Revised Clinical Guideline Effective 11-15-2018

(The following adopted guideline was revised to expand medical necessity indications or criteria.)

  • CG-DRUG-88 - Dupilumab (Dupixent®)

 

Revised Clinical Guidelines Effective 12-12-2018

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

  • CG-DRUG-62 - Fulvestrant (FASLODEX®)
  • CG-DRUG-63 -Levoleucovorin Products
  • CG-DRUG-78 - Antihemophilic Factor and Clotting Factors
  • CG-DRUG-107 - Pharmacotherapy for Hereditary Angioedema
  • CG-GENE-03 - BRAF Mutation Analysis
  • CG-SURG-60 - Cervical Total Disc Arthroplasty
  • CG-THER-RAD-03 - Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy [Note: Content for Lutetium Lu 177 dotatate (Lutathera®) moved from DRUG.00098 Lutetium Lu 177 dotatate (Lutathera®)]

 

Revised Clinical Guidelines Effective 12-12-2018

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

  • CG-DRUG-38 - Pemetrexed Disodium (Alimta®)
  • CG-DRUG-42 - Asparagine Specific Enzymes (Asparaginase)
  • CG-DRUG-44 - Pegloticase (Krystexxa®)
  • CG-DRUG-45 - Octreotide acetate (Sandostatin®; Sandostatin® LAR Depot)
  • CG-DRUG-54 - Agalsidase beta (Fabrazyme®)
  • CG-DRUG-64 - FDA-Approved Biosimilar Products
  • CG-DRUG-66 - Panitumumab (Vectibix®)
  • CG-DRUG-70 - Eribulin mesylate (Halaven®)
  • CG-DRUG-71 - Ziv-aflibercept (Zaltrap®)
  • CG-DRUG-75 - Romiplostim (Nplate®)
  • CG-DRUG-76 - Plerixafor Injection (Mozobil™)
  • CG-DRUG-79 - Siltuximab (Sylvant®)
  • CG-DRUG-80 - Cabazitaxel (Jevtana®)
  • CG-DRUG-87 - Vedolizumab (Entyvio®)
  • CG-MED-19 - Custodial Care
  • CG-MED-26 - Neonatal Levels of Care
  • CG-MED-67 - Melanoma Vaccines
  • CG-MED-68 - Therapeutic Apheresis
  • CG-REHAB-07 - Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
  • CG-SURG-60 - Cervical Total Disc Arthroplasty
  • CG-SURG-62 - Radiofrequency Ablation to Treat Tumors Outside the Liver
  • CG-THER-RAD-04 - Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Tumors

 

Revised Clinical Guideline Effective 12-12-2018

(The following adopted guideline was updated with new procedure and/or diagnosis codes.)

  • CG-DRUG-16 - White Blood Cell Growth Factors

 

Revised Clinical Guidelines Effective 12-27-2018

(The following adopted guidelines were updated with new procedure and/or diagnosis codes.)

  • CG-BEH-02 - Adaptive Behavioral Treatment for Autism Spectrum Disorder
  • CG-DME-43 - Oscillatory Devices for Airway Clearance (High Frequency Chest Compression)
  • CG-DRUG-29 - Hyaluronan Injections
  • CG-DRUG-61 – Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
  • CG-DRUG-94 - Rituximab (Rituxan®) for Non-Oncologic Indications
  • CG-DRUG-68 - Bevacizumab (Avastin®) for Non-Ophthalmologic Indications
  • CG-DRUG-90 - Intravitreal Treatment for Retinal Vascular Conditions

 

Archived Clinical Guidelines Effective 01-01-2019

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

  • CG-SURG-60 - Cervical Total Disc Arthroplasty

 

Revised Clinical Guidelines Effective 01-01-2019

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

  • CG-DME-40 - Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton [Note: Non-invasive electrical bone growth stimulation of the of the spine transitioned to AIM guidelines effective 01-01-2019
  • CG-MED-65 - Manipulation Under Anesthesia [Note: Manipulation under anesthesia of the shoulder transitioned to AIM guidelines effective 01-01-2019]

 

Adopted Clinical Guidelines Effective 01-03-2019

(The following guidelines were previously medical policies and have been adopted and have no significant changes.)

  • CG-MED-79 - Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems [Note: Content moved from MED.00100 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems.]
  • CG-MED-80 - Positron Emission Tomography (PET) and PET/CT Fusion [Note: Content moved from RAD.00002 Positron Emission Tomography (PET) and PET/CT Fusion.]

 

Revised Clinical Guideline Effective 01-12-2019

(The following adopted guideline was updated with new procedure and/or diagnosis codes.)

  • CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry

 

Revised Clinical Guidelines Effective 04-01-2019

(The following adopted guidelines were revised and might result in services that were previously covered but may now be found to be not medically necessary.)

  • CG-DRUG-77 - Radium Ra 223 Dichloride (Xofigo®)
  • CG-GENE-01 - Janus Kinase 2 (JAK2)V617F Gene Mutation Assay Title change: Janus Kinase 2 (JAK2)V617F and JAK2 exon 12 Gene Mutation Assays
  • CG-SURG-27 - Sex Reassignment Surgery

 

Revised Clinical Guideline Effective 04-13-2019

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

  • CG-SURG-61 - Cryosurgical Ablation of Solid Tumors Outside the Liver



Featured In:
January 2019 Empire Provider Newsletter