Medical Policy and Coding Updates

  • We want your feedback

    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 January 1, 2020

    Hip Arthroplasty, 7.01.573
    Hip arthroplasty may be considered medically necessary for the treatment of osteoarthritis, replacement/revision of previous arthroplasty, or other specific conditions.

    Pilot Policy for Designated Centers of Excellence: Total Knee or Total Hip Replacement, 7.01.568
    Total knee or total hip replacement (arthroplasty) for the treatment of osteoarthritis may be considered medically necessary when criteria are met and the surgery is performed in a Designated Center of Excellence. This policy only applies to members whose plan includes the Total Joint Replacement Centers of Excellence Program.

    Effective December 5, 2019

    C5 Complement Inhibitors, 5.01.571
    Ultomiris™ (ravulizumab-cwvz) is added to the site of service review. Soliris® (eculizumab) medical necessity criteria are updated for atypical hemolytic uremic syndrome (aHUS), generalized myasthenia gravis (gMG), and is now indicated for neuromyelitis optica spectrum disorder (NMOSD) in adult patients.

    Radicava® (edaravone), 5.01.578
    Medical necessity criteria are updated and require the diagnosis of definite and probable Amyotrophic Lateral Sclerosis (ALS).

    Steroid-Eluting Sinus Stents, 7.01.134
    Steroid-eluting sinus stents used after sinus surgery and the use of drug-eluting sinus stents in all situations is considered investigational.

    Effective November 10, 2019

    Updates to AIM Specialty Health® Clinical Appropriate Guidelines

    Effective for dates of service on and after November 10, 2019, the following updates will apply to the AIM Specialty Health® Advanced Imaging Clinical Appropriateness Guidelines.

    Cardiac Imagining Guideline contains updates to the following:
    Post-cardiac transplantation evaluation when any of the following applies: evaluation of new or worsening cardiac signs, symptoms or new EKG abnormalities; or, surveillance of a stable patient (no new or worsening cardiac signs or symptoms) within the first 6 months of transplant; or, surveillance of a stable patient (no new or worsening cardiac signs or symptoms) at 3-month intervals at 6 to 24 months post-transplant; or, annual surveillance of a stable patient (no new or worsening cardiac signs or symptoms) more than 24 months post-transplant.

    Head and Neck Imagining Guideline contains updates to the following:
    Sinusitis/rhinosinusitis (adult and pediatric): Defined a minimal treatment requirement for uncomplicated sinusitis prior to imaging. Defined indications for preoperative planning for image navigation following a clinical policy statement on appropriate use from the AAO-HNS. Removed CT screening for immunocompromised patients based on lack of evidence. Aligned pediatric and adult sinusitis guidelines and pediatric sinusitis guidelines with ACR and AAO-HNS.

    Trauma (adult and pediatric): Radiograph requirement added for suspected mandibular trauma. MRI TMJ in trauma for suspected internal derangement in surgical candidates.

    Neck mass: Align adult neck imaging guideline with a high-quality guideline from the American Academy of Otorhinolaryngology – Head and Neck Surgery (AAO-HNS) including mass size and feature requirements for advanced imaging.

    Parathyroid adenoma (adult and pediatric): Further defined the patient population that needs evaluation for parathyroid adenomas. Positron CT as a diagnostic test after both ultrasound and parathyroid scintigraphy. Remove MRI as a modality to evaluate for parathyroid adenomas based on lack of evidence for diagnostic accuracy.

    Temporomandibular joint dysfunction (adult and pediatric): Added requirement for conservative treatment and planned intervention for suspected osteoarthritis.

    Hearing loss: More clearly delineated appropriate modalities based on types of hearing loss in pediatric patients.

    Oncologic Imagining Guideline contains updates to the following:
    Colorectal cancer: Removal of FDG-PET/CT for radiation planning to align AIM Appropriateness Criteria with NCCN: ACR appropriateness level 6 (may be appropriate) only for detection of distant metastases. Not addressed for locoregional staging; Low level evidence to support use of PET-CT imaging for radiation treatment planning; and NCCN states that PET-CT is not indicated for pre-operative staging of rectal cancer. PET-CT can also be considered for potentially curable M1.

    Germ cell tumors – testis and ovary: Align AIM Appropriateness Criteria with NCCN for PET-CT, evidence for PET-CT imaging to evaluate residual mass < 3 cm applies to seminoma ONLY. Removed this indication for nonseminoma and malignant ovarian germ cell cancer. Residual nonseminomatous germ cell tumors > 1 cm require surgery.

    Hepatobiliary cancer: Align AIM Appropriateness Criteria with NCCN for management, screening and surveillance.

    Kidney cancer: Align AIM Appropriateness Criteria with NCCN Kidney Cancer Guidelines and ACR Appropriateness Criteria for use of PET imaging in staging and management of Kidney Cancer/Renal Cell Carcinoma. ACR appropriateness level 3 (usually not appropriate) for use of PET imaging in staging of kidney cancer. NCCN states the value of PET in RCC remains to be determined.

    Lung cancer – non-small cell: Use of MRI limited to scenarios where additional imaging would impact management.

    Lymphoma – non-Hodgkin: The majority of mucosal melanomas originate from the head and neck. The qualifier added is intended to prevent inappropriate use of MRI head and neck when of other origin besides head and neck.

    Prostate cancer: Additional criteria for management to address active surveillance in reaction to NCCN recommending an annual limit on mpMRI for active surveillance.

