Effective May 2, 2023
Applied Behavioral Analysis (ABA), 3.01.510 PBC | Premera HMO
Note added
Applied behavioral analysis (ABA) may be considered medically necessary when criteria for Diagnosis, Initial Functional Behavioral Analysis, Initial Treatment Plan, ABA Treatment Services, ABA Treatment Services Settings, Continued Treatment are met. Some plans may not review all of the criteria listed in policy.
Psychotherapy sessionsSection removed
DiagnosisSection added
Medical necessity criteria updated
- Updated diagnostic terminology for consistency with the DSM-5/DSM-5-TR
- Expanded the types of clinicians who can diagnose Autism Spectrum Disorder
Initial Functional Behavioral Analysis
Section added
Initial treatment plan
Section added
ABA treatment services
Section added
Medical necessity criteria updated
Clarified that the maximum number of medically necessary hours of daily and weekly ABA services applies only treatment hours (not to other components of ABA)
ABA treatment settings
Section added
Medical necessity criteria updated
Updated the requirements for agencies to be considered to be ABA treatment services providers
Continued treatment
Section added
Medical necessity criteria updated
Clarified that the after the initial Functional Behavioral Analysis, Functional Behavioral Analysis re-assessments are considered to be medically necessary no more frequently than once every 6 months
Applied Behavior Analysis (ABA) service providers
Section updated
- Expanded the types of clinicians who may provide direct treatment services
- Clarified which ABA services can and cannot be provided by master’s and doctoral level clinicians who are not licensed to practice independently and can only practice under supervision
Benefit application
Section updated
- Added a provision in the Benefit Application section that assessments and supporting assessments by behavioral technicians/therapy assistants/paraprofessionals are non-covered (excluded) services except when included in their legally permitted scope of licensure
- Removed the restriction for group treatment sessions that only social skills group sessions are covered for ABA
- Removed the limitation of a maximum of two group sessions daily
- Added “Group treatment sessions are covered for only one clinician for an identified individual regardless of how many clinicians were present for a group session”
- Added general parenting coaching, and training of nannies or au-pairs or similar persons, to the list of activities that are not considered to constitute ABA services
Effective April 9, 2023
Updates to AIM Specialty Health® Clinical Appropriateness Guidelines
Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging
Updates by section
Abdominal and pelvic imaging
Abdominal/pelvic pain, undifferentiated
Removed indication for MRI following nondiagnostic CT
Uterine leiomyomata
Added indication for advanced imaging when ultrasound suggests leiomyosarcoma
Pancreatic indications
Added indication for pancreatic duct dilatation
Pancreatic mass
Added allowance for more frequent follow-up of lesions with suspicious features or in high-risk patients
Pancreatitis
Removed allowance for MRI following nondiagnostic CT
Pelvic floor disorders
Added indication for MRI pelvis in chronic constipation when preliminary testing is nondiagnostic
Brain imaging
Bell’s palsy
Limited the use of CT to scenarios where MRI cannot be performed
Meningioma
Added more frequent surveillance for WHO grade II/III
Seizure disorder
Added indication for advanced imaging in pediatric patients with nondiagnostic EEG
Chest imaging
Imaging abnormalities
Added indication for evaluation of suspected tracheal or bronchial pathology
Perioperative imaging
Added indication for imaging prior to lung volume reduction procedures
Head and neck imaging
Perioperative imaging
Added indication for imaging prior to facial feminization surgery
Oncologic imaging
Criteria aligned with National Comprehensive Cancer Network (NCCN) for the following:
- Breast cancer screening
- Cervical
- Head and neck
- Histiocytic neoplasms
- Lymphoma (non-Hodgkin and leukemia)
- Multiple myeloma
- Thoracic
- Thyroid
Prostate cancer
- Updated respective conventional imaging prerequisites for 18F Fluciclovine/11C PET/CT and 68Ga PSMA/18F-DCFPyL PET/CT, based on utility of conventional imaging at various PSA thresholds and removal of low risk disease waiver from conventional imaging footnote
- Added 68Ga PSMA or 18F-DCFPyL PET/CT indication aligned with FDA-approved use of Pluvicto (radioligand) treatment for metastatic castrate-resistant disease
Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging of the Heart
Updates by section
Cardiac Imaging
CT coronary angiography (CCTA)
Indications added
- Abnormal prior testing
- Expanded use for evaluation of CAD (now a first-line modality)
- Preoperative testing
