Pharmacologic Treatment of Osteoporosis, 5.01.596Forteo® (teriparatide), Tymlos® (abaloparatide), and Prolia® (denosumab) may be considered medically necessary when criteria are met. They are considered investigational when criteria are not met.
Synthetic Cartilage Implants for Joint Pain, 7.01.160Synthetic cartilage implants are considered investigational for the treatment of articular cartilage damage.
Pharmacotherapy of Arthropathies, 5.01.550The policy is revised to add dose frequency to Remicade® (infliximab), Inflectra® (infliximab-dyyb), and Renflexis®(infliximab-abda). The criteria for Orencia® (abatacept) are updated. Review the policy for full details.
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563The policy is revised to add dose frequency and age restriction to Remicade® (infliximab), Inflectra® (infliximab-dyyb), and Renflexis® (infliximab-abda). Review the policy for full details.
Absorbable Nasal Implant for Treatment of Nasal Valve Collapse, 7.01.163The insertion of an absorbable lateral nasal implant (eg, Latera®) for the treatment of symptomatic nasal valve collapse is considered investigational.
C5 Complement Inhibitors, 5.01.571The policy updates the criteria for Soliris® (eculizumab) for the indication of paroxysmal nocturnal hemoglobinuria. Criteria for the drug Ultomiris™ (ravulizumab-cwvz) are also added.
AIM Clinical Guidelines for Oncologic Imaging to Include PET RadiotracersAIM Specialty Health® Guidelines for Oncologic Imaging have been changed to include PET radiotracers. As of July 14, 2019, AIM will review prior authorization requests for both non-FDG (fluorodeoxyglucose) radiotracers and PET-CT.
Children's Therapeutic Positioning Equipment, 1.01.530Children’s positioning equipment such as reflux wedges, therapeutic positioning seats, and therapeutic positioning seats for use in vehicles may be considered medically necessary when criteria are met. Conventional positioning equipment used for children without positioning needs is excluded by contract and is not covered.
Hematopoietic Cell Transplantation for Primary Amyloidosis, 8.01.42This policy replaces policy 8.01.520. This is a new policy number only; there are no changes to policy statements.
Temporomandibular Joint Disorder, 2.01.535This policy replaces policy 2.01.21. This is a new policy number only; there are no changes to policy statements.
Amniotic Membrane and Amniotic Fluid, 7.01.149The policy is revised to add EpiCord to the medical necessity statement for diabetic lower extremity ulcers. Sutured and non-sutured amniotic membrane may be considered medically necessary for specified ophthalmic conditions.
Bariatric Surgery, 7.01.516The policy is revised to expand medical necessity criteria for revision and reoperation of bariatric surgical procedures.
Mastectomy for Gynecomastia, 7.01.521The policy is revised to add a medical necessity statement for non-malignant indications for mastectomy for gynecomastia.
Phosphate Binders, 5.01.598Auryxia® (ferric citrate), Phoslyra® (calcium acetate oral solution), Fosrenol® (lanthanum carbonate), Renagel® (sevelamer hydrochloride), Renvela® (sevelamer carbonate), and Velphoro® (sucroferric oxyhydroxide) may be considered medically necessary when criteria are met. They are considered investigational when criteria are not met.
BCR-ABL Kinase Inhibitors, 5.01.518The criteria for Tasinga® (nilotinib) are updated.
Dupixent® (dupilumab), 5.01.575The indication of atopic dermatitis is updated to include treatment for people 12 years old and older.
Excessively High Cost Drug Products with Lower Cost Alternatives, 5.01.560The policy is revised to add ZTildo™ (lidocaine topical system) and generic cyclobenzaprine extended release. Medical necessity criteria for Natpara® (parathyroid hormone) are also added.
Herceptin® (trastuzumab), 5.01.514The policy adds criteria for Trazimera™ (trastuzumab-qyyp), a biosimilar to Herceptin. The policy updates criteria for Tykerb® (lapatinib).
Hetlioz® (tasimelteon), 5.01.552The policy is revised to remove the requirement to try ramelteon first. Criteria now include documentation of International Classification of Sleep Disorders.
Immune Checkpoint Inhibitors, 5.01.591The policy is revised to update criteria for Tecentriq® (atezolizumab).
Management of Opioid Therapy, 5.01.529The policy adds Apadaz™ (benzhydrocodone/acetaminophen) and benzhydrocodone/acetaminophen to the list of short-acting opioids that need to meet medical necessity criteria. Buprenorphine patch is added to the list of long-acting opioids that need to meet criteria.
Migraine and Cluster Headache Medications, 5.01.503The policy adds criteria for approving additional quantities of Migranal® (dihydroergotamine) nasal spray.
Pharmacotherapy of Arthropathies, 5.01.550Simponi Aria® (golimumab for infusion) is added as second-line therapy for the indications of psoriatic arthritis and ankylosing spondylitis.
Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Patients, 5.01.517The criteria for Avastin® (bevacizumab) are updated for the indications of metastatic colorectal cancer and epithelial ovarian, fallopian tube, or primary peritoneal cancer.
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.
Deleted April 30, 2019
Hematopoietic Cell Transplantation for Primary Amyloidosis, 8.01.530. Replaced with policy 8.01.42.
Temporomandibular Joint Disorder, 2.01.21.Replaced with policy 2.01.535.
Amniotic Membrane and Amniotic Fluid, 7.01.149Now requires review for medical necessity, now requires prior authorization
65778 - Placement of amniotic membrane on the ocular surface; without sutures
65779 - Placement of amniotic membrane on the ocular surface; single layer, sutured
Auditory Brainstem Implant, 7.01.83Now requires review for medical necessity, now requires prior authorization
92640 - Diagnostic analysis with programming auditory brainstem implant per hour
S2235 - Implantation auditory brain stem implant
Implantable Bone Conduction and Bone-Anchored Hearing Aids, 7.01.547Now requires review for medical necessity, now requires prior authorization
L8625 - External recharging system for battery for use with cochlear implant or auditory osseointegrated device, replacement only, each
Migraine and Cluster Headache Medications, 5.01.503Now requires review for medical necessity
J3030 - Injection, sumatriptan succinate, 6 mg
Implantable Bone Conduction and Bone-Anchored Hearing Aids, 7.01.547No longer requires review for medical necessity, no longer requires prior authorization
L8695 - External recharging system for battery (external) for use with implantable neurostimulator, replacement only
Amniotic Membrane and Amniotic Fluid, 7.01.149Now reviewed for investigative (previously reviewed for medical necessity), no longer requires prior authorization
Q4137 - AmnioExcel, AmnioExcel Plus or BioDExcel, per sq cm
Q4139 - AmnioMatrix or BioDMatrix, injectable, 1 cc
Q4148 - Neox Cord 1K, Neox Cord RT, or Clarix Cord 1K, per sq cm
Q4155 - Neox Flo or Clarix Flo 1 mg
Q4156 - Neox 100 or Clarix 100, per sq cm
Q4162 - WoundEx Flow, BioSkin Flow, 0.5 cc
Q4163 - WoundEx, BioSkin, per sq cm
Amniotic Membrane and Amniotic Fluid, 7.01.149Currently reviewed for investigative, no longer requires prior authorization
Q4176 - NeoPatch, per sq cm
Q4177 - FlowerAmnioFlo, 0.1 cc
Q4178 - FlowerAmnioPatch, per sq cm
Q4180 - Revita, per sq cm
Q4181 - Amnio Wound, per sq cm
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