Medical Policy and Coding Updates

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  • Updates for both non-individual and individual plans

  • Effective September 11, 2022

    Updates to AIM Specialty Health® Clinical Appropriateness Guidelines

    Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging

    Updates by section

    Extremity Imaging

    Fracture

    • Added indication for evaluation of supracondylar fracture
    • Added CT as an alternative to MRI for tibial plateau fracture

    General information/overview

    • Allowed exception to specified durations of conservative management in rare cases

    Perioperative imaging (including delayed hardware failure), not otherwise specified

    • Added statement that advanced imaging is not indicated for robotic-assisted hip arthroplasty

    Rotator cuff tear

    • Updated conservative management time from 4 weeks to 6 weeks for rotator cuff tear

    Shoulder arthroplasty

    • Added statement that advanced imaging is not indicated for robotic-assisted shoulder arthroplasty

    Spine Imaging

    Cervical injury

    • Clarified that post-traumatic neurologic deficit refers specifically to an exam finding

    General information/overview

    • Allowed exception to specified durations of conservative management in rare cases

    Perioperative and periprocedural imaging

    • Added requirement for initial evaluation with radiographs

    Thoracic or lumbar injury

    • Clarified that neurologic deficit refers specifically to an exam finding

    Vascular Imaging: Brain, Head and Neck

    Pulsatile tinnitus

    • Added optional CTA/MRA neck evaluation for pulsatile tinnitus

    Stenosis or occlusion, extracranial carotid arteries

    • Added new screening indications for post-neck irradiation and incidental carotid calcification
    • Revised surveillance guidelines to align with Society for Vascular Surgery for annual imaging, post-revascularization after first year

    Stroke or transient ischemic attach (TIA)

    • Divided this section into two categories: intracranial evaluation and extracranial evaluation
    • Revised guidelines to align with American Hospital Association/American Society of Anesthesiologists
      • Allowed CTA/MRA of the neck without previous prerequisite for subacute stroke/TIA
    • Allowed CTA/MRA for chronic posterior circulation stroke/TIA
    • Added indication for carotid ultrasound

    Vascular Imaging: Abdomen and Pelvis

    Acute aortic syndrome

    • Added optional pelvic imaging

    Aneurysm of the abdominal aorta or iliac arteries

    • Screening: Added femoral aneurysm to the list of lower extremity sites
    • Management: Revised guidelines to align with Society for Vascular Surgery for post-endovascular repair to repeat imaging 12 months after baseline
    • Surveillance: Revised guidelines to align with Society for Vascular Surgery for stable aneurysms treated with endographs
      • Duplex arterial ultrasound annually
      • CT every 5 years

    Venous thrombosis or occlusion

    • Added optional pelvic imaging to Imaging Study section

    Vascular Imaging: Upper Extremity

    Peripheral arterial disease (PAD)

    • Added any sign or symptom with inconclusive physiologic testing, including exercise testing, to diagnostic criteria for suspected PAD and management of known PAD
    • Added criteria for the management of PAD: resting ischemic pain to unilateral cold painful hand

    Vascular Imaging: Lower Extremity

    Peripheral arterial disease (PAD)

    • Added any sign or symptom with inconclusive physiologic testing, including exercise testing, to diagnostic criteria for suspected PAD
    • Revised guidelines to align with Society for Vascular Surgery by adding indication for ultrasound surveillance for repaired popliteal artery aneurysm

    Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Sleep Disorder Management.

    Updates by section

    Sleep Disorder Diagnostic Management

    Established sleep disorder (OSA or other) - follow-up laboratory studies

    • Added option that a follow-up, in-lab sleep study may be allowed to adjust device settings after insertion of a hypoglossal nerve stimulator

    Multiple sleep latency testing (MSLT) and/or maintenance of wakefulness testing (MWT)

    • Added MWT indication for occupational safety  

    Sleep Disorder Treatment Management

    Management of obstructive sleep apnea using oral appliances

    • Added age indication for patients age 16 years and older to the use of a custom fabricated oral appliance

    Effective September 4, 2022

    Updates to AIM Specialty Health® Clinical Appropriateness Guidelines

    Effective for dates of service on and after September 4, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Genetic Testing

