Medical Policy and Coding Updates January 2018

  • Special notice: new medical policy effective in April 2018

    Effective April 4, 2018

    Cognitive (Neurologic) Rehabilitation, 8.03.504
    This policy was previously archived but is now being reinstated. Cognitive (neurologic) rehabilitation programs may be considered medically necessary for patients with cognitive impairment due to traumatic brain injury when criteria are met. It's considered investigational for other indications. Read the full policy.

    New medical policies and guidelines

    Effective January 1, 2018

    Services Reviewed by AIM Specialty Health® (AIM): Sleep Disorder Management, 10.01.524
    This administrative guideline summarizes the type of sleep services reviewed by AIM, effective January 1, 2018. It also provides links to AIM's Sleep Disorder Management guidelines and the AIM Provider website login. Read the full policy.

    Skilled Nursing Facility (SNF): Admission and Transition of Care Guideline, 11.01.510
    This policy was previously archived but is now being reinstated and will replace InterQual skilled nursing facility guidelines. Read the full policy.

    Revised medical policies

    Effective January 1, 2018

    Adoptive Immunotherapy, 8.01.01
    The policy statement now notes that Kymriah™ (tisagenlecleucel) and Yescarta™ (axicabtagene ciloleucel) are addressed in policy 5.01.580. All other adoptive immunotherapies which are not addressed in separate policies are investigational. Read the full policy.

    Bone Mineral Density Studies, 6.01.521
    The policy statements have been clarified but the intent remains unchanged. Read the full policy.

    Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors, 7.01.526
    The policy statement was revised to include lung cancer as a medically necessary indication when criteria are met. Read the full policy.

    Upper Gastrointestinal (UGI) Endoscopy for Adults, 2.01.533
    The criteria were modified to include surveillance for individuals with cirrhosis. The policy statement was clarified to state that UGI is not covered for bariatric surgery when bariatric surgery is contractually excluded, unless other symptoms are present. InterQual® Criteria: Services Reviewed for Medical Necessity, 10.01.531.
    Note: This policy is moving to InterQual® Criteria: Services Reviewed for Medical Necessity, 10.01.531.

    New pharmacy policy

    Effective January 1, 2018

    Chimeric Antigen Receptor (CAR) T Cell Therapies, 5.01.580
    Kymriah™ (tisagenlecleucel) and Yescarta™ (axicabtagene ciloleucel) are considered medically necessary when criteria are met. All other uses of Kymriah, Yescarta, or other chimeric antigen receptor T-cell therapies for conditions not outlined in policies are considered investigational. Note: The services originally described in this policy are now found in policy 8.01.01 Adoptive Immunotherapy.

    Revised pharmacy policies

    Effective January 1, 2018

    Medical Necessity Criteria and Dispensing Quantity Limits for Exchange Formulary Benefits, 5.01.547
    The policy was revised to add step edits for the following drugs:

    • Brilinta® (ticagrelor)
    • Butrans® (buprenorphine)
    • Bystolic® (nebivolol)
    • Colchicine
    • Emsam® (selegiline transdermal system)
    • Epiduo® Forte (adapalene and benzoyl peroxide
    • Lotemax® (loteprednol etabonate)
    • Ranexa® (ranolazine)
    • Suprep® (sodium sulfate, potassium sulfate, magnesium sulfate)
    • Tazarotene
    • Tazorac® (tazarotene)
    • Ventolin® HFA (albuterol sulfate HFA inhalation aerosol)
    • Welchol® (colesevelam hydrochloride)

    The policy was revised to add medical necessity criteria for the following drugs:

    • Actimmune® (interferon gamma-1b)
    • Ilaris® (canakinumab)
    • Jakafi® (ruxolitinib)
    • Leukine® (sargramostim)

    Read the full policy.

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605
    The policy was revised to state that Entresto® (sacubitril/valsartan) is considered not medically necessary in people under 18. Medical necessity criteria were added for Abilify MyCite® (aripiprazole tablets with sensor) and Vyzulta™ (latanoprostene bunod ophthalmic solution, 0.024%). Read the full policy.

    Migraine and Cluster Headache Medications, 5.01.503
    The policy was revised to include whether pediatric dosing is medically necessary. The policy was also updated to reflect that Zecuity® (sumatriptan iontophoretic transdermal system) is discontinued. Read the full policy.

    Multiple Receptor Tyrosine Kinase Inhibitors, 5.01.534
    The policy statement was revised to update the criteria for Calquence® (acalabrutinib). Read the full policy.

