Effective for dates of service on and after July 14, 2019, the following updates will apply to the AIM Advanced Oncologic Imaging Clinical Appropriateness Guideline.

 

• Prostate Cancer - Added criteria for the appropriate use of PET-CT with the radiotracers Axumin and 11-Choline, establishing the position of this test in the care continuum for prostate cancer primarily related to biochemical recurrence
• Neuroendocrine Tumors - Added criteria for the appropriate use of PET-CT with the radiotracer DOTA-TATE , establishing the position of this test in the care continuum for neuroendocrine tumors

 

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortallSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Web Portal at availity.com
• Call the AIM Contact Center toll-free number: 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

 

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here.

Effective for dates of service on and after November 10, 2019, the following updates will apply to the AIM Radiation Oncology: Proton Beam Therapy Clinical Appropriateness Guideline.

 

• Sinonasal cancer: Added criteria and diagnosis codes for locally advanced sinonasal cancer when tumor involves base of skull and proton beam therapy is needed to spare orbit, optic nerve, optic chiasm, or brainstem
• Ocular Melanoma: Removed tumor size restrictions for treating melanoma of the uveal tract
• Pediatric tumors: Clarified proton beam therapy appropriate for all pediatric tumors requiring radiation therapy

 

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortallSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Web Portal at availity.com
• Call the AIM Contact Center toll-free number: 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here.

 

Please note, this program does not apply to FEP or National Accounts.

Effective for dates of service on and after November 10, 2019, the following updates will apply to the AIM Advanced Imaging Clinical Appropriateness Guidelines.

 

Oncologic Imaging Guideline contains updates to the following: 

• Colorectal cancer, germ cell tumors, kidney cancer, multiple myeloma, prostate cancer and cancers of unknown primary / cancers not otherwise specified,
• Added new sections on hepatobiliary cancer and suspected metastases
• Added allowance for MRI and/or MRCP for diagnostic workup of hepatocellular carcinoma, intrahepatic cholangiocarcinoma, and extrahepatic cholangiocarcinoma
• Added allowance for PET “When standard imaging prior to planned curative surgery for cholangiocarcinoma has been performed and has not demonstrated metastatic disease”

 

Vascular Imaging Guideline contains updates to the following:  

• Brain, Head and Neck: Aneurysm - intracranial,  Aneurysm - extracranial, Arteriovenous malformation (AVM) and fistula (AVF), Fibromuscular dysplasia, Hemorrhage - intracranial, Stenosis or occlusion -  extracranial, Stenosis or occlusion -  intracranial, stroke and Venous thrombosis or compression -  intracranial
• Chest: Acute aortic syndrome, Aortic aneurysm, Pulmonary artery hypertension
• Abdomen and Pelvis: Acute aortic syndrome, Aneurysm of the abdominal aorta or iliac arteries, Hematoma/hemorrhage within the abdomen or unexplained hypotension, Renal artery stenosis (RAS)/Renovascular hypertension, Venous thrombosis or compression – intracranial, Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified
• Upper Extremity: Peripheral arterial disease, Venous thrombosis or occlusion
• Lower Extremity: Added physiologic testing for peripheral arterial disease and further defined indications for classic presenting symptoms of lower extremity peripheral arterial disease
• Added arterial ultrasound guideline content
• Aligned peripheral arterial ultrasound with advanced vascular imaging criteria

 

Imaging of the Heart Guideline contains updates to the following:  

• Blood Pool Imaging:  Changes address appropriate evaluation and surveillance of LV function in patients following cardiac transplantation. Additional language is more restrictive based on the literature and aligns with the resting transthoracic echocardiography guideline.
• Cardiac CT:  Quantitative evaluation of coronary artery calcification has been revised with new more expansive language based on review of the literature.

 

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortallSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Web Portal at availity.com
• Call the AIM Contact Center toll-free number: 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

 

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here.

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)]

Empire has identified that providers often bill a duplicate Evaluation and Management (E/M) service on the same day as a procedure even when the same provider (or a provider with the same specialty within the same group TIN) recently billed a service or procedure which included an E/M for the same or similar diagnosis. The use of modifier 25 to support separate payment of this duplicate service is not consistent with correct coding or Empire’s policy on use of modifier 25. 

 

Beginning with claims processed on or after September 1, 2019 Empire may deny the E/M service with a modifier 25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record.

 

If you believe a claim should be reprocessed because there are medical records for related visits that demonstrate an unrelated, significant, and separately identifiable E/M service, please submit those medical records for consideration.

