Version 1019

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Johns Hopkins HealthCare LLCMedical PolicyMedical Policy

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Clinical Practice GuidelinesPage 1 of 6

This document applies to the following Participating Organizations

EHP Johns Hopkins Advantage MD Priority Partners US Family Health Plan

Keywords Guidelines

Table of Contents Page Number

I ACTION 1II POLICY DISCLAIMER 1III POLICY 1IV POLICY CRITERIA 2V DEFINITIONS 5VI BACKGROUND 5VII REFERENCE STATEMENT 6VIII REFERENCES 6IX APPROVALS 6

I ACTION New Policy

X Revising Policy Number CMS1101

Superseding Policy Number

Archiving Policy Number

Retiring Policy Number

II POLICY DISCLAIMERJohns Hopkins HealthCare LLC (JHHC) provides a full spectrum of health care products and services for Employer HealthPrograms Priority Partners Advantage MD and US Family Health Plan Each line of business possesses its own uniquecontract and guidelines which for benefit and payment purposes should be consulted first to know what benefits are availablefor coverage

Specific contract benefits guidelines or policies supersede the information outlined in this policy

III POLICYA JHHC seeks to enrich clinical care and administrative services in every area of the health care delivery system Clinical

Practice Guidelines support providers in treating chronic disease providing preventive care and maintaining officeoperations

B Clinical Practice Guidelines adopted by JHHC are developed by national medical associations and other recognizedhealth care organizations approved by the medical policy-making committees and reviewed at least every two years orwhen national guidelines change

C These guidelines are based on clinical evidence professional standards and may include expert consensus opinion andare provided to facilitate the delivery of evidence-based quality care to enrollees They are not intended to be a substitutefor a health care professionals clinical judgment or imply a guarantee of coverage

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D Clinical Practice Guidelines selected to be used for all JHHC products are adopted to address the needs of enrollees andsupport departmental activities throughout the organization1 Care Management utilizes clinical practice guidelines in the development of system embedded evidence-based

clinical pathways Pathways provide a guide to insuring appropriate care and risk reduction through enrolleeeducation and other interventions which includes care coordination with providers of care

2 Population Health utilizes system embedded evidence-based clinical pathways based on clinical practice guidelinesto support population based initiatives

3 Quality Improvement utilizes evidence-based clinical practice guidelines for conducting quality of care reviews andother activities regarding assessing and insuring the quality of care delivered to enrollees

4 Medical Policy uses multiple evidence-based resources including clinical practice guidelines in the development ofmedical polices which inform on coverage of services and support UM decision-making

5 Utilization Management may utilize clinical practice guidelines as a resource for UM decision-making in theabsence of internal or externally developed clinical review criteria

These guidelines address the following

ADHD DIABETES

ASTHMA GERIATRIC CARE

BACK PAIN HEART FAILURE

CHRONIC KIDNEY DISEASE HYPERTENSION

CORONARY ARTERY DISEASE OBESITY

COPD OPIOIDS FOR CHRONIC PAIN

DEPRESSION OSTEOARTHRITIS

IV POLICY CRITERIA

CLINICAL PRACTICE GUIDELINES

ADHD

bull American Academy of Pediatrics (2011) ADHD Clinical Practice Guideline for the Diagnosis Evaluation andTreatment of Attention DeficitHyperactivity Disorder in Children and Adolescents

bull American Academy of Pediatrics (2011) Implementing the Key Action Statements An Algorithm and Explanation forProcess of Care for the Evaluation Diagnosis Treatment and Monitoring of ADHD in Children and Adolescents

bull National Institute for Health and Care Excellence (2018) Attention Deficit Hyperactivity Disorder Diagnosis andManagement

ASTHMA

bull National Heart Lung and Blood Institute of the National Institute of Health (2007) The Expert Panel Report 3Guidelines for the Diagnosis and Management of Asthma

bull National Heart Lung and Blood Institute of the National Institute of Health (2011) Asthma Care Quick ReferenceGuide Diagnosing and Managing Asthma

copy Copyright 2019 by The Johns Hopkins Health System Corporation andor The Johns Hopkins University