Indication removed
Suspected anomalous coronary arteries (basis for suspicion required)
Fractional Flow Reserve from CCTA (FFR-CT)
Indication updated
Symptomatic person with 40 - 90% coronary stenosis who has failed guideline directed medical therapy and has undergone a CCTA within the previous 90 days
Resting cardiac MRI
Indication added
Fabry disease
Indications updated
- Arrhythmogenic right ventricular dysplasia (ARVD) requirements
- Suspected anomalous coronary arteries (basis for suspicion required)
- Suspected myocarditis (basis for suspicion required)
Resting transthoracic echocardiography (TTE)
Valvular heart disease
Criteria updated
- Removed requirement of valvular dysfunction for those who had surgical mitral valve repair
- Updated frequency of surveillance in patients with prosthetic valves and those who had transcatheter valve replacement/repair
- Removed moderate/severe mitral regurgitation for those who had transcatheter mitral valve repair
Stress cardiac MRI
Indications added
- Abnormal prior testing
- Expanded use for evaluation of CAD (now a first-line modality)
- Preoperative testing
Stress testing with imaging
Indications removed
- Suspected CAD without symptoms
- Established CAD with symptoms
- Established CAD without symptoms
Criteria updated
- Modified indications for suspected CAD with symptoms
- Determined need for testing by pretest probability
- Expanded definition of “chest pain” to include ischemic equivalent pain elsewhere
- Included dyspnea as a standalone symptom
- Treating physician to select imaging modality
- Clarified that exercise is preferred over pharmacologic testing in patients referred for stress testing with imaging
- Clarified that patients with atypical symptoms to undergo non-imaging stress testing (assuming capable of exercise and no precluding resting EKG abnormalities)
Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiation Oncology
Updates by section
Radiation Therapy
Gastrointestinal (GI) cancers
Removed plan comparison requirement for cholangiocarcinoma, esophageal, gastric, hepatocellular, and pancreatic cancer, because IMRT has become standard of care for curative treatment of these cancers
Oligometastatic extracranial disease
Added indication for adrenal metastases in SABR-COMET clinical trial
Prostate cancer - brachytherapy
Added indication for high-dose rate monotherapy in low- and intermediate-risk disease
Image-guided radiation therapy (IGRT)
- Added surface-based guidance technique (no change in coding)
- Added statement that IGRT is not medically necessary to guide superficial radiotherapy for non-melanoma skin cancer (supported by American Society for Radiation Oncology clinical practice guideline)
Therapeutic Radiopharmaceuticals
Prostate cancer
Added indication for Lutetium Lu 177 vipivotide tetraxetan (Pluvicto™), FDA approved for the treatment of adult patients with prostate-specific membrane antigen (PSMA)-positive metastatic castration-resistant prostate cancer who have been treated with AR pathway inhibition and taxane-based chemotherapy
Effective March 1, 2023
Drugs for Rare Diseases, 5.01.576 PBC | Premera HMO
Medical necessity criteria updated
Lumizyme® (alglucosidase alfa)
- Added dose limit of no more than 20 mg per kg of body weight administered every 2 weeks
Site of service review added
- Mepsevii® (vestronidase alfa-vjbk)
- Naglazyme® (galsulfase)
Drug added
Mepsevii® (vestronidase alfa-vjbk)
- Treatment of mucopolysaccharidosis type VII (MPS VII; Sly syndrome)
Site of Service: Infusion Drugs and Biologic Agents, 11.01.523 PBC | Premera HMO
Drugs added
- Mepsevii® (vestronidase alfa-vjbk)
- Naglazyme® (galsulfase)
Effective February 18, 2023
Updates to AIM Specialty Health® Clinical Appropriateness Guidelines
Effective for dates of service on and after February 18, 2023, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Genetic Testing
Updates by section
Carrier Screening in the Prenatal Setting and Preimplantation Genetic Testing
- Clarified testing requirements for Fragile X Syndrome in patients with unexplained ovarian failure
- Clarified carrier screening restrictions for autosomal recessive conditions
- Expanded selected relevant screening for patients at high risk based on ethnicity (e.g., Ashkenazi Jewish, French Canadian, Mennonite) and the conditions for which to test
- Expanded screening when one or both individuals do not have access to biological family history, and allowed preimplantation testing when reproductive donor is of unknown carrier risk
Cell-free DNA Testing (Liquid Biopsy) for the Management of Cancer
Removed specific language regarding the brand names of tests which are considered medically necessary, and generally does not specifically name the therapeutic agents which must be under consideration, allowing appropriate review of claims when new therapies or tests are approved by the FDA
