Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update May 26, 2020

Medical Guidelines Reason for Update
Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemia Specialty Matched Consultant Advisory Panel review 4/15/2020. References added. No change to policy statement.
Antiemetic Injection Therapy Removed policy statements for Varubi (rolapitant) injectable emulsion, as product has been discontinued. Added the following statement to Description and Policy Guidelines sections: "In January 2018, the FDA and drug manufacturer issued an important drug warning for Varubi (rolapitant) injectable emulsion. Anaphylaxis, anaphylactic shock, and other serious hypersensitivity reactions have been associated with use of Varubi (rolapitant) injectable emulsion. Varubi (rolapitant) injectable emulsion has since been discontinued." Reference added. Specialty Matched Consultant Advisory Panel review 3/18/2020.
BCR-ABL1 Testing for Chronic Myeloid Leukemia and Acute Lymphoblastic Leukemia AHS – M2027 Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statement.
Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia Updated Policy Guidelines section. Specialty Matched Consultant Advisory Panel review 4/15/2020. Reference added. No change to policy statement.
Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia Specialty Matched Consultant Advisory Panel review 4/15/2020. Reference added. No change to policy statement.
Immunoglobulin Therapy Updated "When Covered" section for hematopoietic cell transplantation to clarify the following "hematopoietic cell transplantation recipients who are 180 days post-transplantation." Updated Policy Guidelines to include the following statement: "For IVIG requests within 180 days post-transplantation date, please refer to internal protocol found within Blue Cross NC Clinical Transplant Process Guidelines." Clarified definition of standard deviation for hypogammaglobulinemia diagnostic criteria within the Appendix. Medical Director review 5/2020.
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies AHS - G2105 Language under When not covered section revised to accurately reflect non-covered reason. Policy statement clarified as "Immunopharmacologic monitoring of Infliximab, Adalimumab and other therapeutic serum antibodies is not covered for any indication." 80299 added to Coding section.
In Vitro Chemoresistance and Chemosensitivity Assays AHS- G2100 Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statement.
Ipilimumab (Yervoy) Added additional FDA approved indications in Description section for clarity. Added reference to related medical policy: "PD-1 Inhibitors." Specialty Matched Consultant Advisory Panel review 3/18/2020.
Isatuximab-irfc (Sarclisa®) New policy developed. Sarclisa is considered medically necessary for the treatment of adult patients with multiple myeloma when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, J3590, J9999, S0353, and S0354 to Billing/Coding section. References added. Medical Director review 5/2020.
Monoclonal Antibody Imaging for Prostate Cancer Specialty Matched Consultant Advisory Panel review 4/15/2020. Reference added. No change to policy statement.
Multigene Expression Assay for Predicting Colon Cancer Recurrence AHS-M2111 Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statement.
Ovarian and Internal Iliac Vein Embolization, Ablation and Sclerotherapy Reference added. Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statement.
Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities Reference added. Updated Policy Guidelines section.
Pulmonary Hypertension, Drug Management Dosing specifications added to Policy Guidelines. Edits made throughout policy for improved structure and clarity. Reference added. Specialty Matched Consultant Advisory Panel review 3/18/2020.
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders Regulatory section updated with FDA unit limits. Policy Guidelines updated with support of unit limits. Note added limiting units in When covered section. References added. Policy noticed 3/24/20 for effective date 5/26/20.
Treatment For Opioid Use Disorder in Opioid Treatment Programs (OTPs) Notification of new policy. Notification given 3/24/2020 for effective date 5/26/2020.