Medical Policy and Coding Updates March 2020

  • Updates for both non-individual and individual plans

  • Effective June 5, 2020

    Miscellaneous Oncology Drugs, 5.01.540
    Darzalex® (daratumumab) has been added to the policy and may be considered medically necessary for the treatment of multiple myeloma in adults when used as a combination treatment or monotherapy when criteria are met.


    Effective May 17, 2020

    Effective for dates of service on and after May 17, 2020, the following updates by will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiology: Vascular Imaging

    Updates by section:

    • Aneurysm of the abdominal aorta or iliac arteries:
      • Added new indication for asymptomatic enlargement by imaging
      • Clarified surveillance intervals for stable aneurysms as follows:
        • Treated with endografts, annually
        • Treated with open surgical repair, every 5 years
    • Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified:
      • Added surveillance indication and interval for surgical bypass grafts

    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 criterion has changed from age 12 to age 6 and older. Nucala® (mepolizumab) medical necessity criteria have also been updated for the treatment of 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 of Ocrevus® (ocrelizumab) intravenous will now include site of service review. See policy for more details.

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523
    Medical necessity of Ocrevus® (ocrelizumab) intravenous will now include site of service review. See policy for more details.

    Revised medical policies

    Effective March 1, 2020

    Microprocessor-Controlled and Powered Prostheses and Orthoses for the Lower Limb, 1.04.05
    This policy has been retitled from “Microprocessor-Controlled and Powered Protheses for the Lower Limb” to “Microprocessor-Controlled and Powered Prostheses and Orthoses for the Lower Limb.” Microprocessor or electronic-stance-controlled orthoses for knees, ankle-foot, and knee-ankle-foot have been added to the policy and are considered investigational.

    Revised pharmacy policies

    Effective March 1, 2020

    Drugs for Rare Diseases, 5.01.576
    Tepezza™ (teprotumumab-trbw) has been added to the policy and may be considered medically necessary for the treatment of thyroid eye disease in adults age 18 and older when criteria are met. Medical necessity criteria have been updated for the following drugs for the treatment of type 1 Gaucher’s disease: Cerdelga® (eliglustat), Cerezyme® (imiglucerase), Elelyso® (taliglucerase alfa), generic miglustat, Zavesca® (miglustat), and Vpriv® (velaglucerase alfa). A diagnosis of type 1 Gaucher’s disease must be confirmed by genetic testing.

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605
    Palforzia™ [peanut (Arachis hypogaea) allergen powder-dnfp] has been added to the policy and may be considered medically necessary for the treatment of a confirmed peanut allergy in patients ages 4 and older when criteria are met. The following drugs have been added to the policy and may be considered medically necessary when criteria are met: Amzeeq™ (minocycline) for the treatment of moderate to severe acne; Secuado® (asenapine) as a second-generation antipsychotic; Consensi® (amlodipine and celecoxib) as a combination treatment after failure of a trial of generic amlopdipine with generic celecoxib; Tovet™ for the topical treatment of corticosteroid responsive conditions; Jatenzo® (testosterone capsules) and Striant® (testosterone buccal system) as testosterone replacement agents.

    Miscellaneous Oncology Drugs, 5.01.540
    A new indication for Lynparza® (olaparib) has been added to the policy. Lynparza® may be considered medically necessary for the maintenance treatment metastatic pancreatic adenocarcinoma in adults when criteria are met. A new indication for Zejula® (niraparib) has been added to the policy. Zejula® may be considered medically necessary for the treatment advanced ovarian, fallopian tube, or primary peritoneal cancer in adults when criteria are met.

    Pharmacologic Treatment of Sleep Disorders, 5.01.599
    Wakix® (pitolisant) has been added to the policy and may be considered medically necessary for the treatment of excessive daytime sleepiness in adults who have narcolepsy when criteria are met. Xyrem® (sodium oxybate) medical necessity criteria have been updated to include the definition of and required documentation of cataplexy.

    An archived policy is one that's no longer active and is not used for reviews.

    Archived March 1, 2020

    Dry Needling of Myofascial Trigger Points, 2.01.100

    Added codes

    Effective March 5, 2020

    Pharmacotherapy of Multiple Sclerosis, 5.01.565
    Now requires prior authorization, currently reviewed for medical necessity.

    J2350

    Effective March 1, 2020

    Bio-Engineered Skin and Soft Tissue Substitutes, 7.01.113
    Now requires review for investigative.

    A6460, A6461, Q4220, Q4222, Q4226

    Revised codes

    Effective March 1, 2020

    Bio-Engineered Skin and Soft Tissue Substitutes, 7.01.113
    Now reviewed for investigative (previously reviewed for medical necessity). No longer requires prior authorization.

    Q4179, Q4182

    Sacral Nerve Neuromodulation/Stimulation, 7.01.69
    Now requires review for medical necessity (previously investigational).

    64585, 64590, 64595

    Removed codes

    Effective March 1, 2020

    Dry Needling of Myofascial Trigger Points, 2.01.100

    No longer requires review as investigational.

    20560, 20561

  • Updates for only individual plans

  • No updates this month

    Revised codes

    No updates this month

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