Medical Policies

Notification of Policy Revisions Effective November 24, 2020(Posted September 22, 2020)

Medical Policy Revision
Ablation and Neural Therapy Procedures for Headache and Pain Management "Notification" Medical Director review. Policy title changed from Ablation Procedures for Peripheral Neuromas and Peripheral Nerves to Ablation and Neural Therapy Procedures for Headache and Pain Management. Description section updated. Related policies added. Policy statements updated for clarity. When Not Covered section updated for clarity. Policy Guidelines updated. Codes 64620, 64630, 64455, 64999 and 20999 added to Billing/Coding section. ICD-10 diagnosis codes added. Notification given 9/22/2020 for policy effective date 11/24/2020.
Eptinezumab-jjmr (Vyepti™) "Notification" Under "When Covered" section, added the following: "The patient has tried and had an inadequate response to both erenumab (Aimovig) AND galcanezumab (Emgality); OR The patient has a clinical contraindication or intolerance to both erenumab (Aimovig) AND galcanezumab (Emgality) that is not expected to occur with eptinezumab; AND". Medical Director review 7/2020. Notification given 9/22/2020 for effective date 11/24/2020.
Facet Joint Denervation "Notification" Updated policy guidelines #4, #5 and #6 easing requirement to a single medial branch block / facet injection. When not covered section updated with "More than two facet injections/medial branch blocks at the same level are considered investigational." Notification 9/22/20 for effective date 11/24/20.
Injection Therapy for Headache (Migraine and Other) and Non-Spine Management "Notification" Medical Director review. Policy title changed from Sphenopalatine Ganglion Block for Headache to Injection Therapy for Headache (Migraine and Other) and Non-Spine Management. Description section updated. Related Policies added. Policy statements updated for clarity. When Not Covered section updated for clarity. Policy Guidelines updated. Codes 20605, 20606, 20999, 64400, 64405, 64408, 64415, 64417, 64418, 64420, 64421, 64450, 64454, 64455, 64505, 64999 added to Billing/Coding section. ICD-10 diagnosis codes added. Notification given 9/22/2020 for policy effective date 11/24/2020.
Professional Pathology Billing Guidelines AHS -R2169 "Notification" Extensive revisions to "Description" and "Service Guidelines" sections. Added "Billing Guidelines" section. Cytology codes 88104-88199 and Pathology Consultation codes 80500-80502 added to "Billing/Coding/Physician Documentation Information" section. "Scientific Background and Reference Sources" section updated to "Reference Sources". Notification given 9/22/20 for effective date 11/24/20.
Rituximab for the Treatment of Rheumatoid Arthritis "Notification" Under "When Covered" for Rituxan (rituximab), added Truxima (rituximab-abbs) and Ruxience (rituximab-pvvr) biosimilars with same indications as Rituxan (rituximab). Added HCPCS codes C9399, J3490, J3590, Q5115, and Q5119 to Billing/Coding section. References added. Medical Director review 7/2020. Policy notification given 9/22/2020 for effective date 11/24/2020.