Medical Policy Updates

Medical Policy Update for April 30, 2019

Medical Guidelines Reason for Update
Brentuximab Vedotin (Adcetris®) Added the following indication to “When Covered” section: “in combination with cyclophosphamide, doxorubicin, and prednisone for the treatment of patients with previously untreated systemic anaplastic large cell lymphoma or other CD30+ peripheral T-cell lymphomas (PTCL), including angioimmunoblastic T-cell lymphoma and PTCL not otherwise specified,” and added the following statement for clarity “(i.e. doxorubicin, vinblastine, and dacarbazine)” for previously untreated stage III/IV cHL. Updated dosing in Policy Guidelines to reflect additional indication. References added. Specialty Matched Consultant Advisory Panel review 4/17/2019.
Bronchial Thermoplasty Specialty Matched Consultant Advisory Panel review 3/20/2019. No change to policy statement.
Cabazitaxel (Jevtana®) Specialty Matched Consultant Advisory Panel review 4/17/2019. No change to policy statement.
Carfilzomib (Kyprolis®) Minor update made to dosing in “Policy Guidelines” section for clarity. Specialty Matched Consultant Advisory Panel review 4/17/2019. No change to policy intent.
Corneal Collagen Cross-linking Policy archived in error- back to active status.
Daratumumab (Darzalex®) Added the following statement to “When Covered” section: “ In combination with bortezomib, melphalan and prednisone in patients with newly diagnosed disease who are ineligible for autologous stem cell transplantation,” and updated Policy Guidelines with the associated dosing regimen for this indication. References added. Specialty Matched Consultant Advisory Panel review 4/17/2019.
Diagnosis and Treatment of Sacroiliac Joint Pain Updated Description and Policy Guidelines sections. Deleted code 20552 from Billing/Coding section. Reference added. Specialty Matched Consultant Advisory Panel review 4/17/2018.
Eculizumab (Soliris®) Minor typographical changes made throughout policy for clarity. Specialty Matched Consultant Advisory Panel review 4/2019. No change to policy statements.
Electromagnetic Navigation Bronchoscopy Specialty Matched Consultant Advisory Panel review 3/20/2019. Updated Regulatory Status. References added. No change to policy statement.
Elotuzumab (Empliciti®) Added the following indication to “When Covered” section: “At least two prior therapies for multiple myeloma including lenalidomide and a proteasome inhibitor, AND will receive elotuzumab in combination with pomalidomide and dexamethasone.” Updated “Description” and “Policy Guidelines” sections to reflect newly added indication. Reformatted “When Covered” section for clarity. References added. Specialty Matched Consultant Advisory Panel review 4/17/2019.
Endobronchial Valves Specialty Matched Consultant Advisory Panel review 3/20/2019. No change to policy statement.
Epidural Steroid Injections for Back Pain Reference added. Specialty Matched Consultant Advisory Panel review 4/17/2019. No change to policy statement.
Eribulin Mesylate (Halaven®) Specialty Matched Consultant Advisory Panel review 4/17/2019. No change to policy statement.
Facet Joint Denervation If there has been a prior successful radiofrequency denervation, additional diagnostic medial branch blocks for the same level of the spine are not medically necessary. Added the following statements to Item 4 under Policy Guidelines: A successful trial of controlled diagnostic medial branch blocks consists of 2 separate positive blocks on different days with local anesthetic only (no steroids or other drugs), or a placebo-controlled series of blocks, under fluoroscopic guidance, that has resulted in at least a 50% reduction in pain for the duration of the local anesthetic used (eg, 3 hours longer with bupivacaine than lidocaine). No therapeutic intra-articular injections (ie, steroids, saline, or other substances) should be administered for a period of at least 4 weeks prior to the diagnostic medial branch block. The diagnostic blocks should involve the levels being considered for radiofrequency treatment and should not be conducted under intravenous sedation unless specifically indicated (eg, the patient is unable to cooperate with the procedure). These diagnostic blocks should be targeted to the likely pain generator. Single-level blocks lead to more precise diagnostic information, but multiple single-level blocks require several visits and additional exposure to radiation. Specialty Matched Consultant Advisory Panel review 4/17/2019.
