Special notice: revised policy effective December 2017
Effective December 21, 2017
Ultrasound Accelerated Fracture Healing Device, 1.01.05
The policy statement was revised to state that this service isn't medically necessary for surgically and nonsurgically managed fresh fractures and nonunion/delayed union fractures.
Read the full policy.
Revised medical policies
Effective September 1, 2017
Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases, 2.04.123
The policy statement was revised to state that serum biomarker panel testing is considered investigational for all connective tissue
diseases. Read the full policy.
Site of Service: Infusion Drugs and Biologic Agents, 11.01.523
The policy statement was revised to add Renflexis® (infliximab-abda) to the coverage criteria. Read the full policy.
Revised pharmacy policies
Effective September 1, 2017
Excessively High Cost Drug Products with Lower Cost Alternatives, 5.01.560
The policy statement was revised to include medical necessity criteria for Absorica® (isotretinoin), Amrix ER® (cyclobenzaprine), omeprazole ODT, Zyflo® (zileuton),
and Zyflo CR® (zileuton ER). The criteria for Differin® brand and generic adapalene was revised to allow a trial of any strength topical generic tretinoin cream or gel. Read the full policy.
Medical Necessity Criteria for Pharmacy Edits 5.01.605
The policy statement was revised to include medical necessity criteria for Zypitamag™ (pitavastatin). Read the full policy.
Quantity Limits for Opioid Drugs, 5.01.529
In addition to other clarifications, the policy statement was revised to add that a trial of at least three non-opioid drug therapies is needed. Quantity limits were added for Arymo® (morphine sulfate),
Arymo® ER, Bunavail® (buprenorphine and naloxone), and Morphabond™ (morphine sulfate) ER.
Read the full policy.
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
The policy statement for Crohn's disease was clarified to state that Stelara® (ustekinumab) intravenous and subcutaneous administration are both second-line when criteria are met. The
policy statement for ulcerative colitis was revised to add Xeljanz® (tofacitinib) as a second-line therapy for ulcerative colitis when criteria are met. A policy statement was added stating that Xeljanz® XR is investigational for ulcerative colitis.
Read the full policy.
Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564
The policy statement for systemic lupus erythematosus was revised to add Benlysta® (belimumab) subcutaneous. The policy statement for pyoderma gangrenosum was clarified to state
that the second-line treatments Inflectra® (infliximab-dyyb) and Renflexis® (infliximab-abda) are medically necessary when the patient hasn't responded to standard nonbiologic therapy and had an inadequate response or intolerance to Remicade® (infliximab).
Read the full policy.
Coding updates
Added codes
Effective September 1, 2017
Noncovered Services and Procedures, 10.01.517
Now considered noncovered.
T1013 - Sign language or oral interpretive services, per 15 minutes.
T1015 - Clinic visit/encounter, all-inclusive.
Removed codes
Effective September 1, 2017
Deep Brain Stimulation, 7.01.63
No longer requires review for medical necessity.
95970 - Electronic analysis of implanted neurostimulator pulse generator system; simple or complex brain, spinal cord, or peripheral (i.e., cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without
reprogramming.
95971 - Electronic analysis of implanted neurostimulator pulse generator system; simple spinal cord, or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming.
95978 - Electronic analysis of implanted neurostimulator pulse generator system, complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; first hour.
95979 - Electronic analysis of implanted neurostimulator pulse generator system, complex deep brain neurostimulator pulse generator/transmitter, with initial or subsequent programming; each additional 30 minutes after first hour.
Gastric Electrical Stimulation, 7.01.522
No longer requires review for medical necessity.
95980 - Electronic analysis of implanted neurostimulator pulse generator system gastric neurostimulator pulse generator/transmitter; intraoperative, with programming.
Multimarker Serum Testing Related to Ovarian Cancer, 2.04.62
Currently reviewed as investigative, no longer requires prior authorization.
81503 - Oncology (ovarian), biochemical assays of five proteins (CA-125 apolipoprotein A1, beta-2
microglobulin, transferrin, and pre-albumin), utilizing serum, algorithm reported as a risk score.
Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy, 7.01.143
No longer requires review for medical necessity.
95970 - Electronic analysis of implanted neurostimulator pulse generator system; simple or complex brain, spinal cord, or peripheral (i.e., cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without
reprogramming.
95971 - Electronic analysis of implanted neurostimulator pulse generator system; simple spinal cord, or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming.
Sacral Nerve Neuromodulation/Stimulation, 7.01.69
No longer requires review for medical necessity.
95970 - Electronic analysis of implanted neurostimulator pulse generator system; simple or complex brain, spinal cord, or peripheral (i.e., cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without
reprogramming.
95972 - Electronic analysis of implanted neurostimulator pulse generator system; complex spinal cord, or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative
or subsequent programming.
Spinal Cord Stimulation, 7.01.546
No longer requires review for medical necessity.
95970 - Electronic analysis of implanted neurostimulator pulse generator system; simple or complex brain, spinal cord, or peripheral (i.e., cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without
reprogramming.
95971 - Electronic analysis of implanted neurostimulator pulse generator system; simple spinal cord, or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming.
95972 - Electronic analysis of implanted neurostimulator pulse generator system; complex spinal cord, or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative
or subsequent programming.
Vagus Nerve Stimulation, 7.01.20
No longer requires review for medical necessity.
95971 - Electronic analysis of implanted neurostimulator pulse generator system; simple spinal cord, or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming.
95972 - Electronic analysis of implanted neurostimulator pulse generator system; complex spinal cord, or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative
or subsequent programming.
95974 - Electronic analysis of implanted neurostimulator pulse generator system; complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour.