Medical Policy and Coding Updates January 2023

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)

• Added indications
  • Abnormal prior testing
  • Expanded use for evaluation of CAD (now a first-line modality)
  • Preoperative testing
• Removed indication
  • Suspected anomalous coronary arteries (basis for suspicion required)

Fractional Flow Reserve from CCTA (FFR-CT)

• Updated indication
  • 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

• Added indication for Fabry disease
• Modified indications
  • 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
  • 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

• Added indications
  • Abnormal prior testing
  • Expanded use for evaluation of CAD (now a first-line modality)
  • Preoperative testing

Stress testing with imaging

• Removed indications
  • Suspected CAD without symptoms
  • Established CAD with symptoms
  • Established CAD without symptoms
• 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)

Intravenous Iron Replacement Products, 5.01.630 PBC | Premera HMO
New policy
Drugs added

• Feraheme® (ferumoxytol)
• Generic ferumoxytol
• Injectafer® (ferric carboxymaltose) IV
• Monoferric® (ferric derisomaltose) IV
  • Treatment of iron deficiency anemia (IDA) when criteria are met

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

New medical policies

No updates this month

Revised medical policies
Effective January 1, 2023

Gender Transition/Affirmation Surgery and Related Services, 7.01.557  PBC | Premera HMO
Policy coverage criteria statements added

• Description of surgeries and procedures that are covered by most plans
• Some plans have customized benefits or coverage criteria and reference to member contract language
• Notice that some member contracts may use different terms for gender transition/affirmation

Designation removed
Expanded benefit coverage, since all services in policy are considered to be a standard benefit for all plans, with the exception of certain employer-sponsored group plans. Terminology has been updated within the policy.

Hysterectomy for Non-Malignant Conditions, 7.01.548  PBC | Premera HMO
Medical necessity criteria updated
Indication: Abnormal Uterine Bleeding
Separated criteria for premenopausal and postmenopausal individuals

Prescription Digital Therapeutics, 13.01.500  PBC | Premera HMO
Investigational criteria updated
CureSight™ has been added to the list of prescription digital therapeutics that are considered investigational

Upper Gastrointestinal (UGI) Endoscopy for Adults, 2.01.533  PBC | Premera HMO
Alarm symptoms
Medical necessity criteria updated
Indication: Anemia
Clarified that anemia is unexplained or iron deficiency anemia is present when colonoscopy results are negative

Follow-up of known non-malignant conditions
Indication added
Treatment of bleeding from lesions, such as ulcers

Medical necessity criteria updated
Indication: Therapeutic banding (ligation) or sclerotherapy of enlarged veins in the esophagus
Revised repeat upper gastrointestinal endoscopy (UGI) monitoring schedule

Other upper gastrointestinal (UGI) indications
Indications added

• Follow-up UGI endoscopy for gastric, peptic, or esophageal ulcer every 2 months until healed
• To assess diarrhea in individuals suspected of having small-bowel disease (e.g. celiac disease) or inflammatory bowel disease

Indications removed

• Celiac disease (duodenal disease)
• GI symptoms that are consistent with chronic malabsorption (such as diarrhea, weight loss, flatulence, bloating, and abdominal pain)
• Serology tests (antibody levels) are positive for celiac disease

Medical necessity criteria updated
Preoperative UGI endoscopy prior to bariatric surgery has been changed from not medically necessary to medically necessary

Any other conditions
Medical necessity criteria updated
UGI endoscopy performed for monitoring of healed non-cancerous disease (e.g., gastric or duodenal ulcer) is considered not medically necessary

Wearable Cardioverter-Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement, 2.02.506 PBC | Premera HMO
Medical necessity criteria updated

• Added new criteria for implantable cardioverter-defibrillator (ICD) placement
• Ejection fraction (LVEF) ≤ 35% with additional cardiac conditions
• Added re-authorization criteria for a wearable cardioverter-defibrillator for an additional month after the initial 90-day period

Investigational criteria updated
Removed criteria that are now part of medically necessary criteria

• Less than 40 days following a heart attack
• After CABG surgery
• Newly diagnosed heart muscle disease not caused by coronary artery disease

New pharmacy policies

No updates this month

Revised pharmacy policies
Effective January 1, 2023

Antibody-Drug Conjugates, 5.01.582  PBC | Premera HMO
Drug added

• Elahere™ (mirvetuximab soravtansine-gynx)
  • Treatment of adults with folate receptor alpha (FRα) positive, platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer, who have received one or more prior systemic treatment regimens

BRAF and MEK Inhibitors, 5.01.589  PBC | Premera HMO
Drug added

• Cotellic® (cobimetinib)
  • Treatment as a single agent in adults with histiocytic neoplasms

C3 and C5 Complement Inhibitors, 5.01.571  PBC | Premera HMO
Drug with new indications

• Ultomiris® (ravulizumab-cwvz) SC
  • Maintenance treatment of paroxysmal nocturnal hemoglobinuria (PNH) in adults age 18 years and older
  • Maintenance treatment of atypical hemolytic uremic syndrome (aHUS) in adults age 18 years and older

Medical necessity criteria updated

• Empaveli™ (pegcetacoplan)
  • Revised criterion of treatment with Soliris® (eculizumab) or Ultomiris® (ravulizumab-cwvz) to require at least 3 months of therapy with one of these drugs, and the person being treated has failed to achieve a hemoglobin level of ≥ 10.5 g/dL
  • Removed criterion that individuals having active hemolysis as measured by LDH level of 1.5 times the upper limit of normal

Investigational criteria updated
Empaveli™ (pegcetacoplan) allows for short-term (4 weeks) concomitant therapy when switching from Soliris® (eculizumab) or Ultomiris® (ravulizumab-cwvz), but long-term concomitant therapy with Soliris® or Ultomiris® is considered investigational

Folate Antimetabolites, 5.01.617  PBC | Premera HMO
Drug added

• Brand pemetrexed (