    Updates by section

    Hereditary Cardiac Disease

    Appropriate use criteria

    • Added general genetic testing criteria

    Genetic testing of affected individuals

    • Moved content with specific cardiac conditions in "Testing of Asymptomatic Individuals" to this section

    Genetic testing in the evaluation of sudden cardiac arrest

    • Added this new section and medical necessity criteria

    Post-mortem genetic testing

    • Added new medical necessity criteria

    Reproductive Carrier Screening and Prenatal Diagnosis

    Preimplantation genetic testing of embryos

    • Added polygenetic risk scores (PRS) to the list of not medically necessary conditions

    Single Gene and Multifactoral Conditions

    Thrombophilia testing

    • Removed the criterion for an individual with unprovoked venous thromboembolism

    Somatic and Hematologic Tumors Genetic Testing

    Conditions for which testing may be medically necessary

    • Added FoundationOne® as medically necessary for non-small cell lung cancer (NSCLC) stage IIIB and above
    • Added targeted multigene panels as medically necessary for endometrial cancer

    Cell-free testing

    Listed ctDx Lung™ and Target Selector™ NGS Lung Panel as the only approved targeted multi-gene panels for biomarkers in locally advanced or metastatic non-small cell lung cancer (NSCLC)

    Cancer screening

    • Added timing of PSA testing in relation to the PCA3 or ConfirmMDx test  
    • Moved criteria for gene expression classifier testing for indeterminate thyroid nodules (ITN) from Table 1 to this section

    Effective September 2, 2022

    Cervical Spine Surgeries: Discectomy, Laminectomy, and Fusion in Adults, 7.01.560

    Anterior cervical fusion
    Indications added

    • Spine fracture and/or dislocation
    • Cervical spine revision surgery  

    Medical necessity criteria updated
    Indication: Cervical pseudoarthritis

    • Cervical pseudarthrosis must be symptomatic
    • Imaging shows evidence of hardware failure
    • Pain aligns with the level of pseudoarthritis
    • A cervical spine MRI or CT scan 12 months after a previous spinal fusion shows non-union at the same level as symptom/exam findings

    Posterior cervical fusion

    Indication added

    • Implant/instrumentation failure

    Medical necessity criteria updated
    Indication:  Cervical pseudoarthritis

    • Imaging shows evidence of hardware failure
    • Pain aligns with the level of pseudoarthritis
    • A cervical spine MRI or CT scan 12 months after a previous spinal fusion shows non-union at the same level as symptom/exam findings 

    Hysterectomy for Non-Malignant Conditions, 7.01.548

    Medical necessity criteria updated
    Criteria for uterine fibroids has been separated from the abnormal uterine bleeding indication 

    Indications added

    • Chronic pelvic inflammatory disease (PID)
    • Pelvic pain

    Lumbar Spinal Fusion in Adults, 7.01.542

    Indication added
    Revision surgery for implant/instrumentation failure

    Spravato® (esketamine) Nasal Spray, 5.01.609

    All Indications
    Medical necessity criteria updated

    • Documentation of depression must include the patient's symptoms and their severity as measured by one or more standardized depression rating scales
    • The patient must have no current use of any mind- or mood-altering substances, including but not limited to alcohol, marijuana, stimulants, and hallucinogens/psychedelics

    All Indications
    Medical necessity criteria added
    A new course of Spravato® treatment when the patient was previously treated with this drug

    All Indications
    Re-authorization criteria updated

    • The patient must not have a current substance use disorder, unless there has been complete abstinence for a month
    • The patient must have no current use of any mind- or mood-altering substances, including but not limited to alcohol, marijuana, stimulants, and hallucinogens/psychedelics

    Upper Gastrointestinal (UGI) Endoscopy for Adults, 2.01.533

    Medical necessity criteria updated

    • The timing of persistent GERD symptoms following treatment with daily proton pump inhibitor (PPI) therapy has been changed from 4 - 8 weeks to 8 weeks
    • Criterion added that UGI may be performed to evaluate returning GERD or heartburn symptoms after the completion of proton pump inhibitor (PPI) treatment
    • Deleted criterion that a UGI may be performed after 6-12 weeks of treatment with a histamine H2-receptor antagonist
    • Follow-up of known eosinophilic esophagitis has been added to the list of medically necessary conditions

