Revised Medical Policies Effective 05-10-2018

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

  • DRUG.00047 - Brentuximab Vedotin (Adcetris®)
  • DRUG.00053 - Carfilzomib (Kyprolis®)
  • DRUG.00076 - Blinatumomab (Blincyto®)
  • SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation


New Medical Policy Effective 06-06-2018

(The following policy is new and determined to not have significant changes.)

  • DRUG.00098 - Lutetium Lu 177 dotatate (Lutathera®)


Revised Medical Policies Effective 06-06-2018

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

  • DRUG.00046 - Ipilimumab (Yervoy®)
  • DRUG.00071 - Pembrolizumab (Keytruda®)
  • DRUG.00075 - Nivolumab (Opdivo®)
  • GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
  • GENE.00026 - Cell-Free Fetal DNA-Based Prenatal Testing


Revised Medical Policies Effective 06-06-2018

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

  • DME.00022 - Functional Electrical Stimulation FES;  Threshold Electrical Stimulation TES
  • DRUG.00067 - Ramucirumab (Cyramza®)
  • DRUG.00088 - Atezolizumab (Tecentriq®)
  • DRUG.00104 - Nusinersen (SPINRAZA®)
  • DRUG.00107 - Avelumab (Bavencio®)
  • DRUG.00109 - Durvalumab (Imfinzi®)
  • DRUG.00110 - Inotuzumab ozogamicin (Besponsa®)
  • DRUG.00111 - Monoclonal Antibodies to Interleukin-23
  • GENE.00001 - Genetic Testing for Cancer Susceptibility
  • GENE.00002 - Preimplantation Genetic Diagnosis Testing
  • GENE.00005 - BCR-ABL Mutation Analysis
  • GENE.00007 - Cardiac Ion Channel Genetic Testing
  • GENE.00009 - Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
  • GENE.00016 - Gene Expression Profiling for Colorectal Cancer
  • GENE.00017 - Genetic Testing for Diagnosis of Hereditary Cardiomyopathies (including ARVD/C)
  • GENE.00023 - Gene Expression Profiling of Melanomas
  • GENE.00025 - Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors
  • GENE.00031 - Genetic Testing for PTEN Hamartoma Tumor Syndrome
  • GENE.00038 - Genetic Testing for Statin-Induced Myopathy
  • GENE.00040 - Genetic Testing for CHARGE Syndrome
  • GENE.00045 - Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers
  • LAB.00003 - In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
  • LAB.00011 - Analysis of Proteomic Patterns 
  • LAB.00015 - Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer
  • LAB.00025 - Topographic Genotyping
  • MED.00024 - Adoptive Immunotherapy and Cellular Therapy
  • MED.00053 - Non-Invasive Measurement of Left Ventricular End Diastolic Pressure (LVEDP) in the Outpatient Setting
  • MED.00077 - In-Vivo Analysis of Gastrointestinal Lesions
  • MED.00081 - Cognitive Rehabilitation
  • MED.00087 - Imaging Techniques for Screening and Identification of Cervical Cancer
  • MED.00102 - Ultrafiltration in Decompensated Heart Failure
  • MED.00104 - Non-invasive Measurement of Advanced Glycation Endproducts (AGEs) in the Skin
  • MED.00105 - Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
  • MED.00111 - Intracardiac Ischemia Monitoring
  • MED.00112 - Autonomic Testing
  • MED.00118 - Continuous Monitoring of Intraocular Pressure
  • MED.00119 - High Intensity Focused Ultrasound (HIFU) for Oncologic Indications
  • OR-PR.00004 - Partial-Hand Myoelectric Prosthesis
  • RAD.00001 - Computed Tomography to Detect Coronary Artery Calcification
  • RAD.00022 - Magnetic Resonance Spectroscopy (MRS)
  • RAD.00040 - PET Scanning Using Gamma Cameras
  • RAD.00043 - Computed Tomography Scans for Lung Cancer Screening
  • RAD.00054 - MRI of the Bone Marrow
  • RAD.00059 - Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Malignant Lesions Outside the Liver except Central Nervous System (CNS) and Spinal Cord
  • RAD.00066 - Multiparametric Magnetic Resonance Fusion Imaging Targeted Prostate Biopsy
  • SURG.00016 - Stereotactic Radiofrequency Pallidotomy
  • SURG.00022 - Lung Volume Reduction Surgery
  • SURG.00032 - Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
  • SURG.00072 - Lysis of Epidural Adhesions
  • SURG.00075 - Intervertebral Stabilization Devices
  • SURG.00107 - Prostate Saturation Biopsy
  • SURG.00113 - Artificial Retinal Devices
  • SURG.00124 - Carotid Sinus Baroreceptor Stimulation Devices
  • SURG.00137 - Focused Microwave Thermotherapy for Breast Cancer
  • SURG.00139 - Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
  • SURG.00147 - Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders
  • SURG.00148 - Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy
  • SURG.00149 - Percutaneous Ultrasonic Ablation of Soft Tissue
  • TRANS.00016 - Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
  • TRANS.00025 - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
  • TRANS.00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors


Archived Medical Policies Effective 06-28-2018

(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)

  • DME.00035 - Electric Tumor Treatment Field (TTF) [Note: Content transferred to new CG-DME-44]
  • DRUG.00036 - Cetuximab (Erbitux®) [Note: Content transferred to new CG-DRUG-67]
  • DRUG.00041 - Rituximab (Rituxan®) for Non-Oncologic Indications [Note: Content transferred to new CG-DRUG-94]
  • DRUG.00049 - Belatacept (Nulojix®) [Note: Content transferred to new CG-DRUG-95]
  • DRUG.00056 - Ado-trastuzumab emtansine (Kadcyla®) [Note: Content transferred to new CG-DRUG-96]
  • DRUG.00073 - Rilonacept (Arcalyst®) [Note: Content transferred to new CG-DRUG-97]
  • DRUG.00079 - Bendamustine Hydrochloride [Note: Content transferred to new CG-DRUG-98]
  • DRUG.00083 - Elotuzumab (Empliciti™) [Note: Content transferred to new CG-DRUG-99]
  • DRUG.00084 - Interferon gamma-1b (Actimmune®) [Note: Content transferred to new CG-DRUG-100]
  • DRUG.00085 - Ixabepilone (Ixempra®) [Note: Content transferred to new CG-DRUG-101]
  • DRUG.00097 - Olaratumab (Lartruvo™) [Note: Content transferred to new CG-DRUG-102]
  • MED.00026 - Hyperthermia for Cancer Therapy [Note: Content transferred to new CG-MED-72]
  • RAD.00011 - Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors [Note: Content transferred to new CG-SURG-80]
  • SURG.00001 - Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty [Note: Content transferred to new CG-SURG-76]
  • SURG.00009 - Refractive Surgery [Note: Content transferred to new CG-SURG-77]
  • SURG.00065 - Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies [Note: Content transferred to new CG-SURG-78]
  • SURG.00068 - Implantable Infusion Pumps [Note: Content transferred to new CG-SURG-79]


Archived Medical Policy Effective 11-01-2018

(The following policy has been archived and has been replaced by AIM guidelines.)

  • THER-RAD.00002 - Proton Beam Radiation Therapy


Revised Medical Policies Effective 11-01-2018

(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.)

  • DRUG.00050 - Eculizumab (Soliris®)
  • DRUG.00076 - Blinatumomab (Blincyto®)
  • GENE.00006 - Epidermal Growth Factor Receptor (EGFR) Testing
  • GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent

Featured In:
August 2018 Empire Provider Newsletter