Medical Guidelines |
Reason for Update |
Adaptive Behavioral Treatment for Autism Spectrum Disorders |
Specialty Matched Consultant Advisory Panel Review 7/10/2019. No change to policy statement. |
Buprenorphine Implant for Treatment of Opioid Dependence |
Specialty Matched Consultant Advisory Panel review 6/19/2019. No change to policy statement. |
Capsule Endoscopy, Wireless |
Revised wording to 1st bullet under the When Covered section, replaced the term "and" with "OR" for clarity. No change in policy intent. Medical Director review 7/2019. |
Continuous Monitoring of Glucose in the Interstitial Fluid |
Description section updated for Eversense FDA approval. Added clarifying statement to "When not covered" section to include implantable CGM. |
Detection of Circulating Tumor Cells and Cell Free DNA in Cancer Management AHS-G2054 |
Under "When Covered" section: removed item B. "Testing is performed using the Cobas EGFR Mutation Test, Guardant360 test, or OncoBEAM test." Medical Director review 7/2019. |
Esketamine (SpravatoTM) Nasal Spray |
Added the following statement to criterion #3 for initial and continuation (maintenance) criteria within "When Covered" section, "or a comparable standardized rating scale that reliably measures depressive symptoms." Specialty Matched Consultant Advisory Panel review 6/19/2019. |
Place of Service for Medical Infusions |
Added HCPCS codes J0598, J3397 and Q5109 to Billing/Coding section and replaced code Q5102 with codes Q5103 and Q5104. |
Polatuzumab vedotin-piiq (PolivyTM) |
New policy developed. Polivy is considered medically necessary for diffuse large B-cell lymphoma (DLBCL). Added HCPCS codes C9399, J3490, J3590, J9999, S0353, and S0354 to Billing/Coding section. References added. Medical Director review 7/2019. |
Prostatic Urethral Lift |
Medical Director review. Removed the following from the eighth bulleted statement in When Prostatic Urethral Lift is covered: "does not have prostate-specific antigen level >=3 ng/mL, OR". |
Quantitative Electroencephalography as a Diagnostic Aid for Attention Deficit/Hyperactivity Disorder |
Updated Description section and Policy Guidelines. References added. Specialty Matched Consultant Advisory Panel review 7/10/2019. |
Residential Treatment |
Specialty Matched Consultant Advisory Panel review 7/10/2019. No change to policy statement. |
Sensory Integration Therapy and Auditory Integration Therapy |
Updated Description section and Policy Guidelines. References added. Specialty Matched Consultant Advisory Panel review 7/10/2019. |
Sublocade |
Specialty Matched Consultant Advisory Panel review 6/19/2019. No change to policy statement. |