Medical Policy and Coding Updates January 2020

  • 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) IV will now include review for site of service. 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 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 Guidelines contain 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® Radiology 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® 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 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.

    Individual plans only

    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.

    Revised medical policies

    Effective January 1, 2020

    Preventive Care, 10.01.523
    The policy has been updated to include depression screening and psychotherapy for parents with higher risk of perinatal depression any time during pregnancy and up to 1 year after delivery or adoption.

    Revised pharmacy policies

    Effective January 1, 2020

    BRAF and MEK Inhibitors, 5.01.589
    Tafinlar® (dabrafenib) and Mekinist® (trametinib) combination therapy may be considered medically necessary for other medical conditions when criteria are met, including melanoma with BRAF mutations, metastatic non-small cell lung cancer with BRAF mutations, and anaplastic thyroid cancer. Monotherapy medical necessity criteria for Tafinlar® (dabrafenib), Zelboraf® (vemurafenib), and Mekinist® (tramtenib) have been added to the policy for the treatment of metastatic melanoma.

    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.

    Migraine and Cluster Headache Medications, 5.01.503
    Reyvow™ (lasmiditan) has been added to the policy for the treatment of acute episodic migraine in adults 18 and older when medical necessity 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.

    Pharmacotherapy of Type I and Type II Diabetes Mellitus, 5.01.569
    Rybelsus® (semaglutide oral) has been added as a preferred GLP-1 receptor agonist.

    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.

    A deleted policy is one whose number is no longer used but the content is either moved into another policy or replaced with a new policy and number.

    Group plans only

    Effective November 30, 2019

    Upper Gastrointestinal Endoscopy (UGI) for Adults, 2.01.533

    Treatment of Varicose Vein/Venous Insufficiency, 7.01.519

    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

    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® Clinical Appropriateness Guidelines for Radiation Oncology

    Now requires review for medical necessity and prior authorization.

    55874

    Added codes

    Effective January 3, 2020

    Drugs for Rare Diseases, 5.01.576
    Now requires review for medical necessity including site of service. Now requires prior authorization.

    J3060

    Leadless Cardiac Pacemakers, 2.02.32
    Now requires review for medical necessity. Now requires prior authorization.

    33274

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

    J9213

    Added codes

    Effective January 1, 2020

    Ablation of Peripheral Nerves to Treat Pain, 7.01.565
    Now requires review, may be considered investigational.

    64624, 64625

    Cosmetic and Reconstructive Services, 10.01.514
    Now requires review, considered cosmetic.

    15771, 15772, 15773, 15774

    Cranial Electrotherapy Stimulation and Auricular, 8.01.58
    Now requires review, considered investigational.

    K1002

    Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors, 7.01.92
    Now requires review, considered investigational.

    0581T

    Dry Needling of Myofascial Trigger Points, 2.01.100
    Now requires review, considered investigational.

    20560, 20561

    Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome, 9.03.29
    Now requires review, considered investigational.

    0563T

    Focal Treatments for Prostate Cancer, 8.01.61
    Now requires review, considered investigational.

    0582T

    Hip Arthroplasty, 7.01.573
    Now requires review for medical necessity. Now requires prior authorization.

    27130, 27132, 27134, 27137, 27138

    In Vitro Chemoresistance and Chemosensitivity Assays, 2.03.01
    Now requires review for Investigational and prior authorization.

    0564T

    Islet Transplantation, 7.03.12
    Now requires review for medical necessity and prior authorization.

    0584T, 0585T, 0586T

    Measurement of Serum Antibodies to Selected Biologic Agents, 2.04.516
    Now requires review, may be considered investigational.

    80145, 80230, 80280

    Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502
    Now requires review for medical necessity. Now requires prior authorization.

    J9309

    Non-covered Services and Procedures, 10.01.517
    Now considered non-covered.

    K1003

    Therapeutic Radiopharmaceuticals in Oncology, 6.01.525
    Now requires review for medical necessity. Now requires prior authorization.

    A9590

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

    E2398

    Removed codes

    Effective January 1, 2020

    Cognitive (Neurologic) Rehabilitation in the Outpatient Setting, 8.03.504
    No longer requires review for medical necessity. No longer requires prior authorization.

    97127

    Cosmetic and Reconstructive Services, 10.01.514
    No longer requires review for medical necessity. No longer requires prior authorization.

    65760, 65765, 65767

    Dopamine Transporter Imaging with Single-Photon Emission Computed Tomography, 6.01.54
    No longer requires review for medical necessity. No longer requires prior authorization.

    78607

    Gender Reassignment Surgery, 7.01.557
    No longer requires review for medical necessity. No longer requires prior authorization.

    19304

    Revised codes

    Effective January 1, 2020

    Nonpharmacologic Treatment of Rosacea, 2.01.71
    Requires review and prior authorization, considered investigational.

    17106, 17107, 17108

    Proteomic Testing for Systemic Therapy in Non-Small Cell Lung Cancer, 2.04.125
    No longer requires prior authorization, considered investigational.

    81538

    Added codes

    AIM Specialty Health®

    Effective January 1, 2020

    AIM Specialty Health® Radiology Clinical Appropriateness Guidelines

    78429, 78430, 78431, 78433

    AIM Specialty Health® Genetic Testing Clinical Appropriateness Guidelines

    0153U, 0154U, 0155U, 0156U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 81277, 81308, 81309, 81522, 81542, 81552

    Removed codes

    AIM Specialty Health®

    Effective January 1, 2020

    AIM Specialty Health® Genetic Testing Clinical Appropriateness Guidelines

    0081U

    Individual plans only

    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

    Group plans only

    Removed codes

    Effective November 30, 2019

    Upper Gastrointestinal Endoscopy (UGI) for Adults, 2.01.533
    No longer require review or prior authorization.

    43235, 43238, 43239, 43242

    Treatment of Varicose Vein/Venous Insufficiencys, 7.01.519
    No longer require review or prior authorization.

    0524T, 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785

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