Revised medical policies
Effective December 1, 2017
Dynamic Spinal Visualization, 6.01.46
The policy statement was clarified to include specific dynamic spinal visualization techniques, including digital motion x-ray of the spine, cineradiography/videofluoroscopy, and dynamic magnetic resonance
imaging. Read the full policy.
Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502
The policy was revised to add criteria for Rituxan Hycela™ (rituximab and hyaluronidase human) for the FDA-labeled indications of follicular lymphoma, diffuse large B-cell lymphoma,
and chronic lymphocytic leukemia. Read the full policy.
Transcatheter Pulmonary Valve Implantation, 7.01.131
The policy statement was updated to include specific FDA-approved device indications for pulmonary valve regurgitation and stenosis. Read the full policy.
Effective February 2, 2018
Intraoperative Neurophysiologic Monitoring, 7.01.562
The policy statement now identifies the specific spinal, intracranial, vascular, and recurrent laryngeal nerve surgeries which meet policy criteria for intraoperative monitoring. Read the full policy.
Revised pharmacy policies
Effective December 1, 2017
Miscellaneous Oncology Drugs, 5.01.540
The policy statement was revised to add the following indications for Keytruda® (pembrolizumab), which may be considered medically necessary for these indications when criteria are met:
- Refractory classical Hodgkin lymphoma
- Locally advanced or metastatic urothelial carcinoma
- Unresectable or metastatic microsatellite instability-high or mismatch repair deficient solid tumors or colorectal cancer that has progressed
- Locally advanced or metastatic gastric or gastroesophageal junction adenocarcinoma
Read the full policy.
Myalept (metreleptin), 5.01.553
The policy was revised to state that at least one metabolic abnormality must be present in addition to existing criteria for Myalept™ (metreleptin) to be considered medically necessary. Read the full policy.
Rituxan® (rituximab): Non-oncologic and Miscellaneous Uses, 5.01.556
The policy statement was revised to state that Rituxan® (rituximab) may be considered medically necessary as first-line treatment with a new diagnosis
of pemphigus. Note that Rituxan Hycela™ (rituximab and hyaluronidase human) may be covered for both labeled and off-label indications after the first successful treatment with Rituxan. Read the full policy.
Coding updates
Added codes
Effective December 1, 2017
Advanced Therapies for Pharmacological Treatment of Pulmonary Arterial Hypertension, 5.01.522
Now reviewed for medical necessity review; now requires prior authorization
J7686 - Treprostinil, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, 1.74 mg
Genetic Cancer Susceptibility Panels Using Next - Generation Sequencing, 12.04.93
Now reviewed as investigative; now requires prior authorization
0013U - Oncology (solid organ neoplasia), gene rearrangement detection by whole genome next-generation sequencing, DNA, fresh or frozen tissue or cells, report of specific gene rearrangement(s)
0014U - Hematology (hematolymphoid neoplasia), gene rearrangement detection by whole genome next-generation sequencing, DNA, whole blood or bone marrow, report of specific gene rearrangement(s)
Microprocessor-Controlled Prostheses for the Lower Limb, 1.04.05
Now reviewed as investigative; now requires prior authorization
L5859 - Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders, 12.04.102
Now reviewed for medical necessity; now requires prior authorization
0012U - Germline disorders, gene rearrangement detection by whole genome next-generation sequencing, DNA, whole blood, report of specific gene rearrangement(s)
Revised code
Effective December 1, 2017
Molecular Markers in Fine Needle Aspirates of the Thyroid, 12.04.510
Removed from investigational review; now requires review for medical necessity and requires prior authorization
0018U - Oncology (thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to high risk of malignancy
Removed codes
Effective December 1, 2017
Skilled Home Health Care Services, 11.01.508
No longer reviewed for medical necessity
99500 - Home visit for prenatal monitoring and assessment to include fetal heart rate, nonstress test, uterine monitoring, and gestational diabetes monitoring
99501 - Home visit for postnatal assessment and follow-up care
99502 - Home visit for newborn care and assessment
99503 - Home visit for respiratory therapy care (eg, bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation)
99504 - Home visit for mechanical ventilation care
99505 - Home visit for stoma care and maintenance including colostomy and cystostomy
99506 - Home visit for intramuscular injections
99507 - Home visit for care and maintenance of catheter(s) (eg, urinary, drainage, and enteral)
99509 - Home visit for assistance with activities of daily living and personal care
99510 - Home visit for individual, family, or marriage counseling
99511 - Home visit for fecal impaction management and enema administration
99512 - Home visit for hemodialysis
99600 - Unlisted home visit service or procedure
G0156 - Services of home health/hospice aide in home health or hospice settings, each 15 minutes
G0299 - Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes
G0300 - Direct skilled nursing services of a license practical nurse (LPN) in the home health or hospice setting, each 15 minutes
Vagus Nerve Stimulation, 7.01.20
No longer reviewed for medical necessity, no longer requires review for prior authorization
64570 - Removal of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator