depot/Lupron Depot-Ped (Leuprolide Acetate)
Drug
Feb. 1, 2016
UPDATED/REVISED
Continued >
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
< Continued
UnitedHealthcare
Commercial
UnitedHealthcare
Medical Policy, Drug
Policy and Coverage
Determination Guideline
(CDG) Updates
Policy Title
Policy Type
Effective Date
Mechanical Stretching and Continuous Passive
Motion Devices
Medical
Feb. 1, 2016
Omnibus Codes
Medical
Jan. 1, 2016
Feb. 1, 2016
Preventive Care Services
CDG
Jan. 1, 2016
Sodium Hyaluronate
Medical
Jan. 1, 2016
Surgical Treatment for Spine Pain
Medical
Feb. 1, 2016
Temporomandibular Joint Disorders
Medical
Jan. 1, 2016
Xolair (Omalizumab)
Drug
Feb. 1, 2016
Note: The inclusion of a service or procedure on this list does not imply that
UnitedHealthcare provides coverage for the service or procedure. In the event of an
inconsistency between the information in this Bulletin and the posted policy, the posted
policy will prevail.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
UnitedHealthcare Commercial
Reimbursement Policies
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, enrollee benefit coverage documents,
UnitedHealthcare medical or drug policies, and the
UnitedHealthcare Physician, Health Care Professional, Facility
and Ancillary 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 UnitedHealthcareOnline.com > Tools &
Resources > Policies and Protocols > Reimbursement
Policies-Commercial. In the event of an inconsistency
between the information provided in the Network Bulletin and
the posted policy, the posted policy prevails.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
UnitedHealthcare Commercial Reimbursement Policies
Revision to Bilateral Procedures Policy
for Payment of Bilateral Codes
Effective in the second quarter of 2016, UnitedHealthcare
will apply the Centers for Medicare & Medicaid Services’
(CMS) payment adjustment methodology to bilateral eligible
procedures with a CMS National Physician Fee Schedule
(NPFS) Relative Value File Bilateral Indicator of “1” and a
Multiple Procedure Indicator of “0” when the procedure code
is reported bilaterally with a modifier 50 or on two separate
lines with a modifier LT and a modifier RT.
The majority of the codes that meet these criteria are
considered add-on codes and should be reported separately
in addition to the code for the primary procedure. For example,
CPT codes 64491, 64494 and 64495 are three of the 57
codes identified on the 2016 NPFS that will be eligible for
reimbursement at 150 percent of the allowable amount for a
single procedure code, not to exceed billed charges, with one
side reimbursed at 100 percent and the other side reimbursed
at 50 percent of the allowable amount.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
This change will follow the CMS payment adjustment
guidelines for all procedure codes with an NPFS Bilateral
Indicator of “1”regardless of their Multiple Procedure
Indicator.
As a reminder, modifier 50 identifies bilateral procedures that
are performed at the same session. The procedure should be
billed on one line with modifier 50 and one unit with the full
charge for both procedures.
For more information on indicators for Bilateral and Multiple
Procedure Payment Reductions, please visit cms.gov/
Medicare/Medicare-Fee-for-Service-Payment/
PhysicianFeeSched/PFS-Relative-Value-Files.html.
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
UnitedHealthcare Commercial Reimbursement Policies
Replacement Codes Policy Implementation
As communicated in the December 2015 Network Bulletin,
UnitedHealthcare will implement the Replacement Codes
Reimbursement Policy for Commercial plans. Consistent
with the Centers for Medicare and Medicaid Services
(CMS), UnitedHealthcare will deny codes assigned a
status code of “I” on the National Physician Fee Schedule
(NPFS) where a Healthcare Common Procedure Coding
System replacement code has been created and a relative
value unit greater than zero is assigned to the replacement
code.
