Revised medical policies
Effective July 1, 2017
Genetic Testing for Alzheimer Disease, 12.04.13
Genetic testing for early-onset Alzheimer disease may be considered medically necessary when criteria are met. Genetic testing for the late-onset form continues to be considered investigational.
Note: Effective January 4, 2019 the services originally described in this policy are reviewed by AIM Specialty Health®.
Genetic Testing of CADASIL Syndrome, 12.04.75
Testing of symptomatic and presymptomatic family members of people with CADASIL syndrome may be considered medically necessary when criteria are met.
Note: Effective January 4, 2019 the services originally described in this policy are reviewed by AIM Specialty Health®.
New pharmacy policies
Effective July 1, 2017
Quantity Limits for Opioid Drugs, 5.01.579
This policy lists the criteria for approving opioids dispensed in excess of FDA labeled limits. The services originally described in this policy are now found in policy 5.01.529 Management of Opioid Therapy.
Radicava IV, 5.01.578
Radicava (edaravone) may be considered medically necessary for amyotrophic lateral sclerosis when criteria are met. Read the full policy.
Revised pharmacy policies
Effective July 1, 2017
ALK Tyrosine Kinase Inhibitors, 5.01.538
Added coverage criteria for Alunbrig (brigatinib). Read the full policy.
Medical Necessity Criteria for Pharmacy Edits, 5.01.605
Removed criteria for non-insulin diabetic drugs because they are listed in policy 5.01.569. Added medical necessity criteria for Xyrosa (doxycycline), Minolira (minocycline HCl), Livalo
(pitavastatin), Trulance (plecanatide), and Xermelo (telotristat ethyl). Read the full policy.
Miscellaneous Oncology Drugs, 5.01.540
Added coverage criteria for Kisqali (ribociclib), Zejula (niraparib), Bavencio (avelumab), Rydapt (midostaurin), and Imfinzi (durvalumab). Read the full policy.
Pharmacotherapy of Arthropathies, 5.01.550
Added coverage criteria for Renflexis (infliximab-abda). Read the full policy.
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
Added coverage criteria for Renflexis (infliximab-abda). Read the full policy.
Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564
Added coverage criteria for Actemra (tocilizumab) for the treatment of giant cell arteritis. Read the full policy.
Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors, 5.01.558
Updated diagnostic criteria for clinical atherosclerotic cardiovascular disease to exclude angina. Clarified the use of PCSK9 inhibitors for homozygous and heterozygous
familial hypercholesterolemia. Specified when a PCSK9 inhibitor might be used for primary versus secondary prevention. Read the full policy.
Coding updates
Added codes
Effective July 1, 2017
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer, 12.04.36
Requires medical necessity review and requires prior authorization
S3854 Gene expression profiling panel for use in the management of breast cancer treatment
Closure Devices for Patent Foramen Ovale and Atrial Septal Defects , 2.02.09
Requires prior authorization
93580 Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration, atrial septal defect) with implant
Cutaneous T-Cell Lymphomas (CTCL): Systemic Therapies, 5.01.532
Prior authorization is now required (currently reviewed for medical necessity)
J9315 Injection, romidepsin, 1 mg
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
Now requires review for medical necessity and requires prior authorization
Q9989 Ustekinumab, for intravenous injection, 1 mg
Soliris (eculizumab), 5.01.571
Now requires review for medical necessity and requires prior authorization
J1300 Injection, eculizumab, 10 mg
Revised codes
Effective July 1, 2017
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer, 12.04.36
Revised from investigative review; requires medical necessity review and requires prior authorization
0008M Oncology (breast), mRNA analysis of 58 genes using hybrid capture, on formalin-fixed paraffin-embedded (FFPE) tissue, prognostic algorithm reported as a risk score
Cosmetic and Reconstructive Services, 10.01.514
Revised from medical necessity review; will now be reviewed for cosmetic/reconstructive
21280 Medial canthopexy (separate procedure)
21282 Lateral canthopexy
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease, 2.01.38
Revised from medical necessity review; will now be considered investigative
43210 Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders, 12.04.102
Revised from investigative review; requires medical necessity review
81415 Exome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis
81416 Exome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (e.g., parents, siblings) (List separately in addition to code for primary procedure)
81417 Exome (e.g., unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained exome sequence (e.g., updated knowledge or unrelated condition/syndrome)
Removed codes
Effective July 1, 2017
Artificial Intervertebral Disc: Cervical Spine, 7.01.108
No longer requires review for medical necessity and no longer requires prior authorization
22864 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical
Cosmetic and Reconstructive Services, 10.01.514
Removed from cosmetic review
15788 Chemical peel, facial; epidermal
15789 Chemical peel, facial; dermal
15792 Chemical peel, nonfacial; epidermal
15793 Chemical peel, nonfacial; dermal