1 Clinical Policy Title: Telehealth Clinical Policy Number: 18.01.02 Effective Date: June 17, 2015 Initial Review Date: June 19, 2013 Most Recent Review Date: April 10, 2018 Next Review Date: April 2020 Related policies: CP# 04.01.03 Ambulatory blood pressure monitoring CP# 09.01.05 Ambulatory and video electroencephalogram (AEEG, VEEG) CP# 11.02.00 Apnea monitors for infants — in-home use CP# 09.01.01 Autonomic nervous system monitoring for neuropathy CP# 03.03.06 Biofeedback for chronic pain CP# 12.01.01 Home uterine activity monitoring CP# 17.01.02 Medical alert devices CP# 06.02.02 Outpatient diabetes self-management training CP# 04.01.01 Real-time outpatient cardiac monitoring CP# 05.01.02 Prothrombin international normalized ratio — self-testing ABOUT THIS POLICY: AmeriHealth Caritas has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas’ clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by AmeriHealth Caritas when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas’ clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas’ clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas will update its clinical policies as necessary. AmeriHealth Caritas’ clinical policies are not guarantees of payment. Coverage policy AmeriHealth Caritas considers telemedicine to be a covered service for members who meet the following criteria (Lee 2018, Heitkemper 2017, Hayes 2015, American Diabetes Association [ADA] 2014, Hilty 2013, Bender 2010): • A member for whom access to specific necessary medical services is not readily available. • A member's healthcare provider must document that the in-service risk for a life-threatening Policy contains: Asynchronous transfer. Distant or hub site. Distant site practitioner. Originating or spoke site. Synchronous transfer.
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Clinical Policy Title: Telehealth
Clinical Policy Number: 18.01.02
Effective Date: June 17, 2015
Initial Review Date: June 19, 2013
Most Recent Review Date: April 10, 2018
Next Review Date: April 2020
Related policies:
CP# 04.01.03 Ambulatory blood pressure monitoring
CP# 09.01.05 Ambulatory and video electroencephalogram (AEEG, VEEG)
CP# 11.02.00 Apnea monitors for infants — in-home use
CP# 09.01.01 Autonomic nervous system monitoring for neuropathy
CP# 03.03.06 Biofeedback for chronic pain
CP# 12.01.01 Home uterine activity monitoring
CP# 17.01.02 Medical alert devices
CP# 06.02.02 Outpatient diabetes self-management training
CP# 05.01.02 Prothrombin international normalized ratio — self-testing
ABOUT THIS POLICY: AmeriHealth Caritas has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas’
clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by AmeriHealth Caritas when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas’ clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas’ clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas will update its clinical policies as necessary. AmeriHealth Caritas’ clinical policies are not guarantees of payment.
Coverage policy
AmeriHealth Caritas considers telemedicine to be a covered service for members who meet the following
criteria (Lee 2018, Heitkemper 2017, Hayes 2015, American Diabetes Association [ADA] 2014, Hilty 2013,
Bender 2010):
• A member for whom access to specific necessary medical services is not readily available.
• A member's healthcare provider must document that the in-service risk for a life-threatening
Policy contains:
Asynchronous transfer.
Distant or hub site.
Distant site practitioner.
Originating or spoke site.
Synchronous transfer.
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event is low (e.g., cardiac arrest during outpatient cardiac telemetry).
• The results of the telehealth intervention will provide diagnostic information and/or treatment
useful in the ongoing management of the patient.
AmeriHealth Caritas does not consider telemedicine to be a substitute for direct member-provider
encounters.
For AmeriHealth Caritas Medicaid members, the service is listed among one of the following:
Provider office visit (CPT 99201-99215).
A follow-up inpatient telehealth consultation furnished to beneficiaries in hospitals or Skilled
Mental health diagnostic visits and psychotherapy based upon coverage requirements.
End-stage renal disease service applicable to telemedicine (CPT codes 90951, 90952, 90954,
90955, 90957, 90958, 90960, and 90961).
Individual and group medical nutritional counseling within benefits limits (HCPCS code G0270
and CPT codes 97802 – 97804).
