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:
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.
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.
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.
Wheelchairs (Manual or Motorized), 1.01.501 The policy statements were revised to state that:
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:
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.
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.
Diagnosis and Treatment of Sacroiliac Joint Pain, 6.01.23 (replaced with policy 6.01.524, effective March 1, 2018)
Nonpharmacologic Treatment of Rosacea, 2.01.519 (replaced with policy 2.01.71, effective June 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])
Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA, 4.01.21Now 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
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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