Medical Policy and Coding Updates February 2020

  • Updates for both non-individual and individual plans

  • Effective July 2, 2020

    InterQual® Services, 10.01.531
    This policy outlines the specific services the Plan will begin using InterQual® criteria to review against and will replace the following medical policies for dates of service July 2, 2020, and after:

    InterQual® criteria may vary from the medical policies listed above. The plan will begin to review some pediatric services for medical necessity. Sign in to our provider website to view InterQual® criteria and these changes.


    Effective May 17, 2020

    Updates to Updates to AIM Specialty Health® Clinical Appropriateness Guidelines

    Effective for dates of service on and after May 17, 2020, the following updates by will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiology: Vascular Imaging

    Updates by section:

    • Aneurysm of the abdominal aorta or iliac arteries:
      • Added new indication for asymptomatic enlargement by imaging
      • Clarified surveillance intervals for stable aneurysms as follows:
        • Treated with endografts, annually
        • Treated with open surgical repair, every 5 years
    • Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified:
      • Added surveillance indication and interval for surgical bypass grafts

    Effective April 3, 2020

    Herceptin® (trastuzumab) and Other HER2 Inhibitors, 5.01.514
    Trazimera™ (trastuzumab-qyyp), a biosimilar to Herceptin® (trastuzumab), has been changed to a first-line biosimilar for the treatment of HER2-postive breast cancer, HER2-postive metastatic gastric cancer, and HER2-postive gastroesophageal junction adenocarcinoma when criteria are met. The biosimilars Herzuma® (trastuzumab-pkrb), Kanjinti™ (trastuzumab-anns), Ogivri™ (trastuzumab-dkst) and Ontruzant® (trastuzumab-dttb) are second-line biosimilars and require an inadequate response or intolerance to Herceptin® or Trazimera™ when criteria are met.

    IL-5 Inhibitors, 5.01.559
    Nucala® (mepolizumab) medical necessity criteria has been updated for the treatment of patients with severe eosinophilic asthma. Age criteria has changed from age 12 to age 6 and older. Nucala® (mepolizumab) medical necessity criteria has also been updated for the treatment of with eosinophilic granulomatosis with polyangiitis (EGPA) in adults to include blood eosinophil levels and documented evidence of polyangiitis, vasculitis, mononeuritis, or systemic symptoms.

    Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502
    Polivy™ (polatuzumab vedotin-piiq) has been added to the policy and may be considered medically necessary for the treatment of diffuse large B-cell lymphoma (DLBCL) in adults when criteria are met. Ruxience™ (rituximab-pvvr), a biosimilar to Rituxan® (rituximab), has been added to the policy as a first-line biosimilar and may be considered medically necessary for non-Hodgkin’s lymphoma and chronic lymphocytic leukemia. Truxima® (rituximab-abbs) is a second-line biosimilar and requires an inadequate response or intolerance to Rituxan® or Ruxience™ when criteria are met.

    Pharmacotherapy of Arthropathies, 5.01.550
    Ruxience™ (rituximab-pvvr) has been added to the policy and may be considered medically necessary as a second-line anti-CD20 agent when criteria are met.

    Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564
    Ruxience™ (rituximab-pvvr) has been added to the policy and may be considered medically necessary as a first-line treatment for systemic lupus erythematosus when criteria are met.

    Pharmacotherapy of Thrombocytopenia, 5.01.566
    Ruxience™ (rituximab-pvvr) and Truxima® (rituximab-abbs) have been added to the policy and may be considered medically necessary as anti-CD20 agents in for the treatment of chronic immune thrombocytopenia when criteria are met.

    Rituximab: Non-oncologic and Miscellaneous Uses, 5.01.556
    Ruxience™ (rituximab-pvvr), a biosimilar to Rituxan® (rituximab), has been added to the policy as a first-line biosimilar and may be considered medically necessary when criteria are met. Truxima® (rituximab-abbs) is a second-line biosimilar and requires an inadequate response or intolerance to Rituxan® or Ruxience™ when criteria are met.

    Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology, 5.01.517
    Zirabev™ (bevacizumab-bvzr), a biosimilar to Avastin® (bevacizumab), has been changed to a first-line biosimilar and may be considered medically necessary when criteria are met. Mvasi™ (bevacizumab-awwb) is a second-line biosimilar and requires an inadequate response or intolerance to Avastin® (bevacizumab) or Zirabev™ (bevacizumab-bvzr) when criteria are met.


    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) intravenous 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) intravenous 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® Clinical Appropriateness Guidelines for Genetic Testing

    Genetic Testing for Hereditary Cancer Susceptibility 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® Clinical Appropriateness Guidelines for Radiology

    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® Clinical Appropriateness Guidelines for Radiation Oncology

    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® Clinical Appropriateness Guidelines for Sleep Disorder Management

    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

    Revised medical policies

    Effective February 1, 2020

    Cosmetic and Reconstructive Services, 10.01.514
    Medical necessity criteria have been added to the policy for the following reconstructive services: genioplasty, labiaplasty, otoplasty/pinnaplasty, rhytidectomy, scar revision, skin tag removal, and tattoo as part of breast reconstructive surgery. The following services have been added to the list of cosmetic procedures: canthopexy/canthoplasty, facial bone reduction or enhancement, laser skin resurfacing, lip augmentation, liposuction for body contouring for alteration of appearance, and vaginal rejuvenation.

