Clinical Guideline Updates

Revised Clinical Guidelines Effective 08-02-2018

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

• CG-SURG-24 - Functional Endoscopic Sinus Surgery (FESS)
• CG-SURG-73 - Balloon Sinus Ostial Dilation

 

Revised Clinical Guidelines Effective 08-29-2018

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

• CG-DRUG-09 - Immune Globulin (Ig) Therapy
• CG-DRUG-65 – Tumor Necrosis Factor Antagonists
• CG-DRUG-68 - Bevacizumab (Avastin®) for Non-Ophthalmologic Indications
• CG-DRUG-73 - Denosumab (Prolia®, Xgeva®)
• CG-DRUG-81 - Tocilizumab (Actemra®)
• CG-GENE-03 - BRAF Mutation Analysis

 

Revised Clinical Guidelines Effective 08-29-2018

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

• CG-DME-07 - Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)
• CG-DRUG-05 - Recombinant Erythropoietin Products
• CG-DRUG-11 - Infertility Drugs
• CG-DRUG-24 - Repository Corticotropin Injection (H.P. Acthar® Gel)
• CG-DRUG-47 - Level of Care: Specialty Pharmaceuticals
• CG-DRUG-56 - Galsulfase (Naglazyme®)
• CG-DRUG-69 - Ustekinumab (Stelara®)
• CG-DRUG-72 - Pertuzumab (Perjeta®)
• CG-DRUG-90 - Intravitreal Treatment for Retinal Vascular Conditions
• CG-GENE-02 - Analysis of KRAS Status
• CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules
• CG-MED-26 - Neonatal Levels of Care
• CG-REHAB-08 - Private Duty Nursing in the Home Setting
• CG-SURG-05 - Maze Procedure
• CG-SURG-08 - Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
• CG-SURG-12 - Penile Prosthesis Implantation
• CG-SURG-33 - Lumbar Fusion and Lumbar Total Disc Arthroplasty
• CG-SURG-34 - Diagnostic Infertility Surgery
• CG-SURG-35 - Intracytoplasmic Sperm Injection (ICSI)
• CG-SURG-38 - Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy
• CG-SURG-42 - Cervical Fusion
• CG-SURG-43 - Knee Arthroscopy
• CG-SURG-44 - Coronary Angiography in the Outpatient Setting
• CG-SURG-47 - Surgical Interventions for Scoliosis and Spinal Deformity
• CG-SURG-48 - Elective Percutaneous Coronary Interventions (PCI)
• CG-SURG-50 - Assistant Surgeons
• CG-SURG-53 - Elective Total Hip Arthroplasty
• CG-SURG-54 - Elective Total Knee Arthroplasty
• CG-SURG-60 - Cervical Total Disc Arthroplasty
• CG-SURG-65 - Recombinant Human Bone Morphogenetic Protein
• CG-SURG-66 - Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)
• CG-SURG-67 - Treatment of Osteochondral Defects
• CG-SURG-68 - Surgical Treatment of Femoroacetabular Impingement Syndrome
• CG-SURG-69 - Meniscal Allograft Transplantation of the Knee
• CG-THER-RAD-03 - Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy

 

