Medical Guidelines |
Reason for Update |
Abatacept (Orencia®) |
Updated "When Covered" and "When Not Covered" sections, and "Description" and "Policy Guidelines" sections to provide clarity and consistency with FDA label with no change to policy intent. Reference added. Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Ablation Procedures for Peripheral Neuromas and Peripheral Nerves |
References added. Regulatory Guidelines updated. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Ambulance and Medical Transport Services |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy. |
ANA/ENA Testing AHS - G2022 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statement. |
Antisense Oligonucleotide Therapy for Duchenne Muscular Dystrophy |
Policy title revised from "Eteplirsen for Duchenne Muscular Dystrophy" to "Antisense Oligonucleotide Therapy for Duchenne Muscular Dystrophy". Added golodirsen (Vyondys 53) to policy with the following policy statement: "the use of golodirsen is considered investigational for all indications including treatment of Duchenne muscular dystrophy." Updated Description and Policy Guidelines sections to include description and evidence for golodirsen. Other minor typographical edits and additions made for clarity. Added HCPCS codes C9399, J3490, and J3590 to Billing/Coding section. References added. Medical Director review 3/2020. |
Belimumab (Benlysta) |
Updated "When Covered" section to "5 years of age or older". Under "When Not Covered," removed investigational statement for use in children and reorganized criteria formatting for clarity. Added statements in Description and Policy Guidelines sections to reflect approval of IV infusion in patients aged 5 years and older, and subcutaneous injection in patients aged 18 years and older Reference added. Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Βeta-Hemolytic Streptococcus Testing AHS – G2159 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Bone Mineral Density Studies |
Removed "dual x-ray absorptiometry of peripheral sites" from When not covered section. |
Bone Morphogenetic Protein |
Reference added. Specialty Matched Consultant Advisory Panel review 2/19/2020. |
BRCA AHS - M2003 |
Under "When Covered" section 1. age limit of 18 removed. No change to policy intent. |
Breast Brachytherapy for Accelerated Partial Breast Radiotherapy |
Medical Director review 2/2020. Archived. |
Chelation Therapy |
Description, Policy Guidelines, and Reference sections updated. Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statement. |
Chiropractic Services |
Added "Paraspinal Surface Electromyography (SEMG)" to the Related Policies section and removed S3900 from the Billing/Coding section. No change to policy intent. |
Cimzia (Certolizumab Pegol) |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Clinical Trial Services |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy. |
Complementary and Alternative Medicine |
References added. Specialty Matched Consultant Advisory Panel review 02/19/2020. No change to policy statement. |
Diagnostic Testing of Influenza AHS – G2119 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Diagnostic Testing of Iron Homeostasis and Metabolism AHS – G2011 |
Specialty Matched Consultant Advisory Panel 02/19/2020. No changes to policy. |
Diagnostic Testing of Sexually Transmitted Infections AHS – G2157 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Dynamic Posturography |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Electrical Stimulation for the Treatment of Arthritis |
Reference added. Description section updated. Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statement. |
Endothelial Keratoplasty |
Medical Director review 2/2020. Archived. |
Enhanced External Counterpulsation (EECP) |
Removed the following statement from the When Covered statement: ",in the opinion of a cardiologist or cardiothoracic surgeon,". No change to policy intent. Medical Director reviewed 2/2020. |
Folate Testing AHS – G2154 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statement. |
General Inflammation Testing AHS – G2155 |
Specialty Matched Consultant Advisory Panel 02/19/2020. No changes to policy. |
Genetic Testing for Adolescent Idiopathic Scoliosis AHS – M2058 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Golimumab (Simponi Aria®) |
Updated description section to include active psoriatic arthritis and active ankylosing spondylitis as approved indications for Simponi Aria. Minor typographical edits made throughout policy for clarity. Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Hemoglobin A1c AHS – G2006 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statement. |
Hepatitis C AHS – G2036 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
HIV Genotyping and Phenotyping AHS – M2093 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Ibalizumab-uiyk (TrogarzoTM) |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statements. |
Immunoglobulin Therapy |
Minor typographical edits made for clarity. Reference added. Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statements. |