    Revised pharmacy policies

    Effective February 1, 2020

    Drugs for Rare Diseases, 5.01.576
    Generic miglustat and Zavesca® (miglustat) have been added to the policy and may be considered medically necessary for patients age 18 and older for the treatment of Type 1 Gaucher’s disease when criteria are met.

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605
    The following drugs have been added to the policy and may be considered medically necessary when criteria are met: Aklief® (trifarotene) for the treatment of acne; Xcopri® (cenobamate) for adult patients for the treatment of partial-onset seizures; Dayvigo® (lemborexant) for adult patients for the treatment of insomnia; Ibsrela® (tenapanor) for the treatment of irritable bowel syndrome with constipation (IBS-C); Scenesse® (afamelanotide) for patients age 18 and older for the treatment of erythropoietic protoporphyria (EPP). Criteria for Pulmozyme® (dornase alfa) have been updated for the treatment of cystic fibrosis. In patients under age 5, a documented forced expiratory volume (FEV1) value is no longer required. Travoprost has been added to the list of generics which must be tried and failed for a patient to qualify for coverage for brand ophthalmic prostaglandin analogs for the treatment of intraocular pressure with glaucoma.

    Miscellaneous Oncology Drugs, 5.01.540
    Inrebic® (fedratinib) has been added to the policy and may be considered medically necessary for adults for the treatment of intermediate-2 or high-risk primary or secondary (polycythemia vera or post-essential thrombocythemia) myelofibrosis (MF) when criteria are met.

    Pharmacologic Treatment of Cystic Fibrosis with Ivacaftor Products, 5.01.539
    Policy title has been changed from Kalydeco® (ivacaftor), Orkambi® (lumacaftor/ivacaftor), and Symdeko™ (tezacaftor/ivacaftor) to Pharmacologic Treatment of Cystic Fibrosis with Ivacaftor Products. Trikafta™ (elexacaftor/tezacaftor/ivacaftor) has been added to the policy and may be considered medically necessary for patients age 12 and older for the treatment of cystic fibrosis when criteria are met.

    Pharmacologic Treatment of Idiopathic Pulmonary Fibrosis, 5.01.555
    New indication for Ofev® (nintedanib) has been added to the policy and may be considered medically necessary for the treatment of idiopathic pulmonary fibrosis and for patients age 18 and older for the treatment of systemic sclerosis-associated interstitial lung disease (SSc-ILD) when criteria are met.

    Pharmacotherapy of Multiple Sclerosis, 5.01.565
    Vumerity™ (diroximel fumarate) has been added to the policy and may be considered medically necessary for adults for the treatment of relapsing forms of multiple sclerosis, including clinically isolated syndrome, relapse-remitting disease, and active secondary progressive disease when criteria are met. Tecfidera® (dimethyl fumarate) medical necessity criteria have been updated to include the following relapsing forms of multiple sclerosis: clinically isolated syndrome, relapse-remitting disease, and active secondary progressive disease.

    Added codes

    Effective March 5, 2020

    Pharmacotherapy for Multiple Sclerosis, 5.01.565
    Now requires review for site of service as part of medical necessity and prior authorization.

    J2350

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523
    Now requires review for site of service as part of medical necessity and prior authorization.

    J2350


    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® Clinical Appropriateness Guidelines for Radiation Oncology

    Now requires review for medical necessity and prior authorization.

    55874


    Effective February 1, 2020

    Cognitive (Neurologic) Rehabilitation in the Outpatient Setting, 8.03.504
    Now requires review for outpatient rehabilitation through eviCore.

    97129, 97130

    Cosmetic and Reconstructive Services, 10.01.514
    Now requires review for cosmetic and reconstructive.

    67950

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

    J9214

    Myoelectric Prosthetic and Orthotic Components for the Upper Limb, 1.04.502
    Now requires review for investigative.

    L2006

    Wheelchairs (Manual or Motorized), 1.01.501
    Now considered noncovered.

    E2372

    Revised codes

    Effective February 1, 2020

    Allergy Testing, 2.01.500
    Now reviewed for medical necessity (previously reviewed for investigative).

    95060

    Multimarker Serum Testing Related to Ovarian Cancer, 2.04.62
    Currently reviewed for investigative. No longer requires prior authorization.

    0003U

    Wheelchairs (Manual or Motorized), 1.01.501
    Currently reviewed for medical necessity. Now requires prior authorization.

    E0988

    Removed codes

    Effective February 1, 2020

    Miscellaneous Oncology Drugs, 5.01.540

    No longer requires review for medical necessity and prior authorization.

    J9213

  • Updates for only individual plans

  • 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.

    Added codes

    Effective February 21, 2020

    Massage Therapy, 8.03.506

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

    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

  •    Email this article