Policy Updates Medical Policy & Clinical GuidelinesCommercialJuly 31, 2018

Medical policy and clinical guideline updates 8/1/2018

The Medical Policy and Technology Assessment Committee adopted the following new and/or revised Medical Policies and Clinical Guidelines. Some may have expanded rationales, medical necessity indications or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be either not medically necessary or investigational/not medically necessary. Clinical Guidelines adopted by Blue Cross Blue Shield and all the Medical Policies are available at bcbsga.com/provider under “see policies and guidelines”. Please note that our medical policies now include NOC (Not Otherwise Classified) codes to expedite the process of determining services that may require medical review. If you do not have access to the Internet, you may request a hard copy of a specific Medical or Behavioral Health Policy or Clinical UM Guideline by calling Provider Services at (800) 241-7475 Monday through Friday from 8 AM to 7 PM or send written requests (specifying the medical policy or guideline of interest, your name and address to where the information should be sent) to:

Blue Cross Blue Shield of Georgia and Blue Cross Blue Shield Healthcare Plan of Georgia

Attention: Prior Approval, Mail Code GAG009-0002

3350 Peachtree Road NE

Atlanta, GA 30326

NOTE: Any Clinical Guideline included in this standard MPTAC notification is only effective for GA if included on the GA Standard Adopted Clinical Guideline List unless there is a Group-specific review requirement in which case it will be considered ‘Adopted’ for that group only and for the specific type of review required. Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in the GA Standard Adopted Clinical Guideline List may be used to review a provider’s claims when a provider’s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are “Adopted” for those purposes.

*Publish Date*	*Action*	*Policy or Guideline Number*	*Policy or Guideline Title*
11/1/2018	New	DRUG.00098	Lutetium Lu 177 dotatate (Lutathera®)
11/1/2018	New	CG-LAB-12	Testing for Oral and Esophageal Cancer
11/1/2018	New	CG-MED-71	Wound Care in the Home Setting

6/28/2018	Conversion New	CG-DME-44	Electric Tumor Treatment Field (TTF)
6/28/2018	Conversion Archived	DME.00035	Electric Tumor Treatment Field (TTF)
6/28/2018	Conversion New	CG-DRUG-67	Cetuximab (Erbitux®)
6/28/2018	Conversion Archived	DRUG.00036	Cetuximab (Erbitux®)
6/28/2018	Conversion New	CG-DRUG-94	Rituximab (Rituxan®) for Non-Oncologic Indications
6/28/2018	Conversion Archived	DRUG.00041	Rituximab (Rituxan®) for Non-Oncologic Indications
6/28/2018	Conversion New	CG-DRUG-95	Belatacept (Nulojix®)
6/28/2018	Conversion Archived	DRUG.00049	Belatacept (Nulojix®)
6/28/2018	Conversion New	CG-DRUG-96	Ado-trastuzumab emtansine (Kadcyla®)
6/28/2018	Conversion Archived	DRUG.00056	Ado-trastuzumab emtansine (Kadcyla®)
6/28/2018	Conversion New	CG-DRUG-97	Rilonacept (Arcalyst®)
6/28/2018	Conversion Archived	DRUG.00073	Rilonacept (Arcalyst®)
6/28/2018	Conversion New	CG-DRUG-98	Bendamustine Hydrochloride
6/28/2018	Conversion Archived	DRUG.00079	Bendamustine Hydrochloride
6/28/2018	Conversion New	CG-DRUG-99	Elotuzumab (Empliciti™)
6/28/2018	Conversion Archived	DRUG.00083	Elotuzumab (Empliciti™)
6/28/2018	Conversion New	CG-DRUG-100	Interferon gamma-1b (Actimmune®)
6/28/2018	Conversion Archived	DRUG.00084	Interferon gamma-1b (Actimmune®)
6/28/2018	Conversion New	CG-DRUG-101	Ixabepilone (Ixempra®)
6/28/2018	Conversion Archived	DRUG.00085	Ixabepilone (Ixempra®)
6/28/2018	Conversion New	CG-DRUG-102	Olaratumab (Lartruvo™)
6/28/2018	Conversion Archived	DRUG.00097	Olaratumab (Lartruvo™)
6/28/2018	Conversion New	CG-MED-72	Hyperthermia for Cancer Therapy
6/28/2018	Conversion Archived	MED.00026	Hyperthermia for Cancer Therapy
6/28/2018	Conversion New	CG-SURG-76	Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
6/28/2018	Conversion Archived	SURG.00001	Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
6/28/2018	Conversion New	CG-SURG-77	Refractive Surgery
6/28/2018	Conversion Archived	SURG.00009	Refractive Surgery
6/28/2018	Conversion New	CG-SURG-78	Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies
6/28/2018	Conversion Archived	SURG.00065	Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies
6/28/2018	Conversion New	CG-SURG-79	Implantable Infusion Pumps
6/28/2018	Conversion Archived	SURG.00068	Implantable Infusion Pumps
6/28/2018	Conversion New	CG-SURG-80	Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors
6/28/2018	Conversion Archived	RAD.00011	Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors

