UnitedHealthcare
UHC will update its policy on the treatment with Sodium Hyaluronate effective 10/1/19.
Revised coverage rationale indicates Medical Necessity Plans.
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- Added language to indicate:
- Medical Necessity Plans
- Coverage for Durolane, Euflexxa, and Gelsyn-3 is contingent on criteria in the Diagnosis-Specific Criteria section of the policy; prior authorization is not required
- Coverage for GenVisc 850, Hyalgan, Supartz, Visco-3, Hymovis, Orthovisc, Synvisc or Synvisc-One, Gel-One, Monovisc, TriVisc, or Synojoynt is contingent on the Medical Necessity Criteria and Diagnosis-Specific Criteria sections of the policy In order to continue coverage, members already on these products will be required to change therapy to Durolane, Euflexxa, or Gelsyn-3 unless they meet the Medical Necessity Criteria listed in the policy o.
- Treatment with GenVisc 850, Hyalgan, Supartz, Visco-3, Hymovis, Orthovisc, Synvisc or Synvisc-One, Gel-One, Monovisc, TriVisc, or Synojoynt is medically necessary for the indications specified in this policy when one the criteria below are met:
- Both of the following:
- History of a trial of adequate dose and duration of Durolane, Euflexxa, and Gelsyn-3, resulting in minimal clinical response.
- Physician attests that, in their clinical opinion, the clinical response would be expected to be superior than experienced with Durolane, Euflexxa, and Gelsyn-3 or
- Both of the following:
- History of failure, contraindication, or intolerance to Durolane, Euflexxa, and Gelsyn-3
- Physician attests that, in their clinical opinion, the same failure, contraindication, or intolerance would not be expected to occur with GenVisc 850, Hyalgan, Supartz, Visco-3, Hymovis, Orthovisc, Synvisc or Synvisc-One, Gel-One, Monovisc, TriVisc, or Synojoynt
- Both of the following:
- Medical Necessity Plans
- Added language to indicate:
Cigna
The prior authorization form for Hyaluronic Acid drugs was updated. More information can be found here.
The Cigna policy Effective 09/01/2019 for Ziaflex had been updated:
The following has been added: Authorization for Xiaflex for Dupuytren’s contracture will be a maximum of three injections per cord. Authorization for Xiaflex for Peyronie’s disease will be a maximum of 4 treatment cycles (or 8 injections). For additional detailed information and to view the entire policy, click on this link.
Aetna
Aetna has a new policy for ultrasound guidance was effective 8/1/19. This policy lists when Aetna considers ultrasound guidance medically necessary and not medically necessary. Learn more here.
Medicare
A new listing for August, 2019 under the OIG work plan is auditing facet injections.
New DME RAC audit beginning October 1, 2019 is for ankle orthoses.
It is required effective January 1, 2020 that no social security numbers should be used for beneficiary Medicare ID numbers. Please make sure all of your patient’s demographic information has been changed to the new Medicare numbers.
Lynn M. Anderanin, CPC,
CPMA, CPC-I, CPPM,
COSC
847-720-7090
landeranin@healthinfoservice.com