Medical Policy and Coding Updates March 2018

  • Special notice: new medical policies effective in June

    Effective June 1, 2018

    Drugs for Rare Diseases, 5.01.576

    These drugs may be considered medically necessary when the criteria in the policy are met. Each drug below is also reviewed for site of service administration:

    • Cerezyme® (imiglucerase)
    • Elaprase® (idursulfase)
    • Fabrazyme® (agalsidase beta)
    • Lumizyme® (alglucosidase alfa)
    • Vimizim® (elosulfase alfa)
    • Vpriv® (velaglucerase alfa)

    Nonpharmacologic Treatment of Rosacea, 2.01.71
    Nonpharmacologic treatment of rosacea, including but not limited to laser and light therapy, dermabrasion, chemical peels, surgical debulking and electrosurgery, is considered investigational. Replaces policy 2.01.519.

    Site of Service, Select Surgical Procedures, 11.01.524
    Preferred medically necessary sites of service for elective surgical procedures are off campus-outpatient hospital/medical center, on campus-outpatient hospital/medical center, and ambulatory surgical center. When select elective procedures are requested at an inpatient hospital/medical center the plan will review the site of service to ensure this site is medically necessary. Consult the policy of the full list of elective surgical procedures and inpatient hospital/medical center inclusion criteria.

    Exondys 51® (eteplirsen), 5.01.570
    Exondys 51® (eteplirsen) is subject to review for site of service administration.

    Special notice: new medical policies effective in April

    Effective April 4, 2018

    Cognitive (Neurologic) Rehabilitation, 8.03.504
    Note: This policy has been renumbered to 8.03.10, effective April 1, 2020.
    This policy was previously archived and is now being reinstated. Cognitive (neurologic) rehabilitation programs may be considered medically necessary for patients with cognitive impairment due to traumatic brain injury when criteria are met. It is considered investigational for other indications.

    New medical policy

    Effective March 1, 2018

    Diagnosis and Treatment of Sacroiliac Joint Pain, 6.01.524
    Diagnosis and treatment of sacroiliac joint pain and open SIJ fusion are considered medically necessary when criteria are met. Arthrography and radiofrequency denervation of the sacroiliac joint as well as percutaneous and minimally invasive SIJ fusion/stabilization procedures are considered investigational. This policy replaces 6.01.23.

    Revised medical policy

    Effective March 1, 2018

    Wheelchairs (Manual or Motorized), 1.01.501
    The policy statements were revised to state that:

    • Tie downs for manual wheelchairs are considered convenience items and are not covered.
    • Gear reduction drive wheel, lever-activated wheel drives, custom fabricated cushions, nonstandard wheelchairs, power attendant control, and leg elevation systems may be considered medically necessary when criteria are met.
    • Powered add-on accessories, powered seat elevation systems, seat elevator power wheelchairs, and manual standing systems are considered not medically necessary.

    Revised pharmacy policies

    Effective February 14, 2018

    Exondys 51® (eteplirsen), 5.01.570

    Immune Globulin Therapy, 8.01.503

    Nulojix® (belatacept) for Adults, 5.01.536

    Pharmacotherapy of Miscellaneous Autoimmune Disease, 5.01.564

    Rituximab: Non-oncologic and Miscellaneous Uses, 5.01.556

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523

    Soliris® (eculizumab), 5.01.571

    Pharmacotherapy of Arthropathies, 5.01.550
    Approval of site-of-service administration is expanded to 90 days for initial infusion. The medical necessity criteria statements were update as follows:

    • The Xeljanz® (tofacitinib) /Xeljanz XR® criteria were updated for rheumatoid arthritis.
    • Xeljanz/Xeljanz XR were added as a first-line agent for psoriatic arthritis when criteria are met.
    • Taltz™ (ixekizumab) was added as a second-line agent for psoriatic arthritis and may be approved when criteria are met.
    • Taltz and Siliq™ (ixekizumab) criteria for psoriatic arthritis were changed to state that in addition to existing criteria, these agents need to be prescribed by or in consultation with a dermatologist.

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
    Approval of site-of-service administration is expanded to 90 days for initial infusion. The policy was revised to move Stelara® (ustekinumab) from a second-line agent to a first-line agent for Crohn disease; the mandatory use of Humira® (adalimumab) for this indication was removed.

    Effective March 1, 2018

    Kalydeco® (ivacaftor), Orkambi® (lumacaftor/ivacaftor), and Symdeko™ (tezacaftor/ivacaftor), 5.01.539
    The policy was revised to add Symdeko™ (tezacaftor/ivacaftor) for the treatment of cystic fibrosis in patients 12 years old and older when criteria are met.

    Excessively High Cost Drug Products with Lower Cost Alternatives, 5.01.560
    Brand name topical lidocaine products are not medically necessary unless there are documented failures of topical generic lidocaine products.

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605
    The policy was revised to add Adzenys ER™ (amphetamine) to the list of brand stimulants requiring review for the treatment of ADHD and other psychiatric conditions.

    Miscellaneous Oncology Drugs, 5.01.540
    The policy was revised to add a statement of medical necessity and the criteria for Lynparza™ (olaparib) for gBRCAm, HER2-negative metastatic breast cancer.

    Pharmacologic Treatment of Neuropathy, Fibromyalgia, and Seizure Disorders, 5.01.521
    The criteria were updated to include coverage of Lyrica® CR (pregabalin extended release) for adults with diabetic peripheral neuropathy or postherpetic neuralgia when criteria are met.

    Pharmacotherapy of Type 1 and Type II Diabetes Mellitus, 5.01.569
    The policy was revised to add Admelog® (lispro) and Admelog Solostar® (lispro) as nonpreferred rapid acting insulin products. Steglatro® (ertugliflozin) is now a preferred SGLT-2 agent.

    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.

    Deleted on February 28, 2018

    Diagnosis and Treatment of Sacroiliac Joint Pain, 6.01.23 (replaced with policy 6.01.524, effective March 1, 2018)

    To be deleted on May 31, 2018

    Nonpharmacologic Treatment of Rosacea, 2.01.519 (replaced with policy 2.01.71, effective June 1, 2018)

    Added codes

    Effective March 1, 2018

    Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions, 7.01.78

    Now requires medical necessity review, now requires prior authorization

    27415 - Osteochondral allograft, knee, open

    27416 - Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s])

    28446 - Open osteochondral autograft, talus (includes obtaining graft[s])

    29866 - Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s])

    Revised codes

    Effective March 1, 2018

    Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA, 4.01.21
    Now reviewed for investigative, no longer reviewed for medical necessity

    81422 - Fetal chromosomal microdeletion(s) genomic sequence analysis (eg, DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood

    Removed codes

    Removed as of January 1, 2018

    Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer, 12.04.36
    No longer reviewed for medical necessity, no longer 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

    Genetic Testing for Mental health Conditions 12.04.515
    No longer reviewed for investigative, no longer requires prior authorization

    0015U - Drug metabolism (adverse drug reactions), DNA, 22 drug metabolism and transporter genes, real-time PCR, blood or buccal swab, genotype and metabolizer status for therapeutic decision support

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