Effective for dates of service on and after February 9, 2020, the following updates will apply to the AIM Radiation Therapy Clinical Appropriateness Guidelines.

• Special Treatment Procedure and Special Physics Consult

• Removed oral cone endocavitary indication
• Intensity Modulated Radiation Therapy (IMRT), Stereotactic Radiosurgery (SRS) or Stereotactic Body Radiotherapy (SBRT) for bone metastases
• Broadened description of adjacent normal tissues which may be of concern. 
• Single fraction treatment
• Removed poor performance status criteria
• Central Nervous System cancers
• Added evidence review
• Spine Lesions; Primary or Metastatic Lesions of the Spine, Metastatic Lesions in the Lung
• Added note calling out separate criteria for curative intent treatment of extracranial oligometastatic disease.
• SBRT in the treatment of extracranial oligometastatic disease
• Added new section with discussion and indications
• Prostate cancer – hypofractionation
• Added fractionation guideline with EBRT/IMRT.
• Prostate cancer – postoperative radiotherapy and SBRT
• Added indication based on ASTRO/ASCO/AUA recommendation
• Prostate cancer – use of hydrogel spacer
• Added discussion and medical necessity statement about hydrogel spacers for prostate irradiation
• CPT code changes
• Added 77316, 77295 and 55874
• Removed 77427

 

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

• Access AIM’s ProviderPortall^SM 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 and upcoming guidelines here.

 

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

 

Effective for dates of service on and after February 9, 2020, the following updates will apply to the AIM Sleep Disorder Management Clinical Appropriateness Guidelines.

• Polysomnography and Home Sleep Testing: Established sleep disorder (OSA or other) – follow-up laboratory studies
• Expanded contraindications including the addition of chronic narcotic use based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation. 
• Management of OSA using APAP and CPAP Devices
• Expanded treatment of mild OSA with APAP and CPAP to patients with any hypertension based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation
• Expanded contraindications including the addition of chronic narcotic use based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation. 

 

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

• Access AIM’s ProviderPortall^SM 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 and upcoming guidelines here.

 

Effective for dates of service on and after February 9, 2020, the following updates will apply to the AIM Musculoskeletal Program Spine Surgery Clinical Appropriateness Guidelines.

• Conservative management – all sections
• Addition of physical therapy or home therapy requirement and one complementary modality for all spine procedures based on preponderance of benefit over harm to conservative care
• Lumbar Disc Arthroplasty
• Changed the duration of conservative management from 1 year to 6 months based on the FDA prospective study that was done to approve the lumbar disc arthroplasty procedure
• Added age, level requirements, and symptom/sign requirement and clarified contraindications in reflect these changes
• Added exclusions criteria of Prior spine surgery of any form at the target level
• Lumbar Fusion and Treatment of Spinal Deformity (including Scoliosis and Kyphosis)
• Inclusion for implant failure similar to cervical spine
• Consolidated  juvenile and congenital in adolescent idiopathic
• Decreased duration of conservative management required based on lower evidence for efficacy in spinal stenosis and specialty panel feedback
• Excluded anterior lumbar interbody fusion for foraminal stenosis without evidence of instability exclusion due to very low quality evidence for efficacy
• Lumbar Laminectomy
• Decreased duration of conservative care required for known spinal stenosis based on guidance from NASS and less evidence for efficacy of conservative management in this population
• Aligned conservative care duration with discectomy criteria
• Added new indication for synovial cyst
• Noninvasive Electrical Bone Growth Stimulation
• Clarification of guideline intent
• Allow active nicotine use as a risk factor in lumbar uses of bone growth stimulation
• Allow thoracic fusion similar to lumbar
• Bone Graft Substitutes and Bone Morphogenetic Proteins
• Allow active nicotine use as a risk factor for pseudoarthrosis in graft failure 

 

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

• Access AIM’s ProviderPortall^SM 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 and upcoming guidelines here.

 

Effective for dates of service on and after February 9, 2020, the following updates by section will apply to the AIM Advanced Imaging of the Abdomen and Pelvis Clinical Appropriateness Guidelines.

