Medical Policy and Coding Updates November 2021

Effective February 4, 2022

Adjunctive Techniques for Screening and Surveillance of Barrett Esophagus and Esophageal Dysplasia, 7.01.167

• Wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS3D) is considered investigational for all indications, including but not limited to the screening and surveillance of Barrett esophagus and esophageal dysplasia

Drugs for Rare Diseases, 5.01.576

Site of service review added

• Adakveo® (crizanlizumab-tmca)
• Aldurazyme® (laronidase)
• Kanuma® (sebelipase alfa)

Hereditary Angioedema, 5.01.587

Site of service review added

• Cinryze® (pdC1-INH)

IL-5 Inhibitors, 5.01.559

Site of service review added

• Cinqair® (reslizumab)

Medical necessity criteria updated

• Nucala® (mepolizumab)
  Indication: Treatment of adults with eosinophilic granulomatosis with polyangiitis (EGPA)
  • Requirement added that patient has been taking prednisone or prednisolone
  Indication: Treatment of adults and children age 12 years and older with hypereosinophilic syndrome (HES)
  • Genetic testing is required to confirm that the patient does not have FIP1L1-PDGFRA kinase-positive HES 
  • Requirement has been added that the patient has been taking background HES therapy prior to treatment with this drug

Immune GlobulinTherapy, 8.01.503

Site of service review added

• Asceniv™ (immune globulin intravenous, human - slra)

Intravitreal Corticosteroids, 5.01.619

New policy

New drugs added

• Iluvien® (fluocinolone acetonide intravitreal implant)
  • Treatment of diabetic macular edema (DME) in patients age 18 years and older
• Ozurdex® (dexamethasone intravitreal implant)
  • Treatment of macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO) in patients age 18 years and older
  • Treatment of non-infectious uveitis of the posterior segment of the eye in patients age 18 years and older
  • Treatment of diabetic macular edema (DME) in patients age 18 years and older
• Retisert® (fluocinolone acetonide intravitreal implant)
  • Treatment of chronic non-infectious uveitis affecting the posterior segment of the eye in patients age 12 years and older
• Yutiq® (fluocinolone acetonide intravitreal implant)
  • Treatment of chronic non-infectious uveitis of the posterior segment of the eye in patients age 18 years and older

Pharmacologic Treatment of Duchenne Muscular Dystrophy, 5.01.570

•    Amondys 45® (casimersen)

Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563

• Stelara® (ustekinumab) IV 
• Stelara® (ustekinumab) SC

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564

• Uplizna™ (inebilizumab-cdon)

Pharmacotherapy of Arthropathies, 5.01.550

Site of service review added

• Stelara® (ustekinumab)

Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers, 1.01.18

Policy statement added

• The use of lymphedema pumps applied to the head and neck to treat lymphedema has been added to the list of investigational conditions

Site of Service: Infusion Drugs and Biologic Agents, 11.01.523

New drugs added

• Adakveo® (crizanlizumab-tmca)
• Aldurazyme® (laronidase)
• Amondys 45™ (casimersen)
• Asceniv™ (immune globulin intravenous, human – slra)
• Cinqair® (reslizumab)
• Cinryze® (C1 esterase inhibitor [human])
• Kanuma® (sebelipase alfa)
• Stelara® (ustekinumab) IV
• Stelara® (ustekinumab) SC
• Uplizna® (inebilizumab-cdon)

 Total Artificial Hearts and Implantable Ventricular Assist Devices, 7.03.11

Medical necessity criteria updated

• For implantable ventricular assist devices (VADs) for end-stage heart failure, criteria updated based on the 2020 MOMENTUM 3 clinical trial
  • Criterion added of cardiac index while patient is not on inotropes
  • Heart transplant ineligibility criteria removed

Xolair® (omalizumab), 5.01.513

Medical necessity criteria updated

Indication: Treatment of moderate to severe asthma in adults and children age 6 years and older

• Requirement added that an adult patient is not a smoker, or is enrolled in a smoking cessation program
• Requirement added that the patient weighs between 44 and 330 pounds

Indication: Treatment of severe chronic idiopathic urticaria in adults and adolescents age 12 years and older

• The requirement of failure to respond to two therapeutic regimens has been reduced to one

Indication: Treatment of adult patients with inadequately controlled nasal polys

• Requirement added for a pre-treatment IgE antibody score greater than or equal to 30 IU/mL
• Requirement added that the patient weighs between 66 and 330 pounds

Effective January 7, 2022

Cervical Spine Surgeries: Discectomy, Laminectomy, and Fusion in Adults, 7.01.560

