Medical Policy and Coding Updates October 2017

  • Special notice: new medical policies effective in January

    Effective January 5, 2018

    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.

    Revised medical policies

    Effective October 1, 2017

    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.

    Revised pharmacy policies

    Effective September 25, 2017

    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.

    Effective September 15, 2017

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605

    • Statins: Added criteria for Flolipid™ (simvastatin suspension) and Nikita® (pitavastatin)
    • Brand oral acne products: Updated Solodyn® (minocycline), Xyrosa® (doxycycline), and Minolira™ (minocycline HCl) criteria. Added criteria for Acticlate® (doxycycline), Adoxa® (doxycycline), Avidoxy™ (doxycycline), Doryx® (doxycycline), Doryx® MPC (doxycycline), Doxycycline IR-DR, Minocin® (minocycline), Monodox® (doxycycline), Morgidox® (doxycycline), Oracea® (doxycycline), and Targadox™ (doxycycline)
    • Tardive dyskinesia: Added criteria for Ingrezza™ (valbenazine) and Austedo™ (deutetrabenazine)
    • Antihypertensive/diuretics: Added criteria for CaroSpir® (spironolactone)
    Read the full policy.

    Effective October 1, 2017

    Excessively High Cost Drug Products with Lower Cost Alternatives, 5.01.560
    The policy statements were revised as follows:

    • Clarified criteria for Auvi-Q® (epinephrine injection, USP)
    • Updated criteria for Differin® (adapalene)
    • Added criteria for OmePPI (omeprazole and sodium bicarbonate)
    Read the full policy.

    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.

    Archived policies

    An archived policy is no longer active and is not used for reviews.

    Archived on September 30, 2017

    JAK2 and MPL Mutation Analysis in Myeloproliferative Neoplasms, 12.04.60

    Coding updates

    Added codes

    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

    Revised codes

    Effective October 1, 2017

    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

    Removed codes

    Effective October 1, 2017

    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

  •    Email this article