Policy Updates Medical Policy & Clinical GuidelinesCommercialAugust 1, 2018

Clinical Guideline Updates

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Revised Clinical Guideline Effective 05-10-2018

(The following adopted guideline was revised to expand medical necessity indications or criteria.)

  • CG-DRUG-50 - Paclitaxel, protein-bound (Abraxane®)

 

Revised Clinical Guidelines Effective 06-06-2018

(The following adopted guidelines were revised to expand medical necessity indications or criteria.)

  • CG-DRUG-62 - Fulvestrant (FASLODEX®)
  • CG-DRUG-73 - Denosumab (Prolia®, Xgeva®)
  • CG-DRUG-78 - Antihemophilic Factor and Clotting Factors

 

Revised Clinical Guidelines Effective 06-06-2018

(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)

  • CG-DRUG-05 - Recombinant Erythropoietin Products
  • CG-DRUG-08 - Enzyme Replacement Therapy for Gaucher Disease
  • CG-DRUG-09 - Immune Globulin (Ig) Therapy
  • CG-DRUG-16 - White Blood Cell Growth Factors
  • CG-DRUG-25 - Intravenous versus Oral Drug Administration in the Outpatient and Home Setting
  • CG-DRUG-49 - Doxorubicin Hydrochloride Liposome Injection
  • CG-DRUG-51 - Romidepsin (Istodax®)
  • CG-DRUG-53 - Drug Dosage, Frequency, and Route of Administration
  • CG-MED-37 - Intensive Programs for Pediatric Feeding Disorders
  • CG-SURG-18 - Septoplasty
  • CG-SURG-30 - Tonsillectomy for Children with or without Adenoidectomy

 

Revised Clinical Guidelines Effective 06-28-2018

(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)

  • CG-DRUG-16 - White Blood Cell Growth Factors
  • CG-DRUG-64 - FDA-Approved Biosimilar Products
  • CG-DRUG-65 - Tumor Necrosis Factor Antagonists

 

Adopted Clinical Guidelines Effective 06-28-2018

(The following guidelines were previously medical policies and have been adopted and have no significant changes.)

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

 

Revised Clinical Guideline Effective 11-01-2018

(The following adopted guideline was revised and might result in services that were previously covered but may now be found to be not medically necessary.)

  • CG-DRUG-50 - Paclitaxel, protein-bound (Abraxane®)

 

PUBLICATIONS: August 2018 Empire Provider Newsletter