Medical Policy Updates

Revised Medical Policies Effective 08-02-2018

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

• DRUG.00067 - Ramucirumab (Cyramza®)
• DRUG.00071 - Pembrolizumab (Keytruda®)
• GENE.00011 - Gene Expression Profiling for Managing Breast Cancer Treatment
• MED.00124 - Tisagenlecleucel (Kymriah®)

 

Revised Medical Policy Effective 08-02-2018

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

• GENE.00028 - Genetic Testing for Colorectal Cancer Susceptibility

 

Revised Medical Policies Effective 08-29-2018

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

• ADMIN.00007 - Immunizations
• DRUG.00046 - Ipilimumab (Yervoy®)
• DRUG.00075 - Nivolumab (Opdivo®)
• DRUG.00088 - Atezolizumab (Tecentriq®)
• DRUG.00098 - Lutetium Lu 177 dotatate (Lutathera®)
• GENE.00029 - Genetic Testing for Breast and/or Ovarian Cancer Syndrome

 

Revised Medical Policies Effective 08-29-2018

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

• ADMIN.00002 - Preventive Health Guidelines
• ADMIN.00004 - Medical Necessity Criteria
• ADMIN.00005 - Investigational Criteria
• ANC.00006 - Biomagnetic Therapy
• DME.00024 - Transtympanic Micropressure for the Treatment of Ménière’s Disease
• DME.00030 - Altered Auditory Feedback Devices for the Treatment of Stuttering
• DME.00034 - Standing Frames
• DME.00037 - Cooling Devices and Combined Cooling/Heating Devices
• DME.00039 - Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea
• DRUG.00015 - Prevention of Respiratory Syncytial Virus Infections
• DRUG.00095 - Ocrelizumab (Ocrevus®)
• DRUG.00111 - Monoclonal Antibodies to Interleukin-23
• GENE.00021 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
• GENE.00025 - Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors
• GENE.00041 - Genetic Testing to Confirm the Identity of Laboratory Specimens
• GENE.00042 - Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy Syndrome
• GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases
• LAB.00016 - Fecal Analysis in the Diagnosis of Intestinal Disorders
• LAB.00031 - Advanced Lipoprotein Testing
• LAB.00033 - Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
• LAB.00035 - Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
• MED.00055 - Wearable Cardioverter Defibrillators
• MED.00090 - Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
• MED.00098 - Hyperoxemic Reperfusion Therapy
• MED.00106 - Sipuleucel-T (Provenge®)
• MED.00121 - Implantable Interstitial Glucose Sensors
• OR-PR.00005 - Upper Extremity Myoelectric Orthoses
• RAD.00002 - Positron Emission Tomography (PET) and PET/CT Fusion
• RAD.00034 - Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/Videofluoroscopy)
• RAD.00045 - Cerebral Perfusion Imaging using Computed Tomography
• RAD.00046 - Cerebral Perfusion Studies using Diffusion and Perfusion Magnetic Resonance Imaging
• RAD.00049 - Low-Field and Conventional Magnetic Resonance Imaging (MRI) for Screening, Diagnosing and Monitoring
• RAD.00063 - Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
• SURG.00005 - Partial Left Ventriculectomy
• SURG.00010 - Treatments for Urinary Incontinence
• SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia and Other Genitourinary Conditions
• SURG.00071 - Percutaneous and Endoscopic Spinal Surgery
• SURG.00076 - Nerve Graft after Prostatectomy
• SURG.00077 - Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques
• SURG.00084 - Implantable Middle Ear Hearing Aids
• SURG.00105 - Bicompartmental Knee Arthroplasty
• SURG.00116 - High-Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
• SURG.00118 - Bronchial Thermoplasty
• SURG.00120 - Internal Rib Fixation Systems
• SURG.00122 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
• SURG.00125 - Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain
• SURG.00126 - Irreversible Electroporation
• SURG.00133 - Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy
• SURG.00134 - Interspinous Process Fixation Devices
• SURG.00141 - Doppler-Guided Transanal Hemorrhoidal Dearterialization
• SURG.00143 - Perirectal Spacers for Use During Prostate Radiotherapy
• SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
• TRANS.00028 - Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma

 

Archived Medical Policy Effective 09-01-2018

(The following policy has been archived.)

• GENE.00008 - Analysis of Fecal DNA for Colorectal Cancer Screening

 

Revised Medical Policies Effective 09-15-2018

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

• LAB.00027 - Selected Blood, Serum and Cellular Allergy and Toxicity Tests
• SURG.00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
• SURG.00032 - Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention

 

Archived Medical Policies Effective 09-20-2018

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

• RAD.00022 - Magnetic Resonance Spectroscopy
• RAD.00029 - CT Colonography (Virtual Colonoscopy) for Colorectal Cancer
• RAD.00043 - Computed Tomography Scans for Lung Cancer Screening
• RAD.00045 - Cerebral Perfusion Imaging using Computed Tomography
• RAD.00046 - Cerebral Perfusion Studies using Diffusion and Perfusion Magnetic Resonance Imaging
• RAD.00049 - Low-Field and Conventional Magnetic Resonance Imaging (MRI) for Screening, Diagnosing and Monitoring
• RAD.00051 - Functional Magnetic Resonance Imaging
• RAD.00055 - Magnetic Resonance Angiography of the Spinal Canal

 

Archived Medical Policies Effective 09-20-2018

(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)

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

 

Archived Medical Policies Effective 10-31-2018

(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)

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

 

Archived Medical Policies Effective 01-01-2019

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

• RAD.00002 - Positron Emission Tomography (PET) and PET/CT Fusion

 

New Medical Policies Effective 01-01-2019

(The policies below were created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)

• DRUG.00096 - Ibalizumab-uiyk (TrogarzoTM)
• GENE.00049 - Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)

 

Revised Medical Policies Effective 01-01-2019

(The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)

• ANC.00007 - Cosmetic and Reconstructive Services: Skin Related
• DRUG.00003 - Chelation Therapy
• DRUG.00031 - Subcutaneous Hormone Replacement Implants
• DRUG.00071 - Pembrolizumab (Keytruda®)
• GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases
• LAB.00027 - Selected Blood, Serum and Cellular Allergy and Toxicity Tests
• MED.00123 - Axicabtagene ciloleucel (Yescarta®)
• MED.00124 - Tisagenlecleucel (Kymriah®)