Version 1019

Policy Number CMS1101

Effective Date 07012019

Johns Hopkins HealthCare LLCMedical PolicyMedical Policy

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Revision Date 05212019Subject

Clinical Practice GuidelinesPage 2 of 6

D Clinical Practice Guidelines selected to be used for all JHHC products are adopted to address the needs of enrollees andsupport departmental activities throughout the organization1 Care Management utilizes clinical practice guidelines in the development of system embedded evidence-based

clinical pathways Pathways provide a guide to insuring appropriate care and risk reduction through enrolleeeducation and other interventions which includes care coordination with providers of care

2 Population Health utilizes system embedded evidence-based clinical pathways based on clinical practice guidelinesto support population based initiatives

3 Quality Improvement utilizes evidence-based clinical practice guidelines for conducting quality of care reviews andother activities regarding assessing and insuring the quality of care delivered to enrollees

4 Medical Policy uses multiple evidence-based resources including clinical practice guidelines in the development ofmedical polices which inform on coverage of services and support UM decision-making

5 Utilization Management may utilize clinical practice guidelines as a resource for UM decision-making in theabsence of internal or externally developed clinical review criteria

These guidelines address the following

ADHD DIABETES

ASTHMA GERIATRIC CARE

BACK PAIN HEART FAILURE

CHRONIC KIDNEY DISEASE HYPERTENSION

CORONARY ARTERY DISEASE OBESITY

COPD OPIOIDS FOR CHRONIC PAIN

DEPRESSION OSTEOARTHRITIS

IV POLICY CRITERIA

CLINICAL PRACTICE GUIDELINES

ADHD

bull American Academy of Pediatrics (2011) ADHD Clinical Practice Guideline for the Diagnosis Evaluation andTreatment of Attention DeficitHyperactivity Disorder in Children and Adolescents

bull American Academy of Pediatrics (2011) Implementing the Key Action Statements An Algorithm and Explanation forProcess of Care for the Evaluation Diagnosis Treatment and Monitoring of ADHD in Children and Adolescents

bull National Institute for Health and Care Excellence (2018) Attention Deficit Hyperactivity Disorder Diagnosis andManagement

ASTHMA

bull National Heart Lung and Blood Institute of the National Institute of Health (2007) The Expert Panel Report 3Guidelines for the Diagnosis and Management of Asthma

bull National Heart Lung and Blood Institute of the National Institute of Health (2011) Asthma Care Quick ReferenceGuide Diagnosing and Managing Asthma

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bull National Institute for Health and Care Excellence (2017) Asthma Diagnosis Monitoring and Chronic AsthmaManagement

BACK PAIN

bull American College of Physicians (2017) Noninvasive Treatments for Acute Subacute and Chronic Low Back Pain AClinical Practice Guideline from the American College of Physicians

bull National Institute for Health and Care Excellence (2016) Low Back Pain and Sciatica in over 16s Assessment andManagement

bull American Physical Therapy Association (2012) Low Back Pain Clinical Practice Guidelines linked to the InternationalClassification of Functioning Disability and Health from the Orthoaedic Section of the American Physical TherapyAssociation

CHRONIC KIDNEY DISEASE

bull National Kidney Foundation Kidney Disease Outcomes Quality Initiative (2016) Practical Approach to Detection andManagement of Chronic Kidney Disease for the Primary Care Clinician

bull Department of Veterans Affairs and Department of Defense (2014) VADoD Clinical Practice Guideline for theManagement of Chronic Kidney Disease in Primary Care

