Policy Updates Medical Policy & Clinical GuidelinesCommercialJuly 31, 2019

Policy updates

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

These updates list the new and/or revised Empire medical policies, clinical guidelines and reimbursement policies*.  The implementation date for each policy or guideline is noted for each section.  Implementation of the new or revised medical policy, clinical guideline or reimbursement policy is effective for all claims processed on and after the specified implementation date, regardless of date of service.  Previously processed claims will not be reprocessed as a result of the changes.  If there is any inconsistency or conflict between the brief description provided below and the actual policy or guideline, the policy or guideline will govern.

 

Federal and state law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over medical policy and clinical guidelines (and medical policy takes precedence over clinical guidelines) and must be considered first in determining eligibility for coverage.  The member’s contract benefits in effect on the date that the services are rendered must be used. This document supplements any previous medical policy and clinical guideline updates that may have been issued by Empire.  Please include this update with your Provider Manual for future reference.

 

Please note that medical policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.  Empire’s medical policies and clinical guidelines can be found at empireblue.com.

 

*Note: These updates may not apply to all ASO Accounts as some accounts may have non-standard benefits that apply.

 

Medical Policy Updates

 

Transitioned Medical Policies Effective 06-10-2019

(The following policies have been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)

  • DRUG.00046 - Ipilimumab (Yervoy®) [Transitioned to ING-CC-0119 Yervoy (ipilimumab)]
  • DRUG.00053 - Carfilzomib (Kyprolis®) [Transitioned to ING-CC-0120 Kyprolis (carfilzomib)]
  • DRUG.00063 - Ofatumumab (Arzerra®) [Transitioned to ING-CC-0122 Arzerra (ofatumumab)]
  • DRUG.00067 - Ramucirumab (Cyramza®) [Transitioned to ING-CC-0123 Cyramza (ramucirumab)
  • DRUG.00071 - Pembrolizumab (Keytruda®) [Transitioned to ING-CC-0124 Keytruda (pembrolizumab)]
  • DRUG.00075 - Nivolumab (Opdivo®) [Transitioned to ING-CC-0125 Opdivo (nivolumab)]
  • DRUG.00107 - Avelumab (Bavencio®) [Transitioned to ING-CC-0129 Bavencio (avelumab)]

 

New Medical Policy Effective 06-13-2019

(The following policy is new and determined to not have significant changes.)

  • MED.00129 - Gene Therapy for Spinal Muscular Atrophy

 

Revised Medical Policies Effective 06-13-2019

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

  • GENE.00029 - Genetic Testing for Breast and/or Ovarian Cancer Syndrome
  • SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
  • SURG.00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

 

Revised Medical Policy Effective 06-15-2019

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

  • SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions

 

Revised Medical Policies Effective 06-27-2019

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

  • DRUG.00062 - Obinutuzumab (Gazyva®)
  • GENE.00044 - Analysis of PIK3CA Status in Tumor Cells

 

Revised Medical Policies Effective 06-27-2019

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

  • GENE.00025 - Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignancies
  • GENE.00028 - Genetic Testing for Colorectal Cancer Susceptibility
  • SURG.00010 - Treatments for Urinary Incontinence
  • SURG.00121 - Transcatheter Heart Valve Procedures

 

Revised Medical Policies Effective 06-27-2019

(The following policies were updated with the new CPT/HCPCS procedure codes effective on 06-27-2019.)