    Wearable Cardioverter-Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement, 2.02.506

    Medical necessity criteria updated
    A 90-day time limit has been added for the use of a wearable cardioverter-defibrillator as a bridge to a permanent implantable (internal) cardioverter-defibrillator surgery


    Effective August 5, 2022

    Drugs for Rare Diseases, 5.01.576

    Pompe Disease
    Site of service review added

    • Nexviazyme™ (avalglucosidase alfa-ngpt) IV

    Thyroid Eye Disease (TED)
    Medical necessity criteria updated

    • Tepezza™ (teprotumumab-trbw)
      • The patient must have tried glucocorticoids before this drug can be prescribed
      • This drug will be given within 9 months of completing the glucocorticoid trial
        • This drug must be prescribed by an ophthalmologist with expertise in TED treatment or endocrinologist with expertise in TED treatment
        • This drug is not being used in combination with another biologic drug that can be used to treat TED

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523

    Site of service review added

    • Nexviazyme™ (avalglucosidase alfa-ngpt) IV

    Effective July 7, 2022

    Immune Checkpoint Inhibitors, 5.01.591

    Site of service review added

    • Keytruda® (pembrolizumab)
    • Opdivo® (nivolumab)

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523

    Site of service review added

    • Keytruda® (pembrolizumab)
    • Opdivo® (nivolumab)

    Effective July 1, 2022

    For dates of service on or after July 1, 2022, Premera will no longer review home sleep studies for prior authorization and medical necessity. Providers will no longer need to submit a request through AIM Specialty Health® for these services. AIM Specialty Health® will still review supplies/equipment and in lab sleep studies.


    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)

    New medical policies
    Effective June 1, 2022

    Electrical and Electromagnetic Stimulation for the Treatment of Arthritis, 1.01.27

    New policy
    The use of electrical or electromagnetic stimulation for the treatment of osteoarthritis (OA) or rheumatoid arthritis (RA) is considered investigational

    Low Intensity Pulsed Ultrasound Fracture Healing Device, 1.01.537

    Policy renumbered

    • This policy replaces Low Intensity Pulsed Ultrasound Fracture Healing Devices, 1.01.05
    • All other policy statements remain unchanged

    Revised medical policies
    Effective June 1, 2022

    Electrical Stimulation Devices, 1.01.507

    Investigational criteria updated
    Percutaneous electrical nerve field stimulation (PENFS) for abdominal pain associated with irritable bowel syndrome (IBS) has been added to the list of investigational services

    Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain, 7.01.574

    Policy renamed
    From "Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain of Peripheral Nerve Origin" to "Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain"

    Investigational criteria updated
    Peripheral nerve origin has been removed from the investigational statement

    New pharmacy policies

    Effective June 1, 2022

    Pharmacologic Treatment of Atopic Dermatitis, 5.01.628

    New policy
    Drugs added

    • Adbry™ (tralokinumab-ldrm)
    • Cibinqo™ (abrocitinib)
    • Rinvoq® (upadacitinib)
      • The drugs listed above were moved from policy Pharmacotherapy of Arthropathies, 5.01.550
      • Medical necessity criteria remain unchanged

    Drugs added

    • Elidel® (pimecrolimus)
    • Eucrisa® (crisaborole)
    • Opzelura™ (ruxolitinib)
    • Protopic® (tacrolimus)
      • The drugs listed above were moved from policy Medical Necessity Criteria for Pharmacy Edits, 5.01.605
      • Medical necessity criteria remain unchanged

    Revised pharmacy policies

    Effective June 1, 2022

    Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma, 8.01.63

    Drug with new indication

    • Yescarta™ (axicabtagene ciloleucel)
      • Treatment of adults age 18 years and older with follicular lymphoma that has relapsed or can't be treated with surgery

    Documentation requirements updated
    Requirements are listed for each drug's indication

