Medical Policy Updates

Medical Policy Update for June 23, 2020

Medical Guidelines Reason for Update
Alemtuzumab (Lemtrada®) Updated "When Covered" section with the following clarification for relapsing multiple sclerosis: "(to include relapsing-remitting disease and active secondary progressive disease)." Reference added. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Bariatric Surgery References added. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors Specialty Matched Consultant Advisory Panel review 5/20/2020.
Cryosurgical Ablation of Primary or Metastatic Liver Tumors Specialty Matched Consultant Advisory Panel review 5/20/2020.
Eculizumab (Soliris®) Specialty Matched Consultant Advisory Panel (Neurology) review 5/20/2020. No change to policy intent.
Gender Confirmation Surgery and Hormone Therapy Reference added. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Givosiran (Givlaari™) Specialty Matched Consultant Advisory Panel review 5/20/2020. No change to policy intent.
Interleukin-5 Antagonists Under "When Covered" section for continuation of therapy, added the following: "For mepolizumab (Nucala) and benralizumab (Fasenra) requests, the patient has a physical or cognitive limitation that makes the utilization of a self-administered formulation unsafe or otherwise not feasible. This must be demonstrated by both of the following: 1. Inability to self-administer the medication; AND 2. Lack of caregiver or support system for assistance with administration of self-administered products." Policy remains on notice for effective date 6/23/2020.
Intraoperative Neurophysiologic Monitoring Reference added. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Liver Transplant and Combined Liver-Kidney Transplant CPT 47136 removed from policy; code expired. Specialty Matched Consultant Advisory Panel 5/20/2020.
Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease (GERD) Specialty Matched Consultant Advisory Panel review 11/20/2019. Reference added.
Metabolite Markers of Thiopurines AHS – G2115 Minor revision to When Not Covered section; no change to policy intent.
Natalizumab (Tysabri®) Updated "When Covered" section with the following clarification for relapsing forms of multiple sclerosis: "(to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease)." Other minor updates made throughout policy for clarity. Reference added. Specialty Matched Consultant Advisory Panel review 5/20/20.
Ocrelizumab (Ocrevus®) Updated Policy Guidelines to include risk and management of infusion-related reactions. Reference added. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Paraspinal Surface Electromyography (SEMG) Specialty Matched Consultant Advisory Panel review 5/20/2020.
Patisiran (Onpattro™) Reference added. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers Reference added. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Polysomnography for Non‒Respiratory Sleep Disorders Specialty Matched Consultant Advisory Panel review 5/20/2020.
Preimplantation Genetic Testing AHS – M2039 Notification of new policy given 04/14/2020 for effective date 06/23/2020. Reviewed by Avalon 1st Quarter 2020 CAB. Medical Director review 4/2020.
Prescription Medication and Illicit Drug Testing in the Outpatient Setting AHS – T2015 Presumptive testing limits updated in 1a. Requirement to policy statement "documentation in patient's medical record" added. Replaced "up to" with “not to exceed” in policy statements. Criteria added for presumptive urine drug testing in patient populations noted in 1b. Definitive testing policy statement enhanced with "when presumptive testing shows unexpected results." Limiting criteria added to definitive drug testing. Language converted to reimbursement from medically necessary. Removed coding grid and deleted code 0006U. Added PLA codes 0093U and 0143U – 0150U. 2020 Q1 Avalon CAB review. Medical Director review 4/2020. Specialty Matched Consultant Advisory Panel review 04/15/2020. Policy noticed 4/14/2020 for effective date 6/23/2020.
Prostatic Urethral Lift Medical Director review. Description section updated. When Covered section updated. Added three additional non covered indications to When Not Covered section. Updated Policy Guidelines. Policy noticed 4/14/2020 for policy effective date 6/23/2020.
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors Code 41530 added to Billing/Coding section. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Repository Corticotropin (H.P. Acthar Gel) Reference added. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Serum Testing for Evidence of Mild Traumatic Brain Injury AHS – G2151 Specialty Matched Consultant Advisory Panel review 5/20/2020.
Therapeutic Radiopharmaceuticals in Oncology Reference added. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Topical Negative Pressure Therapy for Wounds Reference added. Regulatory status updated. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia Medical Director review. Description section updated. When Covered section updated. Added three additional non covered indications to When Not Covered section. Updated Policy Guidelines. Policy noticed 4/14/2020 for policy effective date 6/23/2020.
Vedolizumab (Entyvio) Removed the following from FDA labeled indication in Description section, "who have had an inadequate response with, lost response to, or were intolerant to a tumor necrosis factor (TNF) blocker or immunomodulator; or had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroids." Specialty Matched Consultant Advisory Panel review 5/20/2020.
Zinplava (bezlotoxumab) Specialty Matched Consultant Advisory Panel review 5/20/2020. No change to policy intent.