Medical Policy and Coding Updates April 2021

  • Updates for both non-individual and individual plans

  • Effective May 10, 2021

    Updates to AIM Specialty Health® Clinical Appropriateness Guidelines

    Effective for dates of service on and after May 10, 2021, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Molecular Testing of Solid and Hematologic Tumors and Malignancies

    Updates by section:

    Conditions for which testing may be medically necessary (Table 1)

    The following solid tumor markers were added:

    • Cholangiocarcinoma: FGFR2 and FoundationOne® CDx
    • Colorectal cancer: Praxis Extended RAS panel
    • Neuroblastoma: chromosomal microarray analysis (CMA), MYCN, ALK
    • Non-small cell lung cancer (NSCLC): Oncomine Dx Target Test
    • Ovarian cancer: myChoice® CDx
    • Prostate cancer (suspected): SelectMDx
    • Prostate cancer: FoundationOne® CDx
    • Tumor agnostic/all solid tumors: microsatellite instability (MSI) and FoundationOne® CDx

    Breast Cancer Gene Expression Classifiers

    • Criteria were clarified to confirm the patient has undergone surgery and full pathological staging
    • Additional statement added explaining testing is not medically necessary to guide decision making for extended endocrine therapy
    • OncotypeDx Recurrence Score test: the definition of unfavorable histological features was clarified

    Minimal Residual Disease (MRD)

    • Testing criteria were revised to require testing performed on bone marrow

    Targeted Molecular Testing for NTRK Fusions

    • Criteria were revised

    Prostate Cancer (symptomatic cancer screening)

    • Added criteria for SelectMDx (81479)
    • Criteria for PCA3 (81313), ExomeDx (0005U) and ConfirmMDx (81551) were revised

    Effective May 6, 2021

    Hereditary Angioedema, 5.01.587

    Medical necessity criteria updated

    • Berinert® (pdC1-INH)
      • Added coverage for acquired angioedema
    • Cinryze® (pdC1-INH)
      • Added patient age, limits to danazol use, and acute HAE frequency requirements
    • Firazyr® (icatibant)
      • Requires use of generic icatibant first
    • Haegarda® (pdC1-INH)
      • Added limits to danazol use and acute HAE frequency requirements
    • Ruconest® (rhC1-INH)
      • Age criteria revised to patients 13 and older
    • Takhzyro® (lanadelumab-flyo)
      • Added limits to danazol use, acute HAE frequency requirements, and quantity limit

    Effective April 7, 2021

    Immune Globulin Therapy, 8.01.503

    Site of service review added

    • Xembify®

    Miscellaneous Oncology Drugs, 5.01.540

    New drug added to policy

    • Jelmyto™ (mitomycin)
      • Treatment of adult patients with low-grade upper tract urothelial cancer (LG-UTUC)

    Site of Service Infusion Drugs and Biologic Agents, 11.01.523

    Site of service review added

    • Xembify®

    New medical policies

    Effective April 1, 2021

    Bioengineered Skin and Soft Tissue Substitutes, 7.01.113

    New policy

    • This policy replaces Bioengineered Skin and Soft Tissue Substitutes, 7.01.582
    • The table of investigational products has been updated and expanded
    • All statements remain unchanged

    Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias, 8.01.538

    New policy

    • This policy replaces Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias, 8.01.22
    • All statements remain unchanged

    New pharmacy policies

    Effective April 1, 2021

    Topical Drugs of Actinic Keratosis and Other Dermatologic Conditions, 5.01.623

    New policy

    The following brand drugs have been added and may be considered medically necessary when criteria are met:

    • Aldara® (imiquimod 5%)
      • Treatment of actinic keratosis in adults
      • Treatment of superficial basal cell carcinoma (sBCC) in adults
      • Treatment of external genital and perianal warts (EGW) in patients age 12 and older
    •  Carac® (fluorouracil 0.5%)
      • Treatment of actinic keratosis in adults
    • Fluoroplex® (fluorouracil 1%)
      • Treatment of actinic keratosis in adults
    • Brand fluorouracil
      • Treatment of actinic keratosis in adults
    • Brand imiquimod 3.75%
      • Treatment of actinic keratosis in adults age 18 and older
      • Treatment of external genital and perianal warts (EGW) in patients age 12 and older
    • Klisyri® (tirbanibulin)
      • Treatment of actinic keratosis in adults
    • Solaraze® (diclofenac 3%)
      • Treatment of actinic keratosis in adults
    • Tolak® (fluorouracil 4%)
      • Treatment of actinic keratosis in adults
    • Zyclara® (imiquimod 2.5% and 3.75%)
      • Treatment of actinic keratosis in adults age 18 and older
    • Zyclara® (imiquimod 3.75%)
      • Treatment of external genital and perianal warts (EGW) in patients age 12 and older

