Absorbable Nasal Implant for Treatment of Nasal Valve Collapse, 7.01.163The insertion of an absorbable lateral nasal implant (eg, Latera®) for the treatment of symptomatic nasal valve collapse is considered investigational.
C5 Complement Inhibitors, 5.01.571The policy updates the criteria for Soliris® (eculizumab) for the indication of paroxysmal nocturnal hemoglobinuria. Criteria for the drug Ultomiris™ (ravulizumab-cwvz) are also added.
AIM Clinical Guidelines for Oncologic Imaging to Include PET RadiotracersAIM Specialty Health® Guidelines for Oncologic Imaging have been changed to include PET radiotracers. As of July 14, 2019, AIM will review prior authorization requests for both non-FDG (fluorodeoxyglucose) radiotracers and PET-CT.
Children's Therapeutic Positioning Equipment, 1.01.530Children’s positioning equipment such as reflux wedges, therapeutic positioning seats, and therapeutic positioning seats for use in vehicles may be considered medically necessary when criteria are met. Conventional positioning equipment used for children without positioning needs is excluded by contract and is not covered.
Pharmacotherapy of Arthropathies, 5.01.550The policy is revised to add dose frequency to Remicade® (infliximab), Inflectra® (infliximab-dyyb), and Renflexis®(infliximab-abda). The criteria for Orencia® (abatacept) are updated. Review the policy for full details.
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563The policy is revised to add dose frequency and age restriction to Remicade® (infliximab), Inflectra® (infliximab-dyyb), and Renflexis® (infliximab-abda). Review the policy for full details.
Injectable Clostridial Collagenase for Fibroproliferative Disorders, 5.01.595This policy replaces the policy previously numbered 5.01.19. No change to criteria.
Therapeutic Radiopharmaceuticals in Oncology, 6.01.525Policy formerly numbered 6.01.60. The policy is updated to reflect current NCCN guidelines and clarifies that lutetium 177 is not used for bronchopulmonary or thymus neuroendocrine tumor.
Hematopoietic Cell Transplantation for Autoimmune Diseases, 8.01.25The policy is revised to state that autologous hematopoietic cell transplantation is medically necessary for systemic sclerosis/scleroderma when criteria are met. When criteria are not met, the treatment is considered investigational for this indication.
Measurement of Serum Antibodies to Infliximab, Adalimumab, Vedolizumab, and Ustekinumab, 2.04.516 The policy states that the Anser™ UST test for the measurement of antibodies to ustekinumab is investigational. The title is also changed.
Pharmacologic Treatment of Hereditary Transthyretin-Mediated Amyloidosis, 5.01.593Onpattro™ (patisiran) and Tegsedi™ (inotersen) may be considered medically necessary for the treatment of polyneuropathy of hereditary transthyretin-mediated amyloidosis in adults when criteria are met. These agents are considered investigational for all other uses.
Herceptin® (trastuzumab) and Other HER2 Inhibitors, 5.01.514The policy adds criteria for Herceptin Hylecta™ (trastuzumab and hyaluronidase-oysk). The policy also adds criteria for two biosimilars to Herceptin (trastuzumab), Herzuma® (trastuzumab-pkrb) and Ontruzant® (trastuzumab-dttb).
Miscellaneous Oncology Drugs, 5.01.540The policy is revised to update criteria for Erivedge® (vismodegib), Odomzo® (sonidegib), and Lonsurf® (trifluridine and tipiracil).
Medical Necessity Criteria for Pharmacy Edits, 5.01.605The policy adds criteria for Motegrity™ (prucalopride) for the indication of chronic idiopathic constipation in adults. Criteria for Aemcolo™ (rifamycin) are added for the indication of traveler’s diarrhea in adults.
Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors, 5.01.558The policy updates and simplifies diagnostic criteria for familial hypercholesterolemia, changes LDL-C target from 100 mg/dL to 70 mg/dL, removes creatine kinase testing requirement for myalgia, and eliminates specialty prescribing requirement.
A deleted policy is one whose number is no longer used but the content is either moved into another policy or replaced with a new policy and number.
Deleted March 31, 2019
Injectable Clostridial Collagenase for Fibroproliferative Disorders, 5.01.19. Replaced with policy 5.01.595.
Therapeutic Radiopharmaceuticals in Oncology, 6.01.60. Replaced with policy 6.01.525
Antibody-Drug Conjugates, 5.01.582Now requires review for medical necessity, now requires prior authorization
J9203 - Injection, gemtuzumab ozogamicin, 0.1 mg
Cosmetic and Reconstructive Service, 10.01.514Now reviewed for medical necessity, now requires prior authorization
54360 - Plastic operation on penis to correct angulation
Immune Checkpoint Inhibitors, 5.01.591Now requires review for medical necessity, now requires prior authorization
J9173 - Injection, durvalumab, 10 mg
Pharmacotherapy of Arthropathies, 5.01.550Now requires review for medical necessity, now requires prior authorization
J0215 - Injection, alefacept, 0.5 mg
Pharmacotherapy of Arthropathies, 5.01.550No longer requires review for medical necessity, no longer requires prior authorization
Email this article
Back to News