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Policy 9.03.28, Corneal Collagen Cross-Linking, is a policy that’s no longer active and not used for reviews, as of July 1, 2019.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