CommercialDecember 31, 2018
Clinical Guideline Updates
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.
(The following adopted guideline was revised to expand medical necessity indications or criteria.)
- CG-DRUG-88 - Dupilumab (Dupixent®)
Revised Clinical Guidelines Effective 12-12-2018
(The following adopted guidelines were revised to expand medical necessity indications or criteria.)
- CG-DRUG-62 - Fulvestrant (FASLODEX®)
- CG-DRUG-63 -Levoleucovorin Products
- CG-DRUG-78 - Antihemophilic Factor and Clotting Factors
- CG-DRUG-107 - Pharmacotherapy for Hereditary Angioedema
- CG-GENE-03 - BRAF Mutation Analysis
- CG-SURG-60 - Cervical Total Disc Arthroplasty
- CG-THER-RAD-03 - Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy [Note: Content for Lutetium Lu 177 dotatate (Lutathera®) moved from DRUG.00098 Lutetium Lu 177 dotatate (Lutathera®)]
Revised Clinical Guidelines Effective 12-12-2018
(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)
- CG-DRUG-38 - Pemetrexed Disodium (Alimta®)
- CG-DRUG-42 - Asparagine Specific Enzymes (Asparaginase)
- CG-DRUG-44 - Pegloticase (Krystexxa®)
- CG-DRUG-45 - Octreotide acetate (Sandostatin®; Sandostatin® LAR Depot)
- CG-DRUG-54 - Agalsidase beta (Fabrazyme®)
- CG-DRUG-64 - FDA-Approved Biosimilar Products
- CG-DRUG-66 - Panitumumab (Vectibix®)
- CG-DRUG-70 - Eribulin mesylate (Halaven®)
- CG-DRUG-71 - Ziv-aflibercept (Zaltrap®)
- CG-DRUG-75 - Romiplostim (Nplate®)
- CG-DRUG-76 - Plerixafor Injection (Mozobil™)
- CG-DRUG-79 - Siltuximab (Sylvant®)
- CG-DRUG-80 - Cabazitaxel (Jevtana®)
- CG-DRUG-87 - Vedolizumab (Entyvio®)
- CG-MED-19 - Custodial Care
- CG-MED-26 - Neonatal Levels of Care
- CG-MED-67 - Melanoma Vaccines
- CG-MED-68 - Therapeutic Apheresis
- CG-REHAB-07 - Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
- CG-SURG-60 - Cervical Total Disc Arthroplasty
- CG-SURG-62 - Radiofrequency Ablation to Treat Tumors Outside the Liver
- CG-THER-RAD-04 - Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Tumors
Revised Clinical Guideline Effective 12-12-2018
(The following adopted guideline was updated with new procedure and/or diagnosis codes.)
- CG-DRUG-16 - White Blood Cell Growth Factors
Revised Clinical Guidelines Effective 12-27-2018
(The following adopted guidelines were updated with new procedure and/or diagnosis codes.)
- CG-BEH-02 - Adaptive Behavioral Treatment for Autism Spectrum Disorder
- CG-DME-43 - Oscillatory Devices for Airway Clearance (High Frequency Chest Compression)
- CG-DRUG-29 - Hyaluronan Injections
- CG-DRUG-61 – Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
- CG-DRUG-94 - Rituximab (Rituxan®) for Non-Oncologic Indications
- CG-DRUG-68 - Bevacizumab (Avastin®) for Non-Ophthalmologic Indications
- CG-DRUG-90 - Intravitreal Treatment for Retinal Vascular Conditions
Archived Clinical Guidelines Effective 01-01-2019
(The following adopted guideline has been archived and has been replaced by AIM guidelines.)
- CG-SURG-60 - Cervical Total Disc Arthroplasty
Revised Clinical Guidelines Effective 01-01-2019
(The following adopted guidelines were revised and had no significant changes to the policy position or criteria.)
- CG-DME-40 - Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton [Note: Non-invasive electrical bone growth stimulation of the of the spine transitioned to AIM guidelines effective 01-01-2019
- CG-MED-65 - Manipulation Under Anesthesia [Note: Manipulation under anesthesia of the shoulder transitioned to AIM guidelines effective 01-01-2019]
Adopted Clinical Guidelines Effective 01-03-2019
(The following guidelines were previously medical policies and have been adopted and have no significant changes.)
- CG-MED-79 - Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems [Note: Content moved from MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems.]
- CG-MED-80 - Positron Emission Tomography (PET) and PET/CT Fusion [Note: Content moved from RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion.]
Revised Clinical Guideline Effective 01-12-2019
(The following adopted guideline was updated with new procedure and/or diagnosis codes.)
- CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
Revised Clinical Guidelines Effective 04-01-2019
(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-DRUG-77 - Radium Ra 223 Dichloride (Xofigo®)
- CG-GENE-01 - Janus Kinase 2 (JAK2)V617F Gene Mutation Assay Title change: Janus Kinase 2 (JAK2)V617F and JAK2 exon 12 Gene Mutation Assays
- CG-SURG-27 - Sex Reassignment Surgery
Revised Clinical Guideline Effective 04-13-2019
(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-SURG-61 - Cryosurgical Ablation of Solid Tumors Outside the Liver
PUBLICATIONS: January 2019 Empire Provider Newsletter
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