Limitations:
Telemedicine and telehealth services for which there is no evidence of improved outcomes or for which
there is no defined benefit in state or federal policy are not covered. AmeriHealth Caritas does not provide
coverage for the transmission of telemedicine data such as teleradiology or telecardiology as such
transmission services are integral to the procedures being covered. Fundus photography (CPT 92250) is a
covered service but the transmission of the retinal photographs is included in the CPT code. Telephone
consultation codes 99441 – 99243 are not considered integral to the physician office visit codes and are not
separately reimbursable. Similarly, CPT code 99444 for email consultation is not a covered benefit.
Alternative covered services:
Office visit for diabetic retinal screening by ophthalmologist or optometrist.
Background
As defined by the American Telemedicine Association:
“…telemedicine is the use of medical information exchanged from one site to
another via electronic communications to improve a patient’s clinical health status.
Telemedicine includes a growing variety of applications and services using two-way
video, email, smart phones, wireless tools and other forms of telecommunications
technology.”
The tradition of patient evaluation solely in direct face-to-face encounter has been altered forever.
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Advances in communications technology now afford the patient and physician greater opportunities for
interaction. Physicians have traditionally engaged in telephonic communication to extend the physician-
patient relationship beyond office hours or hospital rounds. In today's world, electronic technology puts
faster and more secure means of communication at one's fingertips.
Telemedicine in its current sense grew from the needs for access to care in rural areas of the United States.
In the 1960s through the 1980s, telemedicine was conducted in demonstration projects by NASA on space
flights, and in remote areas in Nebraska, New Hampshire, and Georgia. Transmission of digital imaging data
afforded superior results than previous analog technology. Telepsychiatry and teledermatology
subsequently initiated a wave of new applications for transmission of synchronous data between provider
and patient.
Telemedicine may be divided into distinct technical categories:
Telephonic. Telephonic communication has defined CPT codes for third-party coverage.
However, when the use of telephone communication is an extension of an office, hospital, or
emergency room visit, it is considered part of the original encounter. Telephonic consultation is
a uni-modality employment of telemedicine.
Remote patient data transfer. Remote data transfer requires no active participation by the
patient. The treating provider uploads and sends imaging or pathologic information to a remote
consultant for interpretation. This transmission generally is asynchronous.
Remote patient monitoring. Remote monitoring of patient data does not convey verbalized
communication by the patient. Biophysical data (e.g., cardiac telemetry) is transmitted to a
physician or medical facility for synchronous or asynchronous interpretation. The so-called
“tele-ICU” in which data from intensive care unit patients is monitored synchronously by a
nurse or physician is an example.
Video consultation. The patient is in live synchronous video and audio communication with the
provider.
Telehealth. Telemedicine may be considered a part of the global term "telehealth." In common
use it refers to a patient encounter with a provider by electronic means either synchronously or
asynchronously.
Not everyone who resides remotely may benefit from this technology. There are identifiable populations
for which telepsychiatry or telemental health is most appropriate (Hilty, 2013):
"… for diagnosis and assessment, across many populations (adult, child, geriatric
and ethnic); and in disorders in many settings (emergency, home health) it is
comparable to in-person care, and complements other services in primary care."
Searches:
AmeriHealth Caritas searched PubMed and the databases of:
• UK National Health Services Centre for Reviews and Dissemination.
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• Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other
evidence-based practice centers.
• The Centers for Medicare & Medicaid Services (CMS).
We conducted searches on February 13, 2018. Search terms were: “telemedicine” (MeSH), “telehealth”
(MeSH), and “teleconsultation.”
We included:
• Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and
greater precision of effect estimation than in smaller primary studies. Systematic reviews use
predetermined transparent methods to minimize bias, effectively treating the review as a
scientific endeavor, and are thus rated highest in evidence-grading hierarchies.
• Guidelines based on systematic reviews.
• Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple
cost studies), reporting both costs and outcomes — sometimes referred to as efficiency studies
— which also rank near the top of evidence hierarchies.
Findings
While telemedicine has been perceived as a way to expand health care services to individuals who reside
remotely from the appropriate providers, early experience did not demonstrate consistently positive
clinical outcomes.
Recent studies indicate that when the technology is applied selectively, improved outcomes can be
achieved.
