Medical Policy and Coding Updates November 2018

  • Effective February 1, 2019

    Cervical Spine Surgeries: Discectomy, Laminectomy, and Fusion in Adults, 7.01.560
    The policy is updated to include statements for posterior cervical fusion, cervical discectomy, and cervical laminectomy. Title is changed to Cervical Spine Surgeries: Discectomy, Laminectomy, and Fusion in Adults.

    Policy 9.03.28, Corneal Collagen Cross-Linking, is a policy that’s no longer active and not used for reviews, as of July 1, 2019.

    Lanadelumab and HAE Drugs, 5.01.587
    This policy lists the medical necessity criteria for the following drugs for hereditary angioedema:

    • For treatment of acute attacks: Berinert® (pdC1-INH), Firazyr® (icatibant), Kalbitor® (ecallantide), Ruconest® (rhC1-INH)
    • For long-term prophylaxis of acute attacks: Cinryze® (pdC1-INH), Haegarda® (pdC1-INH), Takhyzro® (lanadelumab)

    Trogarzo™ (ibalizumab), 5.01.588
    Trogarzo™ (ibalizumab) may be considered medically necessary in the treatment of HIV-1 patients when criteria are met.

    Effective January 4, 2019

    Genetic Testing: Services Reviewed by AIM, 10.01.526
    As announced in September and October, AIM Specialty Health® will review genetic testing services beginning on January 4, 2019. This administrative policy identifies the specific Premera policies that will be deleted on January 4, 2019, the date that AIM will begin conducting reviews using AIM Clinical Appropriateness Guidelines for Genetic Testing.

    Surgical Treatments for Lymphedema, 7.01.162
    Lymphatic physiologic microsurgery to treat lymphedema in individuals who have been treated for breast cancer is considered investigational. Lymphatic physiologic microsurgery performed during nodal dissection or breast reconstruction to prevent lymphedema in individuals who are being treated for breast cancer is considered investigational.
    Note: The services originally described in this policy are now found in policy 7.01.567 Surgical Treatments for Lymphedema.

    Update to AIM Radiation Oncology clinical appropriateness guidelines

    Effective January 28, 2019

    Update to AIM Radiation Oncology clinical appropriateness guidelines

    Breast cancer

    • Removed age and tumor size criteria for accelerated whole breast irradiation (AWBI)

    Rectal cancer

    • The modified criteria no longer limits treatment with IMRT for rectal adenocarcinoma

    Pancreatic cancer

    • Added criteria for SBRT in treating locally advanced or recurrent disease without evidence of distant metastasis

    Head and neck cancer

    • Added criteria to allow IMRT for head and neck lymphomas
    • Clarified no IMRT for stage I/II glottic cancer

    Lung cancer

    • Added DVH parameter for cardiac V50

    Sarcoma

    • Removed preoperative and joint sparing requirements for IMRT

    Prostate cancer

    • Added discussion on hypofractionation
    • Added discussion on brachytherapy

    Update to AIM Cardiology clinical appropriateness guidelines

    Effective January 28, 2019

    Carotid duplex ultrasound

    • Criteria removed for evaluation of syncope in patients with suspected extracranial arterial disease
    • New criteria address evaluation of TAVR (TAVI) in patients with suspected or established extracranial arterial disease

    Myocardial perfusion imaging (MPI), stress echocardiography, cardiac PET, and coronary CT angiography (CCTA)

    • Clarifications address exercise-induced syncope and exercise-induced dizziness, lightheadedness, or near syncope in symptomatic patients with suspected coronary artery disease

    MPI, stress echocardiography, cardiac PET

    • Criteria added to allow annual surveillance of coronary artery disease in patients with established CAD post-cardiac transplant
    • Clarified definition of established coronary artery disease when diagnosed by CCTA
      • more restrictive for patients diagnosed with coronary artery disease by prior coronary angiography, as FFR must be ≤0.8
      • more permissive for patients diagnosed with coronary artery disease by CCTA with FFR ≤0.8 (patients previously excluded)

    Resting transthoracic echocardiography (TTE)

    • New criteria for evaluation of ventricular function in patients who have undergone cardiac transplantation

    Cardiac MRI

    • New criteria allows for annual study to quantify cardiac iron load in chronically ill patients with cardiomyopathy who require frequent blood transfusions (eg, thalassemia)
    • Removed allowance for annual LV function evaluation when echocardiography is suboptimal

    Effective December 6, 2018

    Ablative Treatments for Occipital Neuralgia, Chronic Headaches, and Atypical Facial Pain, 7.01.563
    Ablative procedures for the treatment of chronic headaches, occipital neuralgia, and persistent idiopathic facial pain/atypical facial pain are considered investigational.

    Pulsed Radiofrequency, 7.01.564
    Pulsed radiofrequency for the treatment of various chronic pain syndromes is considered investigational.

    Revised medical policies

    November 1, 2018

    Adoptive Immunotherapy, 8.01.01
    Medical necessity criteria for chimeric antigen receptor (CAR) T cell therapies are now addressed in this policy.

    Preimplantation Genetic Testing in Embryos, 12.04.305
    The word “fertile” is removed from the first policy statement as the criteria apply to both fertile and infertile couples.
    Note: Effective January 4, 2019, the services originally described in this policy are reviewed by AIM Specialty Health®.

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523
    The policy is reorganized, with minor edits to policy statements for clarity.

    Treatment of Varicose Veins/Venous Insufficiency, 7.01.519
    The policy statement criteria are reordered and clarified by procedure type rather than vein type. Criteria are added for the number of treatment sessions of initial sclerotherapy, and criteria for additional secondary sclerotherapy are added.

