Clinical Guideline Updates

Revised Clinical Guidelines Effective 04-25-2018

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

• CG-BEH-02 - Adaptive Behavioral Treatment for Autism Spectrum Disorder
• CG-BEH-03 - Psychiatric Disorder Treatment
• CG-BEH-07 - Psychological Testing
• CG-DRUG-27 - Clostridial Collagenase Histolyticum Injection
• CG-DRUG-57 - Idursulfase (Elaprase®)
• CG-MED-55 - Level of Care: Advanced Radiologic Imaging
• CG-MED-68 - Therapeutic Apheresis
• CG-REHAB-06 - Speech-Language Pathology Services (Note: applicable to National Accounts only.)
• CG-SURG-09 - Temporomandibular Disorders
• CG-SURG-27 - Sex Reassignment Surgery
• CG-TRANS-02 - Kidney Transplantation

 

Adopted Clinical Guidelines Effective 06-28-2018

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

• CG-BEH-15 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome [Note: Content moved from BEH.00004 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome.]
• CG-DRUG-90 - Intravitreal Treatment for Retinal Vascular Conditions [Note: Content moved from DRUG.00028 Intravitreal Treatment for Retinal Vascular Conditions.]
• CG-DRUG-91 - Intravitreal Corticosteroid Implants [Note: Content moved from DRUG.00032 Intravitreal Corticosteroid Implants.]
• CG-DRUG-92 - Alpha-1 Proteinase Inhibitor Therapy [Note: Content moved from DRUG.00072 Alpha-1 Proteinase Inhibitor Therapy.]
• CG-DRUG-93 - Sarilumab (Kevzara®) [Note: Content moved from .DRUG.00101 Sarilumab (Kevzara®).]
• CG-LAB-13 - Skin Nerve Fiber Density Testing [Note: Content moved from LAB.00020 Skin Nerve Fiber Density Testing.]
• CG-MED-69 - Inhaled Nitric Oxide [Note: Content moved from MED.00076 Inhaled Nitric Oxide.]
• CG-MED-70 - Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule [Note: Content moved from RAD.00030 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule.]
• CG-SURG-73 - Balloon Sinus Ostial Dilation [Note: Content for balloon sinus ostial dilation moved from SURG.00089 Balloon and Self-Expanding Absorptive Sinus Ostial Dilation.]
• CG-SURG-74 - Total Ankle Replacement [Note: Content moved from SURG.00081 Total Ankle Replacement.]
• CG-SURG-75 - Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions [Note: Content moved from SURG.00110 Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions.]
• CG-THER-RAD-07 - Intravascular Brachytherapy (Coronary and Non-Coronary) [Note: Content moved from THER-RAD.00003 Intravascular Brachytherapy (Coronary and Non-Coronary).]

 

Adopted Clinical Guideline Effective 09-01-2018

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

• CG-DRUG-89 - Implantable and Extended-Release Buprenorphine-Containing Products [Note: Content moved from DRUG.00092 Buprenorphine Implant (Probuphine®).]

 

Revised Clinical Guidelines Effective 09-15-2018

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

• CG-DME-06 - Pneumatic Compression Devices for Lymphedema
• CG-REHAB-04 - Physical Therapy
• CG-REHAB-05 - Occupational Therapy

 

Archived Clinical Guidelines Effective 10-31-2018

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

• CG-BEH-03 - Psychiatric Disorder Treatment
• CG-BEH-07 - Psychological Testing

 

Revised Clinical Guideline Effective 11-01-2018

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

• CG-MED-23 - Home Health (Note: Behavioral Health references have been transitioned to MCG guidelines.)