    Suspected metastases not otherwise specified: New criteria for Sodium Fluoride PET.

    Vascular Imagining Guideline contains updates to the following:
    General vascular: Added diagnostic testing strategy for TAVI/TAVR carotid evaluation with initial ultrasound.

    Aneurysm – intracranial: Further define neurological signs and symptoms suggestive of intracranial aneurysm.

    Carotid stenosis or occlusion: Advanced imaging as an add on test for problem solving when ultrasound suggests a high-grade stenosis.

    Hemorrhage – intracranial or subarachnoid: Define use of vascular imaging as an add on test in patients following intracranial hemorrhage. Sequential diagnostic testing strategy for non-acute stroke or TIA with CTA or MRA as an add on test to change management in select circumstances for unexplained strokes.

    Venous thrombosis or compression – extracranial: Added requirement for nondiagnostic venous ultrasound. Further define isolated headache pattern that may require imaging to exclude venous sinus thrombosis. Adopt a sequential diagnostic testing strategy starting with CT or MRI for low risk groups (no risk factors and negative D-dimer).

    Aortic aneurysm or dissection: Annual evaluation of stable aneurysms (new for advanced imaging, aligns with echocardiography guidelines). New screening indication for high risk adults, annual screening for pediatrics.

    Other vascular indications: New criteria for PAH incorporating a diagnostic testing strategy. Annual evaluation of stable aneurysms (new for advanced vascular imaging) 6-month evaluation of newly diagnosed aneurysms. Further define diagnostic indications for suspected aneurysm for advanced imaging. Align pediatrics with adult guidelines. Added requirement that intra-abdominal bleeding be unexplained for advanced vascular imaging. Remove generalized atherosclerotic disease and follow up based solely on abnormal imaging, requirement for 4 or more antihypertensive medications. More specific clinical indications for CTA/MRA in the diagnosis of suspected stenosis. Duplex ultrasound guideline with CTA/MRA alignment in diagnosis, management, and surveillance for upper extremity. Ultrasound requirement for suspected DVT prior to advanced vascular imaging. Remove Raynaud’s syndrome based on low diagnostic yield and low diagnostic accuracy. Remove CTA/MRA for with ABI less than 0.9 alone for peripheral arterial disease.

    Effective for dates of service on and after November 10, 2019

    The following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines: Radiation Oncology.

    Proton Beam Therapy Guideline contains updates to the following:
    Revised proton beam therapy considerations and indications for sinonasal cancer, melanoma of the uveal tract, and pediatric tumors.

    Effective November 1, 2019

    Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain of Peripheral Nerve Origin, 7.01.574
    Trial or permanent placement of an implantable peripheral nerve stimulator for the management of chronic pain is considered investigational.

    New medical policies

    Effective September 1, 2019

    Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia, 2.01.49
    Transurethral water vapor thermal therapy for the treatment of benign prostatic hyperplasia (BPH) and prostate cancer using the Rezum System™ is considered investigational.

    Revised medical policies

    Effective September 1, 2019

    Home Nutritional Support, 8.01.502
    The policy has been renamed and now covers only home oral nutritional support and includes medical necessity criteria for inborn errors of metabolism and eosinophilic gastrointestinal disorders.

    Injectable Clostridial Collagenase for Fibroproliferative Disorders, 5.01.595
    Injectable clostridial collagenase may be considered medically necessary for the treatment of Peyronie’s disease if a sexual dysfunction treatment benefit is available.

    Revised pharmacy policies

    Effective September 1, 2019

    Dupixent® (dupilumab), 5.01.575
    Dupixent® (dupilumab) is now indicated for chronic rhinosinusitis with nasal polyposis.

    Granulocyte Colony-Stimulating Factor (G-CSF) Use in Adult Patients, 5.01.551
    New indications are added for use in patients undergoing autologous peripheral blood progenitor cell collection and patients acutely exposed to myelosuppressive doses of radiation. Medical necessity criteria are updated for patients treated with myelosuppressive anti-cancer regimens who are at risk of severe febrile neutropenia. Granix® (tbo-filgrastim) and Nivestym™ (filgrastim-aafi) do not need preapproval for coverage.

    Pharmacotherapy of Perinatal/Infantile and Juvenile-Onset Hypophosphatasia (HPP), 5.01.573
    Medical necessity criteria for Strensiq® (asfotase alfa) are updated and criteria added to support the diagnosis of hypophosphatasia (HPP).

    Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Patients, 5.01.517
    Zirabev™ (bevacizumab-bvzr), a biosimilar to Avastin® (bevacizumab), is added to the policy. Medical necessity criteria are updated for Revlimid® (lenalidomide).

    Added codes

    Effective September 1, 2019

    Pharmacologic Treatment of Osteoporosis, 5.01.596
    Now requires review for medical necessity and prior authorization

    J0897 - Injection, denosumab, 1 mg

    Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.554
    Now requires review for medical necessity and prior authorization

    21685 - Hyoid myotomy and suspension

    Revised codes

    Effective September 1, 2019

    Automated Percutaneous and Percutaneous Endoscopic Discectomy, 7.01.18
    Now requires review for Investigative (previously reviewed for Medical Necessity); No longer requires Prior Authorization

    62380 - Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar

    Automated Percutaneous and Percutaneous Endoscopic Discectomy, 7.01.18
    Currently requires review for Investigative; no longer requires Prior Authorization

    62287 - Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method, single or multiple levels, lumbar

  •    Email this article