As indicated in the December Network Bulletin, any
revisions based on a review of the 2016 CMS NPFS would
be published in February. As a result of this review, please
reference the following table for a comprehensive list of
codes, which will be denied effective for claims with dates
of service on or after March 1, 2016. UnitedHealthcare will
consider reimbursement for these services when reported
with the appropriate replacement code as directed by CMS.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
Code
Description
44705
Preparation of fecal microbiota for instillation, including
assessment of donor specimen
95941
Continuous intraoperative neurophysiology monitoring, from
outside the operating room
77061
Breast tomosynthesis unilateral
77062
Digital breast tomosynthesis; bilateral
77385
Intensity modulated radiation treatment delivery (IMRT),
includes guidance and tracking, when performed; simple
77386
Intensity modulated radiation treatment delivery (IMRT),
includes guidance and tracking, when performed; complex
77387
Guidance for localization of target volume for delivery of
radiation treatment delivery, includes intrafraction tracking,
when performed
77402
Radiation treatment delivery
77407
Radiation treatment delivery
77412
Radiation treatment delivery
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
UnitedHealthcare Commercial Reimbursement Policies
Revision to Supply Policy – Denial in
Nonfacility Places of Service – Effective Q2
UnitedHealthcare currently denies certain Healthcare
Common Procedure Coding System (HCPCS) supply
codes that are considered incorporated into the Practice
Expense Relative Value Unit (PE RVU) for Evaluation and
Management (E/M) services and/or procedures reported
on the same day in a physician or other health care
professional’s office (places of service 03, 11, 49, 71 and
72). According to the Centers for Medicare & Medicaid
Services (CMS), services paid at nonfacility rates are
inclusive of costs related to providing that service in an
office/clinic setting, patient home or other non-facility
setting.
For a complete list of CMS place of service codes with
descriptions, please see the CMS POS Code Set at
cms.gov/Medicare/Coding/place-of-servicecodes/Place_of_Service_Code_Set.html.
Durable medical equipment and home health providers
will be excluded from this enhancement due to certain
contracting and coverage guidelines. This change will be
effective in the second quarter of 2016.
UnitedHealthcare will further align the supply policy with
CMS by adding the following nonfacility places of service
where supplies will no longer be separately reimbursed
when reported with an E/M service and/or procedure with
the same date of service by the same provider: 01, 04, 09,
12, 13, 14, 15, 16, 17, 20, 33, 50, 54, 55, 57, 60, 62, 65,
81 and 99.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
UnitedHealthcare Community Plan
UnitedHealthcare Community Plan
Medical Policy & Coverage Determination
Guideline Updates
For complete details on the policy updates listed in the
following table, please refer to the January 2016 Medical
Policy Update Bulletin at UHCCommunityPlan.com >
Provider Information > UnitedHealthcare Community
Plan Medical Policies and Coverage Determination
Guidelines.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
< Continued
Policy Title
Policy Type
Effective Date
Abnormal Uterine Bleeding and Uterine Fibroids
Medical
Jan. 1, 2016
Attended Polysomnography for Evaluation of Sleep
Disorders
Medical
Jan. 1, 2016
Breast Imaging for Screening and Diagnosing Cancer
Medical
Jan. 1, 2016
Cochlear Implants
Medical
Jan. 1, 2016
Cosmetic and Reconstructive Procedures
CDG
Jan. 1, 2016
Emergency Health Services and Urgent Care Center
Services
CDG
Jan. 1, 2016
Fecal DNA Testing
Medical
Jan. 1, 2016
Gastrointestinal Motility Disorders, Diagnosis and
Treatment
Medical
Jan. 1, 2016
Gene Expression Tests
Medical
Jan. 1, 2016
Genetic Testing for Hereditary Breast and/or Ovarian
