Medical Policy and Coding Updates December 2019

Effective March 5, 2020

Knee Arthroplasty in Adults, 7.01.550
A description of Kellgren-Lawrence grade 3 is added to the medical necessity statement of radiographic evidence. The conservative management section is modified to now include a requirement of both medical measures and physical measures.

Pharmacotherapy for Multiple Sclerosis, 5.01.565
Medical necessity review of Ocrevus^® (ocrelizumab) IV will now include site of service review. See policy for more details.

Site of Service: Infusion Drugs and Biologic Agents, 11.01.523
Medical necessity of Ocrevus^® (ocrelizumab) IV will now include site of service review. See policy for more details.

Effective March 4, 2020

Updates to AIM Specialty Health® Clinical Appropriateness Guidelines

Effective for dates of service on and after March 4, 2020, the following updates by section will apply to the AIM Specialty Health® Genetic Testing Clinical Appropriateness Guidelines:

Genetic Testing for Hereditary Cancer Susceptibility Clinical Appropriateness Guideline contains updates to the following:

• Criteria for Multi-Gene Panel Testing were revised as follows:
  • Restricting the genes on allowable panels to those with peer-reviewed clinical validity data for the cancers present in the individual’s personal and/or family history
• Criteria for CHEK2 and PALB2 were restricted to exclude coverage for those with a family history of prostate cancer only and no history of other relevant cancers.
• Criteria for prostate cancer were updated to remove RAD51D from the allowable gene list.

Effective February 9, 2020

Updates to AIM Specialty Health® Clinical Appropriateness Guidelines

Effective for dates of service on and after February 9, 2020, the following updates by section will apply to the AIM Specialty Health^® Advanced Imaging Clinical Appropriateness Guidelines:

Abdomen and Pelvis Clinical Appropriateness Guideline contains updates to the following:

Foreign body (pediatric only): Gastrointestinal bleeding, Henoch-Schoenlein purpura, hematoma or hemorrhage – intracranial or extracranial, perianal fistula/abscess (fistula in ano), ascites, biliary tract dilatation or obstruction, cholecystitis, choledocholithiasis, cocal liver lesion, hepatomegaly, jaundice, azotemia, adrenal mass, indeterminate, hematuria, renal mass, urinary tract calculi, adrenal hemorrhage, adrenal mass, lymphadenopathy, splenic hematoma, undescended testicle (cryptorchidism)

Abdominal and/or pelvic pain:

• Combine pelvic pain with abdominal pain criteria into a new “abdominal and/or pelvic pain” indication
• Require ultrasound or colonoscopy for select adult patients based on clinical scenario
• Ultrasound-first approach for pediatric abdominal and pelvic pain

Lower extremity edema: Add requirement to exclude DVT prior to abdominopelvic imaging.

Splenic mass, benign; splenic mass, indeterminate; splenomegaly: New indications for diagnosis, management, and surveillance of splenic incidentalomas following the American College of Radiology White Paper (previously reviewed against “tumor, not otherwise specified”)

Pancreatic mass: Criteria for solid and cystic pancreatic masses are now appear separately and follow up intervals for cystic pancreatic masses are now defined.

Diffuse liver disease: Add criteria to address MR elastography.

Inflammatory bowel disease: Limit requirement for upper endoscopy to patients with relevant symptoms and include new requirement for fecal calprotectin or CRP to differentiate IBS from IBD.

Enteritis or colitis not otherwise specified: Incorporate intussusception (pediatric only), and ischemic bowel.

Prostate cancer: This indication is now found in the Oncologic Imaging Guideline.

Effective for dates of service on and after February 9, 2020, the following updates by section will apply to the AIM Specialty Health^® Radiation Therapy Clinical Appropriateness Guidelines:

Special treatment procedure and special physics consult: Oral cone endocavitary indication is removed.

Intensity modulated radiation therapy (IMRT), stereotactic Radiosurgery (SRS) or stereotactic body radiotherapy (SBRT) for bone metastases: Description of adjacent normal tissues is now broader.

