Cervical Spine Surgeries: Discectomy, Laminectomy, and Fusion in Adults, 7.01.560The 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Policy 9.03.28, Corneal Collagen Cross-Linking, is a policy that’s no longer active and not used for reviews, as of July 1, 2019.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, 5.01.587This policy lists the medical necessity criteria for the following drugs for hereditary angioedema:
Trogarzo™ (ibalizumab), 5.01.588Trogarzo™ (ibalizumab) may be considered medically necessary in the treatment of HIV-1 patients when criteria are met.
Head and neck cancer
Carotid duplex ultrasound
Myocardial perfusion imaging (MPI), stress echocardiography, cardiac PET, and coronary CT angiography (CCTA)
MPI, stress echocardiography, cardiac PET
Resting transthoracic echocardiography (TTE)
Genetic Testing: Services Reviewed by AIM, 10.01.526As 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, 7.01.567Lymphatic 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.
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes, 12.04.506A 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®.
Phosphoinositide 3-Kinase (PI3K) Inhibitors, 5.01.592Aliqopa™ (copanlisib), Copiktra™ (duvelisib), and Zydelig® (idelalisib) may be considered medically necessary when criteria are met. They are considered investigational for all other uses.
Growth Hormone Therapy, 5.01.500The 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, 5.01.605The 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, 2.03.502The policy adds criteria for Lumoxiti™ (moxetumomab pasudotox) and updates the criteria for Arzerra® (ofatumumab).
Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564The policy adds the pediatric indications of uveitis and hydradenitis for Humira® (adalimumab).
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)
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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