Cancer Syndrome (HBOC)
Medical
Jan. 1, 2016
Hepatitis Screening
Medical
Jan. 1, 2016
Home Health Care
CDG
Jan. 1, 2016
Hospice (Applies to the State of Louisiana Only)
CDG
Jan. 1, 2016
Implanted Electrical Stimulator for Spinal Cord
Medical
Jan. 1, 2016
Macular Degeneration Treatment Procedures
Medical
Jan. 1, 2016
Occipital Neuralgia and Headache Treatment
Medical
Jan. 1, 2016
Omnibus Codes
Medical
Jan. 1, 2016
Transcatheter Heart Valve Procedures
Medical
Jan. 1, 2016
Medical
March 1, 2016
ANNUAL CPT/HCPCS CODE UPDATES
UnitedHealthcare
Community Plan
UnitedHealthcare
Community Plan
Medical Policy &
Coverage Determination
Guideline Updates
NEW
Helicobacter Pylori Serology Testing
Continued >
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
< Continued
Policy Title
Policy Type
Effective Date
Balloon Sinus Ostial Dilation
Medical
Feb. 1, 2016
UnitedHealthcare
Community Plan
Bariatric Surgery
Medical
Feb. 1, 2016
Cardiovascular Disease Risk Tests
Medical
Feb. 1, 2016
UnitedHealthcare
Community Plan
Medical Policy &
Coverage Determination
Guideline Updates
Deep Brain Stimulation
Medical
Jan. 1, 2016
Discogenic Pain Treatment
Medical
Feb. 1, 2016
Electrical Stimulation and Electromagnetic Therapy for
Wounds
Medical
Jan. 1, 2016
Electrical Stimulation for the Treatment of Pain and Muscle
Rehabilitation
Medical
Feb. 1, 2016
Femoroacetabular Impingement Syndrome
Medical
Feb. 1, 2016
Genetic Testing for Hereditary Breast and/or Ovarian
Cancer Syndrome (HBOC)
Medical
Jan. 1, 2016
Glaucoma Surgical Treatments
Medical
Feb. 1, 2016
Implantable Beta-Emitting Microspheres for Treatment of
Malignant Tumors
Medical
Jan. 1, 2016
Intensity-Modulated Radiation Therapy
Medical
Feb. 1, 2016
Mechanical Stretching and Continuous Passive Motion
Devices
Medical
March 1, 2016
Omnibus Codes
Medical
UPDATED/REVISED
Jan. 1, 2016
March 1, 2016
Prosthetic Devices, Specialized, Microprocessor or
Myoelectric Limbs
CDG
Feb. 1, 2016
Sodium Hyaluronate
Medical
Feb. 1, 2016
Speech Language Pathology Services
CDG
March 1, 2016
Surgical Treatment for Spine Pain
Medical
March 1, 2016
Note: The inclusion of a service or procedure on this list does not imply that
UnitedHealthcare provides coverage for the service or procedure. In the event of an
inconsistency between the information in this Bulletin and the posted policy, the posted
policy will prevail.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
UnitedHealthcare Community Plan
Injectable Chemotherapy Prior Authorization
Program for UnitedHealthcare Community Plans
in Maryland and Washington
In an effort to improve health care experiences outcomes
and total cost of care for UnitedHealthcare Community Plan
members, prior authorization will be required for injectable
outpatient chemotherapy drugs given for a cancer
diagnosis, effective April 1, 2016, for UnitedHealthcare
Community Plan members in Maryland and May 1, 2016,
for UnitedHealthcare Community Plan members in
Washington.
Additional information about this program will be
available in future Network Bulletins. For more
information on the UnitedHealthcare Injectable
Chemotherapy Prior Authorization program, please go
to UnitedHealthcareOnline.com > Clinician Resources
> Oncology > Chemotherapy (Injectable) Prior
Authorization Program.
Today, UnitedHealthcare uses the National Comprehensive
Cancer Network Guidelines in our oncology decision
making. We have contracted with another company to
provide a web-based application to review chemotherapy
regimens.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
UnitedHealthcare Medicare Solutions
The Centers for Medicare &
Medicaid Services Local Coverage
Determinations for DME
UnitedHealthcare Medicare Solutions is reviewing our current
medical policies and creating new medical policies to be
more consistent with the coverage and medical necessity
criteria outlined in the Centers for Medicare & Medicaid
Services’ (CMS) Durable Medical Equipment (DME) Local
Coverage Determination (LCD) policies.