Single fraction treatment: Poor performance status criteria is now removed.

Central nervous system cancers: Now includes evidence review.

Spine lesions; primary or metastatic lesions of the spine, metastatic lesions in the lung: Incorporate note calling out separate criteria for curative intent treatment of extracranial oligometastatic disease.

SBRT in the treatment of extracranial oligometastatic disease: Add new section with discussion and indications.

Prostate cancer – hypofractionation: Add fractionation guideline with EBRT/IMRT.

Prostate cancer – postoperative radiotherapy and SBRT: Add indication based on ASTRO/ASCO/AUA recommendation.

Prostate cancer – use of hydrogel spacer: Add discussion and medical necessity statement about hydrogel spacers for prostate irradiation.

Effective for dates of service on and after February 9, 2020, the following updates by section will apply to the AIM Specialty Health^® Sleep Disorder Management Clinical Appropriateness Guidelines:

Polysomnography and Home Sleep Testing: Established sleep disorder (OSA or other) – follow-up laboratory studies: Expand contraindications including the addition of chronic narcotic use based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation.

Management of OSA using APAP and CPAP Devices:

• Expand treatment of mild OSA with APAP and CPAP to patients with any hypertension based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation
• Expand contraindications including the addition of chronic narcotic use based on The American Academy of Sleep Medicine Clinical Practice Guideline recommendation

Effective January 3, 2020

Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors, 7.01.92
This policy has been renumbered from policy 7.01.526. Cryosurgical ablation for benign breast fibroadenomas changed from medically necessary to investigational.

Drugs for Rare Diseases, 5.01.576
Cerdelga^® (eliglustat) and Elelyso^® (taliglucerase alfa) have been added to the policy for the treatment of Type I Gaucher’s disease. Xuriden^® (uridine triacetate) has been added to the policy for the treatment of hereditary orotic aciduria. Lumizyme^® (alglucosidase alfa) criteria have been updated to include all ages for the treatment of Pompe disease. All drugs may be considered medically necessary when criteria are met.

Irreversible Electroporation (NanoKnife® System), 7.01.572
The use of irreversible electroporation (NanoKnife^® System) is considered investigational for all indications, including but not limited to ablation of soft tissue or of solid organs, such as the liver or pancreas.

Leadless Cardiac Pacemakers, 2.02.32
The Micra™ transcatheter pacing system is a leadless cardiac pacemaker that may be considered medically necessary for patients who are unable to receive a conventional singular ventricular pacemaker and when additional criteria are met.

Miscellaneous Oncology Drugs, 5.01.540
The interferon agents Intron^® A (interferon alfa-2b) and Sylatron™ (peginterferon alfa-2b) have been added to the policy. Asparlas™ (calaspargase pegol - mknl) has been added to the policy for the treatment of acute lymphoblastic leukemia. Bavencio^® (avelumab) criteria are moved from this policy to Immune Checkpoint Inhibitors, 5.01.591. All drugs may be considered medically necessary when criteria are met.

Effective January 1, 2020

Hip Arthroplasty, 7.01.573
Hip arthroplasty may be considered medically necessary for the treatment of osteoarthritis, replacement/revision of previous arthroplasty, or other specific conditions.

Pilot Policy for Designated Centers of Excellence: Total Knee or Total Hip Replacement, 7.01.568
Total knee or total hip replacement (arthroplasty) for the treatment of osteoarthritis may be considered medically necessary when criteria are met and the surgery is performed in a Designated Center of Excellence. This policy only applies to members whose plan includes the Total Joint Replacement Centers of Excellence Program.

Effective February 21, 2020

Massage Therapy, 8.03.506
Massage therapy may be considered medically necessary when criteria in the policy are met and it is not intended for prolonged treatment.

Services Reviewed Using InterQual® Criteria, 10.01.530
This policy is updated to add physical therapy and occupational therapy services to the list of services that will be reviewed using InterQual® criteria for individual plans.

Effective January 1, 2020

Biofeedback for Incontinence, 2.01.540
Biofeedback for the treatment of incontinence in children and adults may be considered medically necessary when criteria are met.

