Medical Policy and Coding Updates August 2023

  • Updates for both non-individual and individual plans

  • Effective September 1, 2023

    Intraarticular Corticosteroids, 5.01.633  PBC | Premera HMO
    New policy
    Drug added

    • Zilretta (triamcinolone acetonide extended-release injectable suspension) Intra-articular
      • Added as medically necessary for moderate to severe osteoarthritis pain of the knee in adults and may be approved once per knee per lifetime
      • Considered investigational for all other indications

    Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures), 7.01.587  PBC | Premera HMO
    New policy

    Maze or modified maze procedure

    Medical necessity criteria added

    • For the treatment of atrial fibrillation or flutter when performed on a non-beating heart during cardiopulmonary bypass

    Stand-alone minimally invasive, off-pump maze procedures
    Investigational criteria added

    • For the treatment of atrial fibrillation and flutter, including when done via mini thoracotomy

    Hybrid ablation
    Investigational criteria added

    • For the treatment of atrial fibrillation and flutter

    Effective August 4, 2023

    Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
    Miscellaneous intramuscular/intravenous/subcutaneous agents

    Drug added

    • Xgeva (denosumab)
      • For the prevention of skeletal-related events in individuals with bone metastases from solid tumors
      • For the prevention of skeletal-related events in individuals with multiple myeloma

    New medical policies
    Effective August 1, 2023

    Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.569  PBC | Premera HMO
    Policy renumbered
    This policy replaces Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.48
    Medical necessity criteria removed

    • Removed policy criteria on conservative care failure and BMI ≤ 35

    Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome, 2.01.106  PBC | Premera HMO
    New policy
    Investigational criteria added

    • Percutaneous electrical nerve field stimulation for abdominal pain in individuals with irritable bowel syndrome is considered investigational (e.g., IB-Stim)

    Revised medical policies
    Effective August 1, 2023

    Bariatric Surgery, 7.01.516  PBC | Premera HMO
    Medical necessity criteria added

    • Criteria added for indication of treatment of symptomatic gastroesophageal reflux disease under revision surgery

    Investigational criteria updated

    • Added examples of intragastric balloons (Spatz3, TransPyloric Shuttle) considered investigational

    Children's Therapeutic Positioning Equipment, 1.01.530  PBC | Premera HMO
    Medical necessity criteria updated

    • Added criteria that there has been a specialized seating/mobility evaluation performed by a therapist or a professional that is independent from the vendor supplying the equipment

    Non-covered criteria added

    • Added criteria that positioning equipment that is primarily for the purpose of the member to perform leisure, recreation, or sports activities is not covered

    Coronary Angiography for Known or Suspected Coronary Artery Disease in Adults, 2.02.507  PBC | Premera HMO
    Medical necessity criteria added

    • Criteria added for high-risk coronary artery disease based on noninvasive findings of coronary computed tomography angiography

    Psychiatric and Other Specified Evaluations in Inpatient and Residential Behavioral Health Treatment, 3.01.521  PBC | Premera HMO
    Inpatient mental health treatment, inpatient eating disorder treatment, and inpatient substance use disorder treatment

    Medical necessity criteria updated

    • Specified that initial psychiatric evaluation must be done within one day after admission versus within one day of for the purpose of aligning with 2023 InterQual updates
    • Added requirement for a medical history and physical examination within one day after admission versus one day within to align with 2023 InterQual updates

    Mental health residential treatment, eating disorder residential treatment, substance abuse residential treatment
    Note added

    • Clarification made that weekly summaries are not the same as and do not count as psychiatric or psychiatric medical evaluations

    Inpatient mental health treatment, inpatient eating disorder treatment, inpatient substance use disorder treatment
    Medical necessity criteria updated

    • Added requirement for a nursing assessment upon admission and then a nursing staff observation 24 hours per day

    Treatment of Varicose Veins/Venous Insufficiency, 7.01.519  PBC | Premera HMO
    Investigational criteria updated

    • Endovenous radiofrequency or laser ablation of tributary veins is considered investigational
    • Sclerotherapy techniques, other than microfoam sclerotherapy, of great, small, or accessory saphenous veins are considered investigational

    Wilderness Therapy/Outdoor Behavioral Healthcare Residential Wilderness Programs, 3.01.522  PBC | Premera HMO
    Psychiatric/mental health disorders; adults (18 years and older)

