Medical Policy and Coding Updates March 2023

  • Updates for both non-individual and individual plans

  • Effective May 2, 2023

    Applied Behavioral Analysis (ABA), 3.01.510  PBC | Premera HMO
    Note added

    Applied behavioral analysis (ABA) may be considered medically necessary when criteria for Diagnosis, Initial Functional Behavioral Analysis, Initial Treatment Plan, ABA Treatment Services, ABA Treatment Services Settings, Continued Treatment are met. Some plans may not review all of the criteria listed in policy.

    Psychotherapy sessions
    Section removed

    Diagnosis

    Section added
    Medical necessity criteria updated

    • Updated diagnostic terminology for consistency with the DSM-5/DSM-5-TR
    • Expanded the types of clinicians who can diagnose Autism Spectrum Disorder

    Initial Functional Behavioral Analysis
    Section added

    Initial treatment plan
    Section added

    ABA treatment services
    Section added
    Medical necessity criteria updated

    Clarified that the maximum number of medically necessary hours of daily and weekly ABA services applies only treatment hours (not to other components of ABA)

    ABA treatment settings
    Section added
    Medical necessity criteria updated
    Updated the requirements for agencies to be considered to be ABA treatment services providers

    Continued treatment
    Section added
    Medical necessity criteria updated
    Clarified that the after the initial Functional Behavioral Analysis, Functional Behavioral Analysis re-assessments are considered to be medically necessary no more frequently than once every 6 months

    Applied Behavior Analysis (ABA) service providers
    Section updated

    • Expanded the types of clinicians who may provide direct treatment services
    • Clarified which ABA services can and cannot be provided by master’s and doctoral level clinicians who are not licensed to practice independently and can only practice under supervision

    Benefit application
    Section updated

    • Added a provision in the Benefit Application section that assessments and supporting assessments by behavioral technicians/therapy assistants/paraprofessionals are non-covered (excluded) services except when included in their legally permitted scope of licensure
    • Removed the restriction for group treatment sessions that only social skills group sessions are covered for ABA
    • Removed the limitation of a maximum of two group sessions daily
    • Added “Group treatment sessions are covered for only one clinician for an identified individual regardless of how many clinicians were present for a group session”
    • Added general parenting coaching, and training of nannies or au-pairs or similar persons, to the list of activities that are not considered to constitute ABA services

    Effective April 9, 2023

    Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
    (formerly AIM Specialty Health®)

    Effective for dates of service on and after April 9, 2023, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines for Advanced Imaging

    Updates by section

    Abdominal and pelvic imaging

    Abdominal/pelvic pain, undifferentiated
    Removed indication for MRI following nondiagnostic CT

    Uterine leiomyomata
    Added indication for advanced imaging when ultrasound suggests leiomyosarcoma

    Pancreatic indications
    Added indication for pancreatic duct dilatation

    Pancreatic mass
    Added allowance for more frequent follow-up of lesions with suspicious features or in high-risk patients

    Pancreatitis
    Removed allowance for MRI following nondiagnostic CT

    Pelvic floor disorders
    Added indication for MRI pelvis in chronic constipation when preliminary testing is nondiagnostic

    Brain imaging

    Bell’s palsy
    Limited the use of CT to scenarios where MRI cannot be performed

    Meningioma
    Added more frequent surveillance for WHO grade II/III

    Seizure disorder
    Added indication for advanced imaging in pediatric patients with nondiagnostic EEG

    Chest imaging

    Imaging abnormalities

    Added indication for evaluation of suspected tracheal or bronchial pathology

    Perioperative imaging
    Added indication for imaging prior to lung volume reduction procedures

    Head and neck imaging

    Perioperative imaging
    Added indication for imaging prior to facial feminization surgery

    Oncologic imaging

    Criteria aligned with National Comprehensive Cancer Network (NCCN) for the following:

    • Breast cancer screening
    • Cervical
    • Head and neck
    • Histiocytic neoplasms
    • Lymphoma (non-Hodgkin and leukemia)
    • Multiple myeloma
    • Thoracic
    • Thyroid

    Prostate cancer

    • Updated respective conventional imaging prerequisites for 18F Fluciclovine/11C PET/CT and 68Ga PSMA/18F-DCFPyL PET/CT, based on utility of conventional imaging at various PSA thresholds and removal of low risk disease waiver from conventional imaging footnote
    • Added 68Ga PSMA or 18F-DCFPyL PET/CT indication aligned with FDA-approved use of Pluvicto (radioligand) treatment for metastatic castrate-resistant disease

    Effective for dates of service on and after April 9, 2023, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines for Advanced Imaging of the Heart (formerly AIM Specialty Health®)

