Medical Policy and Coding Updates March 2022

Effective June 3, 2022

Phosphoinositide 3-kinase (PI3K) Inhibitors, 5.01.592

Indication removed

• Aliqopa® (copanlisib)
  • Treatment of chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) with this drug is not FDA-approved or supported by the National Comprehensive Cancer Network (NCCN)

Effective March 13, 2022

Updates to AIM Specialty Health® Clinical Appropriateness Guidelines

Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging.

Updates by section

Brain imaging

Acoustic neuroma

• Removed indication for CT brain and replaced with CT temporal bone

Meningioma

• Added new guideline for follow-up intervals

Pituitary adenoma

• Removed allowance for CT following nondiagnostic MRI in macroadenoma

Tumor, not otherwise specified

• Added indication for management; excluded surveillance for lipoma and epidermoid without suspicious features

Chest imaging

Pneumonia

• Removed indication for diagnosis of COVID-19 due to availability and accuracy of lab testing

Pulmonary nodule

• Revised criteria for follow-up of nodules detected on lung cancer screening CT based on Lung-RADS

Head and neck imaging

Parathyroid adenoma

• Added situations where surgery is recommended based on American Association of Endocrine Surgeons guidelines

Temporomandibular joint dysfunction

• Added duration of required conservative management

Abdominal and pelvic imaging

Azotemia

• Removed this indication

Hematuria

• Revised criteria for asymptomatic microhematuria based on American Urological Association guideline

Intussusception

• Removed this indication

Jaundice

• Added requirement for ultrasound prior to advanced imaging in pediatric patients

Sacroiliitis

• Added situations where advanced imaging is indicated (predisposing condition or equivocal radiographs)

Uterine leiomyomata (fibroids)

• Added requirement for ultrasound prior to MRI
• Expanded indication to include most other fertility-sparing procedures

Oncologic imaging

• Updated recommendations based on the National Comprehensive Cancer Network (NCCN) for the following:
  • Breast cancer
  • Hodgkin lymphoma
  • Non-Hodgkin lymphoma
  • Melanoma
  • Neuroendocrine tumors
  • Soft tissue sarcoma
  • Testicular cancer
  • Thyroid cancer

Breast cancer

• Updated clinical scenarios in chart for diagnostic breast MRI and PET/CT for management

Cancer screening

• Added indication for hepatocellular carcinoma screening
• Added age criteria for pancreatic cancer

Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging of the Heart

Updates by section

Cardiac imaging

Coronary CT Angiography

• Removed indication for patients undergoing evaluation for transcatheter aortic valve implantation/replacement who are at moderate coronary artery disease risk

Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiation Oncology

• Removed Eastern Cooperative Oncology Group (ECOG) status as definition for performance status throughout guidelines

New medical policies
Effective March 1, 2022

Laser Interstitial Thermal Therapy for Neurological Conditions, 7.01.170

Laser interstitial thermal therapy (LITT) is considered investigational for all neurological conditions

Revised medical policies
Effective March 1, 2022

Preventive Care, 10.01.523

Policy statements updated

• Definitions of preventive, diagnostic, therapeutic, or surveillance added to colorectal cancer screening section

New pharmacy policies

Effective March 1, 2022

Thymic Stromal Lymphopoietin (TSLP) Inhibitors, 5.01.627

New policy

Drug added

• Tezspire® (tezepelumab)
  • Add-on maintenance treatment of severe asthma in patients age 12 years and older

Revised pharmacy policies
Effective March 1, 2022

Medical Necessity Criteria for Pharmacy Edits, 5.01.605

Hypnotics

Drug added

• Quviviq™ (daridorexant)
  • Treatment of insomnia

Intranasal Brand Corticosteroid Products

Drug added

• Ryaltris™ (olopatadine hydrochloride and mometasone furoate monohydrate)
  • Treatment of allergic rhinitis

SARS-CoV-2 Inhibitors

Quantity limits added

• Molnupiravir
• Paxlovid™ (nirmatrelvir tablets; ritonavir tablets)
  • 1 treatment course every 90 days

Pharmacologic Treatment of High Cholesterol, 5.01.558

New drugs added

• Leqvio® (inclisiran)
  • Treatment of clinical atherosclerotic cardiovascular disease (ASCVD)
• Brand rosuvastatin/ezetimibe
  • Treatment of high cholesterol

Pharmacotherapy of Arthropathies, 5.01.550

Ankylosing Spondylitis

New drugs added

• Xeljanz® (tofacitinib)
• Xeljanz® XR (tofacitinib extended-release)

Medical necessity criteria updated

• Cimzia® (certolizumab pegol)
• Cosentyx® (secukimumab)
• Simponi® (golimumab) SC
• Simponi Aria® (golimumab) IV
  • Xeljanz® (tofacitinib) and Xeljanz® XR (tofacitinib extended-release) have been added to the list of drugs that must be tried before the above drugs can be prescribed

Polyarticular Juvenile Idiopathic Arthritis

Medical necessity criteria updated

• Xeljanz® (tofacitinib) oral
• Xeljanz® Oral Solution (tofacitinib)
  • The patient must have tried Enbrel® (etanercept) or Humira® (adalimumab) before the above drugs can be prescribed

Medical necessity criteria updated

• Orencia® (abatacept) IV/SC
• Simponi Aria® (golimumab) IV
  • Xeljanz® Oral Solution (tofacitinib) has been added to the list of drugs that must be tried before the above drugs can be prescribed

Rheumatoid Arthritis

Medical necessity criteria updated

• Rinvoq™ (upadacitinib)
• Xeljanz® (tofacitinib)
• Xeljanz® XR (tofacitinib extended-release)
  • The patient must have tried Enbrel® (etanercept) or Humira® (adalimumab) before the above drugs can be prescribed

Psoriatic Arthritis

New drug added

• Rinvoq™ (upadacitinib)

Medical necessity criteria updated

• Xeljanz® (tofacitinib)
• Xeljanz® XR (tofacitinib extended-release)
  • The patient must have tried Enbrel® (etanercept) or Humira® (adalimumab) before the above drugs can be prescribed

Medical necessity criteria updated

• Cimzia® (certolizumab pegol)
• Cosentyx® (secukimumab)
• Orencia® (abatacept) IV/SC
• Simponi® (golimumab) SC
• Simponi Aria® (golimumab) IV
  • Rinvoq® (upadacitinib) has been added to the list of drugs that must be tried before the above drugs can be prescribed

Phosphoinositide 3-kinase (PI3K) Inhibitors, 5.01.592

Indication removed

• Copiktra® (duvelisib)
  • Treatment of follicular lymphoma (FL) that has returned or can't be treated with surgery

An archived policy is one that’s no longer active and is not used for reviews.

No updates this month. 

Colorectal Cancer Screening, 10.01.519

Content from this policy has been moved to Preventive Care, 10.01.523

Added codes

Effective March 13, 2022

AIM® Specialty Health Advanced Imaging

Now reviewed by AIM® Specialty Health and requires prior authorization.

0042T, 0648T, 0649T, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T

Added codes

March 1, 2022

Wireless Capsule Endoscopy, 2.01.538

Now requires review for medical necessity and prior authorization.

91112, 91113