The following clinical criteria documents were endorsed at the June 24, 2021 Clinical Criteria meeting. Visit our website to access the clinical criteria information.

 

Revised clinical criteria effective June 30, 2021

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

  • ING-CC-0124: Keytruda (pembrolizumab)
  • ING-CC-0125: Opdivo (nivolumab)

 

New clinical criteria effective June 30, 2021

The criteria below is new and may result in services previously covered now being considered not medically necessary.

  • ING-CC-0201: Rybrevant (amivantamab-ymjw)

 

Revised clinical criteria effective July 26, 2021

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

  • ING-CC-0042: Monoclonal Antibodies to Interleukin-17
  • ING-CC-0067: Prostacyclin Infusion and Inhalation Therapy
  • ING-CC-0077: Palynziq (pegvaliase-pqpz)

 

Revised clinical criteria effective July 26, 2021

The following criteria were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.

  • ING-CC-0031: Intravitreal Corticosteroid Implants
  • ING-CC-0050: Monoclonal Antibodies to Interleukin-23
  • ING-CC-0051: Enzyme Replacement Therapy for Gaucher Disease
  • ING-CC-0076: Nulojix (belatacept)
  • ING-CC-0136: Drug Dosage, Frequency, and Route of Administration
  • ING-CC-0141: Off-Label Drug and Approved Orphan Drug Use
  • ING-CC-0174: Kesimpta (ofatumumab)
  • ING-CC-0182: Agents for Iron Deficiency Anemia

 

Revised clinical criteria effective August 1, 2021

The following criteria were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.

  • ING-CC-0037: Kanuma (sebelipase alfa)
  • ING-CC-0043: Monoclonal Antibodies to Interleukin-5
  • ING-CC-0057: Krystexxa (pegloticase)
  • ING-CC-0066: Monoclonal Antibodies to Interleukin-6
  • ING-CC-0068: Growth Hormone
  • ING-CC-0069: Egrifta (tesamorelin)
  • ING-CC-0111: Nplate (romiplostim)
  • ING-CC-0137: Cablivi (caplacizumab-yhdp)
  • ING-CC-0153: Adakveo (crizanlizumab)
  • ING-CC-0162: Tepezza (teprotumumab-trbw)
  • ING-CC-0194: Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection

 

Revised clinical criteria effective August 23, 2021

The following criteria was reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria.

  • ING-CC-0182: Agents for Iron Deficiency Anemia

 

Revised clinical criteria effective December 1, 2021

The following criteria listed below might result in services that were previously covered now being considered either not medically necessary and/or investigational.

  • ING-CC-0077: Palynziq (pegvaliase-pqpz)

 

1300-0921-PN-NE



Featured In:
September 2021 New Hampshire Provider News