    Immune Checkpoint Inhibitors, 5.01.591

    Drugs with new indications

    • Keytruda® (pembrolizumab)
      • Treatment of endometrial cancer that is microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) when used as a single agent
    • Opdivo® (nivolumab)
      • Treatment given before surgery for non-small cell lung cancer (NSCLC), in combination with platinum-doublet chemotherapy

    Intravitreal and Suprachoroidal Corticosteroids, 5.01.619

    Policy renamed
    From "Intravitreal Corticosteroids" to "Intravitreal and Suprachoroidal Corticosteroids"

    Drug added

    • Xipere™ (triamcinolone acetonide injectable suspension)
      • Treatment of macular edema associated with uveitis

    Migraine and Cluster Headache Medications, 5.01.503

    Medical necessity criteria updated

    • Nurtec™ ODT (rimegepant)
      • Quantity limits revised from 16 tablets to 8 tablets every 30 days
      • This drug may not be used at the same time as Ubrelvy™ (ubrogepant)
    • Reyvow™ (lasmiditan)
      • Quantity limits revised from 16 tablets to 8 tablets every 30 days
    • Ubrelvy™ (ubrogepant)
      • Quantity limits revised from 16 tablets to 10 tablets every 30 days
      • This drug may not be used at the same time as Nurtec™ ODT (rimegepant) 

    Miscellaneous Oncology Drugs, 5.01.540

    Drugs added

    • Vonjo™ (pacritinib)
      • Treatment of adults with myelofibrosis
    • Kimmtrak® (tebentafusp-tebn)
      • Treatment of adult patients with uveal melanoma that has spread to other parts of the body or can't be treated with surgery

    Drug with new indication

    • Lynparza® (olaparib)
      • Treatment of adults with high-risk early breast cancer

    Medical necessity criteria updated

    • Lynparza® (olaparib)
      Indication: Treatment of adult patients with metastatic breast cancer
      • PALB2 mutation is included
      • Criterion added that the cancer must be HER2-negative
    • All indications
      • "Deleterious or suspected deleterious" has been added as a descriptor to the BRCA mutation

    Medical necessity criteria updated

    • Kisqali® (ribociclib)
    • Kisqali® Femara® Co-Pack (ribociclib – letrozole)
      • The trial and failure requirement for the drugs Ibrance® (palbociclib) or Verzenio® (abemaciclib) has been removed

    Policy statement added

    • Inrebic® (fedratinib)
      • Documentation requirements for risk stratification

    Pharmacotherapy of Arthropathies, 5.01.550

    Site of service review added

    • Infliximab (Janssen – unbranded)

    Ankylosing Spondylitis
    Drugs added to first-line treatments

    • Infliximab (Janssen – unbranded)
    • Inflectra® (infliximab-dyyb)
    • Rinvoq™ (upadacitinib)

    Medical necessity criteria updated

    • Xeljanz® (tofacitinib)
    • Xeljanz® XR (tofacitinib extended-release)
      • The patient must have tried one or more TNF blockers before the above drugs may be prescribed

    Medical necessity criteria updated

    • Avsola™ (infliximab-axxq)
    • Renflexis™ (infliximab-abda)
      • The patient must have tried Infliximab (Janssen – unbranded), Inflectra® (infliximab-dyyb), or Remicade® (infliximab) before the above drugs may be prescribed

    Polyarticular Juvenile Idiopathic Arthritis
    Medical necessity criteria updated

    • Xeljanz® (tofacitinib)
    • Xeljanz® Oral Solution (tofacitinib)
      • The patient must have tried one or more TNF blockers before the above drugs may be prescribed

    Enthesitis-Related Arthritis
    New policy section
    Drug added

    • Cosentyx® (secukinumab)

    Rheumatoid Arthritis
    Drugs added to first-line treatments

    • Infliximab (Janssen – unbranded)
    • Inflectra® (infliximab-dyyb)

    Medical necessity criteria updated

    • Rinvoq™ (upadacitinib)
    • Xeljanz® (tofacitinib)
    • Xeljanz® XR (tofacitinib extended-release)
      • The patient must have tried one or more TNF blockers before the above drugs may be prescribed