Beginning March 1, 2016, we will update coverage criteria
in new or existing medical policies. For details on the
Medicare coverage requirements for various DME items
and/or services, please visit the CMS Medicare coverage
database. Any UnitedHealthcare Medicare Solutions
medical policy document changes will be published on
UnitedHealthcareOnline.com.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
UnitedHealthcare Affiliates
Discontinuation and Limitation of OneNet
PPO Products
UnitedHealthcare is making changes to our OneNet PPO network
products. By March 15, 2016, we will no longer offer, market or sell a
number of our OneNet PPO network products, and will limit availability
of others. The changes are as follows:
•
By March 15, 2016, all groups and payers will no longer have
access to the following network products:
–– OneNet PPO medical network (Health)
–– MAPSI behavioral health network, including MAPSI utilization
management services (Health)
–– OneNet Dental PPO network
–– OneNet Dental discount network
•
The OneNet workers’ compensation network will continue to be
used after March 15, 2016, but only groups accessing workers’
compensation programs directly administered, marketed or sold
by UnitedHealth Group affiliates will have access to the OneNet
workers’ compensation network. Facilities, physicians, health care
professionals, ancillaries and behavioral health care providers
currently participating in the OneNet workers’ compensation
network will continue to participate in that network and provide
services to injured workers from groups accessing an authorized
UnitedHealth Group affiliate program.
These changes only affect products marketed or sold under the OneNet
PPO name. No other UnitedHealthcare medical, behavioral health,
dental or workers’ compensation product or program is affected.
For services provided through OneNet’s medical and MAPSI behavioral
health network products, OneNet will continue to process claims with
valid dates of service for up to one year from each group’s termination
date, subject to any timely filing requirements that apply. Claims with dates
of service outside a group’s access dates are not eligible for OneNet
contracted rates and will be returned to the provider.
After March 15, 2016, please direct questions about OneNet claim
pricing to OneNet Customer Care at 800-342-3289. For claims payment
questions, please contact the payer listed on the patient’s ID card.
OneNet’s clients are primarily located in Delaware, Maryland, North
Carolina, Pennsylvania, Virginia, West Virginia, and Washington, D.C.
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
UnitedHealthcare Affiliates
UnitedHealthcare Oxford Medical and
Administrative Policy Updates
For complete details on the policy updates listed in the following table, please refer to the January 2016 Policy Update Bulletin
at OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies
> Policy Update Bulletin.
Policy Title
Policy Type
Effective Date
Abnormal Uterine Bleeding and Uterine Fibroids
Clinical
Jan. 1, 2016
Ambulance Policy
Reimbursement
Jan. 1, 2016
Assistant Surgeons
Reimbursement
Jan. 11, 2016
Attended Polysomnography for Evaluation of Sleep Disorders
Clinical
Jan. 1, 2016
B Bundle Codes
Reimbursement
Jan. 1, 2016
Bariatric Surgery
Clinical
Jan. 1, 2016
Breast Imaging for Screening and Diagnosing Cancer
Clinical
Jan. 1, 2016
Cardiovascular Disease Risk Tests
Clinical
Jan. 1, 2016
Co-Surgeons; Team Surgeons
Reimbursement
Jan. 1, 2016
Cochlear Implants
Clinical
Jan. 1, 2016
Contraceptives
Clinical
Jan. 1, 2016
Cosmetic and Reconstructive Procedures
Clinical
Jan. 1, 2016
Dialysis Services
Clinical
Jan. 1, 2016
Drug Coverage Guidelines
Clinical
Jan. 1, 2016
Durable Medical Equipment, Orthotics and Prosthetics Multiple Frequency
Reimbursement
