New York
Provider Communications
Medical Policy Updates
(The following policies were revised to expand medical necessity indications or criteria.)
- DRUG.00046 - Ipilimumab (Yervoy®)
- DRUG.00071 - Pembrolizumab (Keytruda®)
- DRUG.00075 - Nivolumab (Opdivo®)
- MED.00109 - Corneal Collagen Cross-Linking
- SURG.00120 - Internal Rib Fixation Systems
- SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
Revised Medical Policies Effective 12-12-2018
(The following policies were revised to expand medical necessity indications or criteria.)
- DRUG.00062 - Obinutuzumab (Gazyva®)
- DRUG.00090 - Bezlotoxumab (ZINPLAVA™)
- DRUG.00112 - Gemtuzumab Ozogamicin (Mylotarg®)
- SURG.00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
- SURG.00121 - Transcatheter Heart Valve Procedures
- TRANS.00024 - Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
Archived Medical Policy Effective 12-12-2018
(The following policy has been archived and its content has been transferred to an existing Clinical UM Guideline.)
- DRUG.00098 - Lutetium Lu 177 dotatate (Lutathera®) [Note: Content transferred to CG-THER-RAD-03 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy]
Revised Medical Policies Effective 12-12-2018
(The following policies were reviewed and had no significant changes to the policy position or criteria.)
- ADMIN.00001 - Medical Policy Formation
- BEH.00002 - Transcranial Magnetic Stimulation
- DME.00012 - Intrapulmonary Percussive Ventilation Devices for Airway Clearance
- DRUG.00034 - Insulin Potentiation Therapy
- DRUG.00063 - Ofatumumab (Arzerra®)
- DRUG.00074 - Alemtuzumab (Lemtrada®)
- DRUG.00077 - Monoclonal Antibodies to Interleukin-17A
- DRUG.00086 - Mecasermin (Increlex®)
- DRUG.00099 - Cerliponase Alfa (Brineura™)
- DRUG.00110 - Inotuzumab ozogamicin (Besponsa®)
- DRUG.00111 - Monoclonal Antibodies to Interleukin-23
- DRUG.00116 - Vestronidase alfa (Mepsevii™)
- DRUG.00118 - Copanlisib (Aliqopa®)
- GENE.00006 - Epidermal Growth Factor Receptor (EGFR) Testing
- 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.00030 - Genetic Testing for Endocrine Gland Cancer Susceptibility
- GENE.00035 - Genetic Testing for TP53 Mutations
- GENE.00044 - Analysis of PIK3CA Status in Tumor Cells
- LAB.00026 - Systems Pathology Testing for Predicting Risk of Prostate Cancer Progression and Recurrence
- LAB.00029 - Rupture of Membranes Testing in Pregnancy
- MED.00041 - Microvolt T-Wave Alternans
- MED.00055 - Wearable Cardioverter Defibrillators
- MED.00085 - Antineoplaston Therapy
- MED.00121 - Implantable Interstitial Glucose Sensors
- RAD.00023 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
- RAD.00036 - MRI of the Breast
- RAD.00061 - PET/MRI
- RAD.00065 - Radiostereometric Analysis (RSA)
- SURG.00019 - Transmyocardial Revascularization
- SURG.00044 - Breast Ductal Examination and Fluid Cytology Analysis
- SURG.00052 - Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy [IDET], Percutaneous Intradiscal Radiofrequency Thermocoagulation [PIRFT] and Intradiscal Biacuplasty [IDB])
- SURG.00088 - Coblation® Therapies for Musculoskeletal Conditions
- SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke
- SURG.00130 - Annulus Closure After Discectomy
- SURG.00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
- SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain
- TRANS.00023 - Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
- TRANS.00027 - Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
- TRANS.00029 - Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
- TRANS.00030 - Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
- TRANS.00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus
Revised Medical Policies Effective 12-27-2018
(The following policies were updated with new procedure and/or diagnosis codes.)
- DME.00037 - Cooling Devices and Combined Cooling/Heating Devices
- DRUG.00080 - Monoclonal Antibodies for the Treatment of Eosinophilic Conditions
- DRUG.00108 - Edaravone (Radicava®)
- DRUG.00109 - Durvalumab (Imfinzi®)
- GENE.00009 - Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
- GENE.00011 - Gene Expression Profiling for Managing Breast Cancer Treatment
- GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
- GENE.00023 - Gene Expression Profiling of Melanomas
- GENE.00029 - Genetic Testing for Breast and/or Ovarian Cancer Syndrome
- LAB.00011 - Analysis of Proteomic Patterns
- LAB.00019 - Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
- MED.00109 - Corneal Collagen Cross-Linking
- MED.00111 - Intracardiac Ischemia Monitoring
- MED.00115 - Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
- OR-PR.00005 - Upper Extremity Myoelectric Orthoses
- SURG.00007 - Vagus Nerve Stimulation
- SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia and Other Genitourinary Conditions
- SURG.00102 - Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
- SURG.00104 - Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
- SURG.00111 - Axial Lumbar Interbody Fusion
- SURG.00113 - Artificial Retinal Devices
- SURG.00150 - Leadless Pacemaker
- THER-RAD.00009 - Intraocular Epiretinal Brachytherapy
Revised Medical Policies Effective 01-01-2019
(The following policies were updated with new procedure and/or diagnosis codes.)
- DRUG.00096 - Ibalizumab-uiyk (Trogarzo™)
- GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases
Archived Medical Policy Effective 01-01-2019
(The following policy has been archived and has been replaced by AIM guidelines.)
- SURG.00066 - Percutaneous Neurolysis for Chronic Neck and Back Pain
Archived Medical Policies Effective 01-03-2019
(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)
- MED.00100 - Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems [Note: Content transferred to new CG-MED-79]
- RAD.00002 - Positron Emission Tomography (PET) and PET/CT Fusion [Note: Content transferred to new CG-MED-80]
Revised Medical Policies Effective 01-12-2019
(The following policies were updated with new procedure and/or diagnosis codes.)
- MED.00120 - Voretigene neparvovec-rzyl (Luxturna™)
- MED.00123 - Axicabtagene ciloleucel (Yescarta®)
- MED.00124 - Tisagenlecleucel (Kymriah®)
Revised Medical Policy Effective 04-01-2019
(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.)
- DRUG.00071 - Pembrolizumab (Keytruda®)
Revised Medical Policy Effective 04-13-2019
(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.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency
New Medical Policy Effective 04-13-2019
(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.00126 - Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders
Featured In:
January 2019 Empire Provider Newsletter