Medical Policy Updates

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Medical Policy Update for July 30, 2019

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.