Medical Policy and Coding Updates September 2022

  • Updates for both non-individual and individual plans

  • Effective December 1, 2022

    Pharmacologic Treatment of Gout, 5.01.616

    Medical necessity criteria updated

    Krystexxa® (pegloticase) must be given with oral methotrexate 15 mg weekly, unless there is a medical reason why methotrexate can't be taken

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563

    Medical necessity criteria updated

    • Tysabri® (natalizumab)
      • Patient must have tried and failed treatment with one or more TNF blockers

    Effective November 4, 2022

    Immune Globulin Therapy, 8.01.503

    Site of service review added

    • Cutaquig® (immune globulin subcutaneous [human] - hipp)

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523

    Site of service review added

    • Cutaquig® (immune globulin subcutaneous [human] - hipp)

    Effective September 11, 2022

    Updates to AIM Specialty Health® Clinical Appropriateness Guidelines

    Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging

    Updates by section

    Extremity Imaging

    Fracture

    • Added indication for evaluation of supracondylar fracture
    • Added CT as an alternative to MRI for tibial plateau fracture

    General information/overview

    • Allowed exception to specified durations of conservative management in rare cases

    Perioperative imaging (including delayed hardware failure), not otherwise specified

    • Added statement that advanced imaging is not indicated for robotic-assisted hip arthroplasty

    Rotator cuff tear

    • Updated conservative management time from 4 weeks to 6 weeks for rotator cuff tear

    Shoulder arthroplasty

    • Added statement that advanced imaging is not indicated for robotic-assisted shoulder arthroplasty

    Spine Imaging

    Cervical injury

    • Clarified that post-traumatic neurologic deficit refers specifically to an exam finding

    General information/overview

    • Allowed exception to specified durations of conservative management in rare cases

    Perioperative and periprocedural imaging

    • Added requirement for initial evaluation with radiographs

    Thoracic or lumbar injury

    • Clarified that neurologic deficit refers specifically to an exam finding

    Vascular Imaging: Brain, Head and Neck

    Pulsatile tinnitus

    • Added optional CTA/MRA neck evaluation for pulsatile tinnitus

    Stenosis or occlusion, extracranial carotid arteries

    • Added new screening indications for post-neck irradiation and incidental carotid calcification
    • Revised surveillance guidelines to align with Society for Vascular Surgery for annual imaging, post-revascularization after first year

    Stroke or transient ischemic attach (TIA)

    • Divided this section into two categories: intracranial evaluation and extracranial evaluation
    • Revised guidelines to align with American Hospital Association/American Society of Anesthesiologists
      • Allowed CTA/MRA of the neck without previous prerequisite for subacute stroke/TIA
    • Allowed CTA/MRA for chronic posterior circulation stroke/TIA
    • Added indication for carotid ultrasound

    Vascular Imaging: Abdomen and Pelvis

    Acute aortic syndrome

    • Added optional pelvic imaging

    Aneurysm of the abdominal aorta or iliac arteries

    • Screening: Added femoral aneurysm to the list of lower extremity sites
    • Management: Revised guidelines to align with Society for Vascular Surgery for post-endovascular repair to repeat imaging 12 months after baseline
    • Surveillance: Revised guidelines to align with Society for Vascular Surgery for stable aneurysms treated with endographs
      • Duplex arterial ultrasound annually
      • CT every 5 years

    Venous thrombosis or occlusion

    • Added optional pelvic imaging to Imaging Study section

    Vascular Imaging: Upper Extremity

    Peripheral arterial disease (PAD)

    • Added any sign or symptom with inconclusive physiologic testing, including exercise testing, to diagnostic criteria for suspected PAD and management of known PAD
    • Added criteria for the management of PAD: resting ischemic pain to unilateral cold painful hand

    Vascular Imaging: Lower Extremity

    Peripheral arterial disease (PAD)

    • Added any sign or symptom with inconclusive physiologic testing, including exercise testing, to diagnostic criteria for suspected PAD
    • Revised guidelines to align with Society for Vascular Surgery by adding indication for ultrasound surveillance for repaired popliteal artery aneurysm

    Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Sleep Disorder Management.