• Foreign body (Pediatric only), Gastrointestinal bleeding, Henoch-Schonlein purpura,Hematoma  or hemorrhage – intracranial or extracranial, Perianal fistula/abscess (fistula in ano), Ascites, Biliary tract dilatation or obstruction , Cholecystitis, Choledocholithiasis, Focal liver lesion, Hepatomegaly, Jaundice, Azotemia, Adrenal mass, indeterminate, Hematuria, Renal mass, Urinary tract calculi, Adrenal hemorrhage, Adrenal mass, Lymphadenopathy, Splenic hematoma, Undescended testicle (cryptorchidism)

• Abdominal and/or pelvic pain
• Combined pelvic pain with abdominal pain criteria in new “abdominal and/or pelvic pain” indication
• Required ultrasound or colonoscopy for select adult patients based on clinical scenario
• Ultrasound-first approach for pediatric abdominal and pelvic pain
• Lower extremity edema
• Added requirement to exclude DVT prior to abdominopelvic imaging
• Splenic mass, benign, Splenic mass, indeterminate, Splenomegaly
• Added new indications for diagnosis, management, and surveillance of splenic incidentalomas following the ACR White Paper (previously reviewed against “tumor, not otherwise specified”)
• Pancreatic mass
• Separated criteria for solid and cystic pancreatic masses
• Defined follow up intervals for cystic pancreatic masses
• Diffuse liver disease
• Added criteria for MR elastography
• Inflammatory bowel disease
• Limited requirement for upper endoscopy to patients with relevant symptoms
• New requirement for fecal calprotectin or CRP to differentiate IBS from IBD
• Enteritis or colitis, not otherwise specified
• Incorporated Intussusception (pediatric only),  and Ischemic bowel
• Prostate cancer
• Moved this indication to Oncologic Imaging Guideline
• CPT codes
• Added MR elastography CPT code 76391

 

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

• Access AIM’s ProviderPortall^SM 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 and upcoming guidelines here.

 

These updates list the new and/or revised Empire BlueCross BlueShield (“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

 

Revised Medical Policies Effective 08-29-2019

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

• DRUG.00082 - Daratumumab (DARZALEX®)
• RAD.00023 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

 

Transitioned Medical Policy Effective 09-01-2019

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

• DRUG.00082 - Daratumumab (DARZALEX®) [Transitioned to ING-CC-0127 Darzalex (daratumumab)]

 

Revised Medical Policy Effective 09-25-2019

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

• GENE.00029 - Genetic Testing for Breast and/or Ovarian Cancer Syndrome

 

Revised Medical Policies Effective 09-25-2019

(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
• BEH.00002 - Transcranial Magnetic Stimulation
• DME.00011 - Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices
• DME.00012 - Intrapulmonary Percussive Ventilation Devices for Airway Clearance
• GENE.00010 - Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
• GENE.00011 - Gene Expression Profiling for Managing Breast Cancer Treatment
• GENE.00018 - Gene Expression Profiling for Cancers of Unknown Primary Site
• GENE.00020 - Gene Expression Profile Tests for Multiple Myeloma
• GENE.00024 - DNA-Based Testing for Adolescent Idiopathic Scoliosis
• GENE.00033 - Genetic Testing for Inherited Peripheral Neuropathies
• GENE.00047 - Methylenetetrahydrofolate Reductase Mutation Testing
• LAB.00019 - Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
• LAB.00028 - Serum Biomarker Tests for Multiple Sclerosis
• LAB.00029 - Rupture of Membranes Testing in Pregnancy
• LAB.00030 - Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs
• MED.00055 - Wearable Cardioverter Defibrillators
• MED.00082 - Quantitative Sensory Testing
• MED.00085 - Antineoplaston Therapy
• 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.00037 - Whole Body Computed Tomography Scanning
• RAD.00057 - Near-Infrared Coronary Imaging  and Near-Infrared Intravascular Ultrasound Coronary Imaging
• RAD.00061 - PET/MRI
• 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.00037 - Treatment of Varicose Veins (Lower Extremity)
• SURG.00067 - Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty
• SURG.00082 - Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
• SURG.00088 - Coblation® Therapies for Musculoskeletal Conditions
• 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
• SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
• TRANS.00036 - Stem Cell Therapy for Peripheral Vascular Disease

 

Archived Medical Policies Effective 09-28-2019

(The following policies have been archived.)

• MED.00041 - Microvolt T-Wave Alternans
• RAD.00040 - PET Scanning Using Gamma Cameras

 

Revised Medical Policies Effective 10-01-2019

(The following policies were updated with new CPT/HCPCS/ICD-10-PCS procedure codes or ICD-10-CM diagnosis codes.)