However, a comprehensive analysis of the literature (Hayes, 2015) on diagnosis of malignant skin
neoplasms concluded that:
"Overall, teledermatology appears somewhat inferior to in-person dermatology for
the diagnosis of skin neoplasms, both in terms of accuracy (compared with
histopathology) and concordance among teledermatologists. In addition, the shift
of responsibility to primary care physicians may lead to underdiagnosis as
physicians may not recognize clinically significant lesions. The accuracy of
teledermatology appears to be somewhat inferior compared with in-person
dermatology for the management of skin neoplasms."
Policy updates:
A systematic review and meta-analysis (Heitkemper, 2017) evaluated glycemic control in 3,257 remote,
medically underserved patients. Studies reporting either hemoglobin A1c pre- and post-intervention or its
change at six or 12 months were eligible for inclusion. Pooled A1c decreases were found at six months (-0.36
(95 percent CI, -0.53 and -0.19]; I 2 = 35.1 percent, Q = 5.0), with diminishing effect at 12 months (-0.27 [95
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percent CI, -0.49 and -0.04]; I 2 = 42.4 percent, Q = 10.4). Interventions varied by tele-intervention type:
computer software without internet (n = 2), cellular/automated telephone (n = 4), internet-based (n = 4),
and telemedicine/telehealth (n = 3). The authors concluded that medically underserved patients with
diabetes achieve glycemic benefit following telehealth interventions, with dissipating but significant effects
at 12 months.
Digital self-management interventions for adults with asthma show potential for benefit, with evidence of
improvements in some outcomes, and no evidence of harm from software packages that can combine
health information with decision support to help inform behavior in patients, and are typically delivered
through the internet or via smartphones. Bender (2010) in a study of self-reported asthmatic medication
compliance found that a hand-held corticosteroid index (determined by dividing the number of inhaler
puffs taken each day by the number of puffs prescribed to be taken each day, and then averaged over a 10-
week interval) was higher in the intervention than in the control group by a margin of 64.5 percent to 49.1
percent (p=0.03). However, the evidence base was weak, and it is not yet possible to recommend this
intervention for routine use in clinical practice due to the current lack of large, robust studies conducted
and published.
During the past twelve months there has been further information published regarding telehealth
management of medical conditions (i.e., for oral anticoagulation management).
A systematic review and meta-analysis (Lee 2018) studied the benefits and harms of telehealth
interventions (n = 6955) compared to usual care for oral anticoagulation management. Telehealth
interventions mainly consisted of telephone visits by clinicians, pharmacists and specialists. Meta-analysis
of 3 studies showed significant improvements in the telehealth group for major thromboembolic events (RR
0.43, 95 percent CI 0.25-0.74, p = 0.002), but no significant difference for major bleeding events (RR 0.83,
95 percent CI 0.52-1.33, p = 0.44). There was no significant difference in any of the secondary outcomes.
The overall quality of evidence was rated very low due to high risk of bias and low precision. Based on very
low quality evidence, telehealth interventions may lower the risk of major thromboembolic events, but not
other clinically important outcomes.
Summary of clinical evidence:
Citation Content, Methods, Recommendations
Lee (2018) Do telehealth interventions improve oral anticoagulation management? A systematic review and meta-analysis.
Key points:
Systematic review and meta-analysis studied the benefits and harms of telehealth interventions compared to usual care for oral anticoagulation management.
Telehealth interventions mainly consisted of telephone visits by clinicians, pharmacists and specialists.
Meta-analysis of 3 studies (n = 6955) showed significant improvements in the telehealth group for major thromboembolic events (RR 0.43, 95% CI 0.25-0.74, p = 0.002), but no significant difference for major bleeding events (RR 0.83, 95% CI 0.52-1.33, p = 0.44).
There was no significant difference in any of the secondary outcomes.
The overall quality of evidence was rated very low due to high risk of bias and low precision.
Based on very low quality evidence, telehealth interventions may lower the risk of major thromboembolic events, but not other clinically important outcomes.
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Citation Content, Methods, Recommendations
Heitkemper (2017)
Do health information
technology self-
management
interventions improve
glycemic control in
medically
underserved adults
with diabetes?