    Updates by section

    Sleep Disorder Diagnostic Management

    Established sleep disorder (OSA or other) - follow-up laboratory studies

    • Added option that a follow-up, in-lab sleep study may be allowed to adjust device settings after insertion of a hypoglossal nerve stimulator

    Multiple sleep latency testing (MSLT) and/or maintenance of wakefulness testing (MWT)

    • Added MWT indication for occupational safety

    Sleep Disorder Treatment Management

    Management of obstructive sleep apnea using oral appliances

    • Added age indication for patients age 16 years and older to the use of a custom fabricated oral appliance

    Effective September 4, 2022

    Updates to AIM Specialty Health® Clinical Appropriateness Guidelines

    Effective for dates of service on and after September 4, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Genetic Testing

    Updates by section

    Hereditary Cardiac Disease

    Appropriate use criteria

    • Added general genetic testing criteria

    Genetic testing of affected individuals

    • Moved content with specific cardiac conditions in “Testing of Asymptomatic Individuals” to this section

    Genetic testing in the evaluation of sudden cardiac arrest

    • Added this new section and medical necessity criteria

    Post-mortem genetic testing

    • Added new medical necessity criteria

    Reproductive Carrier Screening and Prenatal Diagnosis

    Preimplantation genetic testing of embryos

    • Added polygenetic risk scores (PRS) to the list of not medically necessary conditions

    Single Gene and Multifactoral Conditions

    Thrombophilia testing

    • Removed the criterion for an individual with unprovoked venous thromboembolis

    Somatic and Hematologic Tumors Genetic Testing

    Conditions for which testing may be medically necessary

    • Added FoundationOne® as medically necessary for non-small cell lung cancer (NSCLC) stage IIIB and above
    • Added targeted multigene panels as medically necessary for endometrial cancer

    Cell-free testing

    • Listed ctDx Lung™ and Target Selector™ NGS Lung Panel as the only approved targeted multi-gene panels for biomarkers in locally advanced or metastatic non-small cell lung cancer (NSCLC)

    Cancer screening

    • Added timing of PSA testing in relation to the PCA3 or ConfirmMDx test
    • Moved criteria for gene expression classifier testing for indeterminate thyroid nodules (ITN) from Table 1 to this section

    Effective September 2, 2022

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

    Anterior cervical fusion

    Indications added

    • Spine fracture and/or dislocation
    • Cervical spine revision surgery

    Medical necessity criteria updated

    Indication: Cervical pseudoarthritis

    • Cervical pseudarthrosis must be symptomatic
    • Imaging shows evidence of hardware failure
    • Pain aligns with the level of pseudoarthritis
    • A cervical spine MRI or CT scan 12 months after a previous spinal fusion shows non-union at the same level as symptom/exam findings

    Posterior cervical fusion

    Indication added

    • Implant/instrumentation failure

    Medical necessity criteria updated

    Indication:  Cervical pseudoarthritis

    • Imaging shows evidence of hardware failure
    • Pain aligns with the level of pseudoarthritis
    • A cervical spine MRI or CT scan 12 months after a previous spinal fusion shows non-union at the same level as symptom/exam findings

    Hysterectomy for Non-Malignant Conditions, 7.01.548

    Medical necessity criteria updated

    Criteria for uterine fibroids has been separated from the abnormal uterine bleeding indication

    Indications added

    • Chronic pelvic inflammatory disease (PID)
    • Pelvic pain

    Lumbar Spinal Fusion in Adults, 7.01.542

    Indication added

    Revision surgery for implant/instrumentation failure

    Spravato® (esketamine) Nasal Spray, 5.01.609

    All Indications

    Medical necessity criteria updated

    • Documentation of depression must include the patient's symptoms and their severity as measured by one or more standardized depression rating scales
    • The patient must have no current use of any mind- or mood-altering substances, including but not limited to alcohol, marijuana, stimulants, and hallucinogens/psychedelics

    All Indications

    Medical necessity criteria added

    A new course of Spravato® treatment when the patient was previously treated with this drug

    All Indications

    Re-authorization criteria updated

    • The patient must not have a current substance use disorder, unless there has been complete abstinence for a month
    • The patient must have no current use of any mind- or mood-altering substances, including but not limited to alcohol, marijuana, stimulants, and hallucinogens/psychedelics

