Revised Medical Policies Effective 11-15-2018

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

  • DRUG.00046 - Ipilimumab (Yervoy®)
  • DRUG.00071 - Pembrolizumab (Keytruda®)
  • DRUG.00075 - Nivolumab (Opdivo®)
  • 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(The following policy has been archived and its content has been transferred to an existing Clinical UM Guideline.)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