CORONARY ARTERY DISEASE

bull American College of Cardiology Foundation and American Heart Association (2013) ACCAHA Guideline on theTreatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults

bull American College of Cardiology Foundation and American Heart Association (2013) AHAACC Guideline on LifestyleManagement to Reduce Cardiovascular Risk

bull American College of Cardiology Foundation and American Heart Association (2013) ACCAHA Guideline on theAssessment of Cardiovascular Risk

bull National Heart Lung and Blood Institute of the National Institute of Health (2012) Expert Panel on IntegratedGuidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents (2012)

bull American College of Cardiology Foundation and American Heart Association (2010) ACCFAHA Guideline forAssessment of Cardiovascular Risk in Asymptomatic Adults

bull American Heart Association (2013) Secondary Prevention of Atherosclerotic Cardiovascular Disease in Older Adults AScientific Statement From the American Heart Association

COPD

bull Global Initiative for Chronic Lung Disease (GOLD) Program A collaboration of the National Heart Lung and BloodInstitute of the National Institute of Health and the World Health Organization (2018) Global Strategy for PreventionDiagnosis and Management of COPD

bull US Department of Veterans Affairs and the Department of Defense (2014) VADoD Clinical Practice GuidelineManagement of Outpatient Chronic Obstructive Pulmonary Disease

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DEPRESSION

bull American Psychiatric Association (2010) Practice Guideline for the Treatment of Patients With Major DepressiveDisorder Third Edition

bull US Department of Veterans Affairs and the Department of Defense (2016) VADoD Clinical Practice GuidelineManagement of Major Depression Disorder

bull National Institute for Health and Care Excellence (2018) Depression in Adults Recognition and Managementbull National Institute for Health and Care Excellence (2017) Depression in Children and Young People Identification and

Management

DIABETES

bull National Diabetes Education Program of the National Institute of Health and the Centers for Disease Control andPrevention (2014) Guiding Principles for the Care of People With or at Risk for Diabetes

bull American Association of Clinical Endocrinologists and American College of Endocrinology (2018) AACEACEComprehensive Type 2 Diabetes Management Algorithm

bull American Association of Clinical Endocrinologists and American College of Endocrinology (2015) AACEACEClinical Practice Guidelines for Developing a Diabetes Mellitus Comprehensive Care Plan

bull US Department of Veterans Affairs and the Department of Defense (2017) VADoD Clinical Practice Guideline for theManagement of Type 2 Diabetes Mellitus in Primary Care

bull American Diabetes Association (2018) Standards of Medical Care in Diabetes

GERIATRIC CARE

bull American College of Surgeons and the American Geriatrics Society (2016) Optimal Perioperative Management of theGeriatric Patient Best Practice Guideline from the American College of Surgeons NSQIP and the American GeriatricsSociety

bull American Geriatrics Society (2012) Patient-Centered Care for Older Adults with Multiple Chronic Conditions AStepwise Approach from the American Geriatrics Society

bull American Geriatrics Society (2019) Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in OlderAdults

bull National Institute for Health and Care Excellence (2018) Dementia Assessment Management and Support for PeopleLiving with Dementia and Their Carers

bull Center for Disease Control and Prevention (2017) STEADI Stopping Elderly Accidents Deaths amp Injuriesbull National Pressure Ulcer Advisory Panel (2014) Prevention and Treatment of Pressure Ulcers Quick Reference Guide

HEART FAILURE

bull American College of Cardiology American Heart Association Task Force on Clinical Practice Guidelines and theHeart Failure Society of America (2017) ACCAHAHFSA Focused Update of the 2013 ACCFAHA Guideline for theManagement of Heart Failure

bull American College of Cardiology American Heart Association Task Force on Clinical Practice Guidelines and the HeartFailure Society of America (2016) ACCAHAHFSA Focused Update on New Pharmacological Therapy for HeartFailure an Update of the 2013 ACCFAHA Guideline for the Management of Heart Failure

bull American College of Cardiology American Heart Association (2013) ACCFAHA Guideline for the Management ofHeart Failure

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bull American College of Cardiology American Heart Association (2013) ACCFAHA Guideline for the Management ofHeart Failure Executive Summary

