Effective July 2, 2020
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.569
Site of service criteria and reference to policy, Site of Service: Select Surgery Procedures – 11.01.524, have been removed. Site of service will be included in the medical necessity review for the primary procedure (knee arthroplasty, knee arthroscopy) using InterQual® criteria.
Electrostimulation and Electromagnetic Therapy for Treating Wounds, 2.01.57
This policy was previously archived in 2018 and is being reinstated. Electrical stimulation and electromagnetic therapy for the treatment of wounds is considered investigational.
Erythroid Maturation Agents, 5.01.614
Reblozyl® (luspatercept-aamt) has been added to the policy and may be considered medically necessary for the treatment of anemia in adults ages 18 and older with beta thalassemia when criteria are met.
Meniscal Allografts and Other Meniscal Implants, 7.01.15
Site of service criteria and reference to policy, Site of Service: Select Surgery Procedures – 11.01.524, have been removed. Site of service will be included within the medical necessity review for a knee arthroscopy procedure using InterQual® criteria.
Miscellaneous Oncology Drugs, 5.01.540
Padcev™ (enfortumab vedotin-ejfv) has been added to the policy and may be considered medically necessary for the treatment of locally advanced or metastatic urothelial cancer (mUC) in adults ages 18 and older when criteria are met.
Effective June 5, 2020
Miscellaneous Oncology Drugs, 5.01.540
Darzalex® (daratumumab) has been added to the policy and may be considered medically necessary for the treatment of multiple myeloma in adults when used as a combination treatment or monotherapy when criteria are met.
Effective May 17, 2020
Effective for dates of service on and after May 17, 2020, the following updates by will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiology: Vascular Imaging
Updates by section:
- Aneurysm of the abdominal aorta or iliac arteries:
- Added new indication for asymptomatic enlargement by imaging
- Clarified surveillance intervals for stable aneurysms as follows:
- Treated with endografts, annually
- Treated with open surgical repair, every 5 years
- Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified:
- Added surveillance indication and interval for surgical bypass grafts
Effective April 3, 2020
Herceptin® (trastuzumab) and Other HER2 Inhibitors, 5.01.514
Trazimera™ (trastuzumab-qyyp), a biosimilar to Herceptin® (trastuzumab), has been changed to a first-line biosimilar for the treatment of HER2-postive breast cancer, HER2-postive metastatic gastric cancer, and HER2-postive gastroesophageal junction adenocarcinoma when criteria are met. The biosimilars Herzuma® (trastuzumab-pkrb), Kanjinti™ (trastuzumab-anns), Ogivri™ (trastuzumab-dkst) and Ontruzant® (trastuzumab-dttb) are second-line biosimilars and require an inadequate response or intolerance to Herceptin® or Trazimera™ when criteria are met.
IL-5 Inhibitors, 5.01.559
Nucala® (mepolizumab) medical necessity criteria has been updated for the treatment of patients with severe eosinophilic asthma. The age criterion has changed from age 12 to age 6 and older. Nucala® (mepolizumab) medical necessity criteria have also been updated for the treatment of eosinophilic granulomatosis with polyangiitis (EGPA) in adults to include blood eosinophil levels and documented evidence of polyangiitis, vasculitis, mononeuritis, or systemic symptoms.
Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502
Polivy™ (polatuzumab vedotin-piiq) has been added to the policy and may be considered medically necessary for the treatment of diffuse large B-cell lymphoma (DLBCL) in adults when criteria are met. Ruxience™ (rituximab-pvvr), a biosimilar to Rituxan® (rituximab), has been added to the policy as a first-line biosimilar and may be considered medically necessary for non-Hodgkin’s lymphoma and chronic lymphocytic leukemia. Truxima® (rituximab-abbs) is a second-line biosimilar and requires an inadequate response or intolerance to Rituxan® or Ruxience™ when criteria are met.
Pharmacotherapy of Arthropathies, 5.01.550
Ruxience™ (rituximab-pvvr) has been added to the policy and may be considered medically necessary as a second-line anti-CD20 agent when criteria are met.
Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564
Ruxience™ (rituximab-pvvr) has been added to the policy and may be considered medically necessary as a first-line treatment for systemic lupus erythematosus when criteria are met.
Pharmacotherapy of Thrombocytopenia, 5.01.566
Ruxience™ (rituximab-pvvr) and Truxima® (rituximab-abbs) have been added to the policy and may be considered medically necessary as anti-CD20 agents in for the treatment of chronic immune thrombocytopenia when criteria are met.
Rituximab: Non-oncologic and Miscellaneous Uses, 5.01.556
Ruxience™ (rituximab-pvvr), a biosimilar to Rituxan® (rituximab), has been added to the policy as a first-line biosimilar and may be considered medically necessary when criteria are met. Truxima® (rituximab-abbs) is a second-line biosimilar and requires an inadequate response or intolerance to Rituxan® or Ruxience™ when criteria are met.
Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment, 5.01.517
Zirabev™ (bevacizumab-bvzr), a biosimilar to Avastin® (bevacizumab), has been changed to a first-line biosimilar and may be considered medically necessary when criteria are met. Mvasi™ (bevacizumab-awwb) is a second-line biosimilar and requires an inadequate response or intolerance to Avastin® (bevacizumab) or Zirabev™ (bevacizumab-bvzr) when criteria are met.