Medical Policy Updates

Medical Policy Update for March 10, 2020

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.