Medical Policy and Coding Updates March 2022

  • Updates for both non-individual and individual plans

  • Effective June 3, 2022

    Phosphoinositide 3-kinase (PI3K) Inhibitors, 5.01.592

    Indication removed

    • Aliqopa® (copanlisib)
      • Treatment of chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) with this drug is not FDA-approved or supported by the National Comprehensive Cancer Network (NCCN)

    Effective March 13, 2022

    Updates to AIM Specialty Health® Clinical Appropriateness Guidelines

    Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging.

    Updates by section

    Brain imaging

    Acoustic neuroma

    • Removed indication for CT brain and replaced with CT temporal bone

    Meningioma

    • Added new guideline for follow-up intervals

    Pituitary adenoma

    • Removed allowance for CT following nondiagnostic MRI in macroadenoma

    Tumor, not otherwise specified

    • Added indication for management; excluded surveillance for lipoma and epidermoid without suspicious features

    Chest imaging

    Pneumonia

    • Removed indication for diagnosis of COVID-19 due to availability and accuracy of lab testing

    Pulmonary nodule

    • Revised criteria for follow-up of nodules detected on lung cancer screening CT based on Lung-RADS

    Head and neck imaging

    Parathyroid adenoma

    • Added situations where surgery is recommended based on American Association of Endocrine Surgeons guidelines

    Temporomandibular joint dysfunction

    • Added duration of required conservative management

    Abdominal and pelvic imaging

    Azotemia

    • Removed this indication

    Hematuria

    • Revised criteria for asymptomatic microhematuria based on American Urological Association guideline

    Intussusception

    • Removed this indication

    Jaundice

    • Added requirement for ultrasound prior to advanced imaging in pediatric patients

    Sacroiliitis

    • Added situations where advanced imaging is indicated (predisposing condition or equivocal radiographs)

    Uterine leiomyomata (fibroids)

    • Added requirement for ultrasound prior to MRI
    • Expanded indication to include most other fertility-sparing procedures

    Oncologic imaging

    • Updated recommendations based on the National Comprehensive Cancer Network (NCCN) for the following:
      • Breast cancer
      • Hodgkin lymphoma
      • Non-Hodgkin lymphoma
      • Melanoma
      • Neuroendocrine tumors
      • Soft tissue sarcoma
      • Testicular cancer
      • Thyroid cancer

    Breast cancer

    • Updated clinical scenarios in chart for diagnostic breast MRI and PET/CT for management

    Cancer screening

    • Added indication for hepatocellular carcinoma screening
    • Added age criteria for pancreatic cancer

    Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging of the Heart

    Updates by section

    Cardiac imaging

    Coronary CT Angiography

    • Removed indication for patients undergoing evaluation for transcatheter aortic valve implantation/replacement who are at moderate coronary artery disease risk

    Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiation Oncology

    • Removed Eastern Cooperative Oncology Group (ECOG) status as definition for performance status throughout guidelines

    New medical policies
    Effective March 1, 2022

    Laser Interstitial Thermal Therapy for Neurological Conditions, 7.01.170

    Laser interstitial thermal therapy (LITT) is considered investigational for all neurological conditions


    Revised medical policies
    Effective March 1, 2022

    Preventive Care, 10.01.523

    Policy statements updated

    • Definitions of preventive, diagnostic, therapeutic, or surveillance added to colorectal cancer screening section

    New pharmacy policies

    Effective March 1, 2022

    Thymic Stromal Lymphopoietin (TSLP) Inhibitors, 5.01.627

    New policy

    Drug added

    • Tezspire® (tezepelumab)
      • Add-on maintenance treatment of severe asthma in patients age 12 years and older

    Revised pharmacy policies
    Effective March 1, 2022

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605

    Hypnotics

    Drug added

    • Quviviq™ (daridorexant)
      • Treatment of insomnia

    Intranasal Brand Corticosteroid Products

    Drug added

    • Ryaltris™ (olopatadine hydrochloride and mometasone furoate monohydrate)
      • Treatment of allergic rhinitis

    SARS-CoV-2 Inhibitors

    Quantity limits added

    • Molnupiravir
    • Paxlovid™ (nirmatrelvir tablets; ritonavir tablets)
      • 1 treatment course every 90 days

    Pharmacologic Treatment of High Cholesterol, 5.01.558

    New drugs added

    • Leqvio® (inclisiran)
      • Treatment of clinical atherosclerotic cardiovascular disease (ASCVD)
    • Brand rosuvastatin/ezetimibe
      • Treatment of high cholesterol

    Pharmacotherapy of Arthropathies, 5.01.550

    Ankylosing Spondylitis

    New drugs added

    • Xeljanz® (tofacitinib)
    • Xeljanz® XR (tofacitinib extended-release)

    Medical necessity criteria updated

    • Cimzia® (certolizumab pegol)
    • Cosentyx® (secukimumab)
    • Simponi® (golimumab) SC
    • Simponi Aria® (golimumab) IV
      • Xeljanz® (tofacitinib) and Xeljanz® XR (tofacitinib extended-release) have been added to the list of drugs that must be tried before the above drugs can be prescribed

    Polyarticular Juvenile Idiopathic Arthritis

    Medical necessity criteria updated

    • Xeljanz® (tofacitinib) oral
    • Xeljanz® Oral Solution (tofacitinib)
      • The patient must have tried Enbrel® (etanercept) or Humira® (adalimumab) before the above drugs can be prescribed

    Medical necessity criteria updated

    • Orencia® (abatacept) IV/SC
    • Simponi Aria® (golimumab) IV
      • Xeljanz® Oral Solution (tofacitinib) has been added to the list of drugs that must be tried before the above drugs can be prescribed

    Rheumatoid Arthritis

    Medical necessity criteria updated

    • Rinvoq™ (upadacitinib)
    • Xeljanz® (tofacitinib)
    • Xeljanz® XR (tofacitinib extended-release)
      • The patient must have tried Enbrel® (etanercept) or Humira® (adalimumab) before the above drugs can be prescribed

    Psoriatic Arthritis

    New drug added

    • Rinvoq™ (upadacitinib)

    Medical necessity criteria updated

    • Xeljanz® (tofacitinib)
    • Xeljanz® XR (tofacitinib extended-release)
      • The patient must have tried Enbrel® (etanercept) or Humira® (adalimumab) before the above drugs can be prescribed

    Medical necessity criteria updated

    • Cimzia® (certolizumab pegol)
    • Cosentyx® (secukimumab)
    • Orencia® (abatacept) IV/SC
    • Simponi® (golimumab) SC
    • Simponi Aria® (golimumab) IV
      • Rinvoq® (upadacitinib) has been added to the list of drugs that must be tried before the above drugs can be prescribed

    Phosphoinositide 3-kinase (PI3K) Inhibitors, 5.01.592

    Indication removed

    • Copiktra® (duvelisib)
      • Treatment of follicular lymphoma (FL) that has returned or can't be treated with surgery

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

    No updates this month. 

    Colorectal Cancer Screening, 10.01.519

    Content from this policy has been moved to Preventive Care, 10.01.523

    Added codes

    Effective March 13, 2022

    AIM® Specialty Health Advanced Imaging

    Now reviewed by AIM® Specialty Health and requires prior authorization.

    0042T, 0648T, 0649T, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T

  • Updates for only non-individual plans

  • No updates this month
    No updates this month
  • Updates for only individual plans

  • No updates this month

    Added codes

    March 1, 2022

    Wireless Capsule Endoscopy, 2.01.538

    Now requires review for medical necessity and prior authorization.

    91112, 91113

  •    Email this article