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News & Announcements

AUA Public Policy Council Update

Posted: June 23, 2022

From the Chair

I am pleased to share updates from the AUA Public Policy Council that may benefit your Section members. Our updates include information on the recent American Medical Association House of Delegates meeting and an action alert for the Specialty Physicians Advancing Rural Care (SPARC) Act, S. 4330.

Action Alert: Urge Your Senator to Cosponsor the SPARC Act

On May 26, Senators Jacky Rosen (D-NV) and Roger Wicker (R-MS) introduced AUA-led S. 4330, the Specialty Physicians Advancing Rural Care (SPARC) Act. The SPARC Act mimics existing loan forgiveness program structures of $250,000 of student loan forgiveness in exchange for six years of service in a rural area. However, it expands eligibility to all medical specialties and adds a requirement for Health Resources Services Administration to report on the shortage of specialty physicians in the United States.

The AUA will continue to advocate for legislation — such as the SPARC Act — that improves the future of the specialty physician workforce. We encourage you to contact your two senators and request they cosponsor S. 4330 today! Access the action center or text AUA to 52886 to get started.

In addition to building support on Capitol Hill, the AUA is working with various organizations to increase external support for the bill. Thus far, the SPARC Act has received endorsements from the American Academy of Allergy, Asthma, and Immunology; American College of Rheumatology; American Gastroenterological Association; American Medical Students Association and Student National Medical Association. We also remain in contact with larger physician groups to garner additional support.

American Medical Association (AMA) House of Delegates (HoD): Medicare Payment Reform and Regulatory Burdens Highlight Annual Meeting

aua-photo

On June 11 – 15, AUA Delegates — Hans Arora, MD, and Jason Jameson, MD; AUA Resident/Fellow Section Delegate Ruchika Talwar, MD and AUA Gallagher Scholar Brian Duty, MD, represented the AUA at the 2022 AMA HoD Annual Meeting. Top issues at the meeting included reforming the Medicare Physician Fee Schedule, delaying appropriate use criteria, telemedicine expansion, scope of practice and professional liability issues.

During the meeting, delegates participated in a variety of specialty caucus pre-meetings, including those hosted by the Surgical Caucus (organized by the American College of Surgeons) and the Cancer Caucus (organized by the American Society of Clinical Oncology).

In addition, the AUA delegation was active in eight different reference committee meetings covering more than 200 distinct reports and resolutions relating to clinical practice, payment, medical education and public health topics. They provided testimony on multiple issues, including on Resolution 226 Coverage for Clinical Trial Ancillary Costs and Resolution 101 Fertility Preservation Benefits for Active-Duty Military Personnel.

To read more about each day of the meeting, follow along on the Policy & Advocacy Brief:

As a reminder, the AMA HoD is the principal policy-making body of the AMA. It represents the views and interests of a diverse group of member physicians from more than 170 societies. These delegates meet twice a year to establish policy on health, medical, professional and governance matters.

AUA, ASM Meet with House Committees to Discuss Payment Reform

On June 1, the AUA participated in an Alliance for Specialty Medicine (ASM) meeting with House Energy & Commerce and House Ways & Means Committees staff. The Alliance discussed Medicare payment reform for specialty medicine and requested committee hearings on Medicare physician payment and MACRA. During the meeting, the AUA and ASM also requested extensions on financial relief until a long-term solution to the Medicare physician payment system is meaningfully addressed and continued dialogue with the Alliance on ways to “fix “the broken Medicare physician payment systems.

As a reminder, the AUA requested that members of the House and Senate support reforming the Medicare Physician Fee Schedule during the 2022 AUA Summit. AUA staff will continue to broaden interest and support for legislative solutions to address the Medicare Physician Fee Schedule.

ICYMI: Updates from the AUA Policy & Advocacy Brief blog

AUA Urges CMS to Prohibit Step Therapy in Medicare Advantage Plans

On May 20, the AUA joined the Step Therapy Coalition in asking the Centers for Medicare & Medicaid Services (CMS) to reinstate the step therapy prohibition in Medicare Advantage (MA) plans for Part B drugs as described in the September 17, 2012 HPMS memo Prohibition on Imposing Mandatory Step Therapy for Access to Part B Drugs and Services. The Step Therapy Coalition highlighted concerns that, if step therapy remains permissible, patients will continue to see reductions in access to care.

The AUA remains committed to reducing regulatory burdens in an effort to promote practice sustainability during the COVID-19 public health emergency and beyond. Please visit the AUA’s Policy & Advocacy Brief for a copy of the letter.