Medical necessity criteria updated

• Site of service (off campus-outpatient hospital/medical center, on campus-outpatient hospital/medical center, and ambulatory surgical center) has been added to the policy for medical necessity review for single-level cervical decompressions and single level cervical fusions (CPT codes 22551, 22554, 22600, 63020, and 63045

Hysterectomy for Non-Malignant Conditions, 7.01.548

New policy

• Hysterectomy, with or without salpingo-oophorectomy (removal of fallopian tubes and ovaries) is considered medically necessary when criteria are met.
• Conditions included in the criteria: abnormal uterine bleeding or uterine fibroids (leiomyomata), adenomyosis, endometriosis, genetic predisposition to cancer, symptomatic pelvic organ prolapse)
• Conditions excluded from review are hysterectomy for malignancies or conditions highly suspicious for malignancy (eg, ovarian mass) and hysterectomy for gender-transition/affirming surgeries
• Site of Service review is included for laparoscopic-assisted vaginal hysterectomy and vaginal hysterectomy

Lumbar Spinal Fusion, 7.01.542

Medical necessity criteria updated

• Site of service (off campus-outpatient hospital/medical center, on campus-outpatient hospital/medical center, and ambulatory surgical center) has been added to the policy for medical necessity review for single-level lumbar fusions (CPT codes 22553, 22558, 22612, 22630, and 22633)

Site of Service: Select Surgical Procedures, 11.01.524

• Single-level cervical discectomy and lumbar spinal fusions, along with some hysterectomy procedures, have been added to this policy as now requiring site of service review for medical necessity and are indicated by the following codes: 22533, 22551, 22554, 22558, 22600, 22612, 22630, 22633, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58294, 58550,58552, 58553, 58554,63020 and 63045. HCPCS code C1726 was removed

Effective December 2, 2021

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564

New drug added to policy

• Arcalyst® (rilonacept)
  • Treatment of cryopyrin-associated period syndromes (CAPS) in adults and children age 12 years and older
  • Treatment of deficiency of interleukin-1 receptor antagonist (DIRA) in adults and children weighing at least 10 kg
  • Treatment of recurrent pericarditis (RP) in patients age 12 years and older

Effective November 5, 2021

Allograft Injection for Degenerative Disc Disease, 7.01.166

New policy

• Injecting a tissue graft from a donor into the space between the spinal vertebrae as a treatment of degenerative joint disease is considered investigational

Medical Necessity Criteria for Pharmacy Edits, 5.01.605

Testosterone Replacement Products

New drug added

• Aveed® (testosterone undecanoate)

Miscellaneous Oncology Drugs, 5.01.540

New drugs added

• Abraxane® (paclitaxel protein-bound particles)
  • Treatment of metastatic breast cancer
  • Treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC)
  • Treatment of metastatic adenocarcinoma of the pancreas
• Arranon® (nelarabine)
  • Treatment of T-cell acute lymphoblastic lymphoma (T-ALL)
  • Treatment of T-cell lymphoblastic lymphoma (T-LBL)
• Empliciti® (elotuzumab)
  • Treatment of multiple myeloma
• Erwinaze® (asparaginase erwinia chrysanthemi)
  • As a part of a multi-agent chemotherapy regimen for the treatment of acute lymphoblastic leukemia (ALL)
• Halaven® (eribulin mesylate)
  • Treatment of metastatic breast cancer
  • Treatment of inoperable or metastatic liposarcoma
• Yondelis® (trabectedin)
  • Treatment of inoperable or metastatic liposarcoma or leiomyosarcoma 

Non-covered Experimental/Investigational Services, 10.01.533

New policy

• The safety and/or effectiveness of treatments, procedures, equipment, drugs, drug usage, medical devices, or supplies that have not been supported by a review of published medical and scientific literature are considered experimental/investigational
• This policy lists several services that are considered experimental/investigational

New medical policies

Effective December 1, 2021

Cryoablation for Chronic Rhinitis, 7.01.168

New policy

• Cryoablation for chronic rhinitis is considered investigational

Treatment of Dry Eye Syndrome, 9.03.513

New policy

• This policy replaces Eyelid Thermal Pulsation for the Treatment of Dry Eye, 9.03.29
• Intense pulsed light (IPL) has been added to the list of investigational therapies

Revised medical policies

Effective December 1, 2021

Ablation of Peripheral Nerves to Treat Pain, 7.01.154

Policy statement updated

• Ablation of peripheral nerves
  • Intercostal neuralgia has been added to the list of investigational conditions

Lumbar Spinal Fusion in Adults, 7.01.542

Policy name changed

• From "Lumbar Spinal Fusion" to "Lumbar Spinal Fusion in Adults"