Adopted Clinical Guidelines Effective 09-20-2018

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

• CG-DME-45 - Ultrasound Bone Growth Stimulation [Note: Content moved from DME.00027 Ultrasound Bone Growth Stimulation]
• CG-DRUG-103 - Botulinum Toxin [Note: Content moved from DRUG.00006 Botulinum Toxin]
• CG-DRUG-104 - Omalizumab (Xolair®) [Note: Content moved from DRUG.00024 Omalizumab (Xolair®)]
• CG-DRUG-105 - Abatacept (Orencia®) [Note: Content moved from DRUG.00040 Abatacept (Orencia®)]
• CG-DRUG-106 - Brentuximab Vedotin (Adcetris®) [Note: Content moved from DRUG.00047 Brentuximab Vedotin (Adcetris®)]
• CG-DRUG-107 - Pharmacotherapy for Hereditary Angioedema [Note: Content moved from DRUG.00058 Pharmacotherapy for Hereditary Angioedema]
• CG-DRUG-108 - Enteral Carbidopa and Levodopa Intestinal Gel Suspension [Note: Content moved from DRUG.00064 Enteral Carbidopa and Levodopa Intestinal Gel Suspension]
• CG-DRUG-109 - Asfotase Alfa (Strensiq™) [Note: Content moved from DRUG.00087 Asfotase Alfa (Strensiq™)]
• CG-DRUG-110 - Naltrexone Implantable Pellets [Note: Content moved from DRUG.00091 Naltrexone Implantable Pellets]
• CG-DRUG-111 - Sebelipase alfa (KANUMA™) [Note: Content moved from DRUG.00093 Sebelipase alfa (KANUMA™)]
• CG-DRUG-112- Abaloparatide (Tymlos™) Injection [Note: Content moved from DRUG.00103 Abaloparatide (Tymlos™) Injection]
• CG-MED-73 - Hyperbaric Oxygen Therapy (Systemic/Topical) [Note: Content moved from MED.00005 Hyperbaric Oxygen Therapy (Systemic/Topical)]
• CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry [Note: Content moved from MED.00051 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry]
• CG-MED-75 - Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome [Note: Content moved from MED.00107 Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome]
• CG-MED-76 - Magnetic Source Imaging and Magnetoencephalography [Note: Content moved from RAD.00019 Magnetic Source Imaging and Magnetoencephalography]
• CG-MED-77 - SPECT/CT Fusion Imaging [Note: Content moved from RAD.00042 SPECT/CT Fusion Imaging]
• CG-REHAB-11 - Cognitive Rehabilitation [Note: Content moved from MED.00081 Cognitive Rehabilitation]
• CG-SURG-81 - Cochlear Implants and Auditory Brainstem Implants [Note: Content moved from SURG.00014 Cochlear Implants and Auditory Brainstem Implants]
• CG-SURG-82 - Bone-Anchored and Bone Conduction Hearing Aids [Note: Content moved from SURG.00020 Bone-Anchored and Bone Conduction Hearing Aids]
• CG-SURG-84 - Mandibular/Maxillary (Orthognathic) Surgery [Note: Content moved from SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery]
• CG-SURG-87 - Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring [Note: Content moved from SURG.00074 Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring]
• CG-SURG-88 - Mastectomy for Gynecomastia [Note: Content moved from SURG.00085 Mastectomy for Gynecomastia]
• CG-SURG-89 - Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia [Note: Content moved from SURG.00090 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia]
• CG-TRANS-03 - Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation [Note: Content moved from TRANS.00018 Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation]

 

Adopted Clinical Guidelines Effective 10-31-2018

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

• CG-SURG-83 - Bariatric Surgery and Other Treatments for Clinically Severe Obesity [Note: Content moved from SURG.00024 Bariatric Surgery and Other Treatments for Clinically Severe Obesity]
• CG-SURG-85 - Hip Resurfacing [Note: Content moved from SURG.00051 Hip Resurfacing]
• CG-SURG-86 - Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection [Note: Content moved from SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection]

 

Archived Clinical Guidelines Effective 01-01-2019

(The following guidelines have been archived and have been replaced by AIM guidelines.)

• CG-SURG-33 - Lumbar Fusion and Lumbar Total Disc Arthroplasty
• CG-SURG-38 - Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy
• CG-SURG-42 - Cervical Fusion
• CG-SURG-43 - Knee Arthroscopy
• CG-SURG-44 - Coronary Angiography in the Outpatient Setting
• CG-SURG-47 - Surgical Interventions for Scoliosis and Spinal Deformity
• CG-SURG-48 - Elective Percutaneous Coronary Interventions (PCI)
• CG-SURG-53 - Elective Total Hip Arthroplasty
• CG-SURG-54 - Elective Total Knee Arthroplasty
• CG-SURG-60 - Cervical Total Disc Arthroplasty
• CG-SURG-65 - Recombinant Human Bone Morphogenetic Protein
• CG-SURG-66 - Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)
• CG-SURG-67 - Treatment of Osteochondral Defects
• CG-SURG-68 - Surgical Treatment of Femoroacetabular Impingement Syndrome
• CG-SURG-69 - Meniscal Allograft Transplantation of the Knee

 

Clinical Guidelines Adopted Effective 01-01-2019

(The following guidelines will be applied and might result in services that were previously covered but may now be found to be not medically necessary.)

• CG-DME-25 - Seat Lift Mechanisms
• CG-DME-26 - Back-Up Ventilators in the Home Setting
• CG-DME-37 - Air Conduction Hearing Aids

Revised Clinical Guideline Effective 01-01-2019

(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-65 – Tumor Necrosis Factor Antagonists