Medical Policy and Coding Updates December 2020

  • Updates for both non-individual and individual plans

  • Effective March 14, 2021

    Updates to AIM Specialty Health® Clinical Appropriateness Guidelines

    Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging

    Updates by section:

    Brain Imaging

    Ataxia, congenital or hereditary

    • Combined with congenital cerebral anomalies to create one section

    Acoustic neuroma

    • More frequent imaging for a watch and wait or incomplete resection
    • New indication for Neurofibromatosis type 2 (NF 2)
    • More frequent imaging when MRI shows findings suspicious for recurrence
    • Single post-operative MRI following gross total resection
    • Included pediatrics with known acoustics (rare but NF 2)

    Tumor – not otherwise specified

    • Repurposed for surveillance imaging of low grade neoplasms

    Seizure disorder and epilepsy

    • Limited imaging for the management of established generalized epilepsy
    • Required optimal medical management (aligning adult and pediatric language) prior to imaging for management in epilepsy

    Headache

    • Removed response to treatment as a primary headache red flag
    • Included pregnancy as a red flag risk factor

    Mental status change and encephalopathy

    • Added requirement for initial clinical and lab evaluation to assess for a more specific cause

    Brain Imaging and Head and Neck Imaging

    Hearing loss

    • Added CT temporal bone for evaluation of sensorineural hearing loss in any pediatric patients or in adults for whom MRI is nondiagnostic or unable to be performed
    • Higher allowed threshold for consecutive frequencies to establish SNHL
    • Removed CT brain as an alternative to evaluating hearing loss based on ACR guidance

    Tinnitus

    • Removed sudden onset symmetric tinnitus as an indication for advanced imaging

    Chest Imaging and Head and Neck Imaging

    Hoarseness, dysphonia, and vocal cord weakness/paralysis – primary voice complaint

    • Required laryngoscopy for the initial evaluation of all patients with primary voice complaint

    Head and Neck Imaging

    Sinusitis/rhinosinusitis

    • Added more flexibility for the method of conservative treatment in chronic sinusitis
    • Required conservative management prior to repeat imaging for patients with prior sinus CT

    Temporomandibular joint dysfunction

    • Removed requirement for radiographs/ultrasound

    Cerebrospinal fluid (CSF) leak of the skull base

    • Added scenario for management of known leak with change in clinical condition

    Oncologic Imaging

    General content changes to align with current oncology recommendations

    • Removal of indications/parameters not addressed by NCCN
    • Average risk inclusion criteria for CT Colonography
    • New allowances for MRI Abdomen and/or MRI Pelvis by tumor type, liver metastatic disease
    • New indications for Acute Leukemia (CT, PET/CT), Multiple Myeloma (MRI, PET/CT), Ovarian Cancer surveillance (CT), Bone Sarcoma (PET/CT)
    • Updated standard imaging pre-requisites prior to PET/CT for Bladder/Renal Pelvis/Ureter, Colorectal, Esophageal/GE Junction, Gastric and Non-Small Cell Lung Cancers
    • Additional PET/CT management scenarios for Cervical Cancer, Hodgkin Lymphoma

    Cancer screening

    • New indication for Pancreatic Cancer screening

    Breast cancer

    • New PET/CT indication for restaging/treatment response for bone-only metastatic disease and limitation of post-treatment Breast MRI after breast conserving therapy or unilateral mastectomy

    Prostate Cancer

    • MRI pelvis: removal of TRUS biopsy requirement, allowance if persistent/unexplained elevation in PSA or suspicious DRE

    Axumin PET/CT

    • Updated inclusion criteria (removal of general MRI pelvis requirement, additional allowance for rising PSA with non-diagnostic mpMRI)

    Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging of the Heart

    Updates by section:

    Evaluation of patients with cardiac arrhythmias

    • Updated repeat TTE criteria
    • Added restrictions for patients whose initial echocardiogram shows no evidence of structural heart disease, and follow-up echocardiography is not appropriate for ongoing management of arrhythmia

    Evaluation of signs, symptoms, or abnormal testing

    • Added restrictions for TTE in evaluation of palpitation and lightheadedness based on literature

    Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiation Oncology

    Updates by section:

    Special Treatment Procedure

    • Removed IV requirement for chemotherapy

    CNS cancer: IMRT for glioblastomas, other gliomas, brain metastases

    • Eliminated the plan comparison requirement based on feedback from reviewers that essentially all cases were able to meet criteria - same change for high-grade and low-grade gliomas
    • Added new indication for hippocampal sparing whole brain radiotherapy

    Lung cancer: IMRT and SBRT for non-small cell, SBRT for small cell; fractionation for non-small cell

    • Eliminated the plan comparison requirement for IMRT to treat stage III non-small cell lung cancer
    • Removed “due to a medical contraindication” language
    • Added new indication as an alternative to surgical resection when certain conditions apply
    • Adjusted fractions of thoracic radiotherapy for non-small cell lung cancer

    Proton Beam Therapy

    • Added new indication for hepatocellular carcinoma and intrahepatic cholangiocarcinoma

    Effective March 3, 2021

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605

    New policy section

    • Interferons

    New drug added to policy

    • Actimmune® (interferon gamma-1b)
      • Reducing the frequency and severity of serious infections associated with Chronic Granulomatous Disease (CGD)
      • Delaying time to disease progression in patients with severe, malignant osteopetrosis (SMO)

    Vascular Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders, 5.01.620

    New policy

    The following brand drugs have been added and may be considered medically necessary when criteria are met:

    • Beovu® (brolucizumab-dbll)
      • Treatment of neovascular (wet) age-related macular degeneration (AMD)
    • Eylea® (aflibercept)
      • Treatment of neovascular (wet) age-related macular degeneration (AMD)
      • Treatment of macular edema following retinal vein occlusion (RVO)
      • Treatment of diabetic macular edema (DME)
      • Treatment of diabetic retinopathy (DR)
    • Lucentis® (ranibizumab)
      • Treatment of neovascular (wet) age-related macular degeneration (AMD)
      • Treatment of macular edema following retinal vein occlusion (RVO)
      • Treatment of diabetic macular edema (DME)
      • Treatment of diabetic retinopathy (DR)
      • Treatment of myopic choroidal neovascularization (mCNV)
    • Macugen® (pegaptanib)
      • Treatment of neovascular (wet) age-related macular degeneration (AMD)

    Effective February 5, 2021

    The following policies are being reinstated and used to review medical necessity for dates of service starting February 5, 2021 and after:

    Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses, 1.01.11

    Artificial Pancreas Device Systems, 1.01.30

    Medical necessity criteria updated

    • The age for an artificial pancreas device system has been lowered from age 14 to age 6 and older
    • The age for a hybrid closed loop insulin delivery system has been lowered from age 7 to age 6 and older

    Cochlear Implant, 7.01.05

    Medical necessity criteria updated

    • The age for bilateral hearing loss has been lowered from 12 months to 9 months or older

    Continuous Passive Motion in the Home Setting, 1.01.10

    Coronary Angiography for Known Suspected Coronary Artery Disease, 2.02.507

    Deep Brain Stimulation, 7.01.63

    Hip Arthroplasty in Adults, 7.01.573

    Hospital Beds and Accessories, 1.01.520

    Knee Arthroplasty in Adults, 7.01.550

    Knee Arthroscopy in Adults, 7.01.549

    Medical necessity criteria updated

    • Knee arthroscopy for a partial meniscectomy is considered not medically necessary for a degenerative tear(s) that do not result in functional impairment symptoms

    Knee Orthoses (Braces), Ankle foot Orthoses and Knee-Ankle-Foot-Orthoses, 1.03.501

