Medical Policy and Coding Updates October 2020

  • Updates for both non-individual and individual plans

  • Effective January 1, 2021

    Pharmacotherapy of Arthropathies, 5.01.550

    Medical necessity criteria updated

    • Actemra® (tocilizumab)
      • Treatment of moderate to severe rheumatoid arthritis. Patient must have tried and failed Humira® (adalimumab) or this drug cannot be tolerated

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563

    Site of service review added

    • Tysabri® (natalizumab)

    Medical necessity criteria updated

    • Tysabri® (natalizumab)
      • Second-line treatment for Crohn’s disease requires trial and treatment failure with corticosteroids, or azathioprine, 6-mercaptopurine, methotrexate, Cimzia® (certolizumab pegol), Entyvio® (vedolizumab), Humira® (adalimumab), Remicade® (infliximab), or Stelara® (ustekinumab)

    Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564

    New drug added to policy

    • Ilaris® (canakinumab)
      • Treatment of periodic fever syndromes
      • Treatment of Still’s disease in patients age 2 and older

    Pharmacotherapy of Multiple Sclerosis, 5.01.565

    Site of service review added

    • Tysabri® (natalizumab)

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523

    New drug added to policy

    • Tysabri® (natalizumab)

    Use of Granulocyte Colony-Stimulating Factors (G-CSF), 5.01.551

    Policy renamed

    • From “Granulocyte Colony-Stimulating Factors (G-CSF) Use in Adult Patients” to “Use of Granulocyte Colony-Stimulating Factors (G-CSF)”

    Medical necessity criteria updated

    • Udenyca® (pegfilgrastim-cbqv) and Ziextenzo® (pegfilgrastim-bmez)
      • As a first-line treatment for patients under age 18 who are at risk of severe febrile neutropenia
      • As a second-line treatment for patients age 18 or older who are at risk of severe febrile neutropenia when Granix® (tbo-filgrastim) or Nivestym® (filgrastim-aafi) has been tried and failed, or there is a medical reason why those two drugs cannot be taken, or there is a valid medical reason why self-injection or home nursing cannot be performed
    • Neulasta® (pegfilgrastim) / Neulasta Onpro®, Fulphila® (pegfilgrastim-jmdb), and Nyvepria™ (pegfilgrastim-apgf)
      • As a second-line treatment of patients under age 18 who are at risk of severe febrile neutropenia when Udenyca® (pegfilgrastim-cbqv) or Ziextenzo® (pegfilgrastim-bmez) have been tried and failed, or there is a medical reason why those two drugs cannot be taken
      • As a third-line treatment of patients age 18 or older who are at risk of severe febrile neutropenia when Granix® (tbo-filgrastim) or Nivestym® (filgrastim-aafi) has been tried and failed, when Udenyca® (pegfilgrastim-cbqv) or Ziextenzo® (pegfilgrastim-bmez) has been tried and failed, or there is a medical reason why those drugs cannot be taken

    Effective December 3, 2020

    Hematopoietic Cell Transplantation for Hodgkin Lymphoma, 8.01.29

    Criteria updated

    • Tandem autologous hematopoietic cell transplantation (HCT) medical necessity criteria have been removed
    • Tandem autologous hematopoietic cell transplantation (HCT) is now considered investigational in patients with Hodgkin lymphoma

    Miscellaneous Oncology Drugs, 5.01.540

    New drugs added to policy

    • Blincyto® (blinatumomab)
      • Treatment of adults and children for B-cell precursor acute lymphoblastic leukemia (ALL) in first or second complete remission with minimal residual disease (MRD)
      • Treatment of adults and children with relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL)
    • Leukine® (sargramostim)
      • Treatment of acute myeloid leukemia after induction chemotherapy
      • Mobilization and following transplant of autologous peripheral blood progenitor cells
      • Myeloid reconstitution after (allogenic or autologous) bone marrow transplant
      • Treatment for bone marrow transplant (allogenic or autologous) failure or engraftment delay
      • Treatment for exposure to myelosuppressive doses of radiation (Hematopoietic Syndrome of Acute Radiation Syndrome)

    Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment, 5.01.517

    New drug added to policy

    • Cyramza® (ramucirumab)
      • Treatment of advanced or metastatic gastric or gastro-esophageal junction (GEJ) cancer that has continued to grow while on or after prior fluoropyrimidine- or platinum- containing chemotherapy when used as a single agent or with paclitaxel
      • Treatment of metastatic non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) gene changes (exon 19 or exon 21) as first-line therapy when used with erlotinib
      • Treatment of metastatic non-small cell lung cancer (NSCLC) that has continued to grow while on or after platinum-based chemotherapy when used with docetaxel
      • Treatment of metastatic colorectal cancer (mCRC) that has continued to grow while on or after prior therapy with bevacizumab, oxaliplatin, and a fluoropyrimidine when used with a FOLFIRI chemotherapy combination
      • Treatment of hepatocellular carcinoma (HCC) in patients who have an elevated alpha fetoprotein and have been treated with sorafenib when used as a single agent

    Effective October 2, 2020

    Miscellaneous Oncology Drugs, 5.01.540

    New drugs added to policy

    • Kyprolis® (carfilzomib)
      • Treatment of multiple myeloma
    • Velcade® (bortezomib)
      • Treatment of multiple myeloma and mantle cell lymphoma

    Pharmacotherapy of Arthropathies, 5.01.550

    Site of service review added

    • Avsola™ (infliximab-axxq)

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563

    Site of service review added

    • Avsola™ (infliximab-axxq)

    Pharmacologic Treatment of Infertility, 5.01.610

    New policy

    The following drugs have been added and may be considered medically necessary when criteria are met:

    • Brand Chorionic Gonadotropin
    • Bravelle® (urofollitropin)
    • Follistim® AQ (follitropin beta)
    • Pregnyl® (chorionic gonadotropin)

    Prostate Cancer Targeted Therapies, 5.01.544

    New drugs added to policy

    • Jevtana® (cabazitaxel)
    • Xofigo® (radium Ra 223 dichloride)

    Rituximab Non-Oncologic and Miscellaneous Uses, 5.01.556

    Site of service review added

    • Ruxience™ (rituximab-pvvr)

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523

    New drug added to policy

    • Avsola™ (infliximab-axxq)

    New medical policies

    Effective October 1, 2020

    Prescription Digital Therapeutics for Substance Use Disorder, 5.01.35

    • Prescription digital therapeutics for substance use disorder are considered investigational

    Revised medical policies

    Effective October 1, 2020

    Intraoperative Neurophysiologic Monitoring, 7.01.562

    Medical necessity criteria updated

    • Train of four monitoring has been added to the policy. It is considered a part of intraoperative monitoring and is not separately payable.

    Revised pharmacy policies

    Effective October 1, 2020

    Multiple Receptor Tyrosine Kinase Inhibitors, 5.01.534

    New drug added to policy

    • Tabrecta™ (capmatinib)
      • Treatment of adult patients with metastatic non-small cell lung cancer (NSCLC)
    • Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564

      New drugs added to policy

      • Avsola™ (infliximab-axxq)
        • As a second-line treatment for pyoderma gangrenosum
      • Enspryng™ (satralizumab-mwge)
        • Treatment of neuromyelitis optica spectrum disorder (NMOSD) in adult patients 18 and older
      • Uplizna™ (inebilizumab-cdon)
        • Treatment of neuromyelitis optica spectrum disorder (NMOSD) in adult patients 18 and older

      Pharmacotherapy of Multiple Sclerosis, 5.01.565

      New drug added to policy

      • Generic dimethyl fumarate
        • As a first-line treatment for relapsing forms of multiple sclerosis, including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease

      Rituximab Non-Oncologic and Miscellaneous Uses, 5.01.556

      Medical necessity criteria updated

      • Rituxan® (rituximab) and Ruxience™ (rituximab-pvvr)
        • Treatment of neuromyelitis optica spectrum disorders (NMOSD) must include a confirmed diagnosis by at least one of the following: optic neuritis; acute myelitis; area postrema syndrome; acute brainstem syndrome; symptomatic narcolepsy or acute diencephalic clinical syndrome with NMOSD-typical diencephalic MRI lesions. An alternative diagnosis (eg, multiple sclerosis) must also be ruled out. The requirement for a trial of a standard immunosuppressive drug (eg, azathioprine or mycophenolate mofetil) has been removed.

    Added codes

    Effective October 2, 2020

    Miscellaneous Oncology Drugs, 5.01.540
    Now requires review for medical necessity and prior authorization.

    J9041, J9047

    Pharmacologic Treatment of Infertility, 5.01.610
    Now requires review for medical necessity and prior authorization.

    J0725, J3355

    Prostate Cancer Targeted Therapies, 5.01.544
    Now requires review for medical necessity and prior authorization.

    A9606, J9043


    Effective October 1, 2020

    Amniotic Membrane and Amniotic Fluid, 7.01.583
    Now requires review for investigative.

    Q4249, Q4250, Q4254, Q4255

    CGRP Inhibitors for Migraine Prophylaxis, 5.01.584
    Now requires review for medical necessity and prior authorization.

    J3032

    Drugs for Rare Diseases, 5.01.576
    Now requires review for medical necessity and prior authorization.

    J3241

    Lipid Apheresis, 8.02.04
    Now requires review for investigative and prior authorization.

    0342T

    Miscellaneous Oncology Drugs, 5.01.540
    Now requires review for medical necessity and prior authorization.

    J9227

    Molecular Genetic Testing: Services Reviewed by AIM®, 10.01.526
    Now reviewed by AIM® Specialty Health and requires prior authorization.

    0015M, 0203U, 0204U, 0205U, 0208U, 0209U, 0211U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U

    Non-covered Services and Procedures, 10.01.527
    No longer covered.

    T2047

    Pharmacologic Treatment of Postpartum Depression, 5.01.608
    Now requires review for medical necessity and prior authorization.

    J1632

    Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities, 1.03.04
    Now requires review for investigative.

    K1007


    Effective September 1, 2020

    SARS-CoV-2 Serology (Antibody) Testing, 2.04.518
    Now requires review for medical necessity.

    86413

    Revised codes

    Effective October 2, 2020

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
    Now requires review for site of service administration. Currently requires review for medical necessity and prior authorization.

    Q5121

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
    Now requires review for site of service administration. Currently requires review for medical necessity and prior authorization.

    Q5119

  • Updates for non-individual plans only

  • Effective January 1, 2021

    Updates to prior authorization for 2021 may be found in the code list.

    No updates this month

  • Updates for individual plans only

  • Effective January 1, 2021

    Updates to prior authorization for 2021 may be found in the code list.

    No updates this month

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