Cardiac Defibrillator, Subcutaneous Implantable, 2.02.512
Subcutaneous implantable cardiac defibrillators may be considered medically necessary for cardiac conditions when criteria are met.

Continuous Home Pulse Oximetry, 1.01.533
Continuous home pulse oximetry may be considered medically necessary in specific situations when criteria are met.

Digital Breast Tomosynthesis, 6.01.526
Digital breast tomosynthesis may be considered medically necessary in screening for breast cancer when criteria are met.

Endometrial Ablation, 7.01.578
Endometrial ablation may be considered medically necessary for abnormal uterine bleeding when criteria are met.

Endovascular Repair/Stent for Abdominal Aortic Aneurysm, 2.02.513
Endovascular repair/stent for abdominal aortic aneurysm may be considered medically necessary to repair the aorta and/or its major branches when criteria are met.

Experimental and Investigational Services, 9.01.504
Policy outlines the conditions under which experimental and investigational services and devices may be considered medically necessary.

External Counterpulsation Therapy, 2.02.514
External counterpulsation therapy may be considered medically necessary for the treatment of chronic disabling stable angina when criteria are met.

Eye-Anterior Segment Optical Coherence Tomography, 9.03.509
Eye-anterior segment optical coherence tomography may be considered medically necessary for several eye conditions when criteria are met.

Glaucoma, Invasive Procedures, 9.03.510
Ex-PRESS™ Mini Glaucoma Shunt, iSTENT^® Trabecular Micro-Bypass Stent, and canalopasty may be considered medically necessary for the treatment of glaucoma when criteria are met.

Hepatitis A Vaccine, 9.01.505
The hepatitis A vaccine may be considered medically necessary for children and adults when criteria are met.

High-Resolution Anoscopy, 2.01.539
High-resolution anoscopy may be considered medically necessary for the identification, management, and treatment of anal dysplasia when criteria are met.

Home Apnea Monitoring, 1.01.534
Home apnea monitoring may be considered medically necessary for infants 12 months or younger when criteria are met.

Home Oxygen Therapy, 1.01.535
Home oxygen therapy may be considered medically necessary for low blood oxygen levels in severe lung disease when criteria are met.

Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring, 1.01.536
Home prothrombin time/international normalized ratio (PT/INR) monitoring may be considered medically necessary for patients taking warfarin with specific heart conditions when criteria are met.

Human Papillomavirus (HPV) Vaccine, 9.01.506
The human papillomavirus (HPV) vaccine may be considered medically necessary for the prevention of genital warts and HPV-related disease in females and males when criteria are met.

Laryngeal Injection for Vocal Cord Augmentation, 2.01.541
Laryngeal injections may be considered medically necessary for the treatment of glottal incompetence in specific conditions when criteria are met.

Meningococcal Vaccine, 9.01.507
Meningococcal vaccines may be considered medically necessary when criteria are met.

Negative Pressure Wound Therapy, 1.01.532
Negative pressure wound therapy in a home or an inpatient setting may be considered medically necessary for ulcers and wounds when criteria are met.

Nerve Block, Paravertebral, Facet Joint, and Sacroiliac Injections, 7.01.575
Paravertebral, facet joint, and sacroiliac joint injections may be considered medically necessary for the treatment of chronic pain and other conditions when criteria are met.

Posterior Tibial Nerve Stimulators, 7.01.579
Posterior tibial nerve stimulators (PTNS) may be considered medically necessary for the treatment of urinary incontinence when criteria are met.

Presbyopia Correcting Intraocular Lenses (PIOLs) and Astigmatism Correcting Intraocular Lenses (ACIOLs), 9.03.511
Presbyopia correcting intraocular lenses (PIOLs) and astigmatism correcting intraocular lenses (ACIOLs) may be considered medically necessary as part of cataract surgery when criteria are met.

Prophylactic Bilateral Salpingo-Oophorectomy, 7.01.580
Prophylactic bilateral salpingo-oophorectomy may be considered medically necessary for individuals at high risk of ovarian or breast cancer when criteria are met.

