Medical Policy and Coding Updates March 2021

  • Updates for both non-individual and individual plans

  • Effective May 10, 2021

    Updates to AIM Specialty Health® Clinical Appropriateness Guidelines

    Effective for dates of service on and after May 10, 2021, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Molecular Testing of Solid and Hematologic Tumors and Malignancies

    Updates by section:

    Conditions for which testing may be medically necessary (Table 1)

    The following solid tumor markers were added:

    • Cholangiocarcinoma: FGFR2 and FoundationOne® CDx
    • Colorectal cancer: Praxis Extended RAS panel
    • Neuroblastoma: chromosomal microarray analysis (CMA), MYCN, ALK
    • Non-small cell lung cancer (NSCLC): Oncomine Dx Target Test
    • Ovarian cancer: myChoice® CDx
    • Prostate cancer (Suspected): SelectMDx
    • Prostate cancer: FoundationOne® CDx
    • Tumor agnostic/all solid tumors: microsatellite instability (MSI) and FoundationOne® CDx

    Breast Cancer Gene Expression Classifiers

    • Criteria were clarified to confirm the patient has undergone surgery and full pathological staging
    • Additional statement added explaining testing is not medically necessary to guide decision making for extended endocrine therapy
    • OncotypeDx Recurrence Score test: the definition of unfavorable histological features was clarified

    Minimal Residual Disease (MRD)

    • Testing criteria were revised to require testing performed on bone marrow

    Targeted Molecular Testing for NTRK Fusions

    • Criteria were revised

    Prostate Cancer (symptomatic cancer screening)

    • Added criteria for SelectMDx (81479)
    • Criteria for PCA3 (81313), ExomeDx (0005U) and ConfirmMDx (81551) were revised

    Effective May 6, 2021

    Hereditary Angioedema, 5.01.587

    Medical necessity criteria updated

    • Berinert® (pdC1-INH)
      • Added coverage for acquired angioedema
    • Cinryze® (pdC1-INH)
      • Added patient age, limits to danazol use, and acute HAE frequency requirements
    • Firazyr® (icatibant)
      • Requires use of generic icatibant first
    • Haegarda® (pdC1-INH)
      • Added limits to danazol use and acute HAE frequency requirements
    • Ruconest® (rhC1-INH)
      • Age criteria revised to patients 13 and older
    • Takhzyro® (lanadelumab-flyo)
      • Added limits to danazol use, acute HAE frequency requirements, and quantity limit

    Effective April 7, 2021

    Immune Globulin Therapy, 8.01.503

    Site of service review added

    • Xembify®

    Miscellaneous Oncology Drugs, 5.01.540

    New drug added to policy

    • Jelmyto™ (mitomycin)
      • Treatment of adult patients with low-grade upper tract urothelial cancer (LG-UTUC)

    Site of Service Infusion Drugs and Biologic Agents, 11.01.523

    Site of service review added

    • Xembify®

    Effective March 14, 2021

    Updates to AIM Specialty Health® Clinical Appropriateness Guidelines

    Effective for dates of service on and after March 14, 2021

    The following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging

    Updates by section:

    Brain Imaging

    Ataxia, congenital or hereditary

    • Combined with congenital cerebral anomalies to create one section

    Acoustic neuroma

    • More frequent imaging for a watch and wait or incomplete resection
    • New indication for neurofibromatosis type 2 (NF 2)
    • More frequent imaging when MRI shows findings suspicious for recurrence
    • Single post-operative MRI following gross total resection
    • Included pediatrics with known acoustics (rare but NF 2)

    Tumor – not otherwise specified

    • Repurposed for surveillance imaging of low-grade neoplasms

    Seizure disorder and epilepsy

    • Limited imaging for the management of established generalized epilepsy
    • Required optimal medical management (aligning adult and pediatric language) prior to imaging for management in epilepsy

    Headache

    • Removed response to treatment as a primary headache red flag
    • Included pregnancy as a red flag risk factor

    Mental status change and encephalopathy

    • Added requirement for initial clinical and lab evaluation to assess for a more specific cause