  • GENE.00001 - Genetic Testing for Cancer Susceptibility
  • GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases
  • LAB.00011 - Analysis of Proteomic Patterns
  • LAB.00015 - Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer

 

Revised Medical Policy Effective 07-10-2019

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

  • MED.00109 - Corneal Collagen Cross-Linking

 

Revised Medical Policies Effective 07-10-2019

(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
  • ADMIN.00007 - Immunizations
  • ANC.00006 - Biomagnetic Therapy
  • ANC.00007 - Cosmetic and Reconstructive Services: Skin Related
  • 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
  • GENE.00011 - Gene Expression Profiling for Managing Breast Cancer Treatment
  • 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.00049 - Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)
  • LAB.00016 - Fecal Analysis in the Diagnosis of Intestinal Disorders
  • LAB.00031 - Advanced Lipoprotein Testing
  • LAB.00035 - Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
  • 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.00123 - Axicabtagene ciloleucel (Yescarta®)
  • MED.00124 - Tisagenlecleucel (Kymriah®)
  • MED.00127 - Chelation Therapy
  • OR-PR.00005 - Upper Extremity Myoelectric Orthoses
  • RAD.00034 - Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
  • RAD.00063 - Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
  • SURG.00005 - Partial Left Ventriculectomy
  • 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.00125 - Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain
  • SURG.00126 - Irreversible Electroporation
  • SURG.00134 - Interspinous Process Fixation Devices
  • SURG.00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
  • SURG.00141 - Doppler-Guided Transanal Hemorrhoidal Dearterialization
  • SURG.00143 - Perirectal Spacers for Use During Prostate Radiotherapy
  • SURG.00147 - Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders

 

Revised Medical Policy Effective 07-20-2019

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

  • SURG.00032 - Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention

 

Transitioned Medical Policies Effective 09-01-2019

(The following policies have been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)

  • DRUG.00062 - Obinutuzumab (Gazyva®) [Transitioned to ING-CC-0121 Gazyva (obinutuzumab)]
  • DRUG.00076 - Blinatumomab (Blincyto®) [Transitioned to ING-CC-0126 Blincyto (blinatumomab)
  • DRUG.00082 - Daratumumab (DARZALEX®) [Transitioned to ING-CC-0127 Darzalex (daratumumab)]
  • DRUG.00088 - Atezolizumab (Tecentriq®) [Transitioned to ING-CC-0128 Tecentriq (atezolizumab)]
  • DRUG.00109 - Durvalumab (Imfinzi®) [Transitioned to ING-CC-0130 Imfinzi (durvalumab)]
  • DRUG.00112 - Gemtuzumab Ozogamicin (Mylotarg®) [Transitioned to ING-CC-0132 Mylotarg (gemtuzumab ozogamicin)]
  • DRUG.00118 - Copanlisib (Aliqopa®) [Transitioned to ING-CC-0133 Aliqopa (copanlisib)]
  • MED.00106 - Sipuleucel-T (Provenge®) [Transitioned to ING-CC-0134 Provenge (Sipuleucel-T)]

 

Revised Medical Policy Effective 09-04-2019

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

  • GENE.00010 - Genotype Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status [Note: Genotype testing for single polymorphisms of metabolizing enzymes for specific drugs moved into a separate clinical utilization management guideline, CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status.]

 

Archived Medical Policies Effective 09-04-2019

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

  • GENE.00021 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies [Note: Content transferred to CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies]
  • SURG.00106 - Ablative Techniques as a Treatment for Barrett’s Esophagus Anomalies [Note: Content transferred to CG-SURG-101 Ablative Techniques as a Treatment for Barrett’s Esophagus]
  • SURG.00133 - Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy [Note: Content transferred to CG-SURG-102 Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy]

 

New Medical Policy Effective 11-01-2019

(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.)

  • GENE.00051 - Bronchial Gene Expression Classification for Diagnostic Evaluation of Lung Cancer

 

Revised Medical Policies Effective 11-01-2019

(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.)

  • DME.00038 - Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
  • LAB.00027 - Selected Blood, Serum and Cellular Allergy and Toxicity Tests
  • LAB.00033 - Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
  • OR-PR.00003 - Microprocessor Controlled Lower Limb Prostheses
  • SURG.00120 - Internal Rib Fixation Systems

 

New Medical Policy Effective 11-09-2019

(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.)

