Clinical Criteria updates for specialty pharmacy

The following Clinical Criteria documents were endorsed at the September 22, 2022, Clinical Criteria meeting. Visit our website to access the Clinical Criteria information.

Revised Clinical Criteria effective March 1, 2023

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-0002 Colony Stimulating Factor Agents*
• ING-CC-0018 Pompe Disease (Lumizyme [alglucosidase alfa], Nexviazyme [avalglucosidase alfa-ngpt])*
• ING-CC-0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors*
• ING-CC-0081 Crysvita (burosumab-twza)*
• ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications*

Coding updates

Revised Clinical Criteria effective March 1, 2023

The following Clinical Criteria were revised with coding updates. This will result in the review of claims for certain diagnoses to determine whether the service meets medical necessity criteria and may result in a not medically necessary determination for certain services:

• ING-CC-0022 Vimizim (elosulfase alfa)*
• ING-CC-0202 Saphnelo (anifrolumab-fnia)*

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

MEBCBS-CM-012401-22