    Brain Imaging and Head and Neck Imaging

    Hearing loss

    • Added CT temporal bone for evaluation of sensorineural hearing loss in any pediatric patients or in adults for whom MRI is nondiagnostic or unable to be performed
    • Higher allowed threshold for consecutive frequencies to establish SNHL
    • Removed CT brain as an alternative to evaluating hearing loss based on ACR guidance

    Tinnitus

    • Removed sudden onset symmetric tinnitus as an indication for advanced imaging

    Chest Imaging and Head and Neck Imaging

    Hoarseness, dysphonia, and vocal cord weakness/paralysis – primary voice complaint

    • Required laryngoscopy for the initial evaluation of all patients with primary voice complaint

    Head and Neck Imaging

    Sinusitis/rhinosinusitis

    • Added more flexibility for the method of conservative treatment in chronic sinusitis
    • Required conservative management prior to repeat imaging for patients with prior sinus CT

    Temporomandibular joint dysfunction

    • Removed requirement for radiographs/ultrasound

    Cerebrospinal fluid (CSF) leak of the skull base

    • Added scenario for management of known leak with change in clinical condition

    Oncologic Imaging

    General content changes to align with current oncology recommendations

    • Removed indications/parameters not addressed by NCCN
    • Average risk inclusion criteria added for CT colonography
    • New allowances added for MRI abdomen and/or MRI pelvis by tumor type, liver metastatic disease
    • New indications added for acute leukemia (CT, PET/CT), multiple myeloma (MRI, PET/CT), ovarian cancer surveillance (CT), bone sarcoma (PET/CT)
    • Updated standard imaging pre-requisites prior to PET/CT for bladder/renal pelvis/ureter, colorectal, esophageal/GE junction, gastric and non-small cell lung cancers
    • Additional PET/CT management scenarios added for cervical cancer, Hodgkin lymphoma

    Cancer screening

    • New indication added for pancreatic cancer screening

    Breast cancer

    • New PET/CT indication added for restaging/treatment response for bone-only metastatic disease and limitation of post-treatment breast MRI after breast conserving therapy or unilateral mastectomy

    Prostate Cancer

    • MRI pelvis: removed TRUS biopsy requirement, allowance if persistent/unexplained elevation in PSA or suspicious DRE

    Axumin PET/CT

    • Updated inclusion criteria (removed general MRI pelvis requirement, additional allowance for rising PSA with non-diagnostic mpMRI)

    Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging of the Heart

    Updates by section:

    Evaluation of patients with cardiac arrhythmias

    • Updated repeat TTE criteria
    • Added restrictions for patients whose initial echocardiogram shows no evidence of structural heart disease, and follow-up echocardiography is not appropriate for ongoing management of arrhythmia

    Evaluation of signs, symptoms, or abnormal testing

    • Added restrictions for TTE in evaluation of palpitation and lightheadedness based on literature

    Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiation Oncology

    Updates by section:

    Special Treatment Procedure

    • Removed IV requirement for chemotherapy

    CNS cancer: IMRT for glioblastomas, other gliomas, brain metastases

    • Eliminated the plan comparison requirement based on feedback from reviewers that essentially all cases were able to meet criteria - same change for high-grade and low-grade gliomas
    • Added new indication for hippocampal sparing whole brain radiotherapy

    Lung cancer: IMRT and SBRT for non-small cell, SBRT for small cell; fractionation for non-small cell

    • Eliminated the plan comparison requirement for IMRT to treat stage III non-small cell lung cancer
    • Removed “due to a medical contraindication” language
    • Added new indication as an alternative to surgical resection when certain conditions apply
    • Adjusted fractions of thoracic radiotherapy for non-small cell lung cancer

    Proton Beam Therapy

    • Added new indication for hepatocellular carcinoma and intrahepatic cholangiocarcinoma

    New medical policies

    Effective March 1, 2021

    Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions, 7.01.165

    New policy

    • Radiofrequency coblation tenotomy is considered investigational as a treatment for musculoskeletal conditions

    Revised medical policies

    Effective March 1, 2021

    Skilled Hourly Nursing Care in the Home, 11.01.522

    Medical necessity criteria updated

    • The following clarifying statements have been added to the policy:
      • "The skilled nursing services are performed in the home as an alternative to a more acute care setting (eg, hospital, skilled nursing facility), or to assist with a transition of care from an acute care setting."
      • "There is a primary caregiver in the home who is willing and has the ability to be trained to care for the patient and assume and be responsible for the patient’s care when the nurse is not in the home or once the patient’s condition has stabilized."