  • SURG.00153 - Cardiac Contractility Modulation Therapy

 

Revised Medical Policy Effective 11-09-2019

(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.00045 - Extracorporeal Shock Wave Therapy

 

Clinical Guideline Updates

 

Transitioned Clinical Guidelines Effective 06-10-2019

(The following adopted guidelines have been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)

  • CG-DRUG-38 - Pemetrexed Disodium (Alimta®) [Transitioned to ING-CC-0094 Alimta (pemetrexed)]
  • CG-DRUG-42 - Asparagine Specific Enzymes (Asparaginase) [Transitioned to ING-CC-0096 Asparagine Specific Enzymes]
  • CG-DRUG-63 - Levoleucovorin Products [Transitioned to ING-CC-0104 Levoleucovorin Agents]
  • CG-DRUG-66 - Panitumumab (Vectibix®) [Transitioned to ING-CC-0105 Vectibix (panitumumab)]
  • CG-DRUG-72 - Pertuzumab (Perjeta®) [Transitioned to ING-CC-0110 Perjeta (pertuzumab)]
  • CG-DRUG-96 - Ado-trastuzumab emtansine (Kadcyla®) [Transitioned to ING-CC-0115 Kadcyla (ado-trastuzumab)]
  • CG-DRUG-98 - Bendamustine Hydrochloride [Transitioned to ING-CC-0116 Bendamustine agents]
  • CG-DRUG-106 - Brentuximab Vedotin (Adcetris®) [Transitioned to ING-CC-0092 Adcetris (brentuximab)]

 

Revised Clinical Guideline Effective 06-27-2019

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

  • CG-DRUG-62 - Fulvestrant (FASLODEX®)

 

Revised Clinical Guideline Effective 07-10-2019

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

  • CG-MED-59 - Upper Gastrointestinal Endoscopy in Adults

 

Revised Clinical Guidelines Effective 07-10-2019

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

  • CG-DME-45 - Ultrasound Bone Growth Stimulation
  • CG-GENE-02 - Analysis of KRAS Status
  • CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)
  • CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
  • CG-MED-75 - Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome
  • CG-MED-76 - Magnetic Source Imaging and Magnetoencephalography
  • CG-MED-77 - SPECT/CT Fusion Imaging
  • CG-MED-83 - Level of Care: Specialty Pharmaceuticals
  • CG-REHAB-11 - Cognitive Rehabilitation
  • CG-SURG-05 - Maze Procedure
  • CG-SURG-08 - Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
  • CG-SURG-12 - Penile Prosthesis Implantation
  • CG-SURG-34 - Diagnostic Infertility Surgery
  • CG-SURG-35 - Intracytoplasmic Sperm Injection (ICSI)
  • CG-SURG-49 - Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
  • CG-SURG-50 - Assistant Surgeons
  • CG-SURG-81 - Cochlear Implants and Auditory Brainstem Implants
  • CG-SURG-82 - Bone-Anchored and Bone Conduction Hearing Aids
  • CG-SURG-84 - Mandibular/ Maxillary (Orthognathic) Surgery
  • CG-SURG-85 - Hip Resurfacing
  • CG-SURG-86 - Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
  • CG-SURG-87 - Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
  • CG-SURG-88 - Mastectomy for Gynecomastia
  • CG-SURG-89 - Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
  • CG-TRANS-03 - Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation

 

Transitioned Clinical Guideline Effective 08-01-2019

(The following adopted guideline has been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)

  • CG-DRUG-76 - Plerixafor Injection (Mozobil™) [Transitioned to ING-CC-0089 Mozobil (plerixafor)]

 

Transitioned Clinical Guidelines Effective 09-01-2019

(The following adopted guidelines have been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)

