Policy Updates Medical Policy & Clinical GuidelinesCommercialNovember 30, 2018

Medical Policy Updates

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Archived Medical Policy Effective 09-20-2018

(The following policy has been archived.)

  • DRUG.00089 - Daclizumab (Zinbryta®)

 

Revised Medical Policy Effective 09-20-2018

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

  • LAB.00019 - Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease

 

Revised Medical Policies Effective 09-20-2018

 (The following policies were updated with new procedure and/or diagnosis codes.)

  • DRUG.00078 - Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors
  • DRUG.00081 - Eteplirsen (Exondys 51™)
  • GENE.00010 - Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
  • GENE.00016 - Gene Expression Profiling for Colorectal Cancer
  • GENE.00023 - Gene Expression Profiling of Melanomas
  • GENE.00041 - Genetic Testing to Confirm the Identity of Laboratory Specimens
  • LAB.00029 - Rupture of Membranes (ROM) Testing in Pregnancy
  • MED.00111 - Intracardiac Ischemia Monitoring

 

Revised Medical Policy Effective10-13-2018

 (The following policy was updated with new procedure and/or diagnosis codes.)

  • SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke

 

Revised Medical Policies Effective 10-17-2018

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

  • ADMIN.00006      Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline
  • DME.00011          Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices
  • DME.00038          Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
  • GENE.00033        Genetic Testing for Inherited Peripheral Neuropathies
  • GENE.00047        Methylenetetrahydrofolate Reductase Mutation Testing
  • LAB.00028            Serum Biomarker Tests for Multiple Sclerosis
  • MED.00057          MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
  • MED.00082          Quantitative Sensory Testing
  • MED.00089          Quantitative Muscle Testing Devices
  • MED.00095          Anterior Segment Optical Coherence Tomography
  • MED.00096          Low-Frequency Ultrasound Therapy for Wound Management
  • MED.00099          Electromagnetic Navigational Bronchoscopy
  • MED.00103          Automated Evacuation of Meibomian Gland
  • OR-PR.00006      Powered Robotic Lower Body Exoskeleton Devices
  • RAD.00004           Peripheral Bone Mineral Density Measurement
  • RAD.00037           Whole Body Computed Tomography Scanning
  • RAD.00057           Near-Infrared Coronary Imaging and Near-Infrared Intravascular Ultrasound Coronary Imaging
  • RAD.00062           Intravascular Optical Coherence Tomography (OCT)
  • RAD.00064           Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
  • SURG.00008       Mechanized Spinal Distraction Therapy
  • SURG.00067       Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty
  • SURG.00082       Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
  • SURG.00092       Implanted Devices for Spinal Stenosis
  • SURG.00095       Viscocanalostomy and Canaloplasty
  • SURG.00101       Suprachoroidal Injection of Pharmacologic Agent
  • SURG.00104       Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
  • SURG.00114       Facet Joint Allograft Implants for Facet Disease
  • SURG.00119       Endobronchial Valve Devices
  • SURG.00127       Sacroiliac Joint Fusion
  • SURG.00128       Implantable Left Atrial Hemodynamic Monitor
  • SURG.00129       Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
  • SURG.00131       Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)
  • SURG.00135       Radiofrequency Ablation of the Renal Sympathetic Nerves
  • SURG.00144       Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
  • TRANS.00035     Mesenchymal Stem Cell Therapy For Orthopedic Indications
  • TRANS.00036     Stem Cell Therapy for Peripheral Vascular Disease

 

Revised Medical Policy Effective 10-20-2018

(The following policy was revised to expand medical necessity indications or criteria.)

  • SURG.00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)

 

Revised Medical Policy Effective 03-01-2019

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

  • LAB.00030 - Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs

 

New Medical Policy Effective 03-16-2019

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

  • MED.00125 - Biofeedback and Neurofeedback

 

Revised Medical Policy Effective 03-16-2019

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

  • SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

PUBLICATIONS: December 2018 Empire Provider Newsletter