Jan. 1, 2016
Eloctate (Antihemophilic Factor (Recombinant), FC Fusion Protein) for Connecticut Lines of Business,
and New Jersey Individual Plans
Clinical
Jan. 1, 2016
Fecal DNA Testing
Clinical
Jan. 1, 2016
From - To Date Policy
Reimbursement
Jan. 1, 2016
ANNUAL CPT/HCPCS CODE UPDATES
Continued >
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
< Continued
UnitedHealthcare
Affiliates
UnitedHealthcare
Oxford Medical and
Administrative Policy
Updates
Policy Title
Policy Type
Effective Date
Gastrointestinal Motility Disorders, Diagnosis and
Treatment
Clinical
Jan. 1, 2016
Gene Expression Tests
Clinical
Jan. 1, 2016
Genetic Testing for Hereditary Breast and/or Ovarian
Cancer Syndrome (HBOC)
Clinical
Jan. 1, 2016
Glaucoma Surgical Treatments
Clinical
Jan. 1, 2016
Home Health Care
Clinical
Jan. 1, 2016
Implanted Electrical Stimulator for Spinal Cord
Clinical
Jan. 1, 2016
Inpatient Maternity Stay and Subsequent Home Nursing
Clinical
Jan. 1, 2016
Macular Degeneration Treatment Procedures
Clinical
Jan. 1, 2016
Manipulative Therapy
Clinical
Jan. 1, 2016
Maximum Frequency Per Day
Reimbursement
Jan. 11, 2016
Moderate Sedation
Reimbursement
Jan. 1, 2016
Molecular Profiling to Guide Cancer Treatment
Clinical
Jan. 1, 2016
Multiple Procedures
Reimbursement
Jan. 11, 2016
Occipital Neuralgia and Headache Treatment
Clinical
Jan. 1, 2016
Omnibus Codes
Clinical
Jan. 1, 2016
One or More Sessions
Reimbursement
Jan. 11, 2016
Oxford's Outpatient Imaging Self-Referral Policy
Clinical
Jan. 1, 2016
Precertification Exemptions for Outpatient Services
Administrative
Jan. 1, 2016
Preventive Care Services
Clinical
Jan. 1, 2016
Preventive Medicine and Screening
Clinical
Jan. 1, 2016
Procedure and Place of Service
Reimbursement
Jan. 11, 2016
Prolonged Services
Clinical
Jan. 1, 2016
Radiation Therapy Procedures Requiring Precertification
For eviCore Healthcare Arrangement
Clinical
Jan. 1, 2016
Radiology Procedures Requiring Precertification for
eviCore Healthcare Arrangement
Clinical
Jan. 1, 2016
Continued >
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
< Continued
UnitedHealthcare
Affiliates
UnitedHealthcare
Oxford Medical and
Administrative Policy
Updates
Policy Title
Policy Type
Effective Date
Sodium Hyaluronate
Clinical
Jan. 1, 2016
Supply Policy
Reimbursement
Jan. 11, 2016
Telemedicine Policy
Reimbursement
Jan. 1, 2016
Time Span Codes
Reimbursement
Jan. 1, 2016
Transcatheter Heart Valve Procedures
Clinical
Jan. 1, 2016
Vaccines
Clinical
Jan. 1, 2016
Helicobacter Pylori Serology Testing
Clinical
Feb. 1, 2016
Physical Medicine & Rehabilitation: Multiple Therapy
Procedure Reduction
Reimbursement
April 1, 2016
Agents for Migraine - Triptans
Clinical
Feb. 1, 2016
Alemtuzumab
Clinical
Feb. 1, 2016
Anemia Drugs: Darbepoetin Alfa, Epoetin Alfa, and
Methoxy Polyethylene Glycol-Epoetin Beta
Clinical
Feb. 1, 2016
Assisted Administration of Clotting Factors and Coagulant
Blood Products
Clinical
Feb. 1, 2016
Balloon Sinus Ostial Dilation
Clinical
Feb. 1, 2016
Behavioral Health Services
Administrative
Feb. 1, 2016
Bilateral Procedures
Reimbursement
NEW
UPDATED/REVISED
Dec. 28, 2015
Jan. 1, 2016
Breast Reduction Surgery
Clinical
Feb. 1, 2016
Clotting Factors and Coagulant Blood Products
Clinical
Feb. 1, 2016
Discogenic Pain Treatment
Clinical
Feb. 1, 2016
Drug Coverage Criteria - New and Therapeutic Equivalent
Medications
Clinical
Feb. 1, 2016
Continued >
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
< Continued
Policy Title
Policy Type
Drug Coverage Guidelines
Clinical
Effective Date
Jan. 1, 2016
Feb. 1, 2016
UnitedHealthcare
Affiliates
UnitedHealthcare
Oxford Medical and
Administrative Policy
Updates
Electrical Stimulation for the Treatment of Pain and Muscle
Rehabilitation
Clinical
Feb. 1, 2016
Entyvio (Vedolizumab)
Clinical
Feb. 1, 2016