Key points:
Systematic review and meta-analysis to examine glycemic control in over 3,000 remote, medically
underserved patients.
Hemoglobin A1c pre- and post-intervention or its change at six or 12 months were the endpoints.
Mean age 55 years; 66% female; 74% racial/ethnic minorities).
Interventions varied: computer software without internet (n = 2), cellular/automated telephone
90792 Psychiatric diagnostic examination with medical services
90832 Psychotherapy, 30 minutes with patient and/or family member
90834 Psychotherapy, 45 minutes with patient and/or family member
+90836 Psychotherapy, 45 minutes with patient and/or family member when performed
with an evaluation & management service
90838 Psychotherapy, 60 minutes with patient and/or family member when performed
with an evaluation & management service
90951
End-Stage Renal Disease-related services monthly for patients younger than 2
years of age to include monitoring for adequacy of nutrition, assessment of
growth and development, and counseling of parents; with 4 or more face-to-
face visits by a physician or other qualified health care professional each
month
90952
End-Stage Renal Disease-related services monthly for patients younger than 2
years of age to include monitoring for adequacy of nutrition, assessment of
growth and development, and counseling of parents; with 2-3 face-to-face
visits by a physician or other qualified health care professional each month
90954
End-Stage Renal Disease-related services monthly for patients 2-11 years of
age to include monitoring for adequacy of nutrition, assessment of growth and
development, and counseling of parents; with 4 or more face-to-face visits by a
physician or other qualified health care professional each month
90955
End-Stage Renal Disease-related services monthly for patients 2-11 years of
age to include monitoring for adequacy of nutrition, assessment of growth and
development, and counseling of parents; with 2-3 face-to-face visits by a
physician or other qualified health care professional each month
90957
End-Stage Renal Disease-related services monthly for patients 12-19 years of
age to include monitoring for adequacy of nutrition, assessment of growth and
development, and counseling of parents; with 4 or more face-to-face visits by a
physician or other qualified health care professional each month
90958
End-Stage Renal Disease-related services monthly for patients 12-19 years of
age to include monitoring for adequacy of nutrition, assessment of growth and
development, and counseling of parents; with 2-3 face-to-face visits by a
physician or other qualified health care professional each month
90960
End-Stage Renal Disease-related services monthly for patients 20 years of
age or older; with 4 or more face-to-face visits by a physician or other qualified
health care professional each month
90961
End-Stage Renal Disease-related services monthly for patients 20 years of
age or older; with 2-3 face-to-face visits by a physician or other qualified health
care professional each month
90963
End-Stage Renal Disease-related services for home dialysis per full month for
patients younger than 2 years of age to include monitoring for adequacy of
nutrition, assessment of growth and development, and counseling of parents
90964
End-Stage Renal Disease-related services for home dialysis per full month for
patients 2-11 years of age to include monitoring for adequacy of nutrition,
assessment of growth and development, and counseling of parents
90965
End-Stage Renal Disease-related services for home dialysis per full month for
patients 12-19 years of age to include monitoring for adequacy of nutrition,
assessment of growth and development, and counseling of parents
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CPT Code Description Comments
90966 End-Stage Renal Disease-related services for home dialysis per full month for
patients 20 years of age or older
90967 End-stage renal disease (ESRD) related services for home dialysis per less than a full month of service, per day for patients younger than 2 years of age
90968 End-stage renal disease (ESRD) related services for home dialysis per less than a full month of service, per day: for patients 2-11 years of age
90969 End-stage renal disease (ESRD) related services for home dialysis per less than a full month of service, per day; for patients 12-19 years of age
90970 End-stage renal disease (ESRD) related services for home dialysis per less than a full month of service, per day: for patients 20 years of age and older
90845 Psychoanalysis
90846 Family psychotherapy (without the patient present)
90847 Family psychotherapy (conjoint psychotherapy)(with patient present)
96116
Neurobehavioral status exam (clinical assessment of thinking, reasoning and
G0508 Telehealth consultation, critical care, initial, physicians typically spend 60 minutes communicating with the patient and providers via telehealth
G0509 Telehealth consultation, critical care, subsequent, physicians typically spend 50 minutes communicating with the patient and providers via telehealth