    Revised pharmacy policies

    Effective April 1, 2021

    Pharmacotherapy of Arthropathies, 5.01.550

    Medical necessity criteria updated

    • Cosentyx® (secukinumab)
      • For the treatment of plaque psoriasis, the patient must have tried and failed four drugs from three or more different drug classes
    • Cosentyx® (secukinumab)
      • For the treatment of psoriatic arthritis, the patient must have tried and failed three drugs from two or more different drug classes

    Removed from site of service review

    • Simponi® (golimumab)

    An archived policy is one that's no longer active and is not used for reviews.

    Archived April 1, 2021

    Acute Inpatient Hospice, 11.01.507

    Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers, 2.04.76

    Deleted April 1, 2021

    Bioengineered Skin and Soft Tissue Substitutes, 7.01.582

    This policy is replaced with Bioengineered Skin and Soft Tissue Substitutes, 7.01.113

    Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias, 8.01.22

    This policy is replaced with Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias, 8.01.538

    Added codes

    Effective April 11, 2021

    Effective for dates of service on and after April 11, 2021, the following will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Genetic Testing.

    Now reviewed by AIM® Specialty Health and requires prior authorization.

    0242U, 0244U, 0245U

    Effective April 7, 2021

    Miscellaneous Oncology Drugs, 5.01.540

    Now requires review for medical necessity and prior authorization.

    J9280

    Effective April 1, 2021

    Bioengineered Skin and Soft Tissue Substitutes, 7.01.582

    Now requires review for investigative.

    Q4108

    Chimeric Antigen Receptor Therapy for Hematologic Malignancies, 8.01.63

    Now requires review for medical necessity.

    Q2053

    Drugs for Rare Diseases, 5.01.576

    Now requires review for medical necessity.

    C9074

    Hospital Beds and Accessories, 1.01.520

    Now requires review for medical necessity and prior authorization.

    E0270

    Hyperbaric Oxygen Therapy, 2.01.04

    Now requires review for investigative and prior authorization.

    A4575

    Immune Globulin Therapy, 8.01.503

    Now requires review for medical necessity.

    J1554

    Microprocessor-Controlled and Powered Prostheses and Orthoses for the Lower Limb, 1.04.503

    Now requires review for medical necessity and prior authorization.

    K1014

    Miscellaneous Oncology Drugs, 5.01.540

    Now requires review for medical necessity and prior authorization.

    J9280

    Miscellaneous Oncology Drugs, 5.01.540

    Now requires review for medical necessity.

    J9037

    Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502

    Now requires review for medical necessity and prior authorization.

    J9349

    Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used with Autologous Bone Marrow), 8.01.52

    Now requires review for investigative.

    0565T, 0566T

    Pharmacologic Treatment of Duchenne Muscular Dystrophy, 5.01.570

    Now requires review for medical necessity.

    J1427

    Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions, 2.01.16

    Now requires review for investigative.

    S9055, G0460

    Steroid-Eluting Sinus Stents, 7.01.134

    Now requires review for investigative.

    S1091

    Vagus Nerve Stimulation, 7.01.20

    Now requires review for investigative.

    K1020

    Removed codes

    Effective April 1, 2021

    Blepharoplasty, Blepharoptosis and Brow Ptosis Surgery, 7.01.508

    No longer requires review for medical necessity and prior authorization.

    67909

    Chimeric Antigen Receptor Therapy for Hematologic Malignancies, 8.01.63

    No longer requires review for medical necessity.

    C9073

    Immune Globulin Therapy, 8.01.503

    No longer requires review for medical necessity.

    C9072

    Intra-Articular Hyaluronan Injections for Osteoarthritis, 2.01.31

    No longer requires review for medical necessity.

    J3333

    Miscellaneous Oncology Drugs, 5.01.540

    No longer requires review for medical necessity.

    C9069

    Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502

    No longer requires review for medical necessity.

    C9070

    Pharmacologic Treatment of Duchenne Muscular Dystrophy, 5.01.570

    No longer requires review for medical necessity.

    C9071

    Steroid-Eluting Sinus Stents, 7.01.134

    Now requires review for investigative.

    J7401

  • Updates for non-individual plans only

  • No updates this month

    No updates this month

  • Updates for individual plans only

  • No updates this month

    No updates this month

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