    Updates by section

    Cardiac Imaging

    CT coronary angiography (CCTA)
    Indications added

    • Abnormal prior testing
    • Expanded use for evaluation of CAD (now a first-line modality)
    • Preoperative testing

    Indication removed
    Suspected anomalous coronary arteries (basis for suspicion required)

    Fractional Flow Reserve from CCTA (FFR-CT)
    Indication updated

    Symptomatic person with 40 - 90% coronary stenosis who has failed guideline directed medical therapy and has undergone a CCTA within the previous 90 days

    Resting cardiac MRI
    Indication added

    Fabry disease
    Indications updated

    • Arrhythmogenic right ventricular dysplasia (ARVD) requirements
    • Suspected anomalous coronary arteries (basis for suspicion required)
    • Suspected myocarditis (basis for suspicion required)

    Resting transthoracic echocardiography (TTE)
    Valvular heart disease
    Criteria updated

    • Removed requirement of valvular dysfunction for those who had surgical mitral valve repair
    • Updated frequency of surveillance in patients with prosthetic valves and those who had transcatheter valve replacement/repair
    • Removed moderate/severe mitral regurgitation for those who had transcatheter mitral valve repair

    Stress cardiac MRI
    Indications added

    • Abnormal prior testing
    • Expanded use for evaluation of CAD (now a first-line modality)
    • Preoperative testing

    Stress testing with imaging
    Indications removed

    • Suspected CAD without symptoms
    • Established CAD with symptoms
    • Established CAD without symptoms

    Criteria updated

    • Modified indications for suspected CAD with symptoms
    • Determined need for testing by pretest probability
    • Expanded definition of “chest pain” to include ischemic equivalent pain elsewhere
    • Included dyspnea as a standalone symptom
    • Treating physician to select imaging modality
    • Clarified that exercise is preferred over pharmacologic testing in patients referred for stress testing with imaging
    • Clarified that patients with atypical symptoms to undergo non-imaging stress testing (assuming capable of exercise and no precluding resting EKG abnormalities)

    Effective for dates of service on and after April 9, 2023, the following updates will apply to the Carelon Medical Benefits Management Clinical Appropriateness Guidelines for Radiation Oncology (formerly AIM Specialty Health®)

    Updates by section

    Radiation Therapy

    Gastrointestinal (GI) cancers
    Removed plan comparison requirement for cholangiocarcinoma, esophageal, gastric, hepatocellular, and pancreatic cancer, because IMRT has become standard of care for curative treatment of these cancers

    Oligometastatic extracranial disease
    Added indication for adrenal metastases in SABR-COMET clinical trial

    Prostate cancer - brachytherapy
    Added indication for high-dose rate monotherapy in low- and intermediate-risk disease

    Image-guided radiation therapy (IGRT)

    • Added surface-based guidance technique (no change in coding)
    • Added statement that IGRT is not medically necessary to guide superficial radiotherapy for non-melanoma skin cancer (supported by American Society for Radiation Oncology clinical practice guideline)

    Therapeutic Radiopharmaceuticals

    Prostate cancer
    Added indication for Lutetium Lu 177 vipivotide tetraxetan (Pluvicto™), FDA approved for the treatment of adult patients with prostate-specific membrane antigen (PSMA)-positive metastatic castration-resistant prostate cancer who have been treated with AR pathway inhibition and taxane-based chemotherapy

    Effective March 1, 2023

    Drugs for Rare Diseases, 5.01.576  PBC | Premera HMO
    Medical necessity criteria updated

    Lumizyme® (alglucosidase alfa)

    • Added dose limit of no more than 20 mg per kg of body weight administered every 2 weeks

    Site of service review added

    • Mepsevii® (vestronidase alfa-vjbk)
    • Naglazyme® (galsulfase)

    Drug added
    Mepsevii® (vestronidase alfa-vjbk)

    • Treatment of mucopolysaccharidosis type VII (MPS VII; Sly syndrome)

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523  PBC | Premera HMO
    Drugs added

    • Mepsevii® (vestronidase alfa-vjbk)
    • Naglazyme® (galsulfase)

    New medical policies
    Effective March 1, 2023

    Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia, 7.01.175  PBC | Premera HMO
    New policy

    The use of a temporarily implanted nitinol device (e.g., iTind®) is considered investigational as a treatment of lower urinary tract symptoms due to benign prostatic hyperplasia.