Prophylactic Mastectomy, 7.01.581
Prophylactic mastectomy may be considered medically necessary for individuals at high risk of breast cancer when criteria are met.

Rabies Vaccine, Home, 9.01.508
The rabies vaccine given in a home setting may be considered medically necessary for possible rabies exposure when criteria are met.

Rotavirus Vaccine, 9.01.509
The rotavirus vaccine may be considered medically necessary for infants as part of preventive immunization guidelines.

Services Reviewed Using InterQual® Criteria, 10.01.530
Services listed in this policy may be considered medically necessary based on InterQual criteria. See policy for details.

Shingles Vaccine, 9.01.510
The shingles vaccine may be considered medically necessary in adults ages 50 and older when criteria are met.

Spinal Orthosis, 1.03.502
Thoracic-lumbar-sacral orthoses (TLSO), Lumbar-sacral orthoses (LSO), Lumbar Orthoses, and custom spinal orthoses may be considered medically necessary to reduce pain or provide structural support when criteria are met.

Supervised Exercise Therapy for Peripheral Artery Disease, 8.01.537
Supervised exercise therapy for symptomatic peripheral artery disease (PAD) may be considered medically necessary when criteria are met.

Surgical Dressings and Wound Care Supplies, 9.01.511
Specific surgical dressings and wound care supplies may be considered medically necessary for removing tissue from a wound or treatment of a wound caused by surgery when criteria are met.

Total Ankle Replacement, 7.01.577
Total ankle replacement surgery may be considered medically necessary for the treatment of advanced end-stage arthritis or for revision of prior total ankle replacement when criteria are met.

Transient Elastography, 2.01.536
Transient elastography may be considered medically necessary for fibrosis with a diagnosis of hepatitis C when criteria are met.

Trigger Point and Transforaminal Epidural Injections, 2.01.537
Trigger point injections may be considered medically necessary for myofascial pain syndrome when criteria are met.

Ultraviolet B Light Therapy in the Home to Treat Skin Conditions, 2.01.542
Ultraviolet B (UVB) light therapy in the home may be considered medically necessary for specific skin conditions when criteria are met.

Visual Evoked Response Test, 9.03.512
Visually evoked response testing may be considered medically necessary to detect problems that affect sight when criteria are met.

Wireless Capsule Endoscopy, 2.01.538
Wireless capsule endoscopy may be considered medically necessary for the evaluation of obscure gastrointestinal bleeding, symptomatic small bowel neoplasm, Crohn’s disease, and Celiac disease when criteria are met.

Revised medical policies

Effective December 1, 2019

Microwave Tumor Ablation, 7.01.133
The policy statement for microwave ablation (MWA) of primary and metastatic tumors has changed from investigational to medically necessary when criteria are met. MWA of more than one single primary or metastatic tumor in the lung is considered investigational. MWA of primary or metastatic tumors other than liver or lung is considered investigational.

Revised pharmacy policies

Effective December 1, 2019

Medical Necessity Criteria for Pharmacy Edits, 5.01.605
Cequa™ (cyclosporine ophthalmic solution) may be considered medically necessary to treat the signs and symptoms of dry eye disease when criteria are met. Nourianz™ (istradefylline) may be considered medically necessary as adjunctive treatment to carbidopa/levodopa in patients with Parkinson’s disease when criteria are met. Generic nitisinone may be considered medically necessary when the patient is diagnosed with hereditary tyrosinemia type 1 and criteria are met. Accrufer™ (ferric maltol) may be considered medically necessary for the treatment of iron deficiency anemia in adults when the patient has inflammatory bowel disease, or non-dialysis dependent chronic kidney disease and criteria are met.

