Amniotic Membrane and Amniotic Fluid, 7.01.149 Criteria for amniotic membrane products added from policy 7.01.113. Treatment of nonhealing diabetic lower‐extremity ulcers using the human amniotic membrane products AmnioBand Membrane, Biovance,
Epifix, or Grafix may be considered medically necessary. All other human amniotic membrane products and indications not listed are considered investigational. Read the full policy.
Bioengineered Skin and Soft Tissue Substitutes, 7.01.113 Updated investigational products list. AlloMend added to medically necessary statement for breast reconstructive surgery. AlloPatch added to medically necessary statement for diabetic
lower‐extremity ulcers. Criteria for human amniotic membrane products for diabetic foot ulcers moved to policy 7.01.149. Read the full policy.
Hematopoietic Cell Transplantation for Hodgkin Lymphoma, 8.01.29 Updated criteria for autologous hematopoietic cell transplantation and tandem transplantation. Title changed. Read the full policy.
Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome, 8.01.17 Updated criteria for autologous hematopoietic cell transplantation and tandem transplantation. Read the full policy.
Immunoglobulin Therapy, 8.01.503 Added five indications which were inadvertently left out of the November 2016 update: toxic shock syndrome, warm antibody autoimmune hemolytic anemia, antiphospholipid syndrome, X-linked hyper-IgM syndrome,
and ataxia telangiectasia. Read the full policy.
Coverage Criteria of Excluded Drugs for Essentials Formulary, 5.01.572 Lists medical necessity criteria for drug coverage when that drug is not included in the formulary. The policy applies to formulary exclusion drugs pertaining to the Essentials
Formulary Benefit. Formulary refers to the applicable formulary list specified in a member's contract. The policy does not apply to other benefit designs. Read the full policy.
Pharmacotherapy of Perinatal/Infantile and Juvenile-Onset Hypophosphatasia (HPP), 5.01.573 Strensiq (asfotase alfa) may be considered medically necessary when genetic testing confirms the diagnosis of perinatal, infantile, or juvenile-onset
hypophosphatasia. Read the full policy.
Pharmacotherapy of Spinal Muscular Atrophy (SMA), 5.01.574 Spinraza (nusinersen) may be considered medically necessary for spinal muscular atrophy (SMA) when genetic tests confirm that the SMN1 gene is present. Using Spinraza for other types
of spinal muscular atrophy or for other conditions is considered investigational. Read the full policy.
Excessively High Cost Drug Products with Lower Cost Alternatives, 5.01.560 Added medical necessity criteria for the brand name acne treatment Differin and its generic, adapalene. This drug is now available without prescription. Read the full policy.
Exondys 51 (eteplirsen), 5.01.570 When medical necessity criteria are met, Exondys may now be approved for one year. Reauthorization depends on results of two six-minute walk tests done over the course of the first year of treatment, compared
to baseline six-minute walk test. Read the full policy.
Medical Necessity Criteria for Pharmacy Edits, 5.01.605 Removed Focalin XR from the list of drugs requiring a prior authorization. Added a requirement for chart notes for Vimovo, Duexis, and Cambia. Updated criteria for Emflaza (deflazacort),
which may be to treat Duchenne muscular dystrophy. Read the full policy.
Miscellaneous Oncology Drugs, 5.01.540 Updated criteria for Lartruvo (olaratumab). It may be considered medically necessary in combination with doxorubicin for adult patients with a type of soft tissue sarcoma that is responsive to an anthracycline
regimen when surgery or radiation can't be used. Read the full policy.
Pharmacotherapy of Arthropathies, 5.01.550 Criteria for all of the drugs listed in this policy have changed to offer more choices and the step therapy has been rearranged. Clarified that intravenous agents listed in the policy are covered
under the medical benefit only. Read the full policy.
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563 Revised criteria for several drugs listed in the policy and added information about whether the administration is subcutaneous or intravenous. Clarified that intravenous agents listed
in the policy are covered under the medical benefit only. Read the full policy.
Pharmacotherapy of Type I and Type II Diabetes Mellitus, 5.01.569 Xultophy (insulin degludec+liraglutide) is on a preferred formulary drug list. Soliqua (insulin glargine+lixisenatide) is on a non-preferred formulary drug list. Soliqua will
have the same coverage criteria but will have a higher cost share. Criteria for both drugs are included. Read the full policy.
An archived policy is no longer active and is not used for reviews.
Analysis of MGMT Promoter Methylation in Malignant Gliomas, 12.04.113
Effective April 1, 2017
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management, 12.04.111 Investigational
0005U-Oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score
Analysis of MGMT Promoter Methylation in Malignant Gliomas, 12.04.113 No longer reviewed as investigative; no longer requires prior authorization
81287-MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme), methylation analysis
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