    Mastectomy for Gynecomastia, 7.01.521

    Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions, 1.01.15

    Panniculectomy and Excision of Redundant Skin, 7.01.523

    Patient Lifts, Seat Lifts, and Standing Devices, 1.01.519

    Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation, 2.02.26

    Power Operated Vehicle (Scooters) (excluding motorized wheelchairs), 1.01.527

    Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers, 1.01.18

    Reduction Mammoplasty for Breast-Related Symptoms, 7.01.503

    Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy, 7.01.143

    Rhinoplasty, 7.01.558

    Semi-Implantable and Fully Implantable Middle Ear Hearing Aids, 7.01.84

    Spinal Cord and Dorsal Root Ganglion Stimulation, 7.01.546

    Transcatheter Aortic Valve Implantation for Aortic Stenosis, 7.01.132

    Treatment of Varicose Veins, 7.01.519

    Upper GI Endoscopy, 2.01.533

    Medical necessity criteria updated

    • Routine preoperative UGI is considered not medically necessary for individuals scheduled for bariatric surgery unless they meet the clinical criteria

    Vagus Nerve Stimulation, 7.01.20

    Wearable Cardioverter Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement , 2.02.506

    Wheelchairs (Manual or Motorized), 1.01.501


    Effective January 1, 2021

    Pharmacotherapy of Arthropathies, 5.01.550

    Medical necessity criteria updated

    • Actemra® (tocilizumab)
      • Treatment of moderate to severe rheumatoid arthritis. Patient must have tried and failed Humira® (adalimumab) or this drug cannot be tolerated

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563

    Site of service review added

    • Tysabri® (natalizumab)

    Medical necessity criteria updated

    • Tysabri® (natalizumab)
      • Second-line treatment for Crohn’s disease requires trial and treatment failure with corticosteroids, or azathioprine, 6-mercaptopurine, methotrexate, Cimzia® (certolizumab pegol), Entyvio® (vedolizumab), Humira® (adalimumab), Remicade® (infliximab), or Stelara® (ustekinumab)

    Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564

    New drug added to policy

    • Ilaris® (canakinumab)
      • Treatment of periodic fever syndromes
      • Treatment of Still’s disease in patients age 2 and older

    Pharmacotherapy of Multiple Sclerosis, 5.01.565

    Site of service review added

    • Tysabri® (natalizumab)

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523

    New drug added to policy

    • Tysabri® (natalizumab)

    Use of Granulocyte Colony-Stimulating Factors (G-CSF), 5.01.551

    Policy renamed

    • From “Granulocyte Colony-Stimulating Factors (G-CSF) Use in Adult Patients” to “Use of Granulocyte Colony-Stimulating Factors (G-CSF)”

    Medical necessity criteria updated

    • Udenyca® (pegfilgrastim-cbqv) and Ziextenzo® (pegfilgrastim-bmez)
      • As a first-line treatment for patients under age 18 who are at risk of severe febrile neutropenia
      • As a second-line treatment for patients age 18 or older who are at risk of severe febrile neutropenia when Granix® (tbo-filgrastim) or Nivestym® (filgrastim-aafi) has been tried and failed, or there is a medical reason why those two drugs cannot be taken, or there is a valid medical reason why self-injection or home nursing cannot be performed
    • Neulasta® (pegfilgrastim) / Neulasta Onpro®, Fulphila® (pegfilgrastim-jmdb), and Nyvepria™ (pegfilgrastim-apgf)
      • As a second-line treatment of patients under age 18 who are at risk of severe febrile neutropenia when Udenyca® (pegfilgrastim-cbqv) or Ziextenzo® (pegfilgrastim-bmez) have been tried and failed, or there is a medical reason why those two drugs cannot be taken
      • As a third-line treatment of patients age 18 or older who are at risk of severe febrile neutropenia when Granix® (tbo-filgrastim) or Nivestym® (filgrastim-aafi) has been tried and failed, when Udenyca® (pegfilgrastim-cbqv) or Ziextenzo® (pegfilgrastim-bmez) has been tried and failed, or there is a medical reason why those drugs cannot be taken

    Effective December 3, 2020

    Hematopoietic Cell Transplantation for Hodgkin Lymphoma, 8.01.29

    Criteria updated

    • Tandem autologous hematopoietic cell transplantation (HCT) medical necessity criteria have been removed
    • Tandem autologous hematopoietic cell transplantation (HCT) is now considered investigational in patients with Hodgkin lymphoma

