Medical Policy Updates

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Medical Policy Update for March 24, 2020

Medical Guidelines Reason for Update
Brexanolone (Zulresso™) Added the following criteria to "When Covered" section: “There is physician attestation that brexanolone will be administered under direct supervision of a healthcare professional at a treatment facility that is certified through the Zulresso REMS program (see Policy Guidelines)." Added the following clarification to "When Covered" section: "The infusion facility must be equipped and staffed with continuous pulse oximetry and staffed with healthcare professionals trained to handle possible excessive sedation and/or sudden loss of consciousness, including acute airway management." Medical Director review 12/2019. Notification given 1/14/2020 for effective date 3/24/2020.
Catheter Ablation as a Treatment for Atrial Fibrillation Policy archived.
Facet Joint Denervation Updated Policy Guidelines item #4. Removed "(ie, steroids, saline, or other substances)." Corrected misspelling in policy guidelines.
Fecal Microbiota Transplantation Policy archived.
Gastric Electrical Stimulation Description section and references updated. No change to policy intent. Medical Director review 2/2020.
Liver Transplant and Combined Liver-Kidney Transplant Reference added.
Ovarian and Internal Iliac Vein Embolization, Ablation and Sclerotherapy Description section updated with definition of gonadal veins. When not covered section clarified with pelvic veins. No change to policy statement.
Place of Service for Medical Infusions Updated "Description" section with the following clarification: "Please note, this policy specifically applies to the infusion drugs that are addressed separately in individual medical policies as referenced below". Medical Director review 3/2020.
Prostate Cancer Screening AHS-G2008 CPT codes 81541, 81551 and PLA code 0005U removed from Billing/Coding section.
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors Reference added. Policy Guidelines updated.
Rehabilitative Therapies Added codes G2168 and G2169 to the Billing/Coding section. No change to policy intent.
Speech Generating Devices Policy archived.
White Blood Cell Growth Factors Removed the following statement from "When Covered" section for Neulasta OnPro requests: "AND iii. Inadequate access to a healthcare facility for assistance with medication administration." Medical Director review 3/2020.