6/6/2018	Revised	DRUG.00046	Ipilimumab (Yervoy®)
5/10/2018	Revised	DRUG.00047	Brentuximab Vedotin (Adcetris®)
11/1/2018	Revised	DRUG.00050	Eculizumab (Soliris®)
5/10/2018	Revised	DRUG.00053	Carfilzomib (Kyprolis®)
6/6/2018	Revised	DRUG.00071	Pembrolizumab (Keytruda®)
6/6/2018	Revised	DRUG.00075	Nivolumab (Opdivo®)
5/10/2018	Revised	DRUG.00076	Blinatumomab (Blincyto®)
6/6/2018	Revised	DRUG.00104	Nusinersen (SPINRAZA®) Previous title: Nusinersen (SPINRAZA™)
11/1/2018	Revised	DRUG.00111	Monoclonal Antibodies to Interleukin-23 Previous title: Guselkumab (Tremfya™)
6/6/2018	Revised	GENE.00012	Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
6/6/2018	Revised	GENE.00026	Cell-Free Fetal DNA-Based Prenatal Testing
5/10/2018	Revised	SURG.00026	Deep Brain, Cortical, and Cerebellar Stimulation
6/6/2018	Revised	SURG.00032	Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
11/1/2018	Revised	CG-ADMIN-02	Clinically Equivalent Cost Effective Services – Targeted Immune Modulators
6/6/2018	Revised	CG-DRUG-05	Recombinant Erythropoietin Products
6/6/2018	Revised	CG-DRUG-09	Immune Globulin (Ig) Therapy
6/6/2018	Revised	CG-DRUG-16	White Blood Cell Growth Factors
11/1/2018	Revised	CG-DRUG-25	Intravenous versus Oral Drug Administration in the Outpatient and Home Setting
5/10/2018	Revised	CG-DRUG-50	Paclitaxel, protein bound (Abraxane®)
6/6/2018	Revised	CG-DRUG-60	Gonadotropin Releasing Hormone Analogs for Treatment of Oncologic Indications
6/6/2018	Revised	CG-DRUG-62	Fulvestrant (FASLODEX®)
6/6/2018	Revised	CG-DRUG-73	Denosumab (Prolia®, Xgeva®)
11/1/2018	Revised	CG-DRUG-78	Antihemophilic Factors and Clotting Factors

6/6/2018	Reviewed	DRUG.00067	Ramucirumab (Cyramza®)
6/6/2018	Reviewed	DRUG.00109	Durvalumab (Imfinzi®) Previous title: Durvalumab (Imfinzi™)
6/6/2018	Reviewed	GENE.00009	Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
6/6/2018	Reviewed	GENE.00023	Gene Expression Profiling of Melanomas
6/6/2018	Reviewed	GENE.00025	Molecular Profiling for the Evaluation of Malignant Tumors
6/6/2018	Reviewed	MED.00077	In Vivo Analysis of Gastrointestinal Lesions
6/6/2018	Reviewed	OR-PR.00003	Microprocessor Controlled Lower Limb Prosthesis
6/6/2018	Reviewed	SURG.00132	Drug-Eluting Devices for Maintaining Sinus Ostial Patency
6/6/2018	Reviewed	SURG.00148	Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy
6/6/2018	Reviewed	TRANS.00031	Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
No change	Reviewed	CG-MED-35	Retinal Telescreening Systems
6/6/2018	Reviewed	CG-REHAB-05	Occupational Therapy
			Cardiology Guidelines
By AIM	AIM		Clinical Appropriateness Guidelines: Diagnostic Coronary Angiography
By AIM	AIM		Clinical Appropriateness Guidelines: Percutaneous Coronary Intervention
			Radiology Guidelines
By AIM	AIM		Clinical Appropriateness Guidelines: Advanced Imaging
			Radiation Oncology Guidelines
By AIM	AIM		Clinical Appropriateness Guidelines: Radiation Oncology: Proton Beam Therapy Guidelines