    Testing Serum Vitamin D Levels, 2.04.507 PBC | Premera HMO
    Policy renumbered

    • This policy replaces Testing Serum Vitamin D Levels, 2.04.135
    • All policy statements remain unchanged

    Revised medical policies
    Effective March 1, 2023

    Hearing Aids (Excludes Implantable Devices), 1.01.528  PBC | Premera HMO
    Non-covered criteria updated

    Over-the counter, FDA-cleared hearing aids that are available without a prescription or exam by a hearing professional have been added to the list of non-covered equipment

    Knee Arthroscopy in Adults, 7.01.549  PBC | Premera HMO
    Intra-articular joint pathology

    Medical necessity criteria updated

    Made correction that all criteria are required instead of one criterion

    Power Operated Vehicles (Scooters) (Excluding Motorized Wheelchairs), 1.01.527  PBC | Premera HMO
    Medical necessity criteria added

    • Difficulty with moving around can't be resolved with a cane or a walker
    • The home allows for access between rooms and space and surfaces for movement of a power operated vehicle
    • The power operated vehicle is prescribed by a qualified, licensed healthcare provider after the person has been assessed by an appropriate medical professional (physical therapist, occupational therapist, or doctor) who documented the therapeutic purposes of the vehicle

    Treatment of Hyperhidrosis, 8.01.519  PBC | Premera HMO
    Medical necessity criteria added

    Added area-specific criteria for hyperhidrosis

    • Axillary
    • Palmar
    • Plantar
    • Craniofacial

    Criteria added

    • Initial authorization may be approved for up to one year
    • Re-authorization may be approved for up to 3 years

    New pharmacy policies

    No updates this month

    Revised pharmacy policies
    Effective March 1, 2023

    Botulinum Toxins, 5.01.512  PBC | Premera HMO
    Note added

    For specific HCPCS codes that are denied, the related injection code(s) will also be subject to denial

    Bruton’s Kinase Inhibitors, 5.01.590  PBC | Premera HMO
    Drug added

    Jaypirca™ (pirtobrutinib)

    • Treatment of mantle cell lymphoma (MCL) that has come back or can't be treated with surgery

    Drug with new indication
    Brukinsa® (zanubrutinib)

    • Treatment of adults with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL)

    Coverage Criteria of Excluded Drugs for Essentials Formulary, 5.01.572  PBC | Premera HMO
    Policy renamed

    From "Coverage Criteria of Excluded Drugs for Essentials Formulary" to "Coverage Criteria for Excluded Drugs"

    Removed from Related Information
    Reference to Essentials formulary

    Drugs for Rare Diseases, 5.01.576  PBC | Premera HMO
    Medical necessity criteria updated

    Enjaymo™ (sutimlimab-jome)

    • Removed requirement that the person receiving treatment has one documented red blood cell transfusion within the past 6 months
    • Removed requirement of documentation for reduction in red blood cell transfusions from baseline in re-authorization criteria

    Fabrazyme® (agalsidase beta)

    • This drug may not be used along with the drug Galafold® (migalastat)

    Galafold® (migalastat)

    • This drug may not be used along with the drug Fabrazyme® (agalsidase beta)

    Xenpozyme™ (olipudase alfa-rpcp)

    • Removed NPC1 and NPC2 from the requirement documenting genetic abnormalities

    Drugs for Weight Management, 5.01.621  PBC | Premera HMO
    All drugs in policy
    Medical necessity criteria updated

    Added requirement that other weight loss drugs may not be used with the drugs in the policy

    Appendix added
    BMI cut-offs for obesity by sex and age for people age 12 years and older

    Drug with new indication
    Wegovy® (semaglutide)

    • Chronic weight management in people between 12 and 17 years

    Pediatric use
    Medical necessity criteria updated

    • Qsymia® (phentermine/topiramate extended-release)
    • Saxenda® (liraglutide)
    • Xenical® (orlistat)
      • The requirement of a trial of behavior modification and dietary restriction has been reduced from 4 months to 3 months
      • Removed the criterion that the person has a BMI of ≥ 85th percentile but < 95th percentile for age and sex

    Pediatric use
    Reauthorization criteria updated

    • Qsymia® (phentermine/topiramate extended-release)
    • Saxenda® (liraglutide)
    • Xenical® (orlistat)
      • Removed the requirement that the person currently has a BMI > 85th percentile

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605  PBC | Premera HMO
    Brand drugs for ADHD and stimulants for other psychiatric conditions

    Medical necessity criteria updated

    Qelbree™ (viloxazine extended-release)

    • The dosage limit has been increased from 400 mg to 600 mg per day

    Brand oral antibiotics and their generics
    Drug added

    Minocycline ER

    Chronic kidney disease treatment
    Medical necessity criteria updated

    Kerendia® (finerenone)

    • Removed the requirement that eplerenone or spironolactone must be tried first

    Gout agents, brand
    Drug added

    Brand colchicine

    Quantity limits - Continuous glucose monitoring (CGM) supplies
    Product added

    Dexcom G7® Sensor

    Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
    Drug added

    Krazati™ (adagrasib)