Genetic Testing for Inherited Conditions
- Clarified criteria on cardiomyopathies for which testing is medically necessary
- Allowed for broader panels for arrhythmia and cardiomyopathy syndromes
Hereditary Cancer Testing
- Added condition-specific criteria based on National Comprehensive Cancer Network (NCCN) recommendations, as well as other clinical guidelines
- Limited testing in the following scenarios:
- Prostate cancer (in select scenarios) for patients without additional familial risk
- Patients with only a second-degree relative with ovarian cancer
- Patients with breast cancer and family history in some select scenarios (e.g., lobular histology only plus personal or family history of gastric cancer)
Pharmacogenomics Testing
- Limited testing for patients being treated with warfarin
- Specified biomarkers for which one-time testing is considered medically necessary
Somatic Tumor Testing
- Clarified criteria about tumor stage in cutaneous melanoma and cholangiocarcinoma, and about histology in non-small cell lung cancer, ovarian cancer (epithelial) and prostate cancer (adenocarcinoma)
- Chromosomal microarray analysis may require additional review
- Specified the genes that must be included in panels for hematologic malignancy testing
- Allowed testing for patients with metastatic uveal melanoma
- Removed specific language regarding the brand names of tests which are considered medically necessary, and generally does not specifically name the therapeutic agents which must be under consideration, allowing appropriate review of claims when new therapies or tests are approved by the FDA
Use of Polygenic Risk Scores in Genetic Testing
Limited polygenic risk score testing
Whole Exome Sequencing and Whole Genome Sequencing
Whole exome sequencing
- Allowed analysis using the same criteria as the initial test
- Limited testing for congenital bilateral hearing loss of unknown etiology, developmental and epileptic encephalopathy, and single anomaly with positive family history
Effective February 3, 2023
Gender Transition/Affirmation Surgery and Related Services, 7.01.557 PBC | Premera HMO
Genital or "bottom surgery"
Surgery added
Site of service review added
Hysterectomy will be reviewed for medical necessity. Breast reduction, laparoscopic-assisted vaginal hysterectomy, rhinoplasty, and vaginal hysterectomy will also include site of service review.
Note removed
Hysterectomies for gender transition/affirmation are not subject to medical necessity review
Hair removal (by laser or electrolysis) prior to genital surgery
Medical necessity criteria updated
Hair removal will be done by a physician, nurse practitioner, physician assistant, or by a professional who is licensed, certified, registered, or otherwise approved by the state for hair removal (e.g., a licensed aesthetician)
Medical necessity criteria updated
Facial, body, or extremity hair removal not related to genital surgery now has separate criteria
Recommendations by Licensed Mental Health Professionals
Section title expanded
Now includes "additional timing requirements for surgery and mental health recommendation letters, and for pre-surgery surgeon evaluations"
Medical necessity criteria updated
- Removed requirement that psychiatrists are board-eligible or board-certified
- Evaluations may be performed by and letters written by state licensed master's and doctoral mental health clinicians who aren't licensed to practice independently if letters are co-signed by mental health professionals who are state licensed to practice independently
- Revised mental health recommendation letter content
- Combined two criteria into documentation of the history of the person's gender dysphoria and gender identity transition to include assigned gender at birth, age of awareness of gender incongruence, symptoms of gender dysphoria, and actions taken to transition to the desired gender
- Past and present treatment for gender dysphoric symptoms has been revised to any current or past psychiatric treatment
- Additional timing requirements for surgery and mental health recommendation letters, and pre-surgery surgeon evaluations now includes the statement: "for facial, body, or extremity hair removal not related to genital surgery, pre-procedure evaluations by either a referring medical provider or the hair removal provider are acceptable as the pre-surgery surgeon evaluations"
Hysterectomy for Non-Malignant Conditions, 7.01.548 PBC | Premera HMO
Policy notes updated
Replaced statement that this policy does not apply to hysterectomy for gender transition/affirming surgeries to reference to medical policy Gender Transition/Affirmation Surgery and Related Services, 7.01.557
- Clarified that the policy does not apply to hysterectomy for gynecologic malignant conditions