Policy statement updated

• Medical necessity criteria for severe progressive juvenile or adolescent idiopathic scoliosis have been removed

Routine Vision Care, 10.01.521

Benefit coverage guidelines updated

• Added routine vision exam description for Vision Care benefit  
• Added medical vision exam description for medical benefit
• Added vision hardware coverage for members age 19 years and older

Revised pharmacy policies

Effective November 1, 2021

Drugs for Rare Diseases, 5.01.576

• Bylvay® (odevixibat)
  • Treatment of itching in patients age 3 months and older with progressive familial intrahepatic cholestasis (PFIC) 
• Livmarli™ (maralixibat)
  • Treatment of itching in patients age 1 year or older with Alagille syndrome (ALGS)
• Nexviazyme™ (avalglucosidase alfa-ngpt)
  • Treatment of late-onset Pompe disease in patients age 1 year or older
• Nulibry™ (fosdenopterin)
  • Management of molybdenum cofactor deficiency (MoCD) Type A
• Ryplazim® (plasminogen, human-tvmh)
  • Treatment of plasminogen deficiency (PLGD) type 1

Medical necessity criteria updated

• Lumizyme® (alglucosidase alfa)
  • Diagnosis of Pompe disease must be confirmed by enzyme deficiency or genetic testing
  • This drug is not used with Nexviazyme™ (avalglucosidase alfa-ngpt)  
• Oxlumo™ (lumasiran)
  • Requirement that the patient has not received a liver or kidney transplant has been added
  • This drug is prescribed by or in consultation with a nephrologist, urologist, or geneticist
• Tepezza™ (teprotumumab-trbw)
  • Requirement of double vision has been added
  • Documentation of thyroid function test results has been added
  • This drug may be prescribed by an endocrinologist

Multiple Receptor Tyrosine Kinase Inhibitors, 5.01.534

Drug with new indication

• Cabometyx (cabozantinib)
  • Treatment of locally advanced or metastatic differentiated thyroid cancer in adult and pediatric patients age 12 years and older

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564

New drug added

• Saphnelo™ (anifrolumab-fnia)
  • Treatment of adult patients with systemic lupus erythematosus (SLE)

Medical necessity criteria updated

• Benlysta® (belimumab) IV and SC
  • This drug is not used with Saphnelo™ (anifrolumab-fnia)

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

Effective November 1, 2021

General Medical Necessity Criteria for Companion Diagnostics Related to Drug Approval, 5.01.543

Added codes

Effective November 5, 2021

Allograft Injection for Degenerative Disc Disease, 7.01.166

Now requires review for investigative.

0627T, 0628T, 0629T, 0630T

Now requires review for medical necessity and prior authorization.

J3145

Miscellaneous Oncology Drugs, 5.01.540

Now requires review for medical necessity and prior authorization.

J9176, J9019, J9179, J9352, J9264, J9261

Non-covered Experimental/Investigational Services, 10.01.533

Now requires review for investigative.

0016M, 0042T, 0100T, 0174U, 0176U, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0206U, 0207U, 0210U, 0219U, 0220U, 0221U, 0222U, 0219T, 0220T, 0221T, 0222T, 0358T, 0469T, 0470T, 0471T, 0472T, 0473T, 0479T, 0485T, 0486T, 0487T, 0561T, 0594T, 0596T, 0597T, 0598T, 0599T, 0602T, 0603T, 0604T, 0605T, 0606T, 0607T, 0608T, 0609T, 0610T, 0611T, 0612T, 0613T, 0615T, 0619T, 0620T, 0621T, 0622T, 0623T, 0624T, 0625T, 0626T, 0631T, 0632T, 0639T, 96000, 96001, 96002, 96003, 96004, C1052, C1761, C1841, C1842, C9752, C9753, C9764, C9765, C9766, C9767, C9772, C9773, C9774, C9775, C9777, K1004, K1009, K1016, K1017, K1018, K1019, L8608, S2300

Effective November 1, 2021

Focal Treatments for Prostate Cancer, 8.01.61

Now requires review for investigative.

0582T

Non-covered Services and Procedures, 10.01.517

No longer covered.

S9432

Total Artificial Hearts and Implantable Ventricular Assist Devices, 7.03.11

Now requires review for investigative.

0451T, 0452T, 0453T, 0454T

Added codes

Effective February 4, 2022

The following codes will require review for medical necessity and prior authorization for services on or after February 4, 2022

American Society of Addiction Medicine (ASAM), 10.01.532

H0031, H0032, H2014, H2019, S5108, S5109, S5110 and S5111