Medical Policy Updates

Notification of Policy Revisions Effective June 23, 2020 (Posted April 14, 2020)

Medical Policy Revision
Interleukin-5 Antagonists "Notification" Under "When Covered" section for continuation of therapy, added the following: "For mepolizumab (Nucala) and benralizumab (Fasenra) requests, the patient has a physical or cognitive limitation that makes the utilization of a self-administered formulation unsafe or otherwise not feasible. This must be demonstrated by both of the following: 1. Inability to self-administer the medication; AND 2. Lack of caregiver or support system for assistance with administration of self-administered products." Policy remains on notice for effective date 6/23/2020.
Preimplantation Genetic Testing AHS – M2039 "Notification" Notification of new policy given 04/14/2020 for effective date 06/23/2020.
Prescription Medication and Illicit Drug Testing in the Outpatient Setting AHS – T2015 "Notification" Presumptive testing limits updated in 1a. Requirement to policy statement "documentation in patient's medical record" added. Replaced "up to" with "not to exceed" in policy statements. Criteria added for presumptive urine drug testing in patient populations noted in 1b. Definitive testing policy statement enhanced with "when presumptive testing shows unexpected results." Limiting criteria added to definitive drug testing. Language converted to reimbursement from medically necessary. Removed coding grid and deleted code 0006U. Added PLA codes 0093U and 0143U – 0150U. 2020 Q1 Avalon CAB review. Policy noticed 4/14/2020 for effective date 6/23/2020.
Prostatic Urethral Lift "Notification" 20 Medical Director review. Description section updated. When Covered section updated. Added three additional non covered indications to When Not Covered section. Updated Policy Guidelines. Policy noticed 4/14/2020 for policy effective date 6/23/2020.
Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia "Notification" Medical Director review. Description section updated. When Covered section updated. Added three additional non covered indications to When Not Covered section. Updated Policy Guidelines. Policy noticed 4/14/2020 for policy effective date 6/23/2020.