Medical Policy and Coding Updates August 2022

  • Updates for both non-individual and individual plans

  • Effective November 4, 2022

    Immune Globulin Therapy, 8.01.503

    Site of service review added

    • Cutaquig® (immune globulin subcutaneous [human] - hipp)

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523

    Site of service review added

    • Cutaquig® (immune globulin subcutaneous [human] - hipp)

    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

    New medical policies
    Effective August 1, 2022

    Remote Electrical Neuromodulation for Migraines, 7.01.171

    New policy

    Remote electrical neuromodulation (REN) for acute migraine is considered investigational

    Revised medical policies
    Effective August 1, 2022

    Bariatric Surgery, 7.01.516

    Medical necessity criteria updated

    Patient selection criteria for adults

    • Revised criterion, "obstructive sleep apnea as documented by a sleep study (polysomnography) that is uncontrolled by medical management (e.g., CPAP or oral appliance)" to "obstructive sleep apnea as documented by a sleep study (polysomnography) that has failed an adequate trial of CPAP or oral appliance"
    • Added note to define CPAP or oral appliance failure

    Investigational criteria updated

    The following endoscopic procedures are now considered investigational:

    • Transoral outlet reduction (TORe)
    • Restorative obesity surgery, endoluminal (ROSE)

    Electrical Stimulation Devices, 1.01.507

    Investigational criteria updated

    External trigeminal nerve stimulation (eTNS) for the management of attention deficit disorder is considered investigational

    Removed from policy

    Remote electrical neuromodulation (REN) for the treatment of acute migraine headaches has been moved to Remote Electrical Neuromodulation for Migraine, 7.01.171

    Facet Joint Denervation, 7.01.555

    Medical necessity criteria updated

    Radiofrequency denervation of thoracic facet joints has been moved from investigational to medically necessary

    Hyperbaric Oxygen Therapy, 2.01.505

    Medical necessity criteria updated

    Hyperbaric oxygen therapy for the treatment of idiopathic sudden sensorineural hearing loss has been moved from investigational to medically necessary

    Leadless Cardiac Pacemakers, 2.02.32

    Policy statement added

    The Aveir™ single-chamber transcatheter pacing system is considered investigational for all indications

    Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation, 2.02.26

    Medical necessity criteria updated

    The Amplatzer™ Amulet™  has been added to the list of FDA-approved left atrial appendage closure devices which may be considered medically necessary

    Prostate Cancer Targeted Therapies, 5.01.544

    Removed from policy

    Xofigo® (radium Ra 223 dichloride) has been removed and added to policy Therapeutic Radiopharmaceuticals in Oncology, 6.01.525. Criteria remain unchanged.

    Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.101

    Medical necessity criteria updated

    Indication: Hypoglossal nerve stimulation

    • CPAP failure from residual AHI ≥ 20 has been revised to ≥ 15

    Therapeutic Radiopharmaceuticals in Oncology, 6.01.525

    Added to policy

    • Lutetium (Lu 177) vipivotide tetraxetan (Pluvicto™
      • Treatment of adult patients with prostate cancer that has not responded to treatments that lower testosterone levels and has spread to other parts of the body (mCRPC)
    • Radium (Ra)-223 dichloride (Xofigo®
      • Treatment of adult patients with prostate cancer that has not responded to treatments that lower testosterone levels and has spread to the bone with symptoms, but has not spread to other parts of the body
      • Xofigo® was moved from Prostate Cancer Targeted Therapies, 5.01.544. Criteria remain unchanged.

    New pharmacy policies

    No updates this month

    Revised pharmacy policies
    Effective August 1, 2022

    BRAF and MEK Inhibitors, 5.01.589

    Indication added

    • Tafinlar® (dabrafenib) in combination with Mekinist® (trametinib)
      • Treatment of adult and pediatric patients ages 6 years and older with solid tumors with the BRAF V600E mutation that have spread to other parts of the body or are not able to be treated with surgery

    Immune Checkpoint Inhibitors, 5.01.591

    Drugs with new indications

    • Opdivo® (nivolumab)
      • Additional treatment after surgery for esophageal or gastroesophageal junction cancer when some cancer cells remain in adult patients who were treated with chemoradiotherapy (CRT) and surgery
      • As a first-line treatment of adult patients with esophageal squamous cell carcinoma (ESCC) that is advanced or has spread to other parts of the body when the cancer cannot be removed with surgery, and when Opdivo® is used along with chemotherapy that contains fluoropyrimidine and platinum
      • As a first-line treatment of adult patients with esophageal squamous cell carcinoma that is advanced or has spread to other parts of the body when the cancer cannot be removed with surgery, and when Opdivo® is used along with the drug ipilimumab
    • Yervoy® (ipilimumab)
      • As a first-line treatment of adult patients with esophageal squamous cell carcinoma that is advanced or has spread to other parts of the body when the cancer cannot be removed with surgery, and when Yervoy® is used along with the drug nivolumab

    Pharmacologic Treatment of Transthyretin-Mediated Amyloidosis, 5.01.593

    Drug added

    • Amvuttra™ (vutrisiran)
      • Treatment of polyneuropathy from hereditary transthyretin-mediated amyloidosis in adults age 18 years and older

    Medical necessity criteria updated

    • Onpattro® (patisiran)
    • Tegsedi® (inotersen)
    • Vyndamax™ (tafamidis)
    • Vyndaqel® (tafamidis meglumine)
      • Amvuttra™ (vutrisiran) may not be used in combination with any of the above listed drugs

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

    Effective August 1, 2022

    Single Photon Emission Computed Tomography (SPECT) for Non-cardiac Indications, 6.01.502

    No updates this month

    Added codes
    Effective August 1, 2022

    Therapeutic Radiopharmaceuticals in Oncology, 6.01.525

    Now requires review for medical necessity and prior authorization.

    A9593, A9594, A9595, A9596, A9699

    Revised codes
    Effective August 5, 2022

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523

    Now requires review for medical necessity, including site of service and prior authorization.

    J0219

    Effective August 1, 2022

    Cosmetic and Reconstructive Services, 10.01.514

    No longer requires review for investigational. Now requires review for cosmetic.

    17106

    Remote Electrical Neuromodulation for Migraines, 7.01.171

    No longer requires review for medical necessity and prior auth. Now requires review for investigational.

    K1023

    Removed codes
    Effective August 1, 2022

    Single Photon Emission Computed Tomography (SPECT) for Non-cardiac Indications, 6.01.502

    No longer requires review. Policy archived.

    A9507

  • Updates for only non-individual plans

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

  • Effective November 4, 2022

    Authorization for Observation versus Inpatient Admission Level of Care, 10.01.534

    New policy

    Criteria and medical conditions added for observation stays for adults and children

    No updates this month

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