CurrentWest Virginia Bureau for Medical Services (Department of Human Services)Policy 2

Tobacco Cessation Services — Coverage and Clinical Criteria

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Coverage and clinical/administrative rules for tobacco cessation medications, nicotine replacement therapies, and counseling/coaching available to West Virginia Medicaid members, including FFS and Managed Care enrollees.

Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyTobacco Cessation Services — Coverage and Clinical Criteria

Policy CodePolicy Policy 2

Change TypeNo material change

Effective DateMar 16, 2023

Last ReviewMar 16, 2023

Next Review DateN/A

Key ActionEnroll the member in an approved Quitline coaching program to secure initial 12-week pharmacotherapy coverage and eligibility for an additional 8 weeks.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 weeksInitial coverage duration

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CurrentWest Virginia Bureau for Medical Services (Department of Human Services)Policy 2

Tobacco Cessation Services — Coverage and Clinical Criteria

Customize your policy alerts

Sign up for West Virginia Bureau for Medical Services (Department of Human Services) Policy 2 alerts

Get alerted when Policy 2 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyTobacco Cessation Services — Coverage and Clinical Criteria

Policy CodePolicy Policy 2

Change TypeNo material change

Effective DateMar 16, 2023

Last ReviewMar 16, 2023

Next Review DateN/A

Key ActionEnroll the member in an approved Quitline coaching program to secure initial 12-week pharmacotherapy coverage and eligibility for an additional 8 weeks.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 weeksInitial coverage duration

8 weeksAdditional authorized after enrollment

99406, 99407Counseling CPT codes

800-QUIT-NOWQuitline phone

Coverage Criteria for Tobacco Cessation

Pharmacotherapy coverage

Covered when the following conditions are met

Enrollment and duration: Member is enrolled in an approved telephone coaching program (Quitline or managed plan program); initial pharmacotherapy coverage is 12 weeks; an additional 8 weeks may be authorized after full enrollment in coaching.initial 12 weeks + 8 weeks after enrollment

Enrollment phone: 800-QUIT-NOW

Continuation therapy / multiple attempts

Coverage for therapy beyond the initial 12-week approval is available when:

Prior authorization for continuation: A written letter from the prescriber must state efficacy of current therapy, reason for longer than typical course, and readiness of the patient to quit.prescriber letter

Coverage for multiple quit attempts per year is allowed with documentation provided with the prior authorization request; initial approval is 12 weeks; additional therapy may be approved after requirements met.

Tobacco cessation counseling

Counseling reimbursement conditions

Counseling billing requirements: Physicians, physician assistants, and advanced practice registered nurses may be reimbursed for face-to-face, time‑sensitive tobacco cessation counseling billed with CPT 99406 or 99407; sessions must be documented in the member's medical record and available upon request. This service may be billed the same day as an E/M if the E/M is significant and separately identifiable and billed with the appropriate modifier.N/A

Documentation must be available to BMS or its designee upon request.

Non-covered services under this policy are not eligible for a West Virginia Department of Health and Human Resources (DHHR) Fair Hearing. See 42 § 431.220 for information on when a hearing is required.

Providers should ensure coverage criteria are met before furnishing services; items or services that do not meet the policy’s coverage requirements are considered non-covered and cannot be appealed through the DHHR Fair Hearing process.

Billing Codes, Limits, and Dosing

Covered CPT Codes for counselingCPTCovered

99406	Smoking and tobacco-use cessation counseling visit; intermediate
99407	Smoking and tobacco-use cessation counseling visit; intensive

Daily maximums for NRT products — gum, patches, lozenges, inhalers, nasal spray limits

Nicotine gum24 pieces per day

Nicotine patches1 patch per day

Nicotine lozenges20 lozenges per day

Nicotine inhalers16 cartridges per day

Nicotine nasal spray12 spray bottles per 30 days (reserved for those who have failed other NRT forms)

Medication daily dose limits — bupropion and varenicline dosing limits

Bupropion (Zyban)

Provider Requirements and Prior Authorization

Prior Authorization

Prior authorization required for therapy beyond initial 12 weeks

Initial pharmacotherapy is covered for 12 weeks without prior authorization. Any request for therapy beyond the initial 12-week approval requires prior authorization for continuation.

