The following clinical criteria documents were endorsed at the December 13, 2021, Clinical Criteria meeting. Visit our website to access the clinical criteria information.

 

Archived clinical criteria effective December 30, 2021

The following clinical criteria document has been archived.

  • ING-CC-0181 Veklury (remdesivir)

 

New clinical criteria effective January 4, 2022

The following clinical criteria are new.

  • ING-CC-0205 Fyarro (sirolimus albumin bound)
  • ING-CC-0206 BESREMi (ropeginterferon alfa-2b-njft)

 

New clinical criteria effective January 17, 2022

The following clinical criteria are new.

  • ING-CC-0207 Vyvgart (efgartigimod alfa-fcab)
  • ING-CC-0208 Adbry (tralokinumab)
  • ING-CC-0209 Leqvio (inclisiran)

 

Revised clinical criteria effective January 28, 2022

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

  • ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists

 

Revised clinical criteria effective January 31, 2022

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

  • ING-CC-0015 Infertility and HCG Agents
  • ING-CC-0029 Dupixent (dupilumab)
  • ING-CC-0079 Strensiq (asfotase alfa)
  • ING-CC-0124 Keytruda (pembrolizumab)
  • ING-CC-0168 Tecartus (brexucabtagene autoleucel)

 

Revised clinical criteria effective January 31, 2022

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

  • ING-CC-0018 Agents for Pompe Disease
  • ING-CC-0154 Givlaari (givosiran)
  • ING-CC-0185 Oxlumo (lumasiran)
  • ING-CC-0190 Nulibry (fosdenopterin)
  • ING-CC-0198 Relizorb (immobilized lipase) cartridge

 

Revised clinical criteria effective June 1, 2022

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

  • ING-CC-0004 Repository Corticotropin Injection* 

 

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

 

635-0322-PN-ME



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March 2022 Anthem Maine Provider News