    Miscellaneous Oncology Drugs, 5.01.540

    New drugs added to policy

    • Blincyto® (blinatumomab)
      • Treatment of adults and children for B-cell precursor acute lymphoblastic leukemia (ALL) in first or second complete remission with minimal residual disease (MRD)
      • Treatment of adults and children with relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL)
    • Leukine® (sargramostim)
      • Treatment of acute myeloid leukemia after induction chemotherapy
      • Mobilization and following transplant of autologous peripheral blood progenitor cells
      • Myeloid reconstitution after (allogenic or autologous) bone marrow transplant
      • Treatment for bone marrow transplant (allogenic or autologous) failure or engraftment delay
      • Treatment for exposure to myelosuppressive doses of radiation (Hematopoietic Syndrome of Acute Radiation Syndrome)

    Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment, 5.01.517

    New drug added to policy

    • Cyramza® (ramucirumab)
      • Treatment of advanced or metastatic gastric or gastro-esophageal junction (GEJ) cancer that has continued to grow while on or after prior fluoropyrimidine- or platinum-containing chemotherapy when used as a single agent or with paclitaxel
      • Treatment of metastatic non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) gene changes (exon 19 or exon 21) as first-line therapy when used with erlotinib
      • Treatment of metastatic non-small cell lung cancer (NSCLC) that has continued to grow while on or after platinum-based chemotherapy when used with docetaxel
      • Treatment of metastatic colorectal cancer (mCRC) that has continued to grow while on or after prior therapy with bevacizumab, oxaliplatin, and a fluoropyrimidine when used with a FOLFIRI chemotherapy combination
      • Treatment of hepatocellular carcinoma (HCC) in patients who have an elevated alpha fetoprotein and have been treated with sorafenib when used as a single agent

    New medical policies

    Effective January 1, 2021

    ASAM Criteria: Services Reviewed for Medical Necessity, 10.01.532

    New policy

    • Effective for dates of service on and after January 1, 2021, American Society of Addiction Medicine (ASAM) criteria will be used to review for medical necessity for inpatient substance use disorder services for adults and adolescents
    • This policy only applies to Washington fully-insured groups, except (student insurance) GAIP and ISHIP

    Revised medical policies

    Effective December 1, 2020

    Balloon Dilation of the Eustachian Tube, 7.01.158

    Policy statement changed

    • Balloon dilation of the eustachian tube for treatment of patients with chronic obstructive eustachian tube dysfunction has been changed from investigational to medically necessary when criteria are met

    Medical necessity criteria added

    • Balloon dilation of the eustachian tube for treatment of patients age 22 and older with chronic obstructive eustachian tube dysfunction

    Revised pharmacy policies

    Effective December 1, 2020

    Chimeric Antigen Receptor Therapy for Hematologic Malignancies, 8.01.63

    New drug added to policy

    • Tecartus™ (brexucabtagene autoleucel)
      • Treatment of relapsed or refractory mantle cell lymphoma

    Drugs for Rare Diseases, 5.01.576

    New drug added to policy

    • Dojolvi™ (triheptanoin)
      • Treatment of long-chain fatty acid oxidation disorders (LC-FAOD)

    IL-5 Inhibitors, 5.01.559

    Drug with new indication

    • Nucala® (mepolizumab)
      • Treatment of adult and pediatric patients with hypereosinophilic syndrome (HES)

    Immune Checkpoint Inhibitors, 5.01.591

    Drugs with new indications

    • Opdivo® (nivolumab)
      • Treatment of unresectable malignant pleural mesothelioma as first-line treatment in combination with Yervoy® (ipilimumab)
    • Yervoy® (ipilimumab)
      • Treatment of unresectable malignant pleural mesothelioma as first-line treatment in combination with Opdivo® (nivolumab)

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605

    Antibiotics

    New drug added to policy

    • Cayston® (aztreonam)
      • Treatment to improve respiratory symptoms in patients age 7 and older with cystic fibrosis

    Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and Combinations

    Drug with new indication

    • Cambia® (diclofenac potassium for oral solution)
      • Acute treatment of migraine attacks in patients age 18 and older

    GnRH Receptor Antagonist Products

    New drug added to policy

    • Oriahnn® (elagolix, estradiol, and norethindrone acetate; elagolix)
      • Treatment of patients 18 and older for heavy menstrual bleeding associated with uterine fibroids

    Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502

    New drug added to policy

    • Monjuvi® (tafasitamab-cxix)
      • In combination with lenalidomide for the treatment of adult patients with relapsed or refractory diffuse large B-cell lymphoma (DLBCL)

    Pharmacotherapy of Arthropathies, 5.01.550

    Drugs with new indications

    • Tremfya® (guselkumab)
      • Second-line agent for the treatment of active psoriatic arthritis
    • Xeljanz® (tofacitinib)
      • Second-line agent for the treatment of polyarticular juvenile idiopathic arthritis

    Pharmacotherapy of Type I and Type II Diabetes Mellitus, 5.01.569

    Long-acting Insulin

    Drug added to Non-preferred

    • Semglee™ (glargine)

    DPP-4 and SGLT-2 Combination

    Drugs added to Preferred

    • Glyxambi® (empagliflozin + linagliptin)
    • Trijardy™ XR (empagliflozin + linagliptin + metformin)

    Drugs removed from Non-preferred

    • Glyxambi® (empagliflozin + linagliptin)
    • Trijardy™ XR (empagliflozin + linagliptin + metformin)

    Medical necessity criteria updated

    • In the DPP-4 and SGLT-2 Combination table, Non-preferred column, coverage criteria for Steglujan™ (ertugliflozin + sitagliptin) requires an adequate trial with Glyxambi® (empagliflozin + linagliptin), Qtern® (dapagliflozin + saxagliptin), or Trijardy™ XR (empagliflozin + linagliptin + metformin)

    Pharmacologic Treatment of HIV/AIDS, 5.01.588

    Policy renamed

    • From “Trogarzo® (ibalizumab)” to “Pharmacologic Treatment of HIV/AIDS”

    New drug added to policy

    • Rukobia® (fostemsavir)
      • Treatment of multidrug-resistant HIV-1 in adult patients

    Pharmacologic Treatment of Sleep Disorders, 5.01.599

    Drug with new indication

    • Wakix® (pitolisant)
      • Treatment of cataplexy in adult patients with narcolepsy

    Medical necessity criteria updated

    • Xywav® (calcium magnesium, potassium, and sodium oxybates)
      • The statement, “Prior therapy with Xyrem® (sodium oxybate) was ineffective, not tolerated, or contraindicated” now includes the following exception statement: “This may be granted if the patient has a concomitant diagnosis of heart failure, hypertension, or renal impairment.”

    Added codes

    Effective December 3, 2020

    Miscellaneous Oncology Drugs, 5.01.540
    Now requires review for medical necessity and prior authorization.

    J9039, J2820

    Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment, 5.01.517
    Now requires review for medical necessity and prior authorization.

    J9308


    Effective December 1, 2020

    Ablation of Peripheral Nerves to Treat Pain, 7.01.154
    Now requires review for investigative.

    0441T, 64624

    Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting, 2.02.24
    Now requires review for investigative.

    93701

    Intra-Articular Hyaluronan Injections for Osteoarthritis, 2.01.31
    Now requires review for medical necessity.

    J7333

    Microwave Tumor Ablation, 7.01.133
    Now requires review for medical necessity and prior authorization.

    47382, 50592

    Revised codes

    Effective December 1, 2020

    Balloon Dilation of the Eustachian Tube, 7.01.158
    Now reviewed for medical necessity (previously reviewed for investigative).

    C9745

  • Updates for only non-individual plans

  • Effective February 5, 2021

    InterQual® Criteria: Services Reviewed for Medical Necessity, 10.01.531

    This policy is updated to remove reference to services replaced with individual policies that address medical procedures and durable medical equipment. See the Special notices (above) under the Updates for non-individual and individual plans for the specific policies.

    No updates this month

  • Updates for only individual plans

  • Effective February 5, 2021

    Services Reviewed Using InterQual® Criteria, 10.01.530

    This policy is updated to remove reference to services replaced with individual policies that address medical procedures and durable medical equipment. See the Special notices (above) under the Updates for non-individual and individual plans for the specific policies.

    No updates this month

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