Medical Policy and Coding Updates February 2019

  • New medical policies

    Effective February 1, 2019

    Measurement of Serum Antibodies to Infliximab, Adalimumab, and Vedolizumab, 2.04.516
    Policy is renumbered from 2.04.84. There are no changes in the policy statements.

    Revised medical policies

    Effective February 1, 2019

    Diagnosis and Treatment of Sacroiliac Joint Pain, 6.01.524
    The policy adds a statement that minimally invasive fixation/fusion of the sacroiliac joints using a titanium triangular implant may be considered medically necessary when medical necessity criteria are met, including use of nonoperative treatment and a trial of therapeutic sacroiliac joint injection.

    Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Select Intra-Abdominal and Pelvic Malignancies, 2.03.07
    The policy adds a statement that hyperthermic intraperitoneal chemotherapy may be considered medically necessary for the treatment of newly diagnosed stage III ovarian cancer when criteria are met.

    Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.554
    The policy is revised to state that hypoglossal nerve stimulation may be considered medically necessary under specified conditions.

    Revised pharmacy policies

    Effective February 1, 2019

    Ampyra® (dalfampridine), 5.01.527
    The criteria are added for generic dalfampridine. Criteria for the brand drug Ampyra® (dalfampridine) are revised to add the trial of generic dalfampridine.

    Cutaneous T-Cell Lymphomas (CTCL): Systemic Therapies, 5.01.532
    Poteligeo® (mogamulizumab-kpkc) may be considered medically necessary for relapsed or refractory mycosis fungoides or Sézary syndrome when criteria are met.

    Drugs for Rare Diseases, 5.01.576
    Criteria are added for Galafold® (migalastat) for Fabry disease, Revcovi® (elapegademase-lvlr) for adenosine deaminase severe combined immune deficiency, and Firdapse® (amifampridine) for Lambert-Eaton myasthenic syndrome.

    Excessively High Cost Drug Products with Lower Cost Alternatives, 5.01.560
    Suvicort (topical 2% lidocaine plus aloe vera gel) is added to the list of topical lidocaine products that must meet medical necessity criteria.

    Medical Necessity Criteria and Dispensing Quantity Limits for Exchange Formulary Benefits, 5.01.547
    The policy is revised to add Inveltys™ (loteprednol etabonate ophthalmic suspension) to the list of ophthalmic corticosteroids that must meet medical necessity criteria.

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605
    This policy is updated as follows:

    • Brand topical acne and rosacea products, as well as adapalene products, are updated to state that medication trial and failure is within the last 2 years.
    • Bryhali™ (halobetasol propionate) and Lexette® (halobetasol propionate) are added to the list of brand topical corticosteroids that must meet medical necessity criteria.
    • Diacomit® (stiripentol) criteria are added for the treatment of seizures associated with Dravet syndrome.
    • Jornay PM® (methylphenidate hydrochloride) is added to the list of brand ADHD drugs that must meet medical necessity criteria.
    • Seysara® (sarecycline) is added to the list of brand oral antibiotics that must meet medical necessity criteria.
    • Xelpros™ (latanoprost ophthalmic emulsion 0.005%) is added to the list of brand ophthalmic prostaglandin analogue drugs that must meet medical necessity criteria.
    • Xifaxan® (rifaximin) criteria are updated for the treatment of traveler’s diarrhea.
    • Xofluza (baloxavir marboxil) quantity limits are added.

    Miscellaneous Oncology Drugs, 5.01.540
    The policy is revised to add Daurismo® (glasdegib) for the treatment of acute myeloid leukemia when criteria are met. It also adds criteria for Vitrakvi® (larotrectinib) to treat solid tumors in pediatric and adult patients. The additional indication for maintenance treatment of advanced epithelial ovarian, fallopian tube, or primary peritoneal cancer is added for Lynparza® (olaparib).

    Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502
    The criteria for Adcetris® (brentuximab vedotin) are updated to include treatment for CD30-expressing peripheral T-cell lymphomas when criteria are met.

    Pharmacotherapy of Arthropathies, 5.01.550
    This policy is revised as follows:

    • Actemra® (tocilizumab) is added as second-line treatment for polyarticular juvenile idiopathic arthritis, and criteria are updated for other indications.
    • Xeljanz® (tofacitinib) and Xeljanz® XR (tofacitinib ER) are added as first-line treatment for psoriatic arthritis.

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
    Xeljanz® (tofacitinib) is added as first-line treatment for ulcerative colitis. (Xeljanz XR is not approved for use in ulcerative colitis.)

    Venclexta® (venetoclax) BCL-2 Inhibitor, 5.01.568
    This policy is updated to add the indication of acute myeloid leukemia for Venclexta® (venetoclax).

    A deleted policy is one whose number is no longer used but the content is either moved into another policy or replaced with a new policy and number.

    Deleted January 31, 2019

    Measurement of Serum Antibodies to Infliximab, Adalimumab, and Vedolizumab, 2.04.84. Policy is renumbered to 2.04.516. Policy statements are unchanged.

