Revised Clinical Guidelines Effective 09-20-2018

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

  • CG-DRUG-94 - Rituximab (Rituxan®) for Non-Oncologic Indications
  • CG-SURG-79 - Implantable Infusion Pumps

 

Revised Clinical Guidelines Effective 09-20-2018

(The following adopted guidelines were updated with new procedure and/or diagnosis codes effective 09-20-2018.)

  • CG-DRUG-16 - White Blood Cell Growth Factors
  • CG-DRUG-64 - FDA-Approved Biosimilar Products

 

Revised Clinical Guidelines Effective 10-13-2018

(The following adopted guidelines were updated with new procedure and/or diagnosis codes effective 10-13-2018.)

  • CG-SURG-03 - Blepharoplasty, Blepharoptosis Repair, and Brow Lift
  • CG-SURG-09 - Temporomandibular Disorders

 

Revised Clinical Guidelines Effective 10-17-2018

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

  • CG-DRUG-107 - Pharmacotherapy for Hereditary Angioedema
  • CG-MED-46 - Electroencephalography and Video Electroencephalographic Monitoring

 

Revised Clinical Guidelines Effective 10-17-2018

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

  • CG-DME-41 - Ultraviolet Light Therapy Delivery Devices for Home Use
  • CG-DRUG-03 - Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
  • CG-DRUG-08 - Enzyme Replacement Therapy for Gaucher Disease
  • CG-DRUG-09 - Immune Globulin (Ig) Therapy
  • CG-DRUG-55 - Elosulfase alfa (Vimizim®)
  • CG-DRUG-58 - Laronidase (Aldurazyme®)
  • CG-DRUG-61 - Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
  • CG-DRUG-74 - Canakinumab (Ilaris®)
  • CG-MED-63 - Treatment of Hyperhidrosis
  • CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation)
  • CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue
  • CG-REHAB-04 - Physical Therapy
  • CG-REHAB-05 - Occupational Therapy
  • CG-REHAB-06 - Speech-Language Pathology Services
  • CG-REHAB-08 - Private Duty Nursing in the Home Setting
  • CG-SURG-28 - Transcatheter Uterine Artery Embolization
  • CG-SURG-63 - Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure

 

Clinical Guideline Adopted Effective 11-01-2018

(The following guideline will be applied and might result in services that were previously covered but may now be found to be not medically necessary.)

  • CG-MED-59 - Upper Gastrointestinal Endoscopy in Adults



Featured In:
December 2018 Empire Provider Newsletter