Initial approval duration: 12 weeks.
Continuation beyond 12 weeks requires prior authorization.

Step Therapy

Quantity limits, step therapy, and coaching enrollment

Quantity limits and step therapies as specified in the policy may apply. Member enrollment in an approved Quitline or managed plan coaching program is required for continued Medicaid coverage of the remainder of therapy; an additional 8 weeks may be authorized after full enrollment.

Quantity limits and step therapies may apply as specified.
Member must initiate a call to the Quitline to enroll in an approved coaching program for continued coverage.

Clinical Background

Tobacco use substantially increases the risk of cancer, cardiovascular disease, respiratory disease, reproductive harms including infertility, and other adverse health outcomes. West Virginia Medicaid supports evidence-based treatment to assist members in quitting because counseling combined with medications or coaching can significantly increase cessation success.

Medicaid reimburses qualified clinicians for face-to-face tobacco cessation counseling using CPT codes 99406 (intermediate) and 99407 (intensive). Counseling sessions must be time-based, documented in the medical record, and available upon request. Counseling may be billed the same day as an evaluation and management service if the E/M is significant and separately identifiable; when billed together the E/M must include the appropriate modifier.

Key Definitions

Tobacco Cessation Services — definition of services (medications and counseling)

DefinitionMedications and counseling provided to discontinue the use of tobacco.

Medications includedNicotine replacement therapies (gum, patches, lozenges, inhalers, nasal spray), bupropion, and varenicline.

Counseling requirementServices are available to members enrolled in an approved telephone coaching program (Quitline or managed plan program).

Quitline contactBureau for Public Health Quitline: https://wvtobaccoquitline.com/ or 800-QUIT-NOW (800-784-8669).

Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyTobacco Cessation Services — Coverage and Clinical Criteria

Policy CodePolicy Policy 2

Change TypeNo material change

Effective DateMar 16, 2023

Last ReviewMar 16, 2023

Next Review DateN/A

Key ActionEnroll the member in an approved Quitline coaching program to secure initial 12-week pharmacotherapy coverage and eligibility for an additional 8 weeks.

SourceLink

On This Page

Varenicline (Chantix)2 mg daily

Coverage duration noteAll agents are first-line therapies and will be covered for 12 weeks (short-term 4-week discharge approval may be obtained via Rational Drug Therapy Program)

An additional 8 weeks of therapy shall be authorized after full enrollment in the coaching program.

Documentation Required

Counseling documentation for CPT 99406/99407

Tobacco cessation counseling billed with CPT 99406 or 99407 must be face-to-face, time-based, and documented in the member's medical record; documentation must be available to BMS or its designee upon request.

Sessions are face-to-face and time sensitive.
Documentation must be in the medical record and available upon request.
May be billed same day as E/M if the E/M is significant and separately identifiable; use the appropriate modifier.

Documentation Required

Prescriber letter required with continuation prior authorization

Prior authorization requests for continuation beyond the initial 12-week approval must include a written letter from the prescriber that addresses the efficacy of the current therapy, the reason a longer-than-typical course is required, and the patient's readiness to quit.

Written prescriber letter must state: efficacy of current therapy, reason for extended duration, and patient readiness to quit.
Provide documentation of multiple quit attempts when requesting coverage for multiple attempts per year.

Denial Risk

Enrollment in approved coaching program required

The member must be enrolled in an approved Quitline coaching program (or managed plan program); failure to enroll the member will make the remainder of therapy ineligible for Medicaid coverage.

Enrollment phone for the Bureau for Public Health Quitline: 800-QUIT-NOW (800-784-8669).
Medicaid members in The Health Plan should contact The Health Plan to enroll in their tobacco cessation coaching program.

Prior Authorization

Continuation prior authorization must include prescriber justification

Requests for therapy beyond the initial 12-week approval require prior authorization accompanied by a written prescriber letter documenting efficacy, justification for longer therapy, and patient readiness; lacking this documentation may result in denial.

Continuation prior authorization must include the prescriber letter described above.
Coverage for multiple quit attempts per year is available but requires the same documentation with the prior authorization request.