The following clinical criteria documents were endorsed at the November 19, 2021 Clinical Criteria meeting. Visit our website to access the clinical criteria information.

 

New clinical criteria effective December 1, 2021

The following clinical criteria is new.

  • ING-CC-0204 Tivdak (tisotumab vedotin-tftv)

 

Revised clinical criteria effective December 1, 2021

The following clinical criteria was reviewed with no significant change to the medical necessity indications or criteria.

  • ING-CC-0167 Rituximab Agents for Oncologic Indications

 

Revised clinical criteria effective December 1, 2021

The following clinical criteria were revised to expand medical necessity indications or criteria.

  • ING-CC-0043 Monoclonal Antibodies to Interleukin-5
  • ING-CC-0075 Rituximab agents for Non-Oncologic Indications
  • ING-CC-0107 Bevacizumab for Non-ophthalmologic Indications
  • ING-CC-0124 Keytruda (pembrolizumab)
  • ING-CC-0128 Tecentriq (atezolizumab)
  • ING-CC-0168 Tecartus (brexucabtagene autoleucel)

 

Revised clinical criteria effective December 20, 2021

The following clinical criteria were revised to expand medical necessity indications or criteria.

  • ING-CC-0003 Immunoglobulins
  • ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
  • ING-CC-0105 Vectibix (panitumumab)
  • ING-CC-0106 Erbitux (cetuximab)

 

Revised clinical criteria effective December 20, 2021

The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.

  • ING-CC-0002 Colony Stimulating Factor Agents
  • ING-CC-0006 Hyaluronan Injections
  • ING-CC-0007 Synagis (palivizumab)
  • ING-CC-0039 GamaSTAN [immune globulin (human)]
  • ING-CC-0040 Prialt (ziconotide)
  • ING-CC-0047 Trogarzo (ibalizumab-uiyk)
  • ING-CC-0048 Spinraza (nusinersen)
  • ING-CC-0068 Growth Hormone [Note: Moved content of ING-CC-0183 Sogroya (somapacitan-beco) to this document.]
  • ING-CC-0073 Alpha-1 Proteinase Inhibitor Therapy
  • ING-CC-0074 Akynzeo (fosnetupitant and palonosetron) for injection
  • ING-CC-0133 Aliqopa (copanlisib)
  • ING-CC-0150 Kymriah (tisagenlecleucel)
  • ING-CC-0151 Yescarta (axicabtagene ciloleucel)
  • ING-CC-0155 Ethyol (amifostine)
  • ING-CC-0166 Trastuzumab Agents
  • ING-CC-0184 Danyelza (naxitamab-gqgk)
  • ING-CC-0187 Breyanzi (lisocabtagene maraleucel)
  • ING-CC-0194 Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection
  • ING-CC-0199 Empaveli (pegcetacoplan)

 

Archived clinical criteria effective December 20, 2021

The following clinical criteria document has been archived.

  • ING-CC-0183 Sogroya (somapacitan-beco) [Note: Content moved to ING-CC-0068 Growth Hormone.]

 

Revised clinical criteria effective January 1, 2022

The following clinical criteria were updated with new procedure and/or diagnosis codes.

  • ING-CC-0002 Colony Stimulating Factor Agents
  • ING-CC-0096 Asparagine Specific Enzymes
  • ING-CC-0195 Abecma (idecabtagene vicleucel)
  • ING-CC-0197 Jemperli (dostarlimab-gxly)
  • ING-CC-0201 Rybrevant (amivantamab-ymjw)

 

Revised clinical criteria effective January 4, 2022

The following clinical criteria were revised to expand medical necessity indications or criteria.

  • ING-CC-0062 Tumor Necrosis Factor Antagonists

 

Revised clinical criteria effective May 1, 2022

The following clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.

  • ING-CC-0001 Erythropoiesis Stimulating Agents* 
  • ING-CC-0041 Complement Inhibitors* 
  • ING-CC-0042 Monoclonal Antibodies to Interleukin-17* 
  • ING-CC-0049 Radicava (edaravone)* 
  • ING-CC-0050 Monoclonal Antibodies to Interleukin-23* 
  • ING-CC-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications* 
  • ING-CC-0062 Tumor Necrosis Factor Antagonists* 
  • ING-CC-0063 Stelara (ustekinumab)*
  • ING-CC-0064 Interleukin-1 Inhibitors* 
  • ING-CC-0065 Agents for Hemophilia A and von Willebrand Disease*
  • ING-CC-0066 Monoclonal Antibodies to Interleukin-6* 
  • ING-CC-0068 Growth Hormone* 
  • ING-CC-0071 Entyvio (vedolizumab)* 
  • ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists* 
  • ING-CC-0075 Rituximab agents for Non-Oncologic Indications* 
  • ING-CC-0078 Orencia (abatacept)* 
  • ING-CC-0148 Agents for Hemophilia B* 
  • ING-CC-0149 Select Clotting Agents for Bleeding Disorders* 
  • ING-CC-0170 Uplizna (inebilizumab-cdon)*
  • ING-CC-0173 Enspryng (satralizumab-mwge)* 
  • ING-CC-0195 Abecma (idecabtagene vicleucel)* 

 

*The applicable policy is attached to this article in PDF format.

 

1530-0222-PN-ME



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February 2022 Anthem Maine Provider News