AUAPAC Participates in Fundraisers for Key House Committee Members

On June 8, AUAPAC participated in a fundraiser for Representative Paul Tonko (D-NY-20). Rep. Tonko serves on the House Energy & Commerce Committee and is a staunch supporter of working to ease the impending physician workforce shortage, particularly in rural America. During the fundraiser, the congressman expressed the desire to have a physician workforce that can meet the needs of the communities they serve.

On June 9, AUAPAC participated in a fundraiser for Representative Pete Aguilar (D-CA-31). Rep. Aguilar is vice-chair of the House Democratic Caucus and serves on the House Appropriations Committee, which oversees our nation’s federally funded research programs. He is supportive of legislation that would expand access to care by adding additional graduate medical education training slots and measures that would reduce regulatory burdens on physicians. During the fundraiser, the congressman expressed a desire to support physicians and ease the obstacles physicians face, including medical student loan debt.

AUA Urges CMS to Study Effects of Implementation of Appropriate Use Criteria (AUC)

On May 17, the AUA joined with the American Medical Association (AMA) to send a letter to the Centers for Medicare & Medicaid Services (CMS) regarding CMS’ reporting requirements to the Congress about the implementation of the Appropriate Use Criteria (AUC) Program. In the letter, the AMA requests that CMS consider engaging with physicians before preparing its report to Congress. The AMA highlighted that CMS should assess the impact of AUC on small and rural practices, release additional drill-down data about the Education and Operations Testing period and evaluate alternatives to claims-based reporting for AUC information and include it in the final report.

According to CMS, the Appropriate Use Criteria program works to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries. Under this program, at the time a practitioner orders an advanced diagnostic imaging service for a Medicare beneficiary, they will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals through which AUC is accessed. The CDSM provides a determination of whether the order adheres to AUC or if the AUC consulted was not applicable. This program impacts all physicians that order advanced diagnostic imaging services. As a result, the AUA has been working closely with other provider organizations such as the American Medical Association to delay implementation of AUC until, among other things, technical and workflow challenges that add to clinicians’ administrative burden and practice expenses are addressed. Read a full overview of the AUC Program.

Please visit the AUA’s Policy & Advocacy Brief for a copy of the letter.

AUA Supports FY 2023 CDMRP Funding in Letter to Defense Appropriations Subcommittees

On June 2, the AUA and 120 organizations signed onto a Defense Health Research Consortium (DHRC) letter addressed to leaders of the House and Senate defense appropriations subcommittee urging them to protect funding for the Congressionally Directed Medical Research Programs (CDMRP) and to swiftly pass a Fiscal Year 2023 Appropriations bill. Specifically, the letter supports a five percent plus inflation funding increase for defense health research programs. Please see the AUA’s Policy & Advocacy Brief for a copy of the letters.

The AUA continues to advocate on behalf of prostate, kidney and bladder cancer funding within CDMRP.

AUA Supports Rational Medicare Physician Payment System Guiding Principles

On May 27, the AUA joined the American Medical Association (AMA) in a guiding principles document entitled “Characteristics of a Rational Medicare Physician Payment System.” The AMA is aware of the growing financial instability of the Medicare Physician Payment System and the threat it creates to patients’ access to care. The AMA has suggested principles to guide advocacy efforts in addressing the instability of the physician payment system, including ensuring financial stability and predictability, promoting value-based care and safeguarding access to high-quality care. The document can be found here.

The AUA continues to help guide advocacy efforts in addressing cost and reimbursement for patients and physicians.

AUA Meets with House Ways & Means Member, Discusses Key Legislative Priorities

On May 17, the AUA met with staff in the office of Representative Dan Kildee (D-MI-5), who serves on the House Ways & Means Committee. During the meeting, AUA staff thanked Rep. Kildee’s office for his support of H.R. 2903, the CONNECT for Health Act, and his support for H.R. 2256, the Resident Physician Shortage Reduction Act. As a reminder, the CONNECT for Health Act permanently expands telehealth services and the Resident Physician Shortage Reduction Act adds an extra 14,000 GME slots over the next seven years — both of which remain top legislative priorities.

On May 26, the AUA met with staff in the office of Representative Vern Buchanan (R-FL-16), who serves as the ranking member of the House Ways & Means Health Subcommittee. The purpose of the meeting was to highlight the AUA’s various legislative priorities, including expressing our support for such initiatives as easing the specialty physician workforce shortage, making telehealth expansion permanent and reforming the Medicare Physician Fee Schedule.

