Medical Policy Updates

Medical Policy Update for October 13, 2020

Medical Guidelines Reason for Update
Antisense Oligonucleotide Therapy for Duchenne Muscular Dystrophy Added viltolarsen (Viltepso) to policy with the following policy statement: "the use of viltolarsen is considered investigational for all indications including treatment of Duchenne muscular dystrophy." Updated Description and Policy Guidelines sections to include description and evidence for viltolarsen. Other minor typographical edits and additions made for clarity. Added HCPCS codes C9399, J3490, and J3590 to Billing/Coding section. References added. Medical Director review 9/2020.
Bone Mineral Density Studies Specialty Matched Consultant Advisory Panel review 9/29/2020. Description, Policy guidelines and References updated. "Axial (central)" removed from policy statement.
Bone Turnover Markers Testing AHS – G2051 Specialty Matched Consultant Advisory Panel review 9/29/20. No change to policy statement.
Botulinum Toxin Injection Added "AND/OR" throughout "When Covered" section for clarity of policy intent. The following edits made to preferred product criteria within "When Covered" section for clarity and consistency: "the patient has tried and had an inadequate response to OR has a clinical contraindication or intolerance to." Updated indications in "Description" section for Botox and Xeomin. References added. Medical Director review 10/2020.
Denosumab (Prolia™, XGEVA™) Specialty Matched Consultant Advisory Panel review 9/16/2020. No change to policy intent. Medical Director review 10/2020.
Guselkumab (Tremfya®) and Tildrakizumab-asmn (Ilumya®) Added new indication within "When Covered" section for Tremfya for active psoriatic arthritis when specified medical criteria and guidelines are met. Updated Description and Policy Guidelines sections to reflect new indication. References added. Medical Director review 10/2020.
Infertility Diagnosis and Treatment – B0006 Specialty Matched Consultant Advisory Panel review 9/29/2020. References updated. No change to policy statement.
Ocrelizumab (Ocrevus®) Updated SOC criteria in "Policy Guidelines" section from "first infusion OR less than 3 months since first infusion" to "the patient is new to therapy, defined as initial infusion OR less than 3 months since initial infusion" for clarity. Added the following to SOC criteria: "first infusion after at least a one-month gap in therapy outside of the approved dosing interval for drugs requiring every 6 months dosing duration (i.e. at least seven months of no ocrelizumab infusions)". Notification given 8/11/2020 for effective date 10/13/2020.
Place of Service for Medical Infusions Updated criteria in "When Covered" section from "first infusion OR less than 3 months since first infusion" to "the patient is new to therapy, defined as initial infusion OR less than 3 months since initial infusion" for clarity. Added the following to "When Covered" section: "first infusion after at least a one-month gap in therapy outside of the approved dosing interval for drugs requiring every 6 months dosing duration," and added the following clarification to "first infusion after six months of no infusions": "for drugs with an approved dosing interval less than 6 months duration". Notification given 8/11/2020 for effective date 10/13/2020.
Preimplantation Genetic Testing AHS – M2039 Specialty Matched Consultant Advisory Panel review 9/29/2020. No change to policy statement.
Romosozumab-aqqg (Evenity™) Updated "When Covered" section to include the following criteria: "A pre-treatment bone mineral density (BMD) T-score of ≤ -3 at the total hip or femoral neck," and requirement of trial and failure or contraindication to bisphosphonates or other injectable osteoporosis therapies for T-score of ≤ -2.5 with no history of osteoporosis related fracture. Edit made to statement in "When Not Covered" section to clarify intent. Updated clinical evidence summary in Policy Guidelines. Specialty Matched Consultant Advisory Panel review 9/16/2020. Medical Director review 10/2020.