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    v1.0.28
    OpenPayerPolicy UpdatesPreventive Services & ScreeningWest Virginia Medicaid Tobacco Cessation Coverage …
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    CurrentWest Virginia Bureau for Medical Services (Department of Human Services)Policy 2

    Tobacco Cessation Services Coverage Criteria

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    Defines West Virginia Medicaid coverage for tobacco cessation medications, nicotine replacement therapies, and counseling/coaching programs for Medicaid members enrolled in approved telephone coaching programs; applies to Fee-for-Service and Managed Care enrollees.

    Policy Summary
    PayerWest Virginia Bureau for Medical Services (Department of Human Services)
    PolicyTobacco Cessation Services Coverage Criteria
    Policy CodePolicy Policy 2
    Change TypeNo material change
    Effective DateMar 16, 2023
    Last ReviewMar 16, 2023
    Next Review Date
    Key ActionEnroll the member in an approved telephone coaching program (call 800-QUIT-NOW) to qualify for coverage beyond the initial authorization.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 weeksinitial coverage duration

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    additional 8 weeks
    authorization after enrollment
    99406/99407counseling codes
    800-QUIT-NOWQuitline

    Coverage Criteria for Tobacco Cessation

    inv-01: Covered when ALL of the following are met

    Covered when ALL of the following are met

    Enrollment: Member is enrolled in an approved telephone coaching program (e.g., Bureau for Public Health Quitline) or, for The Health Plan members, enrolled per their plan-specific programenrollment required for full coverage

    Enrollment via Quitline phone number 800-QUIT-NOW (800-784-8669) or the member's managed care plan is required

    Initial therapy duration: All first-line smoking cessation agents (NRTs, bupropion, varenicline) are covered for an initial 12-week course12 weeks

    Drugs may be combined for concurrent use unless contraindicated

    Product limits and reserved therapies: Products are subject to per-day or per-30-day maximums and certain therapies (e.g., nicotine nasal spray) are reserved for members who have failed other forms of NRTsee product-specific limits

    Daily/30-day limits: gum 24 pieces/day; patches 1 patch/day; lozenges 20/day; inhalers 16 cartridges/day; nasal spray 12 spray bottles per 30 days; bupropion 300 mg daily; varenicline 2 mg daily

    Continuation authorization: Continuation of therapy beyond the initial 12 weeks requires prior authorization with a written prescriber letter describing therapy efficacy, reason for extended course, and patient readiness; multiple quit attempts in a year may be covered with documentationdocumentation and prior authorization required

    A 4-week short-term authorization may be granted at discharge for inpatient-initiated therapy by calling the Rational Drug Therapy Program (1-800-847-3859)

    Non-covered services are not eligible for a West Virginia Department of Health and Human Resources (DHHR) Fair Hearing per 42 § 431.220. Providers should note that denials or decisions classed as non-covered under this policy do not trigger the DHHR Fair Hearing process and should follow standard appeals or grievance procedures outlined by the Bureau for Medical Services.

    Coding, Dosing, and Quantity Limits

    Covered CPT Codes for counselingCPTCovered
    99406Smoking and tobacco use cessation counseling visit; intermediate
    99407Smoking and tobacco use cessation counselling visit; intensive
    Daily maximums for NRT products — gum, patches, lozenges, inhalers, nasal spray
    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)
    Medication daily doses (bupropion, varenicline)
    Bupropion (Zyban)

    Provider Requirements, Prior Authorization, and Documentation

    Prior Authorization

    Initial 12-week coverage; PA required for continuation

    Initial cessation pharmacotherapy is covered for a 12-week course; any continuation of therapy beyond the initial 12 weeks requires prior authorization from West Virginia Medicaid. A short 4-week authorization may be granted at discharge for inpatients who initiated pharmacotherapy by calling the Rational Drug Therapy Program at 1-800-847-3859.

    • Initial approval duration: 12 weeks.
    • Short 4-week discharge approval available when initiated inpatient; prescriber must call Rational Drug Therapy Program (1-800-847-3859).
    • Requests for therapy beyond initial approval require prior authorization and meeting continuation requirements.
    Step Therapy

    Quantity limits and reserved nasal spray

    Quantity limits and step therapy rules apply to nicotine replacement products as specified; nicotine nasal spray is reserved for members who have failed other forms of nicotine replacement therapy.

    Background and Rationale

    Tobacco use substantially increases the risk of cancer, cardiovascular and pulmonary disease, and other adverse health outcomes. Evidence-based tobacco cessation services—comprising medications, nicotine replacement therapy (NRT), and counseling or coaching—significantly increase quit rates and are supported for coverage when program enrollment requirements are met. West Virginia Medicaid supports tobacco cessation through coverage of pharmacotherapies and reimbursement for counseling when sessions are documented, and by linking members to approved telephone coaching programs (for enrollment assistance call 800-QUIT-NOW). Counseling visits using CPT 99406 (intermediate) and CPT 99407 (intensive) are reimbursable when provided face-to-face, time-specific, and documented in the medical record.

    Definitions

    Definition of Tobacco Cessation Services (medications and counseling)
    DefinitionMedications and counseling provided to discontinue the use of tobacco.
    Components includedNicotine replacement therapies, bupropion, varenicline, and behavioral counseling/coaching programs.
    Program enrollmentServices are available to members enrolled in an approved telephone coaching program (e.g., Bureau for Public Health Quitline).
    Policy Summary
    PayerWest Virginia Bureau for Medical Services (Department of Human Services)
    PolicyTobacco Cessation Services Coverage Criteria
    Policy CodePolicy Policy 2
    Change TypeNo material change
    Effective DateMar 16, 2023
    Last ReviewMar 16, 2023
    Next Review Date
    Key ActionEnroll the member in an approved telephone coaching program (call 800-QUIT-NOW) to qualify for coverage beyond the initial authorization.
    SourceLink
    On This Page
    Coverage Criteria for Tobacco CessationCoding, Dosing, and Quantity LimitsProvider Requirements, Prior Authorization, and DocumentationBackground and RationaleDefinitions
    300 mg daily
    Varenicline (Chantix)2 mg daily
    Therapy duration noteAll agents are first-line therapies and will be covered for an initial 12-week course
    • Daily maximums: gum 24 pieces/day; patches 1 patch/day; lozenges 20/day; inhalers 16 cartridges/day; nasal spray 12 spray bottles/30 days.
    • Nasal spray reserved for those who have failed other NRT forms.
    • An additional 8 weeks may be authorized after enrollment in a coaching program (see prior auth/enrollment rules).
    Documentation Required

    PA must include prescriber letter and supporting medical records

    Prior authorization for therapy beyond the initial 12 weeks must include a written letter from the prescriber that briefly documents the efficacy of the current therapy, the reason a longer-than-typical course is required, and the patient’s readiness to quit. Counseling sessions billed with CPT 99406/99407 must be documented in the medical record and available upon request.

    • Prescriber letter must address: efficacy of current therapy; reason for extended course; patient readiness to quit.
    • Medical record must contain documentation of tobacco cessation counseling (CPT 99406, 99407) and be available to BMS or its designee upon request.
    Denial Risk

    Member must enroll in approved Quitline coaching for extended coverage

    Coverage beyond short approvals (and authorization of additional therapy after the initial approval) requires that the member initiate a call to the Bureau for Public Health Quitline and be enrolled in an approved telephone coaching program; Medicaid will not cover the remainder of therapy beyond short-term authorizations if the member has not enrolled.

    • Quitline enrollment phone number: 800-QUIT-NOW (800-784-8669).
    • An additional 8 weeks of therapy will be authorized after the member is fully enrolled with the coaching program.