Miscellaneous Oncology Drugs, 5.01.540 PBC | Premera HMO
Drugs added
- Elzonris™ (tagraxofusp-erzs)
- Treatment of blastic plasmacytoid dendritic cell neoplasm (BPDCN) in adults and children age 2 years and older
- Onivyde® (irinotecan liposome injection)
- Treatment of pancreatic cancer that has spread to other parts of the body
- Treatment of bile duct cancer that has spread to other parts of the body
Site of Service: Select Surgical Procedures, 11.01.524 PBC | Premera HMO
Policy added
Gender Transition/Affirmation Surgery and Related Services, 7.01.557, added to policy to address breast reduction, laparoscopic-assisted vaginal hysterectomy, rhinoplasty, and vaginal hysterectomy
Spravato® (esketamine) Nasal Spray, 5.01.609 PBC | Premera HMO
Indication: Depression
Medical necessity criteria updated
- A trial and failure of four antidepressants from at least two different classes has been reduced to a trial and failure of three antidepressants from two different classes
- A trial and failure of three antidepressants from at least two different classes plus an augmenting agent has been reduced to two antidepressants from two different classes plus an augmenting agent
- No current substance use disorder unless in remission now includes definition of three months of complete abstinence
Indication: New course of Spravato® after previous treatment
Medical necessity criteria updated
No current substance use disorder unless in remission now includes definition of three months of complete abstinence
Investigational criteria updated
Use of Spravato® (esketamine) along with any other formulation of ketamine or with any psychedelic drug is considered investigational
All indications
Medical necessity criteria updated
Use of Spravato® (esketamine) with more than one provider/group/clinic at the same time is considered not medically necessary
Documentation requirements updated
- For failed medication trials, each medication that failed must be individually identified, along for the reason(s) for failure
- For each failed medication trial, there must be documentation of at least 30 continuous days with no or inadequate improvement unless stopped sooner because of intolerable adverse effects
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders, 2.01.526 PBC | Premera HMO
Policy statements added
- Types of transcranial magnetic stimulation (TMS) covered
- Deep transcranial magnetic stimulation of the brain
- Standard/conventional repetitive transcranial magnetic stimulation of the brain
- Theta burst stimulation of the brain
- Specific medical conditions where TMS may be considered medically necessary
- Major depression as a component of bipolar disorder
- Major depressive disorder
- Obsessive-compulsive disorder
Investigational criteria updated
- Added list of all other types of transcranial magnetic stimulation (TMS)
- Theta burst stimulation is considered investigational for the treatment of major depression as a component of bipolar disorder and the treatment of obsessive-compulsive disorder
- TMS for all other psychiatric conditions, for all substance use conditions, and for all neurologic conditions are considered investigational
- Use of TMS to boost the effectiveness of other treatment modalities, including but not limited to drugs or other devices, is considered investigational
- Technology computer-assisted TMS of the prefrontal cortex is considered investigational
Major depressive disorder
Medical necessity criteria updated
- Age requirement reduced from 18 years and older to age 15 years and older
- The number of failed medication trials has been reduced from four to three
- Theta burst stimulation has been added as a type of TMS for this condition
Major depression as a component of bipolar disorder
Medical necessity criteria updated
- The number of failed medication trials has been increased from two to three
- Theta burst stimulation is considered investigational for this condition
Obsessive-compulsive disorder
Indication added
Medical necessity criteria added
- Standard/conventional TMS and deep TMS may be considered medically necessary
- Theta burst stimulation is considered investigational for this condition
All indications
Contraindications added
- History of or presence of a brain tumor
- History of repetitive or severe head trauma/traumatic brain injury
Policy sections added
Medical necessity criteria added
- Course of full intensive TMS
- Extended intensive course or extended intensive phase (deep TMS)
- Extended taper
- Accelerated intensive TMS
- Maintenance TMS
- Repeat full intensive course
- Short of brief intensive course
- Consecutive or overlapping courses of TMS for different conditions
- TMS with more than one provider at the same time
- TMS along with Spravato® (esketamine), or ketamine, or any other psychedelic drug
- TMS along with other types of neuromodulation