Epiduroscopy, Epidural Lysis of Adhesions and Functional
Anesthetic Discography
Clinical
Jan. 1, 2016
Femoroacetabular Impingement Syndrome Treatment
Clinical
Feb. 1, 2016
Global Days
Reimbursement
Feb. 1, 2016
Hearing Aids and Devices Including Wearable, BoneAnchored and Semi-Implantable
Clinical
Jan. 1, 2016
Hip Resurfacing Arthroplasty
Clinical
Jan. 1, 2016
Immune Globulin (IVIG and SCIG)
Clinical
Feb. 1, 2016
Injectable Chemotherapy Drugs: Application of NCCN
Clinical Practice Guidelines
Clinical
Feb. 1, 2016
Injection and Infusion Services
Reimbursement
Feb. 1, 2016
Lupron-Depot / Lupron-Depot Ped (Leuprolide Acetate)
Clinical
Feb. 1, 2016
Mechanical Circulatory Support Device (MCSD)
Clinical
Feb. 1, 2016
Omnibus Codes
Clinical
Jan. 1, 2016
Feb. 1, 2016
Oxford's Outpatient Imaging Self-Referral Policy
Clinical
Jan. 1, 2016
Par Gastroenterologists Using Non-Par Anesthesiologists:
In-Office & Ambulatory Surgery Centers
Administrative
March 1, 2016
Preventive Care Services
Clinical
Jan. 1, 2016
Prosthetic Devices, Wigs, Specialized, Microprocessor or
Myoelectric Limbs
Clinical
Feb. 1, 2016
Continued >
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
< Continued
UnitedHealthcare
Affiliates
UnitedHealthcare
Oxford Medical and
Administrative Policy
Updates
32
32
Policy Title
Policy Type
Effective Date
Select Brand Medications
Clinical
Feb. 1, 2016
Sodium Hyaluronate
Clinical
Jan. 1, 2016
Xolair (Omalizumab)
Clinical
Feb. 1, 2016
Note: The appearance of a service or procedure on this list does not imply that Oxford
provides coverage for the service or procedure. In the event of an inconsistency or conflict
between the information provided in this bulletin and the posted policy, the provisions of the
posted policy will 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.
Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
UnitedHealthcare Affiliates
UnitedHealthcare of the River Valley
Preauthorization List and Coverage Policy Updates
For complete details on the policy updates listed in the following table, please refer to the January 2016 Policy Update
Bulletin at UHCRiverValley.com > Providers > Coverage Policy Library > Policy Update Bulletin.
Policy Title
Policy Type
TAKE NOTE
UnitedHealthcare of the River Valley Coverage Policy Transition
Feb. 1, 2016
ANNUAL CPT/HCPCS CODE UPDATES
Abnormal Uterine Bleeding and Uterine Fibroids
Jan. 1, 2016
Attended Polysomnography for Evaluation of Sleep Disorders
Jan. 1, 2016
Bariatric Surgery
Jan. 1, 2016
Breast Imaging for Screening and Diagnosing Cancer
Jan. 1, 2016
Cardiovascular Disease Risk Tests
Jan. 1, 2016
Cochlear Implants
Jan. 1, 2016
Cosmetic and Reconstructive Procedures
Jan. 1, 2016
Fecal DNA Testing
Jan. 1, 2016
Gastrointestinal Motility Disorders, Diagnosis and Treatment
Jan. 1, 2016
Gene Expression Tests
Jan. 1, 2016
Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC)
Jan. 1, 2016
Glaucoma Surgical Treatments
Jan. 1, 2016
Hepatitis Screening
Jan. 1, 2016
Home Health Care
Jan. 1, 2016
Continued >
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
< Continued
UnitedHealthcare
Affiliates
UnitedHealthcare
of the River Valley
Preauthorization List
and Coverage Policy
Updates
Policy Title
Policy Type
Implanted Electrical Stimulator for Spinal Cord
Jan. 1, 2016
Macular Degeneration Treatment Procedures
Jan. 1, 2016
Molecular Profiling to Guide Cancer Treatment
Jan. 1, 2016
Occipital Neuralgia and Headache Treatment
Jan. 1, 2016
Omnibus Codes
Jan. 1, 2016
Preventive Care Services
Jan. 1, 2016
Sodium Hyaluronate
Jan. 1, 2016
Transcatheter Heart Valve Procedures
Jan. 1, 2016
UPDATED/REVISED
Alemtuzumab
Feb. 1, 2016
Anemia Drugs: Darbepoetin Alfa, Epoetin Alfa, and Methoxy Polyethylene GlycolEpoetin Beta
Feb. 1, 2016
Bone or Soft Tissue Healing and Fusion Enhancement Products
Jan. 1, 2016