Immunohistochemistry AHS – P2018 |
Specialty Matched Consultant Advisory Panel 02/19/2020. No change to policy statement. |
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies AHS - G2105 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statement. |
Implantable Bone Conduction Hearing Aids |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Implantation of Intrastromal Corneal Ring Segments |
Medical Director review 2/2020. Archived. |
Infliximab (Remicade®) and Infliximab Biosimilars |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statements. |
Infusion Therapy in the Home |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy. |
Injectable Clostridial Collagenase for Fibroproliferative Disorders |
Specialty Matched Consultant Advisory Panel (Orthopedics) review 2/19/2020. No change to policy statements. |
Intracellular Micronutrient Analysis AHS – G2099 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statement. |
Intravenous Antibiotic Therapy for Lyme Disease |
Reference added. Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statements. |
Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids |
Policy guidelines updated. No change to policy statement. |
Lyme Disease AHS – G2143 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Microprocessor-Controlled Prostheses for the Lower Limb |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
New-To-Market Specialty Drug PPA Requirements |
Specialty Matched Consultant Advisory Panel (Rheumatology) review 2/19/2020. |
Noninvasive Respiratory Assist Devices |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Observation Room Services |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy. |
Oral Screening Lesion Identification Systems and Genetic Screening AHS – G2113 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statement. |
Orthopedic Applications of Stem Cell Therapy |
Reference added. Background section and Policy Guidelines section updated. Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Place of Service for Medical Infusions |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statement. |
Plasma HIV-1 RNA Quantification for HIV-1 Infection AHS – M2116 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Plugs for Fistula Repair |
Reference added. |
Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Private Duty Nursing Services |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy. |
Quantose Impaired Glucose Tolerance (IGT) Test AHS - G2135 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statement. |
Respiratory Syncytial Virus Prophylaxis e |
Reference added. Specialty Matched Consultant Advisory Panel review- 2/19/2020. No change to policy statements. |
Rituximab for the Treatment of Rheumatoid Arthritis |
Reference added. Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statements. |
Semi-Implantable and Fully Implantable Middle Ear Hearing Aid |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Skilled Nursing Facility Care |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statement. |
Skilled Nursing Services |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statement. |
Sphenopalatine Ganglion Block for Headache |
Reference added. |
Subtalar Arthroereisis |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Synthetic Cartilage Implants for Joint Pain |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Testing for Diagnosis of Active or Latent Tuberculosis AHS – G2063 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Testing for Mosquito or Tick-Related Infections AHS – G2158 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Testing of Homocysteine Metabolism Related Conditions AHS – M2141 |
Specialty Matched Consultant Advisory Panel 02/19/2020. No change to policy statement. |
Three Dimensional Printed Orthopedic Implants |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Tocilizumab (Actemra) |
Minor edits made throughout policy for consistency with FDA labeling with no change to policy intent. References added. Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders |
Description section updated. Clarified When covered statement to include all types of repetitive TMS. When covered section #4 added to require protocol and device be FDA approved. Note listing forms of rTMS added to Policy Guidelines for clarity. References added. |
Ultrasound Accelerated Fracture Healing Device |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |
Urinalysis and Urine Culture Testing for Bacteria AHS – G2156 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statement. |
Vectra DA Blood Test for Rheumatoid Arthritis AHS – G2127 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. No change to policy statement. |
Vitamin B12 and Methylmalonic Acid Testing AHS – G2014 |
Specialty Matched Consultant Advisory Panel 02/19/2020. No change to policy statement. |
Vitamin D Testing AHS – G2005 |
Specialty Matched Consultant Advisory Panel 02/19/2020. No change to policy statement. |
ZIKA Virus Risk Assessment AHS – G2133 |
Specialty Matched Consultant Advisory Panel review 2/19/2020. |