    New pharmacy policies

    Effective November 1, 2018

    BRAF and MEK Inhibitors, 5.01.589
    BRAF and MEK inhibitors are considered medically necessary for treating unresectable or metastatic melanoma with a BRAF V600E or V600K variant. Indications are updated based on FDA labeling. Content is transferred from policy 5.01.534 into this policy. Criteria for Braftovi™ (encorafenib) and Mektovi® (binimetinib) are added.

    Bruton’s Kinase Inhibitors, 5.01.590
    Criteria for Imbruvica® (ibrutinib) and Calquence® (acalabrutinib) are transferred from policy 5.01.534 into this policy. Indications are updated based on FDA labeling.

    Gene Therapy for Inherited Retinal Dystrophy, 2.04.144
    Voretigene neparvovec-rzyl adeno-associated virus vector-based gene therapy (Luxturna™) subretinal injection is considered medically necessary for patients with vision loss due to biallelic RPE65 variant-associated retinal dystrophy meeting criteria. This policy replaces 8.01.536.

    Immune Checkpoint Inhibitors, 5.01.591
    Criteria for Imfinzi® (durvalumab), Keytruda® (pembrolizumab), Opdivo® (nivolumab), Tecentriq® (atezolizumab), and Yervoy® (ipilimumab), and are transferred from policy 5.01.540 into this policy. Criteria are added for Libtayo® (cemiplimab).

    Revised pharmacy policies

    November 1, 2018

    CGRP Inhibitors for Migraine Prophylaxis, 5.01.584
    Medical necessity criteria are added for Emgality™ (galcanezumab).

    Epidermal Growth Factor Receptor (EGFR) Inhibitors, 5.01.603
    Criteria are added for Visimpro® (dacomitinib), and all indications are updated based on FDA labeling.

    Hemlibra® (emicizumab‐kxwh), 5.01.581
    The criteria are updated to reflect the FDA expanded indication for hemophilia A with or without anti‐factor VIII.

    Kalydeco® (ivacaftor), Orkambi® (lumacaftor/ivacaftor), and Symdeko™ (tezacaftor/ivacaftor), 5.01.539
    This policy updates the age criterion for Orkambi® (lumacaftor/ivacaftor) to 2 years old, instead of 6 years old.

    Medical Necessity Criteria and Dispensing Quantity Limits for Exchange Formulary Benefits, 5.01.547
    This policy is revised to include HIV drug quantity limits.

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605
    This policy now includes criteria for Epidiolex® (cannabidiol), Orilissa® (elagolix), Jynarque™ (tolvaptan), Qbrexza™ (glycopyrronium cloth), Plixda™ (adapalene), and all branded single-source oral NSAIDs. Criteria are also added for the purpose of establishing statin intolerance.

    Miscellaneous Oncology Drugs, 5.01.540
    This policy is revised as follows:

    • Added medical necessity criteria for Tibsovo® (ivosidenib)
    • Updated indications for all agents per FDA labeling
    • Organized the drugs listed in the policy by pharmacology
    • Moved immunotherapy drugs to new policy 5.01.591

    Multiple Receptor Tyrosine Kinase Inhibitors, 5.01.534
    This policy is revised as follows:

    • Added new label indication for Lenvima® (lenvatinib) for hepatocellular carcinoma
    • Added Braftovi™ (encorafenib) and Mektovi® (binimetinib) for BRAF V600 mutated melanoma
    • Moved all BRAF and MEK inhibitors to new policy 5.01.589
    • Moved Bruton’s Kinase Inhibitors, Imbruvica™ (ibrutinib) and Calquence® (acalabrutinib), to new policy 5.01.590
    • Reorganized policy and updated indications per FDA labeling

    Pharmacotherapy of Multiple Sclerosis, 5.01.565
    Medical necessity criteria are added for Ocrevus™ (ocrelizumab) as first-line therapy for relapsing-remitting multiple sclerosis. For Copaxone 40 mg, the criterion is added that a generic equivalent must be tried first.

    Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Patients, 5.01.517
    The policy updates Avastin® (bevacizumab) criteria for ovarian cancer based on FDA labeling.

    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 November 1, 2018

    Chimeric Antigen Receptor (CAR) T Cell Therapies 5.01.580. The policy is deleted and the information is moved to 8.01.01.

    Gene Therapy for Inherited Retinal Dystrophy with Luxturna™ (voretigene neparvovec) 8.01.536. The policy is deleted and is replaced with 2.04.144.

    Archived policies

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

    Archived November 1, 2018

    Plasma Exchange 8.02.02

    Added codes

    Effective November 1, 2018

    Total Artificial Hearts and Implantable Ventricular Assist Devices, 7.03.11
    Now reviewed for investigative

    33992 - Removal of percutaneous ventricular assist device at separate and distinct session from insertion

    Total Artificial Hearts and Implantable Ventricular Assist Devices, 7.03.11
    Now reviewed for medical necessity, now requires prior authorization

    33975 - Insertion of ventricular assist device; extracorporeal, single ventricle

    33976 - Insertion of ventricular assist device; extracorporeal, single biventricular

    33979 - Insertion of ventricular assist device, implantable intracorporeal, single ventricle

    33981 - Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single or each pump

    33982 - Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary bypass

    33983 - Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, with cardiopulmonary bypass

    Effective November 2, 2018

    Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting, 2.02.24
    Now reviewed for investigative

    93701 - Bioimpedance-derived physiologic cardiovascular analysis

    Alcohol Injections for Treatment of Peripheral Neuromas, 2.01.97

    Ablation Procedures for Peripheral Neuromas, 7.01.147
    Now reviewed for investigative

    64632 - Destruction by neurolytic agent; plantar common digital nerve

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