• GENE.00001 - Genetic Testing for Cancer Susceptibility
• GENE.00009 - Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
• GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
• GENE.00028 – Genetic Testing for Colorectal Cancer Susceptibility
• GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases
• LAB.00011 - Analysis of Proteomic Patterns
• SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke
• TRANS.00016 - Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
• TRANS.00023 – Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
• TRANS.00024 - Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
• TRANS.00027 – Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
• TRANS.00028 - Hematopoietic Stem Cell Transplant for Hodgkin Disease and non-Hodgkin Lymphoma
• TRANS.00029 – Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
• TRANS.00030 – Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
• TRANS.00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
• TRANS.00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus

 

Revised Medical Policies Effective 11-09-2019

(The following policies were updated with new CPT/HCPCS/ICD-10-PCS procedure codes or ICD-10-CM diagnosis codes.)

• SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency

 

Archived Medical Policy Effective 11-12-2019

(The following policy has been archived and its content has been transferred to a new Clinical UM Guideline.)

• GENE.00044 - Analysis of PIK3CA Status in Tumor Cells [Note: Content transferred to CG-GENE-12 PIK3CA Mutation Testing]

 

Archived Medical Policy Effective 11-12-2019

(The following policy has been archived and its content has been transferred to an existing Clinical UM Guideline.)

• RAD.00004 - Peripheral Bone Mineral Density Measurement [Note: Content transferred to CGMED-39 Bone Mineral Density Testing Measurement

 

Revised Medical Policies Effective 02-01-2020

(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.)

• GENE.00023 - Gene Expression Profiling of Melanomas
• GENE.00041 - Genetic Testing to Confirm the Identity of Laboratory Specimens
• GENE.00046 - Prothrombin (Factor II) Genetic Testing
• MED.00110 - Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment, Soft Tissue Grafting, and Regenerative Therapy
• SURG.00052 - Percutaneous Vertebral Disc and Vertebral Endplate Procedures
• TRANS.00035 - Non-Hematopoietic Adult Stem Cell Therapy

 

New Medical Policy Effective 02-15-2020

(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.00130 - Surface Electromyography Devices for Seizure Monitoring

 

Revised Medical Policy Effective 02-15-2020

(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

 

Clinical Guideline Updates

 

Revised Clinical Guidelines Effective 09-25-2019

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

• CG-DME-41 - Ultraviolet Light Therapy Delivery Devices for Home Use
• CG-DME-44 - Electric Tumor Treatment Field (TTF)
• CG-GENE-03 - BRAF Mutation Analysis
• CG-MED-63 - Treatment of Hyperhidrosis
• CG-MED-65 - Manipulation Under Anesthesia
• CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue
• CG-REHAB-04 - Physical Therapy
• CG-REHAB-05 - Occupational Therapy
• CG-REHAB-06 - Speech-Language Pathology Services
• CG-REHAB-07 - Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
• CG-REHAB-08 - Private Duty Nursing in the Home Setting
• CG-SURG-28 - Transcatheter Uterine Artery Embolization
• CG-SURG-79 - Implantable Infusion Pumps

 

Revised Clinical Guideline Effective 10-01-2019

(The following adopted guidelines were updated with new CPT/HCPCS/ICD-10-PCS procedure codes or ICD-10-CM diagnosis codes.)

• 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-SURG-09 - Temporomandibular Disorders
• CG-SURG-86 – Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
• CG-SURG-97 - Cardioverter Defibrillators

 

Revised Clinical Guideline Effective 10-12-2019

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

• CG-MED-68 - Therapeutic Apheresis

 

Revised Clinical Guideline Effective 10-12-2019

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

• CG-SURG-63 - Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure

 

Revised Clinical Guideline Effective 11-09-2019

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

• CG-SURG-49 - Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities

 

Unadopted Clinical Guideline Effective 11-12-2019

(The criteria in the following guideline will no longer be applied to any member claims.)

• CG-SURG-78 - Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies

 

Archived Clinical Guideline Effective 11-12-2019

(The following adopted clinical guideline has been archived and its content has been transferred to an existing Clinical UM Guideline.)

• CG-SURG-80 - Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors [Note: Content transferred to CG-SURG-78 - Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies]

 

Adopted Clinical Guideline Effective 11-12-2019

(The following guideline was previously a medical policy and has been adopted and has no significant changes.)

• CG-GENE-12 - PIK3CA Mutation Testing [Note: Content moved from GENE.00044 Analysis of PIK3CA Status in Tumor Cells]

 

Revised Clinical Guidelines Effective 02-01-2020

(The following adopted guidelines were revised and might result in services that were previously covered but may now be found to be not medically necessary.)