Chromosome Microarray Testing
Jan. 1, 2016
Cochlear Implants
Jan. 1, 2016
Deep Brain Stimulation
Jan. 1, 2016
Electrical Stimulation And Electromagnetic Therapy For Wounds
Jan. 1, 2016
Entyvio (Vedolizumab)
Feb. 1, 2016
Fecal DNA Testing
Jan. 1, 2016
Gastrointestinal Motility Disorders, Diagnosis and Treatment
Jan. 1, 2016
Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC)
Jan. 1, 2016
Hereditary Angioedema (HAE), Treatment and Prophylaxis
Feb. 1, 2016
Hysterectomy for Benign Conditions
Jan. 1, 2016
Immune Globulin (IVIG and SCIG)
Feb. 1, 2016
Continued >
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Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
< Continued
UnitedHealthcare
Affiliates
UnitedHealthcare
of the River Valley
Preauthorization List
and Coverage Policy
Updates
Policy Title
Policy Type
Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors
Jan. 1, 2016
Intensity-Modulated Radiation Therapy
Feb. 1, 2016
Mechanical Stretching and Continuous Passive Motion Devices
Feb. 1, 2016
Off-Label/Unproven Specialty Drug Treatment
Jan. 1, 2016
Jan. 1, 2016
Omnibus Codes
Feb. 1, 2016
Panniculectomy and Body Contouring Procedures
Jan. 1, 2016
Preventive Care Services
Jan. 1, 2016
Sodium Hyaluronate
Jan. 1, 2016
Surgical Treatment for Spine Pain
Feb. 1, 2016
Temporomandibular Joint Disorders
Jan. 1, 2016
Xolair (Omalizumab)
Feb. 1, 2016
RETIRED/REPLACED
Cardiology- Diagnostic Catheterization, Electrophysiology (EP) Implants,
Echocardiogram and Stress Echocardiogram
Feb. 1, 2016
Complementary and Alternative Medicine
Feb. 1, 2016
Infertility Diagnosis and Treatment
Feb. 1, 2016
Mechanical Circulatory Support Device (MCSD)
Feb. 1, 2016
Nutrition (Including Counseling, Therapy, Enteral Nutrition, Infant Formula, Breast
Milk, Supplements and Food)
Feb. 1, 2016
Radiology/Advanced Outpatient Imaging Procedures
Feb. 1, 2016
Routine Foot Care
Feb. 1, 2016
Note: The inclusion of a service or procedure on this list does not imply that
UnitedHealthcare provides coverage for the service or procedure. In the event of an
inconsistency between the information in this Bulletin and the posted policy, the posted
policy will prevail.
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35
Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
Next Article >
UnitedHealthcare Affiliates
SignatureValue/UnitedHealthcare Benefits Plan of
California Benefit Interpretation Policy Updates
For complete details on the policy updates listed in the following table, please refer to the January 2016 SignatureValue/
UnitedHealthcare Benefits Plan of California Benefit Interpretation Policy Update Bulletin at UHCWest.com >
Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.
Policy Title
Applicable State(s)
Effective Date
California
Jan. 1, 2016
All (California, Oklahoma,
Oregon, Texas, & Washington)
Feb. 1, 2016
Complementary and Alternative Medicine
All
Feb. 1, 2016
Dental Care and Oral Surgery
California
Jan. 1, 2016
Diabetes: Diabetic Management, Services and Supplies
California
Feb. 1, 2016
All
Jan. 1, 2016
California
Feb. 1, 2016
Medical Necessity
All
Feb. 1, 2016
Pain Management
California
Feb. 1, 2016
Parenteral Nutrition Therapy
California
Feb. 1, 2016
Post Mastectomy Surgery
All
Feb. 1, 2016
Rehabilitation Services (Physical, Occupational, and Speech Therapy)
All
Feb. 1, 2016
Vision Care and Services
California
Feb. 1, 2016
TAKE NOTE
Policies to Apply to UnitedHealthcare Benefits Plan of California
NEW
Habilitative Services
UPDATED/REVISED
Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics
(Non-Foot Orthotics) and Medical Supplies Grid
Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the
service or procedure. In the event of an inconsistency between the information in this Bulletin and the posted policy, the
posted policy will prevail.