  • CG-DRUG-01 - Off-Label Drug and Approved Orphan Drug Use [Transitioned to ING-CC-0141 Off-Label Drug and Approved Orphan Drug Use]
  • CG-DRUG-49 - Doxorubicin Hydrochloride Liposome Injection [Transitioned to ING-CC-0098 Doxorubicin Hydrochloride Liposome]
  • CG-DRUG-50 - Paclitaxel, protein-bound (Abraxane®) [Transitioned to ING-CC-0099 Abraxane (paclitaxel protein-bound)]
  • CG-DRUG-51 - Romidepsin (Istodax®) [Transitioned to ING-CC-0100 Istodax (romidepsin)]
  • CG-DRUG-53 - Drug Dosage, Frequency, and Route of Administration [Transitioned to ING-CC-0136 Dose, frequency, and route of administration]
  • CG-DRUG-62 - Fulvestrant (FASLODEX®) [Transitioned to ING-CC-0103 Faslodex (fulvestrant)]
  • CG-DRUG-67 - Cetuximab (Erbitux®) [Transitioned to ING-CC-0106 Erbitux (cetuximab)]
  • CG-DRUG-68 - Bevacizumab (Avastin®) for Non-Ophthalmologic Indications [Transitioned to ING-CC-0107 Bevacizumab for Non-ophthalmologic Indications (Avastin, Mvasi)]
  • CG-DRUG-70 - Eribulin mesylate (Halaven®) [Transitioned to ING-CC-0108 Halaven (eribulin)]
  • CG-DRUG-71 - Ziv-aflibercept (Zaltrap®)[Transitioned to ING-CC-0109 Zaltrap (ziv-aflibercept)]
  • CG-DRUG-75 - Romiplostim (Nplate®) [Transitioned to ING-CC-0111 Nplate (romiplostim)]
  • CG-DRUG-77 - Radium Ra 223 Dichloride (Xofigo®)[Transitioned to ING-CC-0112 Xofigo (Radium Ra 223 Dichloride)]
  • CG-DRUG-80 - Cabazitaxel (Jevtana®) [Transitioned to ING-CC-0114 Jevtana (cabazitaxel)]
  • CG-DRUG-99 - Elotuzumab (Empliciti™) [Transitioned to ING-CC-0117 Empliciti (elotuzumab)]
  • CG-DRUG-100 - Interferon gamma-1b (Actimmune®) [Transitioned to ING-CC-0085 Actimmune (interferon gamma-1B)]
  • CG-DRUG-101 - Ixabepilone (Ixempra®) [Transitioned to ING-CC-0090 Ixempra (ixabepilone)]
  • CG-DRUG-102 - Olaratumab (Lartruvo™) [Transitioned to ING-CC-0091 Lartruvo (olaratumab)]
  • CG-DRUG-113 - Inotuzumab ozogamicin (Besponsa®) [Transitioned to ING-CC-0131 Besponsa (inotuzumab ozogamicin)]
  • CG-MED-67 - Melanoma Vaccines [Transitioned to ING-CC-0135 Melanoma Vaccines]
  • CG-THER-RAD-03 - Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy [Transitioned to ING-CC-0118 Radioimmunotherapy: Zevalin; azedra; Lutathera]

 

Adopted Clinical Guidelines Effective 09-04-2019

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

  • CG-GENE-10 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies [Note: Content moved from GENE.00021 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies.]
  • CG-GENE-11 - Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status [Note: Content for genotype testing for single polymorphisms of metabolizing enzymes for specific drugs moved from GENE.00010 Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status.]
  • CG-SURG-101 - Ablative Techniques as a Treatment for Barrett’s Esophagus[Note: Content moved from SURG.00106 Ablative Techniques as a Treatment for Barrett’s Esophagus Anomalies.]

 

Transitioned Clinical Guideline Effective 11-01-2019

(The following adopted guideline has been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)

  • CG-DRUG-79 - Siltuximab (Sylvant®) [Transitioned to ING-CC-0113 Sylvant (siltuximab)]

PUBLICATIONS: August 2019 Empire Provider News