• CG-ANC-07 - Inpatient Interfacility Transfers
• CG-GENE-02 - Analysis of RAS Status

 

Revised Clinical Guideline Effective 02-15-2020

(The following adopted guideline was revised and might result in services that were previously covered but may now be found to be not medically necessary.)

• CG-SURG-83 - Bariatric Surgery and Other Treatments for Clinically Severe Obesity

 

The following Clinical Criteria documents were endorsed at the August 16, 2019 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

Empire BlueCross BlueShield’s (“Empire”) pre-service 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.

 

New Clinical Criteria effective September 23, 2019

The following clinical criteria are new.

• ING-CC-0142 Somatuline Depot (lanreotide)
• ING-CC-0144 Lumoxiti (moxetumomab pasudotox-tdfk)

 

Revised Clinical Criteria effective September 23, 2019

The following current clinical criteria were revised to expand medical necessity indications or criteria.

• ING-CC-0011 Ocrevus (ocrelizumab)
• ING-CC-0014 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
• ING-CC-0027 Denosumab Agents
• ING-CC-0029 Dupixent (dupilumab)
• ING-CC-0030 Implantable and ER Buprenorphine Containing Agents
• ING-CC-0038 Human Parathyroid Hormone Agents
• ING-CC-0105 Vectibix (panitumumab)
• ING-CC-0114 Jevtana (cabazitaxel)
• ING-CC-0124 Keytruda (pembrolizumab)
• ING-CC-0127 Darzalex (daratumumab)
• ING-CC-0128 Tecentriq (atezolizumab)
• ING-CC-0134 Provenge (sipuleucel-T)

 

Revised Clinical Criteria effective September 23, 2019

The following current clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.

• ING-CC-0004 H.P. Acthar Gel (repository corticotropin injection)
• ING-CC-0008 Subcutaneous Hormonal Implants
• ING-CC-0009 Lemtrada (alemtuzumab)
• ING-CC-0010 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
• ING-CC-0020 Tysabri (natalizumab)
• ING-CC-0036 Naltrexone Implantable Pellets
• ING-CC-0044 Exondys 51 (eteplirsen)
• ING-CC-0094 Alimta (pemetrexed disodium)
• ING-CC-0099 Abraxane (paclitaxel, protein bound)
• ING-CC-0104 Levoleucovorin Agents
• ING-CC-0119 Yervoy (ipilimumab)
• ING-CC-0125 Opdivo (nivolumab)
• ING-CC-0129 Bavencio (avelumab)
• ING-CC-0130 Imfinzi (durvalumab)

 

Revised Clinical Criteria effective October 1, 2019

The following current clinical criteria were updated with new procedure and/or diagnosis codes.

• ING-CC-0006 Hyaluronan Injections
• ING-CC-0087 Gamifant
• ING-CC-0088 Elzonris (tagraxofusp-erzs)

 

Revised Clinical Criteria effective February 1, 2020

The following current 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-0001 Erythropoiesis Stimulating Agents
• ING-CC-0002 Colony Stimulating Factor Agents
• ING-CC-0003 Immunoglobulins
• ING-CC-0007 Synagis (palivizumab)
• ING-CC-0013 Mepsevii (vestronidase alfa)
• ING-CC-0018 Lumizyme (alglucosidase alfa)
• ING-CC-0021 Fabrazyme (agalsidase beta)
• ING-CC-0022 Vimizim (elosulfase alfa)
• ING-CC-0023 Naglazyme (galsulfase)
• ING-CC-0024 Elaprase (idursufase)
• ING-CC-0025 Aldurazyme (laronidase)
• ING-CC-0028 Benlysta (belimumab)
• ING-CC-0031 Intravitreal Corticosteroid Implants
• ING-CC-0032 Botulinum Toxin
• ING-CC-0033 Xolair (omalizumab)
• ING-CC-0034 Hereditary Angioedema Agents
• ING-CC-0041 Complement Inhibitors
• ING-CC-0043 Monoclonal Antibodies to Interleukin-5
• ING-CC-0048 Spinraza (nusinersen)
• ING-CC-0050 Monoclonal Antibodies to Interleukin-23
• ING-CC-0051 Enzyme Replacement Therapy for Gaucher Disease
• ING-CC-0058 Octreotide Agents
• ING-CC-0061 GnRH Analogs for the treatment of non-oncologic indications
• ING-CC-0062 Tumor Necrosis Factor Antagonists
• ING-CC-0063 Stelara (ustekinumab)
• ING-CC-0066 Monoclonal Antibodies to Interleukin-6
• ING-CC-0071 Entyvio (vedolizumab)
• ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
• ING-CC-0073 Alpha-1 Proteinase Inhibitor Therapy
• ING-CC-0075 Rituximab Agents for Non-Oncology Indications
• ING-CC-0082 Onpattro (patisiran)
• ING-CC-0106 Erbitux (cetuximab)
• ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications

 

New Clinical Criteria effective February 1, 2020

The following clinical criteria are new.

