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Medical Policies and Clinical Utilization Management Guidelines update
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 |
Featured In:
June 2018 Empire Provider Newsletter