    Pharmacotherapy of Atopic Dermatitis, 5.01.575
    The policy was revised to include a table summarizing high potency corticosteroids. Read the full policy.

    Pharmacotherapy of Type I and Type II Diabetes Mellitus, 5.01.569
    The policy was revised to add medical necessity criteria for Ozempic® (semaglutide). Read the full policy.

    An archived policy is no longer active and isn't used for reviews.

    Archived on December 31, 2017

    Whole Body Dual X-Ray Absorptiometry to Determine Body Composition, 6.01.40

    Special note: As of January 1, 2018, AIM Specialty Health® reviews sleep services; consequently, these policies are archived as of December 31, 2017.

    • Intraoral Appliances for the Treatment of Obstructive Sleep Apnea, 2.01.532
    • Polysomnography and Home Sleep Study for Diagnosis of Obstructive Sleep Apnea, 2.01.503
    • Polysomnography for Nonrespiratory Sleep Disorders, 2.01.99
    • Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea, 1.01.524

    Added codes

    Effective January 1, 2018

    Amniotic Membrane and Amniotic Fluid, 7.01.149
    Now requires review for investigative, now requires prior authorization

    Q4176 - Neopatch, per square centimeter

    Q4177 - Floweramnioflo, 0.1 cc

    Q4178 - Floweramniopatch, per square centimeter

    Q4180 - Revita, per square centimeter

    Q4181 - Amnio wound, per square centimeter

    Bioengineered Skin and Soft Tissue Substitutes, 7.01.113
    Now reviewed for medical necessity, now requires prior authorization

    Q4179 - Flowerderm, per square centimeter

    Q4182 - Transcyte, per square centimeter

    Chimeric Antigen Receptor (CAR) T-Cell Therapies, 5.01.580
    Now reviewed for medical necessity, now requires prior authorization

    Q2040 - Tisagenlecleucel, up to 250 million car-positive viable t cells, including leukapheresis and dose preparation procedures, per infusion

    Exondys 51 (eteplirsen), 5.01.570
    Now reviewed for medical necessity, now requires prior authorization

    J1428 - Injection, eteplirsen, 10 mg

    Immune Globulin therapy, 8.01.503
    Now reviewed for medical necessity, now requires prior authorization

    J1555 - Injection, immune globulin (cuvitru), 100 mg

    Miscellaneous Oncology Drugs, 5.01.540
    Now reviewed for medical necessity, now requires prior authorization

    J9022 - Injection, atezolizumab, 10 mg

    J9023 - Injection, avelumab, 10 mg

    J9285 - Injection, olaratumab, 10 mg

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
    Now reviewed for medical necessity, now requires prior authorization

    J3358 - Ustekinumab, for intravenous injection, 1 mg

    Pharmacotherapy of Multiple Sclerosis, 5.01.565
    Now reviewed for medical necessity, now requires prior authorization

    J2350 - Injection, ocrelizumab, 1 mg

    Pharmacotherapy of Spinal Muscular Atrophy (SMA), 5.01.574
    Now reviewed for medical necessity, now requires prior authorization

    J2326 - Injection, nusinersen, 0.1mg

    Site of Service Infusion Drugs and Biologic Agents, 11.01.523
    Now reviewed for medical necessity, now requires prior authorization

    J1555 - Injection, immune globulin (cuvitru), 100 mg

    Effective January 5, 2018

    Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.48
    Now reviewed for medical necessity, now requires prior authorization

    27412 - Autologous chondrocyte implantation, knee

    J7330 - Autologous cultured chondrocytes, implant

    S2112 - Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)

    Revised codes

    Effective January 1, 2018

    Adoptive Immunotherapy, 8.01.01
    Now reviewed for medical necessity, now requires prior authorization, no longer reviewed as investigative

    S2107 - Adoptive immunotherapy ie, development of specific antitumor reactivity (eg, tumor-infiltrating lymphocyte therapy) per course of treatment

    Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors, 7.01.526
    Now reviewed for medical necessity, now requires prior authorization, no longer reviewed as investigative

    0340T - Ablation, pulmonary tumor(s), including pleura or chest wall when involved by tumor extension, percutaneous, cryoablation, unilateral, includes imaging guidance (terminated January 1, 2018)

    32994 - Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; cryoablation (Effective January 1, 2018)

    Removed code

    Effective January 1, 2018

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
    No longer reviewed for medical necessity, no longer requires prior authorization

    Q9989 - Ustekinumab, for intravenous injection, 1 mg

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