Medical Policy and Coding Updates

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  • Effective September 28, 2019

    Updates to AIM Advanced Imaging Clinical Appropriateness Guidelines

    Effective for dates of service on and after September 28, 2019, the following updates will apply to the AIM Specialty Health® Advanced Imaging Clinical Appropriateness Guidelines.

    Brain Imaging Guideline contains updates to the following:
    Infection, multiple sclerosis and other white matter diseases, movement disorders (adult only), neurocognitive disorders (adult only), trauma, pituitary adenoma, tumor, hematoma or hemorrhage – intracranial or extracranial, Hydrocephalus/ventricular assessment, pseudotumor cerebri, spontaneous intracranial hypotension, abnormality on neurologic exam, ataxia, dizziness or vertigo, headache, hearing loss and tinnitus.

    Extremity Imaging Guideline contains updates to the following:
    Congenital or developmental anomalies of the extremity (pediatric only), discoid meniscus (pediatric only), soft tissue infection, osteomyelitis, septic arthritis, bursitis, capitellar osteochondritis, fracture, patellar dislocation, patellar sleeve avulsion, trauma complications, bone lesions, soft tissue mass – not otherwise specified, Lisfranc injury, labral tear – hip, labral tear – shoulder, meniscal tear and ligament tear of the knee, rotator cuff tear (adult only), avascular necrosis, lipohemarthrosis (pediatric only), Paget’s disease – new multimodality indication and general perioperative imaging (including delayed hardware failure), not otherwise specified.

    Spine Imaging Guideline contains updates to the following:
    Multiple sclerosis or other white matter disease, spinal infection, cervical injury, thoracic or lumbar injury, Paget’s disease, spontaneous (idiopathic) intracranial hypotension (SIH), perioperative imaging, including delayed hardware failure, not otherwise specified, neck pain (cervical), mid-back pain (thoracic).

    Effective September 8, 2019

    Updates to AIM Specialty Health® Clinical Appropriateness Guidelines for Genetic Testing

    Effective for dates of service on and after September 8, 2019, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Genetic Testing.

    Genetic Testing for Single-Gene and Multifactorial Conditions Guideline contains updates to the following:
    The single gene and multigene criteria were re-formatted and combined into one section entitled, Genetic Testing for Germline Conditions. No criteria changes.

    Molecular Testing of Solid and Hematologic Tumors and Malignancies Guideline contains updates to the following:
    Scope revised to include the need for potential additional adjudication for testing required by plans’ pharmaceutical policies. Coverage Criteria revised to include testing criteria for NTRK fusions. Coverage Criteria revised to expand recommendations for breast cancer gene expression classifiers for prognostic purposes. More specific criteria was included for pancreatic cancer.

    Genetic Testing for Pharmacogenetic and Thrombophilia Guideline contains updates to the following:
    Coverage Criteria expanded to allow pharmacogenetic testing when identification of the genetic variant is required or recommended prior to initiating therapy with a target drug as noted by the FDA-approved prescribing label.

    Effective August 2, 2019

    Pharmacologic Treatment of Osteoporosis, 5.01.596
    Forteo® (teriparatide), Tymlos® (abaloparatide), and Prolia® (denosumab) may be considered medically necessary when criteria are met. They are considered investigational when criteria are not met. The policy is revised to add medical necessity criteria for Evenity™ (romosozumab-aqqg) and update the criteria for Tymlos® (abaloparatide).

    Synthetic Cartilage Implants for Joint Pain, 7.01.160
    Synthetic cartilage implants are considered investigational for the treatment of articular cartilage damage.

    Effective July 31, 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.

    Effective July 14, 2019

    AIM Clinical Guidelines for Oncologic Imaging to Include PET Radiotracers
    AIM Specialty Health® Guidelines for Oncologic Imaging have been changed to include PET radiotracers. As of July 14, 2019, AIM will review prior authorization requests for both non-FDG (fluorodeoxyglucose) radiotracers and PET-CT.

    Effective July 4, 2019

    Absorbable Nasal Implant for Treatment of Nasal Valve Collapse, 7.01.163
    The insertion of an absorbable lateral nasal implant (eg, Latera®) for the treatment of symptomatic nasal valve collapse is considered investigational.

    C5 Complement Inhibitors, 5.01.571
    The policy updates the criteria for Soliris® (eculizumab) for the indication of paroxysmal nocturnal hemoglobinuria. Criteria for the drug Ultomiris™ (ravulizumab-cwvz) are also added.

    New medical policies

    Effective June 1, 2019

    Imaging: Services Reviewed by AIM®, 10.01.528
    New administrative guideline. This administrative guideline is implemented for transparency and to support navigation; AIM Specialty Health has been reviewing these services since 2009.

    Radiation Oncology: Services Reviewed by AIM®, 10.01.527
    New administrative guideline. This administrative guideline is implemented for transparency and to support navigation; AIM Specialty Health has been reviewing these services since July 1, 2016.

    Revised medical policies

    Effective June 1, 2019

    Amniotic Membrane and Amniotic Fluid, 7.01.149
    A statement is added regarding size-appropriate graft applications.

    Upper Gastrointestinal (UGI) Endoscopy for Adults, 2.01.533
    Post cardiac ablation for the treatment of arrhythmia is added as medically necessary indication.

    Effective June 29, 2019

    AIM Specialty Health Clinical Guidelines

    Sleep Disorder Management Guideline enhancements:

    • For clarity, moved criteria for patients with established CSA and combined under one indication: BPAP with and without back-up rate feature.
    • Removed the condition to try rate support for central sleep apnea to align with clinical practice.

    Cardiac Imaging Clinical Appropriateness Guideline enhancements:

    • Resting Transthoracic Echocardiography (TTE) and Blood Pool Imaging
      • Changes made to address frequency of surveillance of LV function for cardio-oncology.
    • TTE
      • Changes made to address frequency of surveillance echocardiography following transcatheter mitral valve repair. These recommendations follow CMS guidelines.

    New pharmacy policies

    Effective June 1, 2019

    Pharmacologic Treatment of Postpartum Depression, 5.01.608
    Zulresso™ (brexanolone) may be considered medically necessary for moderate to severe postpartum depression in adults when the medical record shows documentation of DSM-5 diagnostic criteria for major depressive disorder with peripartum onset, patient is 6 months or less postpartum, and the drug is administered as a one-time 60-hour infusion. See policy for full details.

    Pharmacologic Treatment of Sleep Disorders, 5.01.599
    Xyrem® (sodium oxybate) moved from policy 5.01.605. Criteria for Sunosi™ (solriamfetol) are also added.

    Revised pharmacy policies

    Effective June 1, 2019

    Multiple Receptor Tyrosine Kinase Inhibitors, 5.01.534
    The policy is revised to add medical necessity criteria for Xospata® (gilteritinib).

    A deleted policy is one whose number is no longer used but the content is either moved into another policy or replaced with a new policy and number.

    Deleted May 31, 2019

    Ultrasound Accelerated Fracture Healing Device, 1.01.05. Replaced with policy 1.01.531.

    Added codes

    Effective June 1, 2019

    Granulocyte Colony-Stimulating Factor (G-CSF) Use in Adult Patients, 5.01.551
    Now requires review for medical necessity, now requires prior authorization

    Q5111 - Injection, pegfilgrastim-cbqv, biosimilar, (Udenyca), 0.5 mg

    Myoelectric Prosthetic and Orthotic Components for the Upper Limb, 1.04.502
    Now requires review for medical necessity, now requires prior authorization

    L6895 - External recharging system for battery (external) for use with implantable neurostimulator, replacement

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