• ING-CC-0143 Polivy (polatuzumab vedotin-piiq)
• ING-CC-0145 Libtayo (cemiplimab-rwlc)

 

Effective for dates of service on and after February 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our pre-service 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.

 

To access the clinical criteria document information please click here.  

 

Empire BlueCross BlueShield’s (“Empire”) prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Review of specialty pharmacy 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-0072	Q5118	00069-0315-01 00069-0342-01	Zirabev
ING-CC-0075	Q5115	63459-0103-10 63459-0104-50	Truxima
ING-CC-0075	J3490	00069-0238-01 00069-0249-01	Ruxience
ING-CC-0107	Q5118	00069-0315-01 00069-0342-01	Zirabev
ING-CC-0142	J1930	15054-1060-03 15054-1060-04 15054-1090-03 15054-1090-04 15054-1120-03 15054-1120-04	Somatuline Depot
ING-CC-0143	C9399 J9999	50242-0105-01	Polivy
ING-CC-0144	J9313	50242-0105-01	Lumoxiti
ING-CC-0145	J9119	61755-0008-01	Libtayo

 

* Non-oncology use is managed by Empire’s medical specialty drug review team; oncology use is managed by AIM.

 

Quantity limit updates

Effective January 31, 2020, clinical criteria document ING-CC-0136 Drug dosage, frequency, and route of administration will be archived.

 

Effective for dates of service on and after February 1, 2020, prior authorization clinical review of drug dosage, frequency and route of administration for the following specialty pharmacy codes from new or current clinical criteria will be based on the quantity limits established in the applicable clinical criteria document. The table below will assist you in identifying the applicable clinical criteria documents and corresponding HCPCS codes.

 

To access the clinical criteria document information please click here.  

 

Empire’s prior authorization clinical review of these specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team.

 

Clinical Criteria Document Number	Clinical Criteria Name	Drug(s)	HCPCS Code(s)
ING-CC-0001	Erythropoiesis Stimulating Agents	Aranesp, Epogen, Mircera, Procrit, Retacrit	J0881, J0882, J0885, J0887, J0888, Q4081, Q5105, Q5106
ING-CC-0003	Immunoglobulins	Asceniv, Bivigam, Carimune NF, Flebogamma DIF. Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen	J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599
ING-CC-0007	Synagis (palivizumab)	Synagis	90378
ING-CC-0013	Mepsevii (vestronidase alfa)	Mepsevii	J3397
ING-CC-0018	Lumizyme (alglucosidase alfa)	Lumizyme	J0221
ING-CC-0021	Fabrazyme (agalsidase beta)	Fabrazyme	J0180
ING-CC-0022	Vimizim (elosulfase alfa)	Vimizim	J1322
ING-CC-0023	Naglazyme (galsulfase)	Naglazyme	J1458
ING-CC-0024	Elaprase (idursufase)	Elaprase	J1743
ING-CC-0025	Aldurazyme (laronidase)	Aldurazyme	J1931
ING-CC-0028	Benlysta (belimumab)	Benlysta	J0490
ING-CC-0031	Intravitreal Corticosteroid Implants	Illuvien, Retisert, Ozurdex, Yutiq	J7311, J7312, J7313, J7314
ING-CC-0032	Botulinum Toxin	Botox, Xeomin, Dysport, Myobloc	J0585, J0586, J0587, J0588
ING-CC-0033	Xolair (omalizumab)	Xolair	J2357
ING-CC-0034	Agents for Hereditary Angioedema	Cinryze, Haegarda, Berinert, Berinert, Firazyr, Ruconest, Kalbitor, Takhzyro	J0596, J0597, J0598, J1290, J1744, J0599, J0593
ING-CC-0041	Complement Inhibitors	Soliris, Ultomiris	J1300, J1303
ING-CC-0043	Monoclonal Antibodies to Interleukin-5	Cinqair, Fasenra, Nucala	J0517, J2182, J2786
ING-CC-0050	Monoclonal Antibodies to Interleukin-23	Tremfya, Ilumya	J1628, J3245
ING-CC-0051	Enzyme Replacement Therapy for Gaucher Disease	Cerezyme, Elelyso, Vpriv	J1786, J3060, J3385
ING-CC-0058	Octreotide Agents	Sandostatin, Sandostatin LAR Depot	J2353, J2354
ING-CC-0061	GnRH Analogs for the treatment of non-oncologic indications	Lupron Depot/Depot-Ped	J1950, J9217
ING-CC-0062	Tumor Necrosis Factor Antagonists	Simponi Aria, Remicade, Inflectra, Renflexis, Ixifi, Humira, Enbrel, Cimzia	J1602, J1745, Q5103, Q5104, Q5109, J0135, J1438, J0717
ING-CC-0063	Stelara (ustekinumab)	Stelara	J3357, J3358
ING-CC-0066	Monoclonal Antibodies to Interleukin-6	Actemra	J3262
ING-CC-0071	Entyvio (vedolizumab)	Entyvio	J3380
ING-CC-0072	Selective Vascular Endothelial Growth Factor (VEGF) Antagonists	Avastin, Lucentis, Eylea, Macugen, Zirabev, Mvasi	J2503, C9257, J9035, J2778, J0178, Q5118, Q5017
ING-CC-0073	Alpha-1 Proteinase Inhibitor Therapy	Aralast, Glassia, Prolastin-C, Zemaira	J0256, J0257
ING-CC-0075	Rituxan (rituximab) for Non-Oncologic Indications	Rituxan, Truxima	J9312, Q5115

