MedicaidOctober 1, 2018
Medical Policies and Clinical Utilization Management Guidelines update: effective 11/1/18
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.
The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.
Note:
- Effective November 1, 2018, MCG Heath Care Guidelines will be used for reviews, to include the use of customizations to certain guidelines and:
- o Inpatient and Surgical Care Guidelines.
- o General Recovery Care Guidelines.
- o Recovery Facility Care Guidelines.
- o Chronic Care Guidelines.
- o Behavioral Health Care Guidelines (NEW).
- Additionally, effective November 1, 2018, AIM Specialty HealthÒ Proton Beam Therapy will be used for clinical reviews.
Please share this notice with other members of your practice and office staff.
To search for specific policies or guidelines, visit http://www.empireblue.com/medicalpolicies/search.html.
Medical Policies
On May 3, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Empire BlueCross BlueShield HealthPlus (Empire).
Publish date |
Medical Policy number |
Medical Policy title |
New or revised |
6/6/2018 |
DRUG.00098 |
Lutetium Lu 177 dotatate (Lutathera®) |
New |
6/6/2018 |
DRUG.00046 |
Ipilimumab (Yervoy®) |
Revised |
5/10/2018 |
DRUG.00047 |
Brentuximab Vedotin (Adcetris®) |
Revised |
5/10/2018 |
DRUG.00053 |
Carfilzomib (Kyprolis®) |
Revised |
6/6/2018 |
DRUG.00071 |
Pembrolizumab (Keytruda®) |
Revised |
6/6/2018 |
DRUG.00075 |
Nivolumab (Opdivo®) |
Revised |
5/10/2018 |
DRUG.00076 |
Blinatumomab (Blincyto®) |
Revised |
6/6/2018 |
DRUG.00111 |
Monoclonal Antibodies to Interleukin-23 |
Revised |
5/10/2018 |
SURG.00026 |
Deep Brain, Cortical and Cerebellar Stimulation |
Revised |
Clinical UM Guidelines
On May 3, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on April 19, 2018.
(Metatags: medical policy, policy updates, member, benefits, claims, clinical guidelines,)
Publish date |
Clinical UM Guideline number |
Clinical UM Guideline title |
New or revised |
6/6/2018 |
CG-LAB-12 |
Testing for Oral and Esophageal Cancer |
New |
6/6/2018 |
CG-MED-71 |
Wound Care in the Home Setting |
New |
6/28/2018 |
CG-DME-44 |
Electric Tumor Treatment Field (TTF) |
New |
6/28/2018 |
CG-DRUG-67 |
Cetuximab (Erbitux®) |
New |
6/28/2018 |
CG-DRUG-94 |
Rituximab (Rituxan®) for Nononcologic Indications |
New |
6/28/2018 |
CG-DRUG-95 |
Belatacept (Nulojix®) |
New |
6/28/2018 |
CG-DRUG-96 |
Ado-trastuzumab emtansine (Kadcyla®) |
New |
6/28/2018 |
CG-DRUG-97 |
Rilonacept (Arcalyst®) |
New |
6/28/2018 |
CG-DRUG-98 |
Bendamustine Hydrochloride |
New |
6/28/2018 |
CG-DRUG-99 |
Elotuzumab (Empliciti™) |
New |
6/28/2018 |
CG-DRUG-100 |
Interferon gamma-1b (Actimmune®) |
New |
6/28/2018 |
CG-DRUG-101 |
Ixabepilone (Ixempra®) |
New |
6/28/2018 |
CG-DRUG-102 |
Olaratumab (Lartruvo™) |
New |
6/28/2018 |
CG-MED-72 |
Hyperthermia for Cancer Therapy |
New |
6/28/2018 |
CG-SURG-76 |
Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty |
New |
6/28/2018 |
CG-SURG-77 |
Refractive Surgery |
New |
6/28/2018 |
CG-SURG-78 |
Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies |
New |
6/28/2018 |
CG-SURG-79 |
Implantable Infusion Pumps |
New |
6/28/2018 |
CG-SURG-80 |
Transcatheter Arterial Chemoembolization and Transcatheter Arterial Embolization for Treating Primary or Metastatic Liver Tumors |
New |
5/10/2018 |
CG-DRUG-50 |
Paclitaxel, protein bound (Abraxane®) |
Revised |
6/6/2018 |
CG-DRUG-60 |
Gonadotropin Releasing Hormone Analogs for the Treatment of Oncologic Indications |
Revised |
6/6/2018 |
CG-DRUG-62 |
Fulvestrant (FASLODEX®) |
Revised |
6/6/2018 |
CG-DRUG-78 |
Antihemophilic Factors and Clotting Factors |
Revised |
PUBLICATIONS: October 2018 Empire Provider Newsletter
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