Miscellaneous Oncology Drugs, 5.01.540
Kisqali^® Femara^® co-pack (ribociclib – letrozole) may be considered medically necessary to treat premenopausal or postmenopausal women with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced or metastatic breast cancer when criteria are met. Use as maintenance therapy following response to chemotherapy regimens is considered not medically necessary. Xpovio™ (selinexor) in combination with dexamethasone may be considered medically necessary to treat adult patients with relapsed or refractory multiple myeloma (RRMM) when criteria are met. Rozlytrek™ (entrctinib) may be considered medically necessary to treat adult patients with metastatic non-small cell lung cancer (NSCLC) or adult and pediatric patients 12 years of age and older with solid tumors when criteria are met. Piqray® (alpelisib) in combination with fulvestrant may be considered medically necessary to treat men and postmenopausal women with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative, PIK3CA-mutated, advanced or metastatic breast cancer when criteria are met.

Multiple Receptor Tyrosine Kinase Inhibitors, 5.01.534
Lenvima^® (lenvatinib) has an added medically necessary indication for use in combination with pembrolizumab and may be considered medically necessary to treat patients with advanced endometrial carcinoma when criteria are met. Turalio™ (pexidartinib) may be considered medically necessary for the treatment of adult patients with symptomatic tenosynovial giant cell tumor (TGCT) when criteria are met.

Pharmacologic Treatment of Hereditary Transthyretin-Mediated Amyloidosis, 5.01.593
Vyndamax™ (tafamidis) and Vyndaqel^® (tafamidis meglumine) may be considered medically necessary for the treatment of cardiomyopathy of wild type or hereditary transthyretin-mediated amyloidosis (ATTR-CM) when criteria are met. All other uses are considered investigational.

Pharmacotherapy of Multiple Sclerosis, 5.01.565
The expanded disability status score (EDSS) criteria for Mayzent® (siponimod) was changed from 6 to 7.

Prostate Cancer Targeted Therapies, 5.01.544
Nubeqa^® (darolutamide) may be considered medically necessary to treat patients with non-metastatic castration-resistant prostate cancer. Erleada™ (apalutamide) has an added medically necessary indication for treatment of metastatic castration-sensitive prostate cancer.

Added codes

Effective March 5, 2020

Now requires review for site of service as part of medical necessity and prior authorization.

Pharmacotherapy for Multiple Sclerosis, 5.01.565

Site of Service: Infusion Drugs and Biologic Agents, 11.01.523
J2350

Added codes

Effective December 5, 2019

Steroid-Eluting Sinus Stents, 7.01.134

Now requires review, considered investigational.

J7401

Added codes

Effective February 9, 2020

Effective for dates of service on and after February 9, 2020, the following updates by section will apply to the AIM Specialty Health^® Radiation Therapy Clinical Appropriateness Guidelines:

Now requires review for medical necessity and prior authorization.

55874

Added codes

Effective February 21, 2020

Now requires review for medical necessity after initial 6 visits in an episode of care.

Massage Therapy, 8.03.506
97010, 97112, 97124, 97140

Services Reviewed Using InterQual® Criteria, 10.01.530
97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97127, 97139, 97140, 97150, 97164, 97168, 97530, 97533, 97535, 97542, 97750, 97755, 97760, 97761, 97763, 97799, G0283

Added codes

Effective January 1, 2020

Now requires review for medical necessity.

Eye-Anterior Segment Optical Coherence Tomography, 9.03.509
92132

Biofeedback for Incontinence, 2.01.540
90911, 90901

Continuous Home Pulse Oximetry, 1.01.533
E0445, A4606

Digital Breast Tomosynthesis, 6.01.526
77061, 77062, 77063, 77046, 77047, 77048, 77049, 77065, 77066, 77067, G0279

Endometrial Ablation, 7.01.578
58353, 58356, 58563

Endovascular Repair/Stent for Abdominal Aortic Aneurysm, 2.02.513
0254T, 34701, 34702, 34703, 34704, 34705, 34706, 34707, 34708, 34709, 34710, 34711, 34712, 34713, 34714, 34715, 34716, 34808, 34812, 34813, 34820, 34833, 34834, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848