11/1/2018	Archived	THER-RAD.00002	Proton Beam Radiation Therapy

6/6/2018	Annual Review	DME.00022	Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
6/6/2018	Annual Review	DRUG.00088	Atezolizumab (Tecentriq®)
6/6/2018	Annual Review	DRUG.00107	Avelumab (Bavencio®)
6/6/2018	Annual Review	DRUG.00110	Inotuzumab ozogamicin (Besponsa®)
6/6/2018	Annual Review	GENE.00001	Genetic Testing for Cancer Susceptibility
6/6/2018	Annual Review	GENE.00002	Preimplantation Genetic Diagnosis Testing
6/6/2018	Annual Review	GENE.00005	BCR-ABL Mutation Analysis
11/1/2018	Annual Review	GENE.00006	Epidermal Growth Factor Receptor (EGFR) Testing
6/6/2018	Annual Review	GENE.00007	Cardiac Ion Channel Genetic Testing
6/6/2018	Annual Review	GENE.00016	Gene Expression Profiling for Colorectal Cancer
6/6/2018	Annual Review	GENE.00017	Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including ARVD/C)
6/6/2018	Annual Review	GENE.00031	Genetic Testing for PTEN Hamartoma Tumor Syndrome
6/6/2018	Annual Review	GENE.00038	Genetic Testing for Statin-Induced Myopathy
6/6/2018	Annual Review	GENE.00040	Genetic Testing for CHARGE Syndrome
6/6/2018	Annual Review	GENE.00045	Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers
6/6/2018	Annual Review	LAB.00003	In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
6/6/2018	Annual Review	LAB.00011	Analysis of Proteomic Patterns
6/6/2018	Annual Review	LAB.00015	Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer
6/6/2018	Annual Review	LAB.00025	Topographic Genotyping
6/6/2018	Annual Review	MED.00024	Adoptive Immunotherapy and Cellular Therapy
6/6/2018	Annual Review	MED.00053	Non-Invasive Measurement of Left Ventricular End Diastolic Pressure (LVEDP) in the Outpatient Setting
6/6/2018	Annual Review	MED.00087	Imaging Techniques for Screening and Identification of Cervical Cancer
6/6/2018	Annual Review	MED.00102	Ultrafiltration in Decompensated Heart Failure
6/6/2018	Annual Review	MED.00104	Non-invasive Measurement of Advanced Glycation Endproducts (AGEs) in the Skin
6/6/2018	Annual Review	MED.00105	Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
6/6/2018	Annual Review	MED.00111	Intracardiac Ischemia Monitoring
6/6/2018	Annual Review	MED.00112	Autonomic Testing
6/6/2018	Annual Review	MED.00118	Continuous Monitoring of Intraocular Pressure
6/6/2018	Annual Review	MED.00119	High Intensity Focused Ultrasound (HIFU) for Oncologic Indications
6/6/2018	Annual Review	MED.00124	Tisagenlecleucel (Kymriah™)
6/6/2018	Annual Review	OR-PR.00004	Partial-Hand Myoelectric Prosthesis
6/6/2018	Annual Review	RAD.00001	Computed Tomography to Detect Coronary Artery Calcification
6/6/2018	Annual Review	RAD.00022	Magnetic Resonance Spectroscopy (MRS)
6/6/2018	Annual Review	RAD.00040	PET Scanning Using Gamma Cameras
6/6/2018	Annual Review	RAD.00043	Computed Tomography Scans for Lung Cancer Screening
6/6/2018	Annual Review	RAD.00054	MRI of the Bone Marrow
6/6/2018	Annual Review	RAD.00059	Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Malignant Lesions Outside the Liver except Central Nervous System (CNS) and Spinal Cord
6/6/2018	Annual Review	RAD.00066	Multiparametric Magnetic Resonance Fusion Imaging Targeted Prostate Biopsy
