Humana – Cardiology Code Edits

August 2017 ~

Humana released three Cardiology code edits that will be effective as of August 2017, as well as significant revisions to certain medical coverage policies.

These updates are as follows:

Cardiology – Noninvasive Vascular Diagnostic Studies

• UPDATE: Duplex scan of extracranial arteries, study, is eligible for reimbursement only for a patient 18 years of age or older and only when billed with a diagnosis showing carotid artery stenosis (CAS) symptom(s).
  • Note: This code edit was previously implemented for commercial products effective January 26, 2015. This notification expands the scope of the code edit to Florida and Illinois Medicaid products.
• Reason behind Change:
  • According to the U.S. Preventive Services Task Force (USPSTF), it is not appropriate to screen for CAS in adult asymptomatic patients. After internal review, and consistent with USPSTF recommendations, Humana has determined that the service is only indicated for adults exhibiting symptoms that may be associated with CAS.
• Providers affected:
  • Inpatient/Outpatient Facilities
  • Physician/Health Care Providers
• Impacted products:
  • Medicaid – Florida
  • Medicaid – Illinois
• Effective date: August 31, 2017

Cardiology – Cardiac Output Monitoring by Thoracic Electrical Bioimpedance (TEB)

• UPDATE: Bioimpedance-derived physiologic cardiovascular analysis is eligible for reimbursement only when billed with a diagnosis code supported by an indication in the Medicare National Coverage Determinations Manual.
• Reason behind Change:
  • According to Humana policy, and as supported by the Medicare National Coverage Determinations Manual, bioimpedance-derived physiologic cardiovascular analysis is indicated only for the conditions described above.
• Providers affected:
  • Inpatient/Outpatient Facilities
  • Physician/Health Care Providers
• Impacted products:
  • Medicaid – Florida
  • Medicaid – Illinois
• Effective date: August 31, 2017

Cardiology – Electrocardiograms (ECG)

• UPDATE: For a patient 18 years of age or older, a charge for routine ECG is not eligible for reimbursement when submitted with an office place of service and a diagnosis of general medical exam or cardiovascular screening.
  • Note:This code edit was previously implemented for commercial and Medicare products effective Nov. 9, 2015. This notification expands the scope of the code edit to Florida Medicaid products.
• Reason behind Change:
  • The U.S. Preventive Services Task Force (USPSTF) discourages the use of ECG for asymptomatic adults at low risk for coronary heart disease (CHD) events. After internal review, and consistent with USPSTF recommendations, Humana has determined that such routine ECG is not medically necessary and, therefore, is not covered.
• Providers affected:
  • Inpatient/Outpatient Facilities
  • Physician/Health Care Providers
• Impacted products:
  • Medicaid – Florida
• Effective date: August 3, 2017

New and Revised Pharmacy and Medical Coverage Policies

Recent changes to Anthem’s medical and pharmacy coverage policies are as follows:

• New Pharmacy Coverage Policies
  • Actemra (tocilizumab)
  • Aubagio (teriflunomide)
  • Berinert (human c1 inhibitor)
  • Chantix (varenicline)
  • Corticosteroid and long-acting beta agonist combination inhalers
  • Extavia (interferon beta-1b)
  • Kalydeco (ivacaftor)
  • Molindone
  • Neupogen (filgrastim)
  • Plegridy (peginterferon beta-1a)
  • Tecfidera (dimethyl fumarate)
  • Xeljanz and Xeljanz XR (tofacitinib)
  • Xgeva (denosumab)
  • Zinbryta (daclizumab)
  • Zyban (bupropion SR)
• Pharmacy Coverage Policies with Significant Revisions
  • Bavencio (avelumab)
  • Ingrezza (valbenazine)
  • Tymlos (abaloparatide)
  • Zejula (niraparib)
• New Medical Coverage Policies
  • Molecular diagnostic testing for vaginitis and sexually transmitted infections
  • Recurrent pregnancy loss
• Medical Coverage Policies with Significant Revisions
  • Chronic vertigo evaluation and treatments
  • Discography
  • Electrical stimulators for pain and nausea/vomiting
  • Gender reassignment surgery
  • Genetic testing for diagnosis and monitoring – noncancer indications
  • Home health
  • Nasal surgical treatments (balloon dilation and endoscopic)
  • Speech generating devices, voice prostheses
  • Tilt table testing

Source(s): Humana Claim Processing Edits; Humana Medical Coverage Policies; Humana Physician Articles;