External Counterpulsation Therapy, 2.02.514
G0166

Glaucoma, Invasive Procedures, 9.03.510
0191T, 0253T, 66174, 66175, 66183

Hepatitis A Vaccine, 9.01.505
90460, 90461, 90471, 90472, 90632, 90633, 90634, 90636

High Resolution Anoscopy, 2.01.539
46601, 46607

Home Apnea Monitoring, 1.01.534
94774, 94775, 94776, 94777

Home Oxygen Therapy, 1.01.535
E0424, E0431, E0433, E0434, E0439, E0441, E0442, E0443, E0444, E1390, E1391, E1392, E1405, E1406, K0738

Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring, 1.01.536
G0248, G0249, G0250

Human Papillomavirus (HPV) Vaccine, 9.01.506
90649, 90650, 90651

Laryngeal Injections for Vocal Cord Augmentation, 2.01.541
31513, 31570, 31571, 31573, 31574

Meningococcal Vaccines, 9.01.507
90621, 90644, 90733, 90734

Posterior Tibial Nerve Stimulators, 7.01.579
64566

Presbyopia Correcting Intraocular Lenses (PIOLs) and Astigmatism Correcting Intraocular Lenses (ACIOLs), 9.03.511
66982, 66983, 66984, V2630, V2631, V2632

Prophylactic Bilateral Salpingo-Oophorectomy, 7.01.580
58720, 58940

Rabies Vaccine, Home, 9.01.508
90675, 90676, 90375, 90376

Rotavirus Vaccine, 9.01.509
90460, 90461, 90471, 90472, 90680, 90681

Shingles Vaccine, 9.01.510
90736, 90750

Supervised Exercise Therapy for Peripheral Artery Disease, 8.01.537
93668

Surgical Dressings and Wound Care Supplies, 9.01.511
A4450, A4452, A4461, A4463, A4649, A6010, A6011, A6021, A6022, A6023, A6024, A6154, A6196, A6197, A6198, A6199, A6203, A6204, A6205, A6206, A6207, A6208, A6209, A6210, A6211, A6212, A6213, A6214, A6215, A6216, A6217, A6218, A6219, A6220, A6221, A6222, A6223, A6224, A6231, A6232, A6233, A6234, A6235, A6236, A6237, A6238, A6239, A6240, A6241, A6242, A6243, A6244, A6245, A6246, A6247, A6248, A6251, A6252, A6253, A6254, A6255, A6256, A6257, A6258, A6259, A6261, A6262, A6266, A6402, A6403, A6404, A6407, A6410, A6411, A6413, A6441, A6442, A6443, A6444, A6445, A6446, A6447, A6448, A6449, A6450, A6451, A6452, A6453, A6454, A6455, A6456, A6457, A6501, A6502, A6503, A6504, A6505, A6506, A6507, A6508, A6509, A6510, A6511, A6512, A6513, A6545

Ultraviolet B Light Therapy in the Home to Treat Skin Conditions, 2.01.542
E0691, E0692, E0693, E0694, A4633

Visually Evoked Response Test, 9.03.512
95930

Added codes

Effective January 1, 2020

Now requires review for medical necessity and prior authorization.

Cardiac Defibrillator, Subcutaneous Implantable, 2.02.512
33270

Negative Pressure Wound Therapy, 1.01.532
A6550, A7000, E2402

Nerve Block, Paravertebral, Facet Joint, and Sacroiliac Injections, 7.01.575
20526, 27096, 64450, 64455, 64461, 64462, 64463, 64490, 64491, 64492, 64493, 64494, 64495, 77003, G0260

Spinal Orthosis, 1.03.502
L0450, L0452, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0635, L0636, L0637, L0638, L0639, L0640, L0641, L0642, L0643, L0648, L0649, L0650, L0651, L0980, L0982, L0984, L4002

Total Ankle Replacement, 7.01.577
27702, 27703

Transient Elastography, 2.01.536
91200

Trigger Point and Transforaminal Epidural Injections, 2.01.537
20552, 20553, 64479, 64480, 64483, 64884

Wireless Capsule Endoscopy, 2.01.538
91110, 91111