Infliximab, Infliximab-dyyb, Infliximab-abda, Infliximab-qbtx Under “When Covered,” added the indication “Immune Checkpoint Inhibitor-Related Gastrointestinal Toxicity” with the following criteria: “to treat moderate to severe diarrhea or colitis that develops during immune checkpoint inhibitor (PD-1, PD-L1) therapy, and stool evaluation has ruled out an infectious etiology, and the gastrointestinal symptoms are steroid-refractory.” Updated Policy Guidelines to reflect dosing guidelines for additional indication. References added. Medical Director review 4/2019.
Intravenous Anesthetics for the Treatment of Chronic Pain Added “psychiatric disorders” to list of non-covered indications. Reference added. Specialty Matched Consultant Advisory Panel review 4/17/2019. No change to policy statement.
Lung and Lobar Lung Transplantation Policy archived. See policy titled: Genetic Testing for Dilated Cardiomyopathy AHS - M2073.
Lung Volume Reduction Surgery Specialty Matched Consultant Advisory Panel review 3/20/19. No change to policy statement.
Lysis of Epidural Adhesions Reference added. Specialty Matched Consultant Advisory Panel review 4/17/2019. No change to policy statement.
Maternal and Fetal Diagnostics Specialty Matched Consultant Advisory Panel review 3/20/2019. No change to policy statement.
Modifier Guidelines Corrected typo. Modifier “SP” changed to “XP” throughout.
Monoclonal Antibodies for Non-Hodgkin Lymphoma and Acute Myeloid Leukemia In the Non-Hematopoietic Stem Cell Transplant Setting Under “When Covered” for Ofatumumab (Arzerra), added the following indication: “for the treatment of patients with CLL refractory to fludarabine and alemtuzumab”; and restructured existing indications for clarity with no change to policy intent. Added the following indication under “When Covered” for Obinutuzumab (Gazyva): “the treatment of adult patients with previously untreated stage II bulky, III, or IV follicular lymphoma, in combination with chemotherapy, followed by Gazyva monotherapy, in patients achieving at least a partial remission.” Specialty Matched Consultant Advisory Panel review 4/17/2019.
Neural Therapy Minor changes to Policy Guidelines section. Reference added. Specialty Matched Consultant Advisory Panel review 4/17/2019. No change to policy statement.
Oscillatory Devices for the Treatment of Respiratory Conditions Specialty Matched Consultant Advisory Panel review 3/20/2019. No change to policy statement.
Paclitaxel (Abraxane)® Specialty Matched Consultant Advisory Panel review 4/17/2019. No change to policy statement.
Panitumumab (Vectibix®) New policy developed. Vectibix is considered medically necessary for the treatment of patients with wild-type RAS (defined as wild-type in both KRAS and NRAS) metastatic colorectal cancer. Added HCPCS codes J9303, S0353, and S0354 to Billing/Coding section. References added. Medical Director review 4/2019.
Pemetrexed (Alimta®) Updated “When Covered” and “Description” sections with the following indication: “in combination with pembrolizumab and platinum chemotherapy as first-line therapy for metastatic disease in patients with no EGFR or ALK genomic tumor aberrations.” References added. Specialty Matched Consultant Advisory Panel review 4/17/2019.
Pertuzumab for Treatment of Malignancies Reference added. Specialty Matched Consultant Advisory Panel review 4/17/2019. No change to policy statements.
Prolotherapy Minor changes to Description section. Reference added. No change to policy statement. Specialty Matched Consultant Advisory Panel review 4/17/2019.
Ravulizumab-cwvz (UltomirisTM) New policy developed. Ravulizumab-cwvz (Ultomiris) is considered medically necessary for the treatment of adult patients (≥ 18 years old) with paroxysmal nocturnal hemoglobinuria (PNH). Added HCPCS codes C9399, J3490, and J3590 to Billing/Coding section. References added. Medical Director review 4/2019.
Siltuximab (Sylvant®) Specialty Matched Consultant Advisory Panel review 4/17/2019. No change to policy statement.
TENS (Transcutaneous Electrical Nerve Stimulator) Updated Policy Guidelines section. Reference added. Specialty Matched Consultant Advisory Panel review 4/17/2019. No change to policy statement.
White Blood Cell Growth Factors Specialty Matched Consultant Advisory Panel review 4/17/2019. No change to policy statements.