    • Treatment of KRAS G12C-mutated non-small cell lung cancer (NSCLC) that is locally advanced or has spread to other parts of the body

    Drug with new indication
    Trodelvy™ (sacituzumab govitecan-hziy)

    • Treatment of HR-positive, HER2-negative breast cancer that is locally advanced or has spread to other parts of the body and can't be treated with surgery

    Medical necessity criteria updated
    Ibrance® (palbociclib)

    • Removed the requirement that the individual is postmenopausal

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  PBC | Premera HMO
    Crohn's disease

    Medical necessity criteria updated

    • Amjevita™ (adalimumab-atto)
    • Avsola ™ (infliximab-axxq)
    • Cimzia® (certolizumab pegol)
    • Entyvio® (vedolizumab)
    • Humira® (adalimumab)
    • Inflectra® (infliximab-dyyb)
    • Infliximab (Janssen – unbranded)
    • Remicade® (infliximab)
    • Renflexis® (infliximab-abda)
    • Skyrizi® (risankizumab-rzaa) IV
    • Skyrizi® (risankizumab-rzaa) SC
    • Stelara® (ustekinumab) IV
    • Stelara® (ustekinumab) SC
    • Tysabri® (natalizumab)
      • Added option for current use of a corticosteroid drug in the corticosteroid trial requirement
      • Added methylprednisolone and mesalamine extended-release (Pentasa® formulation) as examples of other drugs that may be tried to treat Crohn's disease

    Ulcerative colitis
    Medical necessity criteria updated

    • Amjevita™ (adalimumab-atto)
    • Avsola ™ (infliximab-axxq)
    • Entyvio® (vedolizumab)
    • Humira® (adalimumab)
    • Inflectra® (infliximab-dyyb)
    • Infliximab (Janssen – unbranded)
    • Remicade® (infliximab)
    • Renflexis® (infliximab-abda)
    • Simponi® (golimumab) SC
    • Stelara® (ustekinumab) IV
    • Stelara® (ustekinumab) SC
    • Zeposia® (ozanimod)
      • Removed the requirement the individual has tried and failed one traditional systemic agent or has pouchitis

    Pharmacotherapy of Multiple Sclerosis, 5.01.565  PBC | Premera HMO
    Drugs added

    • Briumvi™ (ublituximab-xiiy)
    • Generic fingolimod
      • Treatment of relapsing forms of multiple sclerosis, including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease

    Medical necessity criteria updated

    • Gilenya® (fingolimod)
    • Tascenso ODT™ (fingolimod)
      • The person must have tried generic fingolimod first before the drugs listed above may be prescribed

    Pharmacotherapy of Type I and Type II Diabetes Mellitus, 5.01.569  PBC | Premera HMO
    CD3-directed antibody (Intravenous)

    Drug added

    Tzield™ (teplizumab-mzwv)

    • To delay the onset of Stage 3 type 1 diabetes in people with Stage 2 type 1 diabetes in people age 8 years and older

    Sodium-glucose cotransporter 2 inhibitors (SGLT-2)
    Drug added to non-preferred

    Brenzavvy™ (bexagliflozin)

    No updates this month

    Effective March 1, 2023

    Testing Serum Vitamin D Levels, 2.04.135
    Content from this policy has been moved to Testing Serum Vitamin D Levels, 2.04.507

    Added codes
    Effective March 1, 2023

    Botulinum Toxins, 5.01.512  PBC | Premera HMO
    Now requires review for medical necessity and prior authorization.

    46505, 52287, 64611, 64612, 64615, 64616, 64617, 64642, 64643, 64644, 64645, 64646, 64647, 67345, S2340, S2341

    Drugs for Rare Diseases, 5.01.576  PBC | Premera HMO

    Now requires review for medical necessity, including site of service and prior authorization.

    J3397

    Treatment of Hyperhidrosis, 8.01.519  PBC | Premera HMO
    Now requires review for medical necessity and prior authorization.

    64650, 64653, 64818

    Revised codes
    Effective March 1, 2023

    Drugs for Rare Diseases, 5.01.576  PBC | Premera HMO
    Now requires review for site of service. Currently requires review for medical necessity and prior authorization.

    J1458

    Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease, 2.01.38  PBC | Premera HMO
    Now requires review for Prior Authorization. Currently requires review for Investigational.

    43201, 43257

  • Updates for only non-individual plans

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

  • No updates this month

    Revised codes
    Effective March 1, 2023

    Bariatric Surgery, 7.01.516  PBC
    No longer covered.

    43290, 43291, 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43889, 43888

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