    Medical necessary criteria updated

    • Admission criteria
      • Added criterion of very problematic sexual behavior
    • Continued stay criteria
      • Updated to include the criterion of socially withdrawn or interacting with others in very strange or angry or threatening ways, or with very problematic sexual behavior, in or including in the treatment program
    • Minimum service requirements
      • Added inclusion criterion that treatment is taking place in a licensed wilderness therapy/outdoor behavioral healthcare residential wilderness program

    Psychiatric/mental health disorders; adolescents (13 to 17 years old)
    Medical necessity criteria updated

    • Admission criteria
      • Clarification made to include problematic or abusive sexual behavior
    • Continued stay criteria
      • Added tantrums, severe irritability, or rage; problematic sexual behavior; psychomotor agitation; symptoms interfering with functioning in school and unresponsible to staff intervention; and, interacting with others in a very angry or threatening way, including in the treatment program to the list of qualifying criteria
    • Minimum service requirements
      • Added inclusion criterion that treatment is taking place in a licensed wilderness therapy/outdoor behavioral healthcare residential wilderness program

    Substance use disorders; adolescents and adults (13 years old and older)
    Medical necessity criteria updated

    • Minimum service requirements
      • Clarified that treatment must take place in a program that is licensed for substance use disorder outdoor behavioral healthcare residential treatment or licensed for residential substance use

    New pharmacy policies
    Effective August 1, 2023

    No updates this month

    Revised pharmacy policies
    Effective August 1, 2023

    BCR-ABL Kinase Inhibitors, 5.01.518  PBC | Premera HMO
    Medical necessity criteria updated

    • Gleevec (imatinib)
      • Updated criteria to have trial and failure to generic imatinib
      • Removed refractory and relapsed, and added in combination with chemotherapy to the criteria for treatment of adult and pediatric individuals with Philadelphia Chromosome positive acute lymphoblastic leukemia
    • Sprycel (dasatinib)
      • Updated criteria to include treatment of newly diagnosed pediatric and adult individuals with Philadelphia Chromosome positive acute lymphoblastic leukemia in combination with chemotherapy

    Medical necessity criteria added

    • Generic imatinib
      • Added a new coverage criterion for generic imatinib

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605  PBC | Premera HMO
    Attention-deficit/hyperactivity disorder drugs, brands

    Drug added

    • Xelstrym (dextroampetamine)

    Constipation
    Drug added

    • Linzess (linaclotide)
      • Treatment of functional constipation in pediatric individuals 6 to 17 years old

    Dry Eye
    Drug added

    • Vevye (cyclosporin Ophthalmic solution)
      • Treatment of dry eye disease

    Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502  PBC | Premera HMO
    Medical necessity criteria added

    • Columvi (glofitamab-gxbm)
      • Treatment of adult individuals with relapsed or refractory diffuse large B-cell lymphoma, not otherwise specified or large B-cell lymphoma arising from follicular lymphoma, after two or more lines of systemic therapies

    Multiple Receptor Tyrosine Kinase Inhibitors, 5.01.534  PBC | Premera HMO
    Medical necessity criteria updated

    • Ayvakit (avapritinib)
      • Updated indication to include treatment of adult individuals with indolent systemic mastocytosis

    Pharmacologic Treatment of Clostridioides Difficile, 5.01.631  PBC | Premera HMO
    Drug added

    • Vowst (fecal microbiota spores, live-brbk)

    Pharmacologic Treatment of Psoriasis, 5.01.629  PBC | Premera HMO
    Second-Line IL-17 Inhibitors

    Drugs added

    • Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
      • Added to the list of drugs that must be tried and failed to qualify for Siliq (brodalumab) for treatment of moderate to severe plaque psoriasis
      • Added to the list of drugs that must be tried and failed to qualify for Cosentyx (secukinumab) SC for treatment of moderate to severe plaque psoriasis

    Second-Line IL-23 Inhibitors
    Drugs added

    • Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
      • Added to the list of drugs that must be tried and failed to qualify for Ilumya (tildrakizumab-asmn) for treatment of moderate to severe plaque psoriasis

    Second-Line Tyrosine Kinase 2 (TYK2) Inhibitors
    Drugs added

    • Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
      • Added to the list of drugs that must be tried and failed to qualify for Sotyktu (deucravacitinib) for treatment of moderate to severe plaque psoriasis

    TNF-α Inhibitors
    Drugs added

    • Cyltezo LCF (adalimumab-adbm), Hyrimoz HCF (adalimumab-adaz) and Adalimumab-adaz HCF (Sandoz – unbranded) SC
      • Treatment of plaque psoriasis as preferred products and with the identical coverage criteria as Amjevita (adalimumab-atto) [NDCs starting with 55513]

