Medical Policy and Coding Updates

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    We regularly review policies to make sure they’re consistent with the latest medical evidence. We'd like your feedback on policies scheduled for review. In the document, you can open any title to read the current policy. Email us your policy comments or suggestions today!

  • Effective June 7, 2019

    Children's Therapeutic Positioning Equipment, 1.01.530
    Children’s positioning equipment such as reflux wedges, therapeutic positioning seats, and therapeutic positioning seats for use in vehicles may be considered medically necessary when criteria are met. Conventional positioning equipment used for children without positioning needs is excluded by contract and is not covered.

    Effective June 9, 2019

    Pharmacotherapy of Arthropathies, 5.01.550
    The policy is revised to add dose frequency to Remicade® (infliximab), Inflectra® (infliximab-dyyb), and Renflexis® (infliximab-abda). The criteria for Orencia® (abatacept) are updated. Review the policy for full details.

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
    The policy is revised to add dose frequency and age restriction to Remicade® (infliximab), Inflectra® (infliximab-dyyb), and Renflexis® (infliximab-abda). Review the policy for full details.

    Revised pharmacy policies

    Effective March 1, 2019

    ALK Tyrosine Kinase Inhibitors, 5.01.538
    Lorbrena® (lorlatinib) may be considered medically necessary for the treatment of anaplastic lymphoma kinase (ALK)-positive metastatic non-small cell lung cancer when the disease has progressed following the use of other specific agents.

    BCR‐ABL Kinase Inhibitors, 5.01.518
    Two indications for Sprycel® (dasatinib) are added:

    • Sprycel may be considered medically necessary for the treatment of newly diagnosed pediatric patients with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) in combination with chemotherapy.
    • Sprycel may be considered medically necessary for the treatment of newly diagnosed adult patients with Philadelphia chromosome-positive chronic myeloid leukemia (Ph+ CML) in chronic phase with resistance or intolerance to prior therapy with imatinib.

    Immune Checkpoint Inhibitors, 5.01.591
    Tecentriq® (atezolizumab) may be considered medically necessary for first-line treatment of patients with metastatic non-squamous non-small cell lung cancer with no EGFR or ALK genomic tumor aberrations when used in combination with bevacizumab, paclitaxel, and carboplatin.

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605
    Nonpreferred testosterone replacement agents may be considered medically necessary with a trial and failure of generic testosterone gel 1% or generic testosterone gel 1.62%. For Testopel®, the criteria are also updated to state that trial and failure of generic testosterone gel 1% or generic testosterone gel 1.62% is required.

    Multiple Receptor Tyrosine Kinase Inhibitors, 5.01.534
    Cabometyx® (cabozantinib) may be considered medically necessary for adults with hepatocellular carcinoma who have previously been treated with sorafenib.

    Pharmacotherapy of Thrombocytopenia, 5.01.566
    Promacta® (eltrombopag) may be approved for first-line treatment of adult and pediatric patients 2-years-old and older with severe aplastic anemia when criteria are met.

    Revised codes

    Effective March 1, 2019

    Electronic Brachytherapy for Nonmelanoma Skin Cancer, 8.01.62
    No longer requires prior authorization, currently reviewed as investigative 0394T - High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed

    Site of Service: Select Surgical Procedures, 11.01.524
    Now requires review for site of service administration, currently requires review for medical necessity, currently requires prior authorization

    31253 - Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed

    31257 - Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy

    31259 - Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus

    31298 - Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (eg, balloon dilation)

    Removed codes

    Effective March 1, 2019

    Electronic Brachytherapy for Nonmelanoma Skin Cancer, 8.01.62
    No longer requires review for investigative, no longer requires prior authorization 0395T - High dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction, includes basic dosimetry, when performed

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