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. |