    Upper Gastrointestinal (UGI) Endoscopy for Adults, 2.01.533

    Medical necessity criteria updated

    • The timing of persistent GERD symptoms following treatment with daily proton pump inhibitor (PPI) therapy has been changed from 4 - 8 weeks to 8 weeks
    • Criterion added that UGI may be performed to evaluate returning GERD or heartburn symptoms after the completion of proton pump inhibitor (PPI) treatment
    • Deleted criterion that a UGI may be performed after 6 -12 weeks of treatment with a histamine H2-receptor antagonist
    • Follow-up of known eosinophilic esophagitis has been added to the list of medically necessary conditions

    Wearable Cardioverter-Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement, 2.02.506

    Medical necessity criteria updated

    A 90-day time limit has been added for the use of a wearable cardioverter-defibrillator as a bridge to a permanent implantable (internal) cardioverter-defibrillator surgery

    New medical policies
    Effective September 1, 2022

    Treatment of Hyperhidrosis, 8.01.519

    Policy renumbered

    • This policy replaces Treatment of Hyperhidrosis, 8.01.19
    • All policy statements remain unchanged

    Revised medical policies
    Effective September 1, 2022

    Prescription Digital Therapeutics, 13.01.500

    Investigational criteria updated

    Mahana™ for irritable bowel syndrome (IBS) has been added to the list of investigational prescription digital therapeutics

    Upper Gastrointestinal (UGI) Endoscopy for Adults, 2.01.533

    Indication added

    Therapeutic banding (ligation) or sclerotherapy of esophageal varices has been added to the list of non-malignant conditions where an upper gastrointestinal (UGI) endoscopy may be medically necessary

    New pharmacy policies

    No updates this month

    Revised pharmacy policies
    Effective September 1, 2022

    Dupixent® (dupilumab), 5.01.575

    Medical necessity criteria updated

    Indication: Atopic dermatitis

    • The age criterion for Dupixent® has been changed from 6 years to 6 months of age and older
    • The requirement for using a topical calcineurin inhibitor medication and high potency topical corticosteroid now applies to patients age 2 years and older
    • Individuals from 6 months to 2 years of age must try one topical prescription corticosteroid of any potency before Dupixent® can be prescribed

    Indication added

    Treatment of eosinophilic esophagitis in individuals age 12 years of age and older

    Gonadotropin Releasing Hormone (GnRH) Analogs, 5.01.625

    Medical necessity criteria updated

    Indication: Treatment of early breast cancer

    • The requirement of a high risk of recurrence has been removed

    Medical necessity criteria updated

    Indication: Gender dysphoria

    • The term "adolescent" has been removed and revised to "patient is ≥ 12 years of age (or Tanner state 2 or higher puberty onset) to 19 years of age”

    Medical necessity criteria updated

    Indication: Endometriosis

    • Orilissa® (elagolix) can be approved for 24 months for 150 mg, and 6 months for 200 mg
    • Added note that requests for Orilissa® (elagolix) 150 mg after completing 6 months of therapy with 200 mg of this drug is considered not medically necessary
    • Added re-authorization criterion that use of Orilissa® (elagolix)150 mg beyond 24 months or Orilissa 200 mg beyond 6 months is considered not medically necessary

    Reauthorization criteria updated

    Indication: Gender dysphoria

    • Added age criterion that patient must be ≤ 19 years of age

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563

    Drug added

    • Skyrizi® (risankizumab-rzaa) IV and SC
      • Treatment of moderately to severely active Crohn's disease
      • Initial authorization of Skyrizi® IV may be approved for 90 days to allow for induction therapy
      • Initial authorization of Skyrizi® SC may be approved for up to 1 year and re-authorization of Skyrizi® SC may be approved for up to 3 years

    Medical necessity criteria updated

    • Cimzia® (certolizumab pegol)
    • Stelara® (ustekinumab) IV
    • Stelara® (ustekinumab) SC
    • Tysabri® (natalizumab)
      • Coverage added for patients with abnormal connections between the intestine and rectum, intestine and vagina, rectum and vagina, or intestine through the skin
      • Coverage added for patients who have had partial removal of the colon

    No updates this month

    Effective September 1, 2022

    Alcohol Injections for Treatment of Peripheral Morton Neuromas, 2.01.97

    Content from this policy has been moved into Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas, 7.01.147

    Treatment of Hyperhidrosis, 8.01.19

    • Policy renumbered to Treatment of Hyperhidrosis, 8.01.519
    • All policy statements remain unchanged

    Added codes
    Effective September 1, 2022 

    Cosmetic and Reconstructive Services, 10.01.514

    Now requires review for cosmetic and prior authorization.

