Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.48 Autologous chondrocyte implantation (including MACI) may be considered medically necessary when criteria are met, considered investigational when criteria are
not met. Read the full policy.
Powered Exoskeleton for Ambulation in Patients with Lower-Limb Disabilities, 1.03.04 Use of a powered exoskeleton for ambulation in patients with lower-limb disabilities is considered investigational. This includes the ReWalk®,
Esk™, and Indego® systems. Read the full policy.
Gender Reassignment Surgery, 7.01.557 The policy statement was revised by removing the requirement for meeting DSM diagnostic criteria. An evaluating mental health professional is required to confirm the diagnosis still applies. Read the full policy.
Spinal Cord and Dorsal Root Ganglion Stimulation, 7.01.546 The policy was updated to include high-frequency stimulators. Criteria were added for the replacement of spinal cord stimulators. Dorsal root ganglion stimulators are considered investigational.
Read the full policy.
Hepatitis C Antiviral Therapy, 5.01.606 The policy was revised to add criteria for new preferred direct-acting antiviral agents Mavyret™ (glecaprevir/pibrentasvir) and Vosevi™ (sofosbuvir/velpatasvir/soxilaprevir) when indicated. Harvoni™
(ledipasvir/sofosbuvir) and Epclusa® (sofosbuvir/velpatasvir) remain preferred agents as well. Read the full policy.
Medical Necessity Criteria for Pharmacy Edits, 5.01.605
Excessively High Cost Drug Products with Lower Cost Alternatives, 5.01.560 The policy statements were revised as follows:
Growth Hormone Therapy, 5.01.500 The policy was revised to state that clinical benefit (improvement in bone density or cholesterol studies) is required for reauthorization of adult growth hormone therapy. Read the full policy.
Ivacaftor (Kalydeco) and Lumacaftor/Ivacaftor (Orkambi), 5.01.539 The policy was revised to change the age criteria for Kalydeco® (ivacaftor) from 6 years to 2 years of age and older. This is consistent with the FDA labeling. Verification
of CF mutation needed through mutation testing prior to authorization. Read the full policy.
Pharmacotherapy of Arthropathies, 5.01.550 The policy was revised to clarify the criteria for Taltz® (ixekizumab) and Siliq™ (brodalumab). Criteria were added for Tremfya™ (guselkumab). Read the full policy.
Pharmacotherapy of Type I and Type II Diabetes Mellitus, 5.01.569 The policy was revised to add criteria for Symlin® (pramlintide). Read the full policy.
An archived policy is no longer active and is not used for reviews.
JAK2 and MPL Mutation Analysis in Myeloproliferative Neoplasms, 12.04.60
Effective October 1, 2017
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer, 12.04.33 Now requires investigational review
0021U- Oncology (prostate), detection of 8 autoantibodies (ARF 6, NKX3-1, 5'-UTR-BMI1, CEP 164, 3'-UTR-Ropporin, Desmocollin, AURKAIP-1, CSNK2A2), multiplexed immunoassay and flow cytometry serum, algorithm reported as risk score
Molecular Markers in Fine Needle Aspirates of the Thyroid Malignancies, 12.04.510 Now requires investigational review
0018U-Oncology (thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to high risk of malignancy
Noncovered Services and Procedures, 10.01.517 Now considered a non-covered service
T1002-RN services, up to 15 minutes
Pharmacotherapy of Miscellaneous Autoimmune Disease, 5.01.564 Now requires prior authorization; (currently requires medical necessity review)
J1438- Injection, etanercept, 25 mg
Radioembolization for Primary and Metastatic Tumors of the Liver, 8.01.521 Now requires medical necessity review and prior authorization
79445- Radiopharmaceutical therapy, by intra-arterial particulate administration
Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma, 8.01.533 Now requires prior authorization (currently requires review for medical necessity)
A9542- Indium In-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 millicuries
Total Artificial Hearts and Implantable Ventricular Assist Devices, 7.03.11 Now requires medical necessity review; now requires prior authorization
0051T-Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy
0052T- Replacement or repair of thoracic unit of a total replacement heart system (artificial heart)
0053T-Replacement or repair of implantable component or components of total replacement heart system (artificial heart), excluding thoracic unit
Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma, 8.01.533 Revised from investigational review; will now be reviewed for medical necessity and now requires prior authorization
79403- Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion
Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies, 2.03.07 No longer requires investigational review
77600-Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less)
77605-Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm)
77610-Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators
77615-Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators
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