6/6/2018	Annual Review	SURG.00016	Stereotactic Radiofrequency Pallidotomy
6/6/2018	Annual Review	SURG.00022	Lung Volume Reduction Surgery
6/6/2018	Annual Review	SURG.00072	Lysis of Epidural Adhesions
6/6/2018	Annual Review	SURG.00075	Intervertebral Stabilization Devices
6/6/2018	Annual Review	SURG.00107	Prostate Saturation Biopsy
6/6/2018	Annual Review	SURG.00113	Artificial Retinal Devices
6/6/2018	Annual Review	SURG.00124	Carotid Sinus Baroreceptor Stimulation Devices
6/6/2018	Annual Review	SURG.00137	Focused Microwave Thermotherapy for Breast Cancer
6/6/2018	Annual Review	SURG.00139	Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
6/6/2018	Annual Review	SURG.00147	Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders
6/6/2018	Annual Review	SURG.00149	Percutaneous Ultrasonic Ablation of Soft Tissue
6/6/2018	Annual Review	TRANS.00016	Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
6/6/2018	Annual Review	TRANS.00025	Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
6/6/2018	Annual Review	CG-DRUG-04	Use of Low Molecular Weight Heparin Therapy, Fondaparinux (Arixtra®), and Direct Thrombin Inhibitors in the Outpatient Setting
6/6/2018	Annual Review	CG-DRUG-08	Enzyme Replacement Therapy for Gaucher Disease
6/6/2018	Annual Review	CG-DRUG-34	Docetaxel (Docefrez™, Taxotere®)
6/6/2018	Annual Review	CG-DRUG-41	Zoledronic acid
6/6/2018	Annual Review	CG-DRUG-46	Fosaprepitant (Emend®)
6/6/2018	Annual Review	CG-DRUG-48	Azacitidine (Vidaza®)
6/6/2018	Annual Review	CG-DRUG-49	Doxorubicin Hydrochloride Liposome Injection
6/6/2018	Annual Review	CG-DRUG-51	Romidepsin (Istodax®)
6/6/2018	Annual Review	CG-DRUG-53	Drug Dosage, Frequency, and Route of Administration
6/6/2018	Annual Review	CG-MED-37	Intensive Programs for Pediatric Feeding Disorders
6/6/2018	Annual Review	CG-MED-45	Transrectal Ultrasonography
6/6/2018	Annual Review	CG-MED-50	Visual, Somatosensory and Motor Evoked Potentials
6/6/2018	Annual Review	CG-SURG-17	Trigger Point Injections
6/6/2018	Annual Review	CG-SURG-18	Septoplasty
6/6/2018	Annual Review	CG-SURG-30	Tonsillectomy for Children with or without Adenoidectomy
6/6/2018	Annual Review	CG-SURG-36	Adenoidectomy
6/6/2018	Annual Review	CG-SURG-40	Cataract Removal Surgery for Adults
6/6/2018	Annual Review	CG-SURG-46	Myringotomy and Tympanostomy Tube Insertion
6/6/2018	Annual Review	CG-SURG-55	Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation
			OrthoNet
By OrthoNet	OrthoNet - Annual Review		Physical and Occupational Therapy Management Programs OrthoNet maintains 64 distinct guidelines addressing the medical necessity of physical therapy (PT) and occupational therapy (OT), which includes the following atypical guidelines; Bell’s Palsy, Congenital Infantile Muscular Torticollis, General Neuromuscular Criteria, and Vestibular Disorders.
	CODING
11/1/2018	Coding Update of Existing Document	CG-DRUG-89	Implantable and Extended-Release Buprenorphine-Containing Products

PUBLICATIONS: August 2018 BCBSGa Provider Newsletter

Provider NewsGeorgia

Provider News Georgia

Provider News Georgia

Medical policy and clinical guideline updates 8/1/2018

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