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.
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.