AUA staff will continue to broaden interest and support for our top priorities among key policymakers during the second session of this 117th Congress.

The AUA also discussed other AUA priorities, such as reforming the Medicare Physician Fee Schedule, diversifying clinical trials, and easing the specialty physician workforce shortage. We will continue to broaden interest and support for our top priorities among key policymakers during the second session of this 117th Congress.

AUA Joins ASM on Federal Trade Commission’s Pharmacy Benefit Manager RFI

On May 17, the AUA joined the Alliance of Specialty Medicine (ASM) in response to the Federal Trade Commission’s (FTC) Request for Information (RFI) regarding whether the FTC should undertake a study of the pharmacy benefit manager (PBM) industry and if the study should focus on pharmacy industry issues or explore manufacturer issues. In the letter, the Alliance states PBMs become primary gatekeepers to commercial pharmaceutical markets which benefits that price concession system. This ultimately causes out-of-pocket drug prices to increase for patients. The letter references a finalized rule by the Office of the Inspector General to remove the safe harbor from anti-kickback law for rebates from drug companies unless the rebates are accessible to patients. PBMs have over-consolidated the pharmaceutical industry, acquiring physician practices to gain full control of prescriptions.

The AUA continues to lead and support committees in efforts to reduce drug pricing and cost-sharing for treatments associated with urologic diseases. Please find a copy of the letter here.

Below are insurance updates from national insurance carriers.

If you have questions about insurer issues, contact Ray Wezik at rwezik@AUAnet.org.

Aetna

Aetna reviewed its Benign Prostatic Hyperplasia Policy with the following changes:

  • Changing its coverage decision for aquablation from experimental/investigational to medically necessary for members with benign prostatic hypertrophy as an alternative to transurethral resection of the prostate.
  • Added melatonin and XFLO expander system (Mercury expander system) to experimental/investigational treatments for BPH
  • Added code C2596
  • Changed coverage decision for code 0421T from not covered to covered if criteria are met

Read the update

Cigna

Cigna reviewed its Besremi (CA Commercial) Prior Authorization (PA) Criteria stating Besremi may be considered medically necessary when criteria are met.

Read the update

CGS Administrators

CGS Administrators retired its 4Kscore Assay (MolDX) Local Coverage Article (LCA) stating that this LCA is being retired because this is no longer within the scope of MolDX program and the lab is not in Jurisdiction 15 so they do not anticipate any claims for this service.

Read the update. (J15, A56944)
Read the update. (J15, L36979)

CGS Administrators released its draft Prostate Cancer Detection with IsoPSA (J15) (DL39284) Local Coverage Determination (LCD) on May 19. A synopsis of draft:

  • The IsoPSA test will be considered medically reasonable and necessary when all the following are met: testing of men 50 years of age and older prior to an initial biopsy, who have a confirmed moderately elevated PSA (greater than 4 and less than 10 ng/mL).
  • PSA elevation should be verified after a few weeks under standardized conditions (e.g., no ejaculation, manipulations, and urinary tract infections, no medications such as 5α-reductase) in the same laboratory or other CLIA approved laboratory before considering a biopsy.
  • No other relative contraindication for prostate biopsy including less than a 10-year life expectancy with benign disease not ruled out.

Read the update.

Food and Drug Administration (FDA)

The FDA published its Recent New and Generic Drug Approvals Administrative Document adding abiraterone acetate.

Read the update

FDA reviewed its Recent New and Generic Drug Approvals Drug Administrative Document adding Erleada.

Read the update

National Government Services

National Government Services released its Sterilization (J6, JK) (A59060) Local Coverage Article (LCA), effective May 1.

Read the update

National Government Services reviewed its Urodynamics (J06, JK) (A57455) Local Coverage Article (LCA) issuing a new version of the document, stating “Due to a provider request, ICD-10 codes N81.2 and N81.3 have been added to group 1 of the ICD-10-CM codes that support medical necessity section, effective for dates of service on or after May 5.”

Read the update

Noridian

Noridian released its draft 4Kscore Assay Local Coverage Determination (LCD) stating “This LCD is being retired because this lab or test is no longer available and Noridian does not anticipate any claims for this service.”

Read the update. (JE) (DL37120)
Read the update. (JF) (DL37122)

Palmetto

Palmetto released its draft Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (MolDX) (JJ, JM) (L38985) Local Coverage Determination (LCD) into future effective policy. The associated response to comments article can be found here.