    Documentation requirements updated

    • The following documentation requirement has been added: "The specific number of skilled nursing hours being requested as well as the anticipated duration of the skilled nursing services to be provided."

    Revised pharmacy policies

    Effective March 1, 2021

    Drugs for Rare Diseases, 5.01.576

    New drug added to policy

    • Imcivree™ (setmelanotide)
      • Treatment of chronic weight management due to POMC, PCSK1, or LEPR deficiency

    Medical necessity criteria updated

    • Firdapse® (amifampridine)
      • Age limitation of age 18 or older has been removed
      • Patient must have tried Ruzurgi® (amifampridine) first
    • Ruzurgi® (amifampridine)
      • The age limitation of age 18 and older has been removed

    Epidermal Growth Factor Receptor (EGFR) Inhibitors, 5.01.603

    Drug with new indication

    • Tagrisso® (osimertinib)
      • Treatment after surgery in patients with non-small cell lung cancer (NSCLC) whose tumors have EGFR exon 19 deletions or exon 21 L858R mutations

    Herceptin® (trastuzumab) and Other HER2 Inhibitors, 5.01.514

    New drugs added to policy

    • Generic lapatinib
      • Treatment of HER2-positive breast cancer
    • Margenza™ (margetuximab-cmkb)
      • Treatment of metastatic HER2-positive breast cancer

    Drug with new indication

    • Enhertu® (fam-trastuzumab deruxtecan-nxki)
      • Treatment of gastric or gastroesophageal junction adenocarcinoma

    Medical necessity criteria updated

    • Tykerb® (lapatinib)
      • Patient must have tried and failed generic lapatinib first

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605

    Anticonvulsants

    Medical necessity criteria updated

    • The initial authorization period for all anticonvulsant drugs has been updated to 3 years

    Brand Gabapentin Products

    Drug with new indication

    • Gralise® (gabapentin extended-release)
      • Treatment of neuropathic pain

    Brand Topical Acne or Rosacea Products

    New drugs added to policy

    • Arazlo™
    • Atralin®
    • Soolantra®

    Cystic Fibrosis

    New policy section

    New drug added to policy

    • Bronchitol® (mannitol)
      • Treatment of cystic fibrosis in adults age 18 or older

    Added codes

    Effective March 3, 2021

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605
    Now requires review for medical necessity and prior authorization.

    J9216

    Vascular Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders, 5.01.620
    Now requires review for medical necessity and prior authorization.

    J0178, J0179, J2503, J2778


    Effective March 1, 2021

    Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.48
    Now requires review for medical necessity and prior authorization as well as site of service.

    S2112

    Bioengineered Skin and Soft Tissue Substitutes, 7.01.582
    Now requires review for investigative.

    Q4104

    Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors, 7.01.92

    Now requires review for investigative and prior authorization.

    20983

    Wheelchairs (Manual or Motorized), 1.01.501
    Now requires review for medical necessity and prior authorization.

    E0988, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1011, E1110, E1280

    Revised codes

    Effective March 1, 2021

    Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease, 2.01.38
    Now requires review for investigative and prior authorization.

    43236

    Removed codes

    Effective March 1, 2021

    Bioengineered Skin and Soft Tissue Substitutes, 7.01.582
    No longer requires review for investigative.

    Q4114


    Effective February 5, 2021

    InterQual® Services, 10.01.531
    No longer requires review for medical necessity and prior authorization.

    95961, L4631

  • Updates for only non-individual plans

  • No updates this month

    No updates this month

  • Updates for only individual plans

  • No updates this month

    No updates this month

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