New York
Provider Communications

Jan 1, 2019 • Policy Updates / Medical Policy & Clinical Guidelines

(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(The following policy has been archived and its content has been transferred to an existing Clinical UM Guideline.)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