Read the update

Palmetto released its draft Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer (MolDX) Local Coverage Determination (LCD) and Local Coverage Article (LCA) into future effective policy. The associated response to comments article can be found here. Article addresses billing and coding guidelines that complement the LCD for “MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer” (L38966).

Read the update. (JJ, JM, LCD L38966)
Read the update. (JJ, JM, LCA A58652)

Palmetto published its Response to Comments: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (MolDX) (JJ, JM) (A59069) Local Coverage Article (LCA). This comment/response article is published for DL38985- MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer. The comments were collected from May 20, 2021 to July 3, 2021.

Read the update

United Healthcare

United Healthcare reviewed its Prostate Surgeries and Interventions Policy updating the InterQual reference to access medical necessity clinical coverage criteria for transurethral ablation of the prostate, cryoablation of the prostate, and surgical prostatectomy.

Read the update

United Healthcare reviewed its Prostate Surgeries and Interventions (Value & Balance Exchange) Policy updating InterQual reference to access medical necessity clinical coverage criteria for transurethral ablation of the prostate, cryoablation of the prostate, and surgical prostatectomy.

Read the update

WPS Government Health Administrators

WPS Government Health Administrators published its new Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer (MolDX) Local Coverage Article (LCA) and Local Coverage Determination (LCD). The article addresses billing and coding guidelines that complement the LCD for “MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer” (L39040).

Read the update. (J05, J08, A58756)
Read the update. (J05, J08, L39040)

WPS Government Health Administrators released its draft Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (MolDX) (J05, J08) (L39042) Local Coverage Determination (LCD) into future effective policy. The associated response to comments article can be found here.

Read the update. (J05, J08, L39042)

WPS Government Health Administrators published its Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (MolDX) (J5, J8) (A58759) Local Coverage Article (LCA). The article addresses billing and coding guidelines that complement the LCD for “MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer.” (L39042).

Read the update

WPS Government Health Administrators published its Response to Comments: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer (MolDX) (J5, J8) (A59116) Local Coverage Article (LCA). The comment/response article is published for DL39040 - MolDX: Lab-Developed Tests for Inherited Cancer Syndromes.

Read the update

WPS Government Health Administrators published its Response to Comments: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (MolDX) (J5, J8) (A59118) Local Coverage Article (LCA). The comment/response article is published for DL39042 - MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer. The comments were collected from May 20, 2021 to July 3, 2021.

Read the update

Local and Regional Updates

The following are updates in your Section. The AUA routinely monitors state legislative, regulatory, and insurance policy trends. Please contact AUA State Advocacy Manager Catherine Hendricks at chendricks@AUAnet.org for more information on any of these issues.

Alabama

BCBS Alabama
BCBS Alabama reviewed its Nerve Graft with Radical Prostatectomy (Commercial) Policy with changes to criteria language and supplementary information.

Read the update

Louisiana

BCBS Louisiana
BCBS Louisiana reviewed its Whole Gland Cryoablation of Prostate Cancer Policy stating the National Comprehensive Cancer Network (NCCN) does not recommend cryotherapy as routine primary therapy for localized prostate cancer due to limited data comparing cryotherapy with radiation or radical prostatectomy.

Read the update

North Carolina

BCBS North Carolina
BCBS North Carolina reviewed its Infertility Agents (Commercial) Policy adding quantity and dose limitations.

Read the update

BCBS North Carolina reviewed its Revlimid (Commercial) Prior Authorization (PA) Criteria with changes to approval criteria.

Read the update

S.B. 345 – Scope of Practice
Introduced by Senator Jim Perry (R), S.B. 345 allows certain physician assistants in team-based settings to practice without supervision by a physician, prescribe drugs, initiate non-pharmacological therapies and certify medical documents. The bill passed the Senate and was referred to the Rules, Calendar, and Operations of the House Committee.

South Carolina

BCBS South Carolina
BCBS South Carolina reviewed its General Genetic Testing, Germline Disorders Policy adding codes: 96040, S0265, 0269U, 0277U, 0318U.

Read the update

BCBS South Carolina reviewed its Urinary Tumor Markers for Bladder Cancer Policy removing codes 86386, 88120, 88121, 0012M.

Read the update

Tennessee

BCBS Tennessee
BCBS Tennessee reviewed its Novel Biomarkers for the Diagnosis and Management of Prostate Cancer Policy changing PSA unit from mg/mL to ng/mL.

Read the update