May 1, 2019 • Policy Updates

Archived Medical Policy and Clinical UM Guideline numbers effective 04-24-2019:
  • CG-DRUG-25 Intravenous versus Oral Drug Administration [Note: Content of CG-DRUG-25 has been transferred to new clinical UM guideline CG-MED-82.]
  • CG-DRUG-47 Level of Care: Specialty Pharmaceuticals [Note: Content of CG-DRUG-47 has been transferred to new clinical UM guideline CG-MED-83.]
  • DRUG.00003 Chelation Therapy [Note: Content of DRUG.00003 has been transferred to new coverage guideline MED.00127.]
  • DRUG.00034 Insulin Potentiation Therapy [Note: Content of DRUG.00034 has been transferred to new coverage guideline MED.00128.]

  

Archived Medical Policy Numbers Effective 05-09-2019:

  • DRUG.00110 Inotuzumab ozogamicin (Besponsa®) [Note: Content of DRUG.00110 has been transferred to new clinical UM guideline CG-DRUG-113.]
  • GENE.00002 Preimplantation Genetic Diagnosis Testing [Note: Content of GENE.00002 has been transferred to clinical UM guideline CG-GENE.06.]  
  • GENE.00005 BCR-ABL Mutation Analysis (Qualitative) [Note: Content of GENE.00005 has been transferred to new clinical UM guideline CG-GENE-07.]
  • GENE.00031 Genetic Testing for PTEN Hamartoma Tumor Syndrome [Note: Content of GENE.00031 has been transferred to clinical UM guideline CG-GENE-08.]
  • GENE.00040 Genetic Testing for CHARGE Syndrome [Note: Content of GENE.00040 has been transferred to new clinical UM guideline CG-GENE-09.]
  • MED.00119 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications [Note: Content of MED.00119 has been transferred to new clinical UM guideline CG-MED-81.]
  • RAD.00066 Multiparametric Magnetic Resonance Fusion Imaging Targeted Prostate Biopsy [Note: Content of RAD.00066 has been transferred to new clinical UM guideline CG-SURG.98.]
  • SURG.00048 Panniculectomy, Abdominoplasty [Note: Content of SURG.00048 has been transferred to new clinical UM guideline CG-SURG-99.]

 

Archived Medical Policy Number Effective 06-24-2019:

  • SURG.00033 Cardioverter-Defibrillators [Note: Content of SURG.00033 has been transferred to new clinical UM guideline CG-SURG-97.]


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