Coverage guidelines informational notice

Archived coverage guideline numbers effective June 28, 2018

 

The following coverage guideline numbers have been archived.

 

DME.00035 Electric Tumor Treatment Field (TTF) [Note: Content of DME.00035 has been transferred to new clinical UM guideline CG-DME-44.] 

 

DRUG.00036 Cetuximab (Erbitux®) [Note: Content of DRUG.00036 has been transferred to clinical UM guideline CG-DRUG-67.]  

 

DRUG.00041Rituximab (Rituxan®) for Non-Oncologic Indications [Note: Content of DRUG.00041 has been transferred to new clinical UM guideline CG-DRUG-94.]

 

DRUG.00049 Belatacept (Nulojix®) [Note: Content of DRUG.00049 has been transferred to clinical UM guideline CG-DRUG-95.]

 

DRUG.00056 Ado-trastuzumab emtansine (Kadcyla®) [Note: Content of DRUG.00056 has been transferred to new clinical UM guideline CG-DRUG-96.]

 

DRUG.00073 Rilonacept (Arcalyst®) [Note: Content of DRUG.00073 has been transferred to new clinical UM guideline CG-DRUG-97.]

 

DRUG.00079 Bendamustine Hydrochloride [Note: Content of DRUG.00079 has been transferred to new clinical UM guideline CG-DRUG-98.]

 

DRUG.00083 Elotuzumab (Empliciti™) [Note: Content of DRUG.00083 has been transferred to new clinical UM guideline CG-DRUG-99.]

 

DRUG.00084 Interferon gamma-1b (Actimmune®) [Note: Content of DRUG.00084 has been transferred to new clinical UM guideline CG-DRUG-100.]

 

DRUG.00085 Ixabepilone (Ixempra®) [Note: Content of DRUG.00085 has been transferred to new clinical UM guideline CG-DRUG-101.]

 

DRUG.00097 Olaratumab (Lartruvo™) [Note: Content of DRUG.00097 has been transferred to new clinical UM guideline CG-DRUG-102.]

 

MED.00026 Hyperthermia for Cancer Therapy [Note: Content of MED.00026 has been transferred to new clinical UM guideline CG-MED-72.]

 

SURG.00001 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty [Note: Content of SURG.00001 has been transferred to new clinical UM guideline CG-SURG-76.]

 

SURG.00009 Refractive Surgery [Note: Content of SURG.00009 has been transferred to new clinical UM guideline CG-SURG-77.]

 

SURG.00065 Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies [Note: Content of SURG.00065 has been transferred to new clinical UM guideline CG-SURG-78.]

 

SURG.00068 Implantable Infusion Pumps [Note: Content of SURG.00068 has been transferred to new clinical UM guideline CG-SURG-79.]

 

RAD.00011 Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors [Note: Content of RAD.00011 has been transferred to new clinical UM guideline CG-SURG-80.]

 

 

Archived coverage guideline effective November 1, 2018

 

Anthem’s coverage guideline, THER-RAD.000002 Proton Beam Radiation Therapy will be archived effective November 1, 2018. This policy will be applied as a part of AIM Clinical Guidelines beginning November 1, 2018.