Medical Policy Updates

Medical Policy Update for January 12, 2021

Medical Guidelines Reason for Update
Atezolizumab (Tecentriq) for Intravenous Use Updated "When Covered" section with the following indications: metastatic NSCLC with no EGFR or ALK genomic tumor aberrations and whose tumors have high PD-L1 expression as determined by an FDA-approved test, and are receiving atezolizumab as first-line treatment; metastatic NSCLC with no EGFR or ALK genomic tumor aberrations, and are receiving atezolizumab as first-line treatment in combination with paclitaxel protein-bound and carboplatin; unresectable or metastatic HCC with no prior systemic chemotherapy; and BRAF V600 mutation-positive unresectable or metastatic melanoma. Updated Policy Guidelines with appropriate dosing by indication. Minor edits made throughout policy for clarity. Reference added. Specialty Matched Consultant Advisory Panel review 11/18/2020.
Blinatumomab (Blincyto®) Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy intent.
Copanlisib (Aliqopa™) Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy intent.
Daunorubicin and Cytarabine (Vyxeos™) Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy intent.
Enfortumab vedotin-ejfv (Padcev™) Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy statements.
Genetic Testing for Neurodegenerative Disorders AHS – M2167 New policy developed. Genetic testing for neurodegenerative disorders is covered when coverage criteria are met. Notification given 11/10/2020 for policy effective date 01/12/2021.
Injection Therapy for Headache (Migraine and Other) and Non-Spine Management Specialty Matched Consultant Advisory Panel review 10/21/2020. ICD-10 diagnosis codes from M16 series, M17 series, M19 series, and M25 series removed from Billing/Coding section.
Inotuzumab (Besponsa®) Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy intent.
Luspatercept-aamt (Reblozyl®) Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy statements.
Olaratumab (Lartruvo™) Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy intent.
Rituximab for the Treatment of Rheumatoid Arthritis Under "When Covered" for Rituxan (rituximab), added additional biosimilar, Riabni (rituximab-arrx), with same indications and coverage criteria as Rituxan (rituximab). Reference added. Medical Director review 1/2021.
Romiplostim (NPlate) Specialty Matched Consultant Advisory Panel 11/18/2020. No change to policy intent.