HYPERTENSION

bull Eighth Joint National Committee on the Prevention Detection Evaluation and Treatment of High Blood Pressure(2014) Evidence-Based Guideline for the Management of High Blood Pressure in Adults

bull American Heart Association American College of Cardiology and the Centers for Disease Control and Prevention(2014) An Effective Approach to High Blood Pressure Control

bull American College of Cardiology and American Heart Association Task Force on Clinical Practice Guidelines(2017) Guideline for the Prevention Detection Evaluation and Management of High Blood Pressure in Adults

bull US Department of Veterans Affairs and the Department of Defense (2014) VADoD Clinical Practice GuidelineManagement of Hypertension in Primary Care

OBESITY

bull American Heart Association American College of Cardiology and The Obesity Society (2013) AHAACCTOSGuideline for the Management of Overweight and Obesity in Adults

bull National Heart Lung and Blood Institute of the National Institute of Health (2013) Managing Overweight and Obesityin Adults Systematic Evidence Review from the Obesity Expert Panel

bull Department of Veterans Affairs and Department of Defense (2014) Management of Obesity and Overweight bull US Preventative Services Task Force (2012) Obesity in Adults Screening and Managementbull US Preventative Services Task Force (2017) Screening for Obesity in Children and Adolescents

OPIODS FOR CHRONIC PAIN

bull Centers for Disease Control and Prevention (2016) CDC Guideline for Prescribing Opioids for Chronic Painbull Centers for Disease Control and Prevention (2016) Guideline Resources Clinical Tools

OSTEOARTHRITIS

bull American College of Rheumatology (2012) Recommendations for the Use of Nonpharmacologic and PharmacologicTherapies in Osteoarthritis of the Hand Hip and Knee

bull US Department of Veterans Affairs and the Department of Defense (2014) VADoD Clinical Practice Guideline for theNon-Surgical Management of Hip amp Knee Osteoarthritis

V DEFINITIONSClinical Practice Guideline A document created by JHHC or a nationally recognized medical organization with the aim ofguiding decisions and providing criteria regarding diagnosis management and treatment in specific areas of healthcare basedon an examination of current evidence in the medical literature

VI BACKGROUNDClinical Practice Guidelines are systematically developed statements that provide best-practice recommendations intended tooptimize patient care and assist clinicians in decision-making about appropriate healthcare for specific clinical conditions andcircumstances (AHRQ) Guideline development is based on rigorous systematic review and analysis of published medicalliterature and assessment of the benefits and harms of various treatment options

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According the Health and Medicine Division (HMD) of the National Academies of Sciences formerly the Institute ofMedicine (IOM) ideally guidelines are developed by a multidisciplinary panel of clinicians and other experts in the fieldof study and should include patients to be affected by the guideline All evidence should be summarized including anygaps in evidence and each recommendation should be rated to inform about the quality of the evidence and strength of therecommendation Additionally the roll of expert opinion in recommendation development should be disclosed

Guidelines are a tool and not intended to be fixed protocols as individual patients may require alternate managementbased on comorbidities cultural preferences availability of resources and biological differences including immuneresponse and variability in drug metabolism (UptoDate)

VII REFERENCE STATEMENTAnalyses of the scientific and clinical references cited below were conducted and utilized by the Johns Hopkins HealthCareLLC (JHHC) Medical Policy Team during the development and implementation of this medical policy The Medical PolicyTeam will continue to monitor and review any newly published clinical evidence and revise the policy and adjust the referencesbelow accordingly if deemed necessary

VIII REFERENCESAgency for Healthcare Research and Quality (2014) Criteria for Inclusion of Clinical Practice Guidelines in NGC NationalGuidelines Clearinghouse Retrieved wwwguidelinegov

Shekelle P Aronson MD (2018) Overview of Clinical Practice Guidelines Up to Date Retrieved wwwuptodatecom

The National Academies of Sciences Engineering Medicine Health and Medicine Division (2011) Finding What Works inHealth Care Standards for Systematic Reviews Retrieved nationalacademiesorg

Note Additional references are embedded in the above policy criteria

IX APPROVALSHistorical Effective Dates 09052013 09052014 06052015 06032016 06022017 07012019

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