    J0591

    Non-covered Experimental/Investigational Services, 10.01.533

    No longer covered.

    K1023

    Revised codes
    Effective September 1, 2022

    Cosmetic and Reconstructive Services, 10.01.514

    Now requires review for cosmetic and prior authorization.

    17107, 17108

    Pharmacologic Treatment of Duchenne Muscular Dystrophy, 5.01.570

    Now requires review for medical necessity and prior authorization.

    J1427

    Removed codes
    Effective September 1, 2022

    Transendoscopic Endoscopic Therapies for Gastroesophageal Reflux Disease, 2.01.38

    No longer requires review.

    43266

  • Updates for only non-individual plans

  • Effective December 1, 2022

    Botulinum Toxins, 5.01.512

    New policy 

    Drugs added

    • Botox® (onabotulinumtoxinA)
      • Prevention of chronic migraine headaches in adults age 18 years and older
      • Treatment of overactive bladder (OAB) in adults age 18 years and older
      • Treatment of urinary incontinence due to overactivity of the detrusor muscle in adults age 18 years and older
      • Treatment of neurogenic detrusor overactivity (NDO) in patients age 5 to 17 years of age
      • Treatment of cervical dystonia in adults age 18 years and older
      • Treatment of adults with dystonia that results in functional impairment and/or pain
      • Treatment of blepharospasm with dystonia in patients age 12 years and older
      • Treatment of chronic anal fissure
      • Treatment of esophageal achalasia
      • Treatment of Hirschsprung disease
      • Treatment of lower and upper limb spasticity in patients age 2 years and older
      • Treatment of strabismus in patients age 12 years and older
    • Dysport® (abobotulinumtoxinA)
      • Treatment of cervical dystonia in adults age 18 years and older
      • Treatment of adults with dystonia that results in functional impairment and/or pain
      • Treatment of chronic anal fissure
      • Treatment of esophageal achalasia
      • Treatment of Hirschsprung disease
      • Treatment of lower and upper limb spasticity in patients age 2 years and older
    • Jeuveau™ (prabotulinumtoxinA-xvfs)
      • For cosmetic use and not covered
    • Myobloc® (rimabotulinumtoxinB)
      • Treatment of cervical dystonia in adults age 18 years and older
      • Treatment of adults with dystonia that results in functional impairment and/or pain
      • Treatment of chronic hypersalivation in adults
    • Xeomin® (incobotulinumtoxinA)
      • Treatment of upper limb spasticity in patients age 2 to 17 years
      • Treatment of cervical dystonia in adults age 18 years and older
      • Treatment of adults with dystonia that results in functional impairment and/or pain
      • Treatment of blepharospasm in patients age 18 years and older
      • Treatment of chronic anal fissure
      • Treatment of chronic hypersalivation in patients age 2 years and older
      • Treatment of esophageal achalasia
      • Treatment of Hirschsprung disease
      • Treatment of upper limb spasticity in adults

    Temporomandibular Joint Disorder, 2.01.535

    • Botulinum toxin is considered investigational as a nonsurgical treatment for temporomandibular joint disorder
    • For dates of service starting on and after December 1, 2022, codes for botulinum toxin will require review for medical necessity and prior authorization (see also the Coding updates section below)

    Treatment of Hyperhidrosis, 8.01.519

    • Botulinum toxin is considered:
      • Medically necessary as a treatment for primary focal hyperhidrosis when criteria are met
      • Investigational as a treatment for severe secondary gustatory hyperhidrosis
    • For dates of service starting on and after December 1, 2022, codes for botulinum toxin will require review for medical necessity and prior authorization (see also the Coding updates section below)

    Effective December 1, 2022

    See also the Special notices section above

    Botulinum Toxins, 5.01.512

    Now requires review for medical necessity and prior authorization.