    Second-Line TNF-α Inhibitors
    Drugs added

    • Hyrimoz LCF (adalimumab-adaz) SC, Abrilada (adalimumab-afzb) SC, Hulio (adalimumab-fkjp) SC, Yusimry (adalimumab-aqvh) SC, Hadlima (adalimumab-bwwd) SC and Yuflyma (adalimumab-aaty) SC
      • Treatment of plaque psoriasis as non-preferred products and with the identical coverage criteria as Amjevita (adalimumab-atto) [NDCs starting with 72511]

    Pharmacotherapy of Arthropathies, 5.01.550  PBC | Premera HMO
    Second Line TNF-α Antagonists

    Medical necessity criteria removed

    • Individual is being started on Amjevita (adalimumab-atto) [NDCs starting with 72511], Humira (adalimumab), or Enbrel (etanercept) concurrently with leflunomide, methotrexate, or sulfasalazine
      • Removed from non-preferred agents’ indication of treatment of polyarticular juvenile idiopathic arthritis

    First-Line TNF-α Inhibitors
    Drugs added

    • Cyltezo LCF(adalimumab-adbm), Hyrimoz HCF (adalimumab-adaz) and Adalimumab-adaz HCF (Sandoz – unbranded) SC
      • Treatment of ankylosing spondylitis, rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, and psoriatic arthritis as preferred products and with the identical coverage criteria as Amjevita (adalimumab-atto) [NDCs starting with 55513]

    Second-Line TNF-α Inhibitors
    Drugs added

    • Hyrimoz LCF (adalimumab-adaz) SC, Abrilada (adalimumab-afzb) SC, Hulio (adalimumab-fkjp) SC, Yusimry (adalimumab-aqvh) SC, Hadlima (adalimumab-bwwd) SC and Yuflyma (adalimumab-aaty) SC
      • Treatment of ankylosing spondylitis, rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, and psoriatic arthritis as non-preferred products and with the identical coverage criteria as Amjevita (adalimumab-atto) [NDCs starting with 72511]
    • Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
      • Added to the list of drugs that must be tried and failed to qualify for Simponi Aria (golimumab) for treatment of polyarticular juvenile idiopathic arthritis

    Second-Line IL-1 Inhibitors
    Drugs added

    • Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
      • Added to the list of drugs that must be tried and failed to qualify for Kevzara (sarilumab) SC for treatment of severe rheumatoid arthritis

    First-Line IL-6 Inhibitors
    Drugs added

    • Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
      • Added to the list of drugs that must be tried and failed to qualify for Actemra (tocilizumab) for treatment of polyarticular juvenile idiopathic arthritis, and severe rheumatoid arthritis

    Second-Line IL-17 Inhibitors
    Drugs added

    • Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
      • Added to the list of drugs that must be tried and failed to qualify for Cosentyx (secukimumab) SC for treatment of ankylosing spondylitis, and active psoriatic arthritis

    Second-Line Janus Kinase Inhibitors
    Drugs added

    • Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
      • Added to the list of drugs that must be tried and failed to qualify for Olumiant (baricitinib) oral for treatment of severe rheumatoid arthritis

    Second-Line T-Cell Costimulation Modulators
    Drugs added

    • Cyltezo LCF (adalimumab-adbm) OR HyrimozTM HCF (adalimumab-adaz) OR Adalimumab-adaz HCF (Sandoz – unbranded)
      • Added to the list of drugs that must be tried and failed to qualify for Orencia (abatacept) IV/SC for treatment of polyarticular juvenile idiopathic arthritis, and severe rheumatoid arthritis, and active psoriatic arthritis

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  PBC | Premera HMO
    First-Line TNF-α Inhibitors

    Drugs added

    • Cyltezo LCF (adalimumab-adbm), Hyrimoz HCF (adalimumab-adaz) and Adalimumab-adaz HCF (Sandoz – unbranded) SC
      • Treatment of Crohn’s disease and ulcerative colitis as preferred products and with the identical coverage criteria as Amjevita (adalimumab-atto) [NDCs starting with 55513]

    Second Line TNF-α Inhibitors
    Drugs added

    • Hyrimoz LCF (adalimumab-adaz) SC, Abrilada (adalimumab-afzb) SC, Hulio (adalimumab-fkjp) SC, Yusimry (adalimumab-aqvh) SC, Hadlima (adalimumab-bwwd) SC and Yuflyma (adalimumab-aaty) SC
      • Treatment of Crohn’s disease and ulcerative colitis as non-preferred products and with the identical coverage criteria as Amjevita (adalimumab-atto) [NDCs starting with 72511]

    Second-line Sphingosine 1-Phosphate Receptor Modulators

    • Cyltezo LCF (adalimumab-adbm), Hyrimoz HCF (adalimumab-adaz) and Adalimumab-adaz HCF (Sandoz – unbranded) SC
      • Added to the list of drugs that must be tried and failed to qualify for Zeposia (ozanimod) oral for treatment of ulcerative colitis

    Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  PBC | Premera HMO
    TNF-α Inhibitors

    Drugs added

    • Cyltezo LCF (adalimumab-adbm), Hyrimoz HCF (adalimumab-adaz) and Adalimumab-adaz HCF (Sandoz – unbranded) SC
      • Treatment of hidradenitis suppurativa, pyoderma gangrenosum, and uveitis as preferred products and with the identical coverage criteria as Amjevita (adalimumab-atto) [NDCs starting with 55513]

    Second Line TNF-α Inhibitors
    Drugs added

    • Hyrimoz LCF (adalimumab-adaz) SC, Abrilada (adalimumab-afzb) SC, Hulio (adalimumab-fkjp) SC, Yusimry (adalimumab-aqvh) SC, Hadlima (adalimumab-bwwd) SC and Yuflyma (adalimumab-aaty) SC
      • Treatment of hidradenitis suppurativa, pyoderma gangrenosum, and uveitis as non-preferred products and with the identical coverage criteria as Amjevita (adalimumab-atto) [NDCs starting with 72511]

    Medical necessity criteria added

    • Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc)
      • Treatment of generalized myasthenia gravis in adult individuals who are anti-acetylcholine receptor antibody positive

    Prostate Cancer Targeted Therapies, 5.01.544  PBC | Premera HMO
    Medical necessity criteria added

    • Zytiga (abiraterone)
      • Treatment of deleterious or suspected deleterious BRCA-mutated (BRCAm) metastatic castration-resistant prostate cancer when used in combination with prednisone and olaparib
    • Generic abiraterone
      • Treatment of deleterious or suspected deleterious BRCAm metastatic castration-resistant prostate cancer when used in combination with prednisone and olaparib

    Spravato (esketamine) Nasal Spray, 5.01.609  PBC | Premera HMO
    Medical necessity criteria updated

    • Spravato (esketamine)
      • New course of Spravato requires individuals to have had a positive response to the previous course of treatment with Spravato

    Gonadotropin Releasing Hormone (GnRH) Analogs, 5.01.625  PBC | Premera HMO
    Gender dysphoria

    Drug added

    • Eligard (leuprolide acetate)

    Medical necessity criteria updated

    • Requires documentation of individual’s gender incongruence and desire to be of a gender other than the individual’s assigned gender are not due to any other psychiatric disorders (e.g., psychotic disorders)

    Effective August 1, 2023

    Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma, 8.01.533

    Effective September 1, 2023

    Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures), 7.01.14
    This policy is replaced with Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures), 7.01.587

    Effective August 1, 2023

    Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.48
    This policy is replaced with Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.569

    Added codes
    Effective August 1, 2023

    Non-covered Experimental/Investigational Services, 10.01.533  PBC | Premera HMO
    Now requires review for investigational.

    0715T

    Revised codes
    Effective August 1, 2023

    No updates this month

    Removed codes
    Effective August 1, 2023

    RadioImmunotherapy in the Treatment of Non-Hodgkin Lymphoma, 8.01.533  PBC | Premera HMO
    No longer requires review.

    79403, A9542, A9543

  • Updates for only non-individual plans

  • No updates this month

    Added codes
    Effective August 1, 2023

    eviCore managed
    Now requires review for investigational.

    0791T

  • Updates for only individual plans

  • No updates this month

    Effective August 1, 2023

    Services Reviewed Using InterQual Criteria, 10.01.530
    This policy updated to reflect additional services

    Effective August 1, 2023

    Endovascular Repair- Stent for Abdominal Aortic Aneurysm, 2.02.513
    This policy is replaced with InterQual criteria

    Prophylactic Mastectomy, 7.01.581
    This policy is replaced with InterQual criteria

     

    No updates this month

     

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