    Added codes

    Effective February 1, 2019

    Cervical Spine Surgeries: Discectomy, Laminectomy, and Fusion in Adults, 7.01.560
    Now requires review for medical necessity, now requires prior authorization

    22600 - Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment

    63020 - Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical

    63045 - Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical

    Corneal Collagen Cross-Linking, 9.03.28
    Now requires review for medical necessity

    0402T - Collagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed)

    Corneal Collagen Cross-Linking, 9.03.28
    Now requires review for medical necessity, now requires prior authorization

    J2787 - Riboflavin 5'-phosphate, ophthalmic solution, up to 3 mL

    Hereditary Angioedema, 5.01.587
    Now requires review for medical necessity, now requires prior authorization

    J0596 - Injection, C1 esterase inhibitor (recombinant), Ruconest, 10 units
    J0597 - Injection, C-1 esterase inhibitor (human), Berinert, 10 units
    J0598 - Injection, C-1 esterase inhibitor (human), Cinryze, 10 units
    J0599 - Injection, c-1 esterase inhibitor (human), (haegarda), 10 units
    J1290 - Injection, ecallantide, 1 mg
    J1744 - Injection, icatibant, 1 mg

    Injectable Clostridial Collagenase for Fibroproliferative Disorders, 5.01.19
    Noncovered Services and Procedures, 10.01.517
    Now considered noncovered

    54200 - Injection procedure for Peyronie disease

    54205 - Injection procedure for Peyronie disease; with surgical exposure of plaque

    Trogarzo (ibalizumab), 5.01.588
    Now requires review for medical necessity, now requires prior authorization

    J1746 - Injection, ibalizumab-uiyk, 10 mg

    Testing Serum Vitamin D Level, 2.04.135
    Now requires review for medical necessity

    0038U - Vitamin D, 25 hydroxy D2 and D3, by LC-MS/MS, serum microsample, quantitative

    Revised codes

    Effective February 1, 2019

    Diagnosis and Treatment of Sacroiliac Joint Pain, 6.01.524
    Now requires review for medical necessity (previously investigational), now requires prior authorization

    27279 - Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device

    Diagnosis and Treatment of Sacroiliac Joint Pain, 6.01.524
    Now requires review for medical necessity (previously investigational)

    27280 - Arthrodesis, sacroiliac joint (including obtaining graft)

    Home Enteral Nutrition, 8.01.502
    No change made to claims processing, updated plan review requirements

    B4100 - Food thickener, administered orally, per oz

    B4102 - Enteral formula, for adults, used to replace fluids and electrolytes (eg, clear liquids), 500 ml = 1 unit

    B4103 - Enteral formula, for pediatrics, used to replace fluids and electrolytes (eg, clear liquids), 500 ml = 1 unit

    B4104 - Additive for enteral formula (eg, fiber)

    B4149 - Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

    B4150 - Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

    B4152 - Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

    B4153 - Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

    B4154 - Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

    B4155 - Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (eg, glucose polymers), proteins/amino acids (eg, glutamine, arginine), fat (eg, medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit

    B4157 - Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

    B4158 - Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit

    B4159 - Enteral formula, for pediatrics, nutritionally complete soy-based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit

    B4160 - Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

    B4161 - Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

    B4162 - Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit B9000 Enteral nutrition infusion pump – without alarm

    B9002 - Enteral nutrition infusion pump – with alarm

    B9004 - Parenteral nutrition infusion pump, portable

    B9006 - Parenteral nutrition infusion pump, Stationary

    B9998 - NOC for enteral supplies

    B9999 - NOC for parenteral supplies

    S9434 - Modified solid food supplements for inborn errors of metabolism

    S9435 - Medical foods for inborn errors of metabolism

    S9340 - Home therapy; enteral nutrition; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem

    S9341 - Home therapy; enteral nutrition via gravity; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem

    S9342 - Home therapy; enteral nutrition via pump; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem

    S9343 - Home therapy; enteral nutrition via bolus; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem

    S9433 - Medical food nutritionally complete, administered orally, providing 100% of nutritional intake

    Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease, 7.01.137
    Currently reviewed for investigative, no longer requires prior authorization

    43284 - Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed

    43285 - Removal of esophageal sphincter augmentation device

    Patient Lifts, Seat Lifts and Standing Devices, 1.01.519
    Now considered noncovered, no longer reviewed for medical necessity, no longer requires prior authorization

    E0171 - Commode chair with integrated seat lift mechanism, nonelectric, any type

    E0625 - Patient lift, bathroom or toilet, not otherwise classified

    Power Operated Vehicles (Scooters) (excluding motorized wheelchairs), 1.01.527
    Now requires review for prior authorization, currently reviewed for medical necessity

    K0899 - Power mobility device, not coded by DME PDAC or does not meet criteria

    Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.554
    Now requires review for medical necessity, no longer reviewed for investigative

    64568 - Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator

    0466T - Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator

    Removed codes

    Effective February 1, 2019

    Bioengineered Skin and Soft Tissue Substitutes, 7.01.113
    No longer reviewed for investigative

    Q4102 - Oasis wound matrix, per sq cm

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