    Medical necessity criteria updated

    • Avsola™ (infliximab-axxq)
    • Renflexis™ (infliximab-abda)
      • The patient must have tried Infliximab (Janssen – unbranded), Inflectra® (infliximab-dyyb), or Remicade® (infliximab) before the above drugs may be prescribed

    Atopic Dermatitis
    Policy section moved to another policy
    Drugs removed

    Plaque Psoriasis
    Drugs added to first-line treatments

    • Infliximab (Janssen – unbranded)
    • Inflectra® (infliximab-dyyb)

    Medical necessity criteria updated

    • Avsola™ (infliximab-axxq)
    • Renflexis™ (infliximab-abda)
      • The patient must have tried Infliximab (Janssen – unbranded), Inflectra® (infliximab-dyyb), or Remicade® (infliximab) before the above drugs may be prescribed

    Psoriatic Arthritis
    Drugs added to first-line treatments

    • Infliximab (Janssen – unbranded)
    • Inflectra® (infliximab-dyyb)

    Medical necessity criteria updated

    • Rinvoq™ (upadacitinib)
    • Xeljanz® (tofacitinib)
    • Xeljanz® XR (tofacitinib extended-release)
      • The patient must have tried one or more TNF blockers before the above drugs may be prescribed

    Medical necessity criteria updated

    • Avsola™ (infliximab-axxq)
    • Renflexis™ (infliximab-abda)
      • The patient must have tried Infliximab (Janssen – unbranded), Inflectra® (infliximab-dyyb), or Remicade® (infliximab) before the above drugs may be prescribed

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563

    Site of service review added

    • Infliximab (Janssen – unbranded)

    Crohn's Disease
    Drugs added to first-line treatments

    • Infliximab (Janssen – unbranded)
    • Inflectra® (infliximab-dyyb)

    Medical necessity criteria updated

    • Avsola™ (infliximab-axxq)
    • Renflexis™ (infliximab-abda)
      • The patient must have tried Infliximab (Janssen – unbranded), Inflectra® (infliximab-dyyb), or Remicade® (infliximab) before the above drugs may be prescribed

    Ulcerative Colitis
    Drugs added to first-line treatments

    • Infliximab (Janssen – unbranded)
    • Inflectra® (infliximab-dyyb)

    Drug added

    • Rinvoq™ (upadacitinib)

    Dosing requirements added

    • Zeposia® (ozanimod)

    Medical necessity criteria updated

    • Avsola™ (infliximab-axxq)
    • Renflexis™ (infliximab-abda)
      • The patient must have tried Infliximab (Janssen – unbranded), Inflectra® (infliximab-dyyb), or Remicade® (infliximab) before the above drugs may be prescribed

    Pharmacotherapy of Miscellaneous Autoimmune Disorders, 5.01.564

    Site of service review added

    • Infliximab (Janssen – unbranded)

    Pyoderma Gangrenosum
    Drugs added to first-line treatments

    • Infliximab (Janssen – unbranded)
    • Inflectra® (infliximab-dyyb)
      • Inflectra® has been added as a first-line treatment

    Medical necessity criteria updated

    • Avsola™ (infliximab-axxq)
    • Renflexis™ (infliximab-abda)
      • The patient must have tried Infliximab (Janssen – unbranded), Inflectra® (infliximab-dyyb), or Remicade® (infliximab) before the above drugs may be prescribed

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523

    Drug added

    • Infliximab (Janssen – unbranded)

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

    No updates this month.

    Effective June 1, 2022

    Low Intensity Pulsed Ultrasound Fracture Healing Devices, 1.01.05

    This policy has been replaced by Low Intensity Pulsed Ultrasound Fracture Healing Device, 1.01.537

    Added codes

    Effective June 1, 2022

    Intravitreal and Suprachoroidal Corticosteroids, 5.01.619

    Now requires review for medical necessity.

    C9092

    Non-covered Experimental/Investigational Services, 10.01.533

    Now requires review for investigational.

    C1832, C1833

  • Updates for only non-individual plans

  • No updates this month
    No updates this month
  • Updates for only individual plans

  • No updates this month

    No updates this month

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