Bundled Services - Professional

Beginning with dates of service on or after November 1, 2019, new Interprofessional CPT codes 99451 and 99452 are not eligible for reimbursement when they are reported with another service or reported as a stand-alone service. These codes have been added to policy section 1 of the Bundled Services and Supplies reimbursement policy.

 

Frequency Editing - Professional

Our Frequency Editing policy applies frequency maximums per day and/or per date span within the same grouping which may be based on the CMS’s MUEs, industry standards, and/or code description.  Beginning with dates of service November 1, 2019, maximum units per day may be based on claims data analysis.

Below are Clinical Criteria and prior authorization updates that were endorsed at the May 17, 2019 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

Empire’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Oncology drugs will be managed by AIM Specialty Health® (AIM), a separate company.

 

Revised Clinical Criteria effective June 10, 2019

The following new clinical criteria were revised to expand medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.

 

Clinical or Coverage Guideline	Clinical Criteria	Clinical Criteria Name	Drug(s)	HCPCS or CPT Code(s)
CG-DRUG-106	ING-CC-0092	Adcetris (brentuximab)	Adcetris	J9042
CG-DRUG-38	ING-CC-0094	Alimta (pemetrexed)	Alimta	J9305
CG-DRUG-42	ING-CC-0096	Asparagine Specific Enzymes	Erwinaze, Asparaginase, Oncaspar	J9019, J9020, J9266
CG-DRUG-63	ING-CC-0104	Leucovorin and Levoleucovorin agents	Fusilev, Khapzory	J0641, C9043, J3490
CG-DRUG-66	ING-CC-0105	Vectibix (panitumumab)	Vectibix	J9303
CG-DRUG-72	ING-CC-0110	Perjeta (pertuzumab)	Perjeta	J9306
CG-DRUG-96	ING-CC-0115	Kadcyla (ado-trastuzumab)	Kadcyla	J9354
CG-DRUG-98	ING-CC-0116	Bendamustine agents	Bendeka, Treanda, Belrapzo	J9034, J9033, C9042, J9999
DRUG.00046	ING-CC-0119	Yervoy (ipilimumab)	Yervoy	J9228
DRUG.00053	ING-CC-0120	Kyprolis (carfilzomib)	Kyprolis	J9047
DRUG.00063	ING-CC-0122	Arzerra (ofatumumab)	Arzerra	J9302
DRUG.00067	ING-CC-0123	Cyramza (ramucirumab)	Cyramza	J9308
DRUG.00071	ING-CC-0124	Keytruda (pembrolizumab)	Keytruda	J9271
DRUG.00075	ING-CC-0125	Opdivo (nivolumab)	Opdivo	J9299
DRUG.00107	ING-CC-0129	Bavencio (avelumab)	Bavencio	J9023

 

Revised Clinical Criteria effective September 1, 2019

The following new clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.  The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.

 

Clinical or Coverage Guideline	Clinical Criteria	Clinical Criteria Name	Drug(s)	HCPCS or CPT Code(s)
CG-DRUG-100	ING-CC-0085	Actimmune (interferon gamma-1B)	Actimmune	J9216
CG-DRUG-101	ING-CC-0090	Ixempra (ixabepilone)	Ixempra	J9207
CG-DRUG-102	ING-CC-0091	Lartruvo (olaratumab)	Lartruvo	J9285
CG-DRUG-49	ING-CC-0098	Doxorubicin Hydrochloride Liposome	Lipodox, Doxorubicin hydrochloride liposomal, Doxil	Q2049, Q2050
CG-DRUG-50	ING-CC-0099	Abraxane (paclitaxel protein-bound)	Abraxane	J9264
CG-DRUG-51	ING-CC-0100	Istodax (romidepsin)	Istodax	J9315
CG-DRUG-62	ING-CC-0103	Faslodex (fulvestrant)	Faslodex	J9395
CG-DRUG-67	ING-CC-0106	Erbitux (cetuximab)	Erbitux	J9055
CG-DRUG-68	ING-CC-0107	Bevacizumab agents (Avastin, Mvasi)	Avastin, Mvasi	J9035, Q5107
CG-DRUG-70	ING-CC-0108	Halaven (eribulin)	Halaven	J9179
CG-DRUG-71	ING-CC-0109	Zaltrap (ziv-aflibercept)	Zaltrap	J9400
CG-DRUG-75	ING-CC-0111	Nplate (romiplostim)	Nplate	J2796
CG-DRUG-77	ING-CC-0112	Xofigo (Radium Ra 223 Dichloride)	Xofigo	A9606, 79101
CG-DRUG-80	ING-CC-0114	Jevtana (cabazitaxel)	Jevtana	J9043
CG-DRUG-99	ING-CC-0117	Empliciti (elotuzumab)	Empliciti	J9176
CG-THER-RAD-03	ING-CC-0118	Radioimmunotherapy: Zevalin; azedra; Lutathera	Zevalin, Azedra, Lutathera	79403, A9543, 79101, A9699, C9408, A9513
DRUG.00062	ING-CC-0121	Gazyva (obinutuzumab)	Gazyva	J9301
DRUG.00076	ING-CC-0126	Blincyto (blinatumomab)	Blincyto	J9039
DRUG.00082	ING-CC-0127	Darzalex (daratumumab)	Darzalex	J9145
DRUG.00088	ING-CC-0128	Tecentriq (atezolizumab)	Tecentriq	J9022
DRUG.00109	ING-CC-0130	Imfinzi (durvalumab)	Imfinzi	J9173
CG-DRUG-113	ING-CC-0131	Besponsa (inotuzumab ozogamicin)	Besponsa	J9229
DRUG.00112	ING-CC-0132	Mylotarg (gemtuzumab ozogamicin)	Mylotarg	J9203
DRUG.00118	ING-CC-0133	Aliqopa (copanlisib)	Aliqopa	J9057
MED.00106	ING-CC-0134	Provenge (Sipuleucel-T)	Provenge	Q2043
CG-MED-67	ING-CC-0135	Melanoma Vaccines	Imlygic	J9325, J3590
CG-DRUG-53	ING-CC-0136	Drug dosage, frequency, and route of administration	N/A	N/A
CG-DRUG-01	ING-CC-0141	Off-Label Drug and Approved Orphan Drug Use	N/A	N/A

