Medical Policies update On February 22, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies which are applicable to Empire BlueCross BlueShield HealthPlus (Empire). These medical policies were developed or revised to support clinical coding edits. Several policies were revised to provide clarification only and are not included in the listing below. The medical policies were made publicly available on the provider website on the publish date listed below. To search for specific policies, visit http://www.empireblue.com/medicalpolicies/search.html. Existing precertification requirements have not changed.

 

Please share this notice with other members of your practice and office staff.

 

Publish date

Medical Policy number

Medical Policy

New/revised

12/27/2017

DRUG.00112

Gemtuzumab Ozogamicin (Mylotarg®)

New

12/27/2017

DRUG.00118

Copanlisib (Aliqopa®)

New

11/9/2017

MED.00123

Axicabtagene ciloleucel (YescartaTM)

New

11/9/2017

DME.00040

Automated Insulin Delivery Devices

Revised

12/27/2017

DRUG.00050

Eculizumab (Soliris®)

Revised

12/27/2017

DRUG.00071

Pembrolizumab (Keytruda®)

Revised

12/27/2017

DRUG.00075

Nivolumab (Opdivo®)

Revised

11/9/2017

DRUG.00081

Eteplirsen (Exondys 51™)

Revised

12/27/2017

DRUG.00109

Durvalumab (Imfinzi™)

Revised

12/27/2017

GENE.00011

Gene Expression Profiling for Managing Breast Cancer Treatment

Revised

11/9/2017

SURG.00089

Balloon and Self-Expanding Absorptive Sinus Ostial Dilation

Revised

12/27/2017

TRANS.00023

Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias

Revised

12/27/2017

TRANS.00024

Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome

Revised

12/27/2017

TRANS.00027

Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors

Revised

12/27/2017

TRANS.00028

Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma

Revised

12/27/2017

TRANS.00029

Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias

Revised

12/27/2017

TRANS.00030

Hematopoietic Stem Cell Transplantation for Germ Cell Tumors

Revised

 

Clinical Utilization Management Guidelines update

On February 22, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Clinical Utilization Management (UM) Guidelines which are applicable to Empire. These clinical guidelines were developed or revised to support clinical coding edits. Several Guidelines were revised to provide clarification only and are not included in the listing below. The Clinical UM Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division on March 30, 2018. To see the full utilization management guidelines on the website, visit http://www.empireblue.com/medicalpolicies/search.html.

 

On March 30, 2018, the clinical guidelines were made publicly available on the Empire Medical Policies and Clinical UM Guidelines subsidiary website. To search for specific guidelines policies, visit http://www.empireblue.com/medicalpolicies/search.html. Existing precertification requirements have not changed.

 

Please share this notice with other members of your practice and office staff.

 

Update to clinical guideline, CG-MED-39, Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry (CG-MED 39), was published March 30, 2018.

 

Effective March 30, 2018, this clinical guideline will apply to Medicaid lines of business.

 

The clinical indication section specific to female screening of osteoporosis was revised to reflect that an initial (baseline) central (hip or spine) bone density measurement is considered medically necessary when conducted in postmenopausal individuals 65 years of age or older.

 

The guideline also identifies other clinical indications when initial and repeat central bone mineral density measurements are medically necessary.

 

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New/revised

12/27/2017

CG-DME-40

Electrical Bone Growth Stimulation

New

12/27/2017

CG-DME-41

Ultraviolet Light Therapy Delivery Devices for Home Use

New

12/27/2017

CG-DRUG-65

Tumor Necrosis Factor Antagonists

New

12/27/2017

CG-DRUG-66

Panitumumab (Vectibix®)

New

12/27/2017

CG-DRUG-68

Bevacizumab (Avastin®) for Non-Ophthalmologic Indications

New

12/27/2017

CG-DRUG-69

Ustekinumab (Stelara®)

New

12/27/2017

CG-DRUG-70

Eribulin mesylate (Halaven®)

New

12/27/2017

CG-DRUG-71

Ziv-aflibercept (Zaltrap®)

New

12/27/2017

CG-DRUG-72

Pertuzumab (Perjeta®)

New

12/27/2017

CG-DRUG-73

Denosumab (Prolia®, Xgeva®)

New

12/27/2017

CG-DRUG-74

Canakinumab (Ilaris®)

New

12/27/2017

CG-DRUG-75

Romiplostim (Nplate®)

New

12/27/2017

CG-DRUG-76

Plerixafor Injection (Mozobil™)

New

12/27/2017

CG-DRUG-77

Radium Ra 223 Dichloride (Xofigo®)

New

12/27/2017

CG-DRUG-78

Antihemophilic Factors and Clotting Factors

New

12/27/2017

CG-DRUG-79

Siltuximab (Sylvant®)

New

12/27/2017

CG-DRUG-80

Cabazitaxel (Jevtana®)

New

12/27/2017

CG-DRUG-81

Tocilizumab (Actemra®)

New

12/27/2017

CG-GENE-01

Janus Kinase 2 (JAK2) V617F Gene Mutation Assay

New

12/27/2017

CG-GENE-02

Analysis of KRAS Status

New

12/27/2017

CG-GENE-03

BRAF Mutation Analysis

New

12/27/2017

CG-GENE-04

Molecular Marker Evaluation of Thyroid Nodules

New

12/27/2017

CG-MED-61

Preoperative Testing for Low Risk Invasive Procedures and Surgeries

New

12/27/2017

CG-MED-62

Resting Electrocardiogram Screening in Adults

New

12/27/2017

CG-MED-63

Treatment of Hyperhidrosis

New

12/27/2017

CG-MED-64

Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)

New

12/27/2017

CG-MED-65

Manipulation Under Anesthesia of the Spine and Joints other than the Knee

New

12/27/2017

CG-MED-66

Cryopreservation of Oocytes or Ovarian Tissue

New

12/27/2017

CG-MED-67

Melanoma Vaccines

New

12/27/2017

CG-MED-68

Therapeutic Apheresis

New

12/27/2017

CG-SURG-61

Cryosurgical Ablation of Solid Tumors Outside the Liver

New

12/27/2017

CG-SURG-62

Radiofrequency Ablation to Treat Tumors Outside the Liver

New

12/27/2017

CG-SURG-63

Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure

New

12/27/2017

CG-SURG-65

Recombinant Human Bone Morphogenetic Protein

New

12/27/2017

CG-SURG-66

Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)

New

12/27/2017

CG-SURG-67

Treatment of Osteochondral Defects

New

12/27/2017

CG-SURG-68

Surgical Treatment of Femoracetabular Impingement Syndrome

New

12/27/2017

CG-SURG-69

Meniscal Allograft Transplantation of the Knee

New

12/27/2017

CG-DRUG-38

Pemetrexed Disodium (Alimta®)

Revised

12/27/2017

CG-DRUG-50

Paclitaxel, protein-bound (Abraxane®)

Revised

12/27/2017

CG-DRUG-61

Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications

Revised

12/27/2017

CG-MED-21

Anesthesia Services and Moderate (“Conscious”) Sedation

Revised

11/9/2017

CG-MED-55

Level of Care: Advanced Radiologic Imaging

Revised



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June 2018 Empire Provider Newsletter