36
36
Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
UnitedHealthcare Affiliates
SignatureValue/UnitedHealthcare Benefits Plan of
California Medical Management Guideline Updates
For complete details on the policy updates listed in the following table, please refer to the January 2016 SignatureValue/
UnitedHealthcare Benefits Plan of California Medical Management Guidelines Update Bulletin at UHCWest.com >
Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.
Policy Title
Effective Date
TAKE NOTE
Policies to Apply to UnitedHealthcare Benefits Plan of California
Jan. 1, 2016
ANNUAL CPT/HCPCS CODE UPDATES
Abnormal Uterine Bleeding and Uterine Fibroids
Jan. 1, 2016
Attended Polysomnography for Evaluation of Sleep Disorders
Jan. 1, 2016
Bariatric Surgery
Jan. 1, 2016
Breast Imaging for Screening and Diagnosing Cancer
Jan. 1, 2016
Cardiovascular Disease Risk Tests
Jan. 1, 2016
Cochlear Implants
Jan. 1, 2016
Cosmetic and Reconstructive Procedures
Jan. 1, 2016
Emergency Health Services and Urgent Care Center Services
Jan. 1, 2016
Fecal DNA Testing
Jan. 1, 2016
Gastrointestinal Motility Disorders, Diagnosis and Treatment
Jan. 1, 2016
Gene Expression Tests
Jan. 1, 2016
Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC)
Jan. 1, 2016
Glaucoma Surgical Treatments
Jan. 1, 2016
Continued >
37
37
Network Bulletin: November 2013 - Volume 58
Network Bulletin: February 2016
For more information, call 877.842.3210
or visit UnitedHealthcareOnline.com
TABLE OF CONTENTS
< Continued
UnitedHealthcare
Affiliates
SignatureValue/
UnitedHealthcare
Benefits Plan of
California Medical
Management Guideline
Updates
Policy Title
Effective Date
Hepatitis Screening
Jan. 1, 2016
Implanted Electrical Stimulator for Spinal Cord
Jan. 1, 2016
Macular Degeneration Treatment Procedures
Jan. 1, 2016
Molecular Profiling to Guide Cancer Treatment
Jan. 1, 2016
Occipital Neuralgia and Headache Treatment
Jan. 1, 2016
Omnibus Codes
Jan. 1, 2016
Preventive Care Services
Jan. 1, 2016
Sodium Hyaluronate
Jan. 1, 2016
Transcatheter Heart Valve Procedures
Jan. 1, 2016
UPDATED/REVISED
Breast Reduction Surgery
Feb. 1, 2016
Deep Brain Stimulation
Jan. 1, 2016
Electrical Stimulation and Electromagnetic Therapy for Wounds
Jan. 1, 2016
Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC)
Jan. 1, 2016
Hysterectomy for Benign Conditions
Jan. 1, 2016
Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors
Jan. 1, 2016
Intensity-Modulated Radiation Therapy
Feb. 1, 2016
Mechanical Stretching and Continuous Passive Motion Devices
Feb. 1, 2016
Omnibus Codes
Jan. 1, 2016
Feb. 1, 2016
Preventive Care Services
Jan. 1, 2016
Sodium Hyaluronate
Jan. 1, 2016
Surgical Treatment for Spine Pain
Feb. 1, 2016
Temporomandibular Joint Disorders
Jan. 1, 2016
Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare
provides coverage for the service or procedure. In the event of an inconsistency between the
information in this Bulletin and the posted policy, the posted policy will prevail.
38
Network Bulletin: February 2016
Doc#: PCA-1-000622_01122016_01202016
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.