 

Revised Clinical Criteria effective November 1, 2019

The following current and new clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.

• ING-CC-0048 Spinraza (nusinersen)
• ING-CC-0002 Colony Stimulating Factor Agents
• ING-CC-0113 Sylvant (siltuximab) [previously CG-DRUG-79]

 

New Clinical Criteria effective November 1, 2019

The following clinical criteria are new.

• ING-CC-0137 Cablivi (caplacizumab-yhdp)
• ING-CC-0138 Asparlas (calaspargase pegol-mknl)
• ING-CC-0139 Evenity (romosozumab-aqqg)
• ING-CC-0140 Zulresso (brexanolone)

 

Expanded specialty pharmacy prior authorization list

Effective for dates of service on and after November 1, 2019, the following non-oncology specialty pharmacy codes from current clinical criteria will be included in our prior authorization review process.

 

Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.

 

Empire’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Oncology drugs will be managed by AIM Specialty Health® (AIM), a separate company.

Clinical Criteria	HCPCS or CPT Code(s)	NDC Code(s)	Drug
ING-CC-0050	J3490 J3590	00074-2042-01 00074-2042-02	Skyrizi™

For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit empireblue.com/pharmacyinformation. The commercial and marketplace drug lists are posted to the web site quarterly (the first of the month for January, April, July and October).

 

To locate Marketplace scroll down to “Select Drug Lists.” This drug list is also reviewed and updated regularly as needed.

 

FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.

In the June newsletter we announced the transition of the medical non-oncology specialty drug review process from AIM Specialty Health® (AIM) to Empire’s medical specialty drug review team, effective June 15, 2019. Here’s a reminder of the changes.

 

What has changed?

• Beginning June 15, 2019, for all new specialty drug review requests and reauthorization specialty drug review requests that were previously performed by AIM, providers need to contact Empire’s medical specialty drug review team:
• by phone at 1-833-293-0659
• by fax at 1-888-223-0550 or
• All inquiries about an existing request (initially submitted to AIM or Empire), peer-to-peer review, or reconsideration are being managed by Empire’s medical specialty drug review team.

 

What has not changed?

• AIM continues to be responsible for performing medical oncology drug reviews for existing commercial medical benefit for our employer group business.
• Specialty drug review processes not previously done by AIM remain unchanged.
• Clinical criteria for medical non-oncology specialty drugs continues to reside on the clinical criteria page.
• Post Service Clinical Coverage Reviews and Grievance and Appeals process and teams have not changed.

 

Here is a summary of the medical specialty drug changes: Beginning June 15, 2019

 

Action	Contact
Submit a new prior authorization request for medical specialty drug reviews   Submit a reauthorization request for a medical specialty drug review previously performed by AIM	Call Empire at 1-833-293-0659   or   Fax us at 1-888-223-0550 for
Inquire about an existing request (initially submitted to AIM or Empire), peer-to-peer review, or reconsideration	Call Empire at 1-833-293-0659