Tobacco Harm Reduction

Health Republic Insurance of New Jersey

Tobacco Harm Reduction

Medical Coverage Policy 2014-01

Effective Date 1/1/2015

Coverage Rationale

Benefit Considerations

Background

Clinical Evidence

Applicable Codes

References

Coverage Rationale

Cigarette smoking and other forms of tobacco use remain major public health challenges. Fifty years after the first Surgeon General’s Report of Smoking and Health, the prevalence of tobacco use remains unacceptably high. Notwithstanding substantial progress in public health measures and the use of smoking cessation interventions including counselling by physicians, quit-lines and medications, 18.1 percent of the adult population continues to smoke (1). These individuals will incur substantial morbidity and will significantly curtail their lifespans. Along the way, they will incur significant cost for treatment of their tobacco related conditions.

In order to mitigate this burden of illness, Health Republic Insurance of New Jersey seeks to provide medical support for those individuals who wish to reduce their risk of tobacco related disease. Counselling and medications currently approved for smoking cessation will be made available for sustained periods for those smokers seeking to reduce or eliminate their exposure to tobacco.

The coverage for smoking cessation counselling is expanded to include discussion of Tobacco Harm Reduction. The coverage for medications approved for smoking cessation is expanded to permit long term use or chronic use of these medications.

Benefit Considerations

This policy expands the coverage for persons using tobacco. Previously, the use of counseling and medication was limited to specific quit attempts by tobacco users. Although no strict limits had been placed on reimbursement for physician counselling, the pharmacy benefit had been limited to two quit attempts per year of 12 weeks duration.

Background

The United States Public Health Service first detailed the evidence-based approach to smoking cessation in 1996 and updated its clinical practice guideline “Treating Tobacco Use and Dependence in 2008. (2).The core of this guideline was a structured approach to physician’s counseling of the patient. The value of this counselling intervention is emphasized by the specific reimbursement for this type of service under Medicare coverage rules, most states’ Medicaid coverage, and the Affordable Care Act. The guideline states that medications approved for smoking cessation be offered to every patient making a quit attempt. Medications, used as adjuncts for smoking cessation, have been available for over 20 years. They are safe and effective, and even cost effective when used for smoking cessation. Some of these medications (Nicotine Patches, Nicotine Gum, and Nicotine Lozenges) are available over the counter; a designation synonymous with safety. The Preventive Services Task Force provides a rating of A for the evidence level supporting the use of the following medications in smoking cessation Nicotine Patch, Nicotine Gum, Nicotine Inhaler, Nicotine Lozenge, Bupropion, and Varenicline 3). As a result these medications have been placed in Tier Zero, with no copayment on health plans following the requirements of the Affordable care Act.

Clinical experience shows that some smokers seek to continue treatment with medication after completion of a normal course of treatment. Many of these patients merely require prolonged treatment than is designated on the package labelling to help them achieve successful abstinence, while others seem to require extended treatment to prevent relapse. To assist patients in this situation, some clinicians have advocated for the use of smoking cessation products for Harm Reduction. This literature has recently been summarized by the British National Health Service Institute for Care Excellence (NICE) (4). NICE advocates the use of nicotine containing medications for smoking cessation for as long as needed in order to assist patients in;

·  Smoking Cessation

·  Cutting down prior to stopping smoking (cutting down to quit)

·  Smoking reduction

·  Temporary abstinence from smoking

The safety of continued use of nicotine containing medication is well established. The FDA recently revised its warning label to state that smokers may continue smoking while using the patch (5). The safety of prolonged use of other medications is also well established. Bupropion is commonly used for the treatment of depression and has been in use in the United States since 1989. Varenicline, available since 2005, has also been used for sustained periods (6).

Clinical Evidence

Harm reduction for smoking cessation is an emerging concept based on extrapolation from known risks (6). The risks associated with smoking are far greater than the risks associated the prolonged use of medications for approved for smoking cessation. Physicians prescribing medications for Tobacco Harm Reduction should be mindful of the same clinical considerations used in selecting medications for smoking cessation. The FDA recently lifted its longstanding warning regarding continued smoking and use of nicotine products as the evidence did not support this assertion (5).

Another emerging body of literature addresses opportunistic smoking cessation attempts: Patients who state they are not ready to quit may nonetheless be able to maintain abstinence from smoking when provided with a structured trial of smoking cessation medications (7). It is therefore possible that smokers prompted to take a harm reduction approach may succeed in quitting altogether.

The evidence supporting the specific use of interventions approved for use in smoking cessation including counselling and medications for the purpose of harm reduction is yet to be assembled. Nonetheless, reasonable extrapolation from currently available data supports this policy and allows physicians to assist their patients in lower their risk of acquiring tobacco related conditions.

Applicable codes

All NDC codes used for medications approved by the FDA for smoking cessation will have no limitations on refills during the calendar year. No prior approval is required. These medications will remain in Tier zero, with zero copayment. These drugs are Nicotine Patches, Nicotine Gum, Nicotine Lozenge, Nicotine Inhaler, Nicotine Nasal Spray, Bupropion and Varenicline.

CPT codes 99406 (Intermediate E/M Tobacco Use Counselling Service) and 99407 (Intensive E/M Tobacco Use Counselling Service) will be reimbursed when billed with a diagnosis of Tobacco Use Disorder (ICD-9) or nicotine dependence (ICD-10);

ICD -9 codes 305.1 Tobacco Use Disorder

ICD-10 codes F17.20 Nicotine dependence, unspecified, F17.21 Nicotine dependence, cigarettes; F17.22 Nicotine dependence, chewing tobacco, F17.29 Nicotine dependence, other tobacco product

These codes can be billed by physicians, nurse practitioners, nurse midwives, physicians’ assistants and Certified Tobacco Treatment Specialists.

Group sessions by a physician, 99078 and other qualified individuals S9453 are also reimbursable.

References

1.  Israel T. Agaku, DMD1,2, Brian A. King, PhD2, Shanta R. Dube, PhD, Current Cigarette Smoking Among Adults — United States, 2005–2012, MMWR, 63/2, pp29-34, 2014

2.  Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

3.  Force, U. S. P. S. T. (2009). "Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: U.S. Preventive Services Task Force reaffirmation recommendation statement." Ann Intern Med 150(8): 551-555.

4.  Tobacco: Harm-reduction approaches to smoking CE guidelines [PH45] Published date: June 2013 http://www.nice.org.uk/guidance/ph45Kathryn

5.  http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM346012.pdf

6.  E. Williams , Karen R. Reeves , Clare B. Billing, Jr , Ann M. Pennington and Jason Gong Current Medical Research and Opinion, A double-blind study evaluating the long-term safety of varenicline for smoking cessation. 2007, Vol. 23, No. 4 , Pages 793-801

7.  Rodu, R., Godschall, W.T. Tobacco harm reduction: an alternative cessation strategy for inveterate smokers. Harm Reduction Journal 2006, 3:37 doi:10.1186/1477-7517-3-37

8.  Carpenter, M. J., et al. (2004). "Both smoking reduction with nicotine replacement therapy and motivational advice increase future cessation among smokers unmotivated to quit." J Consult Clin Psychol 72(3): 371-381.

9.  Fu, S. S., et al. (2014). "Proactive tobacco treatment and population-level cessation: a pragmatic randomized clinical trial." JAMA Intern Med 174(5): 671-677.

Approval History

Initial approval 9/11/2014, Quality Improvement Commiittee of the Board