    J0585, J0586, J0587, J0588

    Temporomandibular Joint Disorder, 2.01.535

    Now requires review for medical necessity and prior authorization.

    J0585, J0586, J0587, J0588

    Treatment of Hyperhidrosis, 8.01.519

    Now requires review for medical necessity and prior authorization.

    J0585, J0586, J0587, J0588

  • Updates for only individual plans

  • Effective December 1, 2022

    Botulinum Toxins, 5.01.512

    New policy replaces InterQual® criteria

    Drugs added

    • Botox® (onabotulinumtoxinA)
      • Prevention of chronic migraine headaches in adults age 18 years and older
      • Treatment of overactive bladder (OAB) in adults age 18 years and older
      • Treatment of urinary incontinence due to overactivity of the detrusor muscle in adults age 18 years and older
      • Treatment of neurogenic detrusor overactivity (NDO) in patients age 5 to 17 years of age
      • Treatment of cervical dystonia in adults age 18 years and older
      • Treatment of adults with dystonia that results in functional impairment and/or pain
      • Treatment of blepharospasm with dystonia in patients age 12 years and older
      • Treatment of chronic anal fissure
      • Treatment of esophageal achalasia
      • Treatment of Hirschsprung disease
      • Treatment of lower and upper limb spasticity in patients age 2 years and older
      • Treatment of strabismus in patients age 12 years and older
    • Dysport® (abobotulinumtoxinA)
      • Treatment of cervical dystonia in adults age 18 years and older 
      • Treatment of adults with dystonia that results in functional impairment and/or pain 
      • Treatment of chronic anal fissure
      • Treatment of esophageal achalasia
      • Treatment of Hirschsprung disease
      • Treatment of lower and upper limb spasticity in patients age 2 years and older
    • Jeuveau™ (prabotulinumtoxinA-xvfs)
      • For cosmetic use and not covered
    • Myobloc® (rimabotulinumtoxinB)
      • Treatment of cervical dystonia in adults age 18 years and older
      • Treatment of adults with dystonia that results in functional impairment and/or pain
      • Treatment of chronic hypersalivation in adults
    • Xeomin® (incobotulinumtoxinA)
      • Treatment of upper limb spasticity in patients age 2 to 17 years
      • Treatment of cervical dystonia in adults age 18 years and older
      • Treatment of adults with dystonia that results in functional impairment and/or pain
      • Treatment of blepharospasm in patients age 18 years and older
      • Treatment of chronic anal fissure
      • Treatment of chronic hypersalivation in patients age 2 years and older
      • Treatment of esophageal achalasia
      • Treatment of Hirschsprung disease
      • Treatment of upper limb spasticity in adults

    Temporomandibular Joint Disorder, 2.01.535

    • Botulinum toxin is considered investigational as a nonsurgical treatment for temporomandibular joint disorder
    • For dates of service starting on and after December 1, 2022, codes for botulinum toxin will require review for medical necessity and prior authorization (see also the Coding updates section below)

    Treatment of Hyperhidrosis, 8.01.519

    • Botulinum toxin is considered:
      • Medically necessary as a treatment for primary focal hyperhidrosis when criteria are met
      • Investigational as a treatment for severe secondary gustatory hyperhidrosis
    • For dates of service starting on and after December 1, 2022, codes for botulinum toxin will require review for medical necessity and prior authorization (see also the Coding updates section below)

    Effective November 4, 2022

    Authorization for Observation versus Inpatient Admission Level of Care, 10.01.534

    New policy

    Criteria and medical conditions added for observation stays for adults and children

    Effective December 1, 2022

    See also the Special notices section above

    Botulinum Toxins, 5.01.512

    Now requires review for medical necessity and prior authorization.

    J0585, J0586, J0587, J0588

    Temporomandibular Joint Disorder, 2.01.535

    Now requires review for medical necessity and prior authorization.

    J0585, J0586, J0587, J0588

    Treatment of Hyperhidrosis, 8.01.519

    Now requires review for medical necessity and prior authorization.

    J0585, J0586, J0587, J0588

     

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