Medical Policy Updates

Medical Policy Update September 22, 2020

Medical Guidelines Reason for Update
CAR-T Therapy Added brexucabtagene autoleucel (Tecartus) to policy to be considered medically necessary for the treatment of patients with relapsed or refractory mantle cell lymphoma (MCL) when specified medical criteria and guidelines are met. Updated Description and Policy Guidelines sections to include information relevant to brexucabtagene autoleucel. Other minor typographical edits made throughout policy for clarity. Added HCPCS codes C9399, J3490, J3590, and J9999 to Billing/Coding section. References added. Medical Director review 9/2020.
Cellular Immunotherapy for Prostate Cancer Specialty Matched Consultant Advisory Panel review 8/19/2020. No change to policy intent.
Givosiran (Givlaari™) Added the following criteria to "When Covered" section "History of one severe attack within the past year with central nervous system (CNS), autonomic nervous system (ANS), or peripheral nervous system (PNS) involvement (e.g., hallucinations, seizures, respiratory failure, paralysis)." Medical Director review 9/2020.
Goserelin Acetate (Zoladex) Specialty Matched Consultant Advisory Panel review 8/19/2020. No change to policy intent.
Hematopoietic Cell Transplantation for Hodgkin Lymphoma Updated Description and Policy Guidelines sections. Under When Not Covered section: coverage for tandem autologous HCT changed to investigational from medically necessary. Medical Director review 7/2020. Reference added. Notification 7/21/2020 for effective date 9/22/2020.
Inebilizumab-cdon (Uplizna™) New policy developed. Uplizna may be considered medically necessary for the treatment of adults with NMOSD when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, and J3590 to Billing/Coding section. References added. Medical Director review 9/2020.
Luspatercept-aamt (Reblozyl®) New indication added to "When Covered" section for anemia associated with MDS-RS and MDS/MPN-RS-T. Updated "Description" and "Policy Guidelines" sections to include this indication. References added. Medical Director review 7/2020.
Moxetumomab pasudotox-tdfk (Lumoxiti™) Specialty Matched Consultant Advisory Panel review 8/19/2020. No change to policy intent.
Panitumumab (Vectibix®) Specialty Matched Consultant Advisory Panel review 8/19/2020. No change to policy intent.
Tinnitus Treatment Reference added. Billing/Coding section updated. Specialty Matched Consultant Advisory Panel review 8/19/2020.
Transtympanic Micropressure Applications as a Treatment of Meniere's Disease Reference added. Specialty Matched Consultant Advisory Panel review 8/19/2020. Medical Director review. Archive policy.