 

Empire BlueCross BlueShield’s (“Empire”) launch of its new pharmacy benefits manager (PBM) solution, IngenioRx, which will serve members of all Empires affiliated health plans is nearly complete. We began transitioning members on May 1, 2019, and have continued throughout 2019, and with all members completely transitioned to IngenioRx by January 1, 2020.

 

As a reminder, most day-to-day pharmacy experiences will not be affected:

• Members will continue to use their prescription drug benefits as they always have, getting their medications using a retail pharmacy, home delivery, or specialty pharmacy.

• Current home delivery and specialty pharmacy prescriptions and prior authorizations will transfer automatically to IngenioRx when a member transitions, with the exception of controlled substances and compound drugs (see more below).
• If you use ePrescribing and are sending home delivery or specialty pharmacy prescriptions, simply select IngenioRx after your patient has transitioned.
• If you do not use ePrescribing, send home delivery and specialty pharmacy prescriptions to IngenioRx after your patient has transitioned (see contact information below).
• Members will continue to use the same drug list.

 

Frequently Asked Questions

 
When can I expect my patients to transition to IngenioRx?

Most Empire members have already transitioned to IngenioRx. The remaining members will be transitioned on January 1, 2020.

 

Do providers need to take any action?

Federal law does not allow prescriptions for controlled substances or compound drugs to be automatically transferred to another pharmacy, so providers with patients using these medications will need to send a new prescription to IngenioRx after they’ve transitioned.

 

Will my patients be notified of this change?

Empire will notify members before they transition to IngenioRx. Members currently filling home delivery and specialty pharmacy medications will be notified by mail.  

How will a provider know if an Empire member has moved to IngenioRx?

Availity displays member PBM information under the patient information section as part of the eligibility and benefits inquiry. We have enhanced this section of Availity to indicate when a member has moved to IngenioRx. Availity includes the name of the PBM and date the member moved to IngenioRx, or the date the member is scheduled to move to IngenioRx.  

 

How will specialty drugs be transitioned?  

Specialty pharmacy prescriptions and prior authorizations will automatically transfer to IngenioRx. In addition, the IngenioRx Care Team will call members to introduce them to IngenioRx and discuss the medications they take.

How do I submit prescriptions to IngenioRx?

If you use ePrescribing and are sending home delivery or specialty pharmacy prescriptions, simply select IngenioRx in your ePrescribing system.

 

If you do not use ePrescribing, you can submit prescriptions using the following information:

 

IngenioRx Home Delivery Pharmacy new prescriptions:

Phone Number: 1-833-203-1742

Fax number: 1-800-378-0323

 

IngenioRx Specialty Pharmacy:

Prescriber phone: 1-833-262-1726

Prescriber fax: 1-833-263-2871

 

What phone number should I call with questions?
For questions, contact the Provider Service phone number on the back of your patient’s ID card.