Medical Policy and Coding Updates December 2018

  • Effective February 1, 2019

    Cervical Spine Surgeries: Discectomy, Laminectomy, and Fusion in Adults, 7.01.560
    The policy is updated to include statements for posterior cervical fusion, cervical discectomy, and cervical laminectomy. Title is changed to Cervical Spine Surgeries: Discectomy, Laminectomy, and Fusion in Adults.

    Policy 9.03.28, Corneal Collagen Cross-Linking, is a policy that’s no longer active and not used for reviews, as of July 1, 2019.

    Lanadelumab and HAE Drugs, 5.01.587
    This policy lists the medical necessity criteria for the following drugs for hereditary angioedema:

    • For treatment of acute attacks: Berinert® (pdC1-INH), Firazyr® (icatibant), Kalbitor® (ecallantide), Ruconest® (rhC1-INH)
    • For long-term prophylaxis of acute attacks: Cinryze® (pdC1-INH), Haegarda® (pdC1-INH), Takhyzro® (lanadelumab)

    Trogarzo™ (ibalizumab), 5.01.588
    Trogarzo™ (ibalizumab) may be considered medically necessary in the treatment of HIV-1 patients when criteria are met.

    Effective January 28, 2019

    Update to AIM Radiation Oncology clinical appropriateness guidelines

    Breast cancer

    • Removed age and tumor size criteria for accelerated whole breast irradiation (AWBI)

    Rectal cancer

    • The modified criteria no longer limits treatment with IMRT for rectal adenocarcinoma

    Pancreatic cancer

    • Added criteria for SBRT in treating locally advanced or recurrent disease without evidence of distant metastasis

    Head and neck cancer

    • Added criteria to allow IMRT for head and neck lymphomas
    • Clarified no IMRT for stage I/II glottic cancer

    Lung cancer

    • Added DVH parameter for cardiac V50


    • Removed preoperative and joint sparing requirements for IMRT

    Prostate cancer

    • Added discussion on hypofractionation
    • Added discussion on brachytherapy

    Update to AIM Cardiology clinical appropriateness guidelines

    Carotid duplex ultrasound

    • Criteria removed for evaluation of syncope in patients with suspected extracranial arterial disease
    • New criteria address evaluation of TAVR (TAVI) in patients with suspected or established extracranial arterial disease

    Myocardial perfusion imaging (MPI), stress echocardiography, cardiac PET, and coronary CT angiography (CCTA)

    • Clarifications address exercise-induced syncope and exercise-induced dizziness, lightheadedness, or near syncope in symptomatic patients with suspected coronary artery disease

    MPI, stress echocardiography, cardiac PET

    • Criteria added to allow annual surveillance of coronary artery disease in patients with established CAD post-cardiac transplant
    • Clarified definition of established coronary artery disease when diagnosed by CCTA
      • more restrictive for patients diagnosed with coronary artery disease by prior coronary angiography, as FFR must be ≤0.8
      • more permissive for patients diagnosed with coronary artery disease by CCTA with FFR ≤0.8 (patients previously excluded)

    Resting transthoracic echocardiography (TTE)

    • New criteria for evaluation of ventricular function in patients who have undergone cardiac transplantation

    Cardiac MRI

    • New criteria allows for annual study to quantify cardiac iron load in chronically ill patients with cardiomyopathy who require frequent blood transfusions (eg, thalassemia)
    • Removed allowance for annual LV function evaluation when echocardiography is suboptimal

    Effective January 4, 2019

    Genetic Testing: Services Reviewed by AIM, 10.01.526
    As announced in September and October, AIM Specialty Health® will review genetic testing services beginning on January 4, 2019. This administrative policy identifies the specific Premera policies that will be deleted on January 4, 2019, and the date that AIM will begin conducting reviews using AIM Clinical Appropriateness Guidelines for Genetic Testing.

    Surgical Treatments for Lymphedema, 7.01.567
    Lymphatic physiologic microsurgery to treat lymphedema in upper or lower extremities is considered investigational. Lymphatic physiologic microsurgery performed during nodal dissection or breast reconstruction to prevent lymphedema in individuals who are being treated for breast cancer is considered investigational. Excisional procedures (debulking, liposuction including SAPL), tissue transfers (eg, omental flap) and reverse lymphatic mapping are considered investigational. Previously numbered 7.01.162.

    Revised medical policies

    Effective December 1, 2018

    Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes, 12.04.506
    A policy statement is added that genetic testing for SMAD4, BMPR1A, or STK11 gene variants may be considered medically necessary for juvenile polyposis syndrome and Peutz‐Jeghers syndrome.
    Note: Effective January 4, 2019, the services originally described in this policy are reviewed by AIM Specialty Health®.

    New pharmacy policies

    Effective December 1, 2018

    Phosphoinositide 3-Kinase (PI3K) Inhibitors, 5.01.592
    Aliqopa™ (copanlisib), Copiktra™ (duvelisib), and Zydelig® (idelalisib) may be considered medically necessary when criteria are met. They are considered investigational for all other uses.

    Revised pharmacy policies

    Effective December 1, 2018

    Growth Hormone Therapy, 5.01.500
    The policy is revised to add the indication of short stature or growth failure associated with SHOX deficiency for treatment with Zomacton® (somatropin).

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605
    The criteria for Horizant® and Orilissa® (elagolix) are updated. The pediatric indication (age 7 and older) is added for Xyrem® (sodium oxybate). Xyosted™ (testosterone enanthate injection) is added to the list of testosterone brands, and branded generic testosterone gels is removed.

    Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502
    The policy adds criteria for Lumoxiti™ (moxetumomab pasudotox) and updates the criteria for Arzerra® (ofatumumab).

    Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564
    The policy adds the pediatric indications of uveitis and hydradenitis for Humira® (adalimumab).

    Added codes

    Effective December 1, 2018

    Treatment of Varicose Veins/Venous Insufficiency, 7.01.519
    Now reviewed for investigative

    36473 - Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated

    36474 - Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

    Effective December 6, 2018

    Ablative Treatments for Occipital Neuralgia, Chronic Headaches, and Atypical Facial Pain, 7.01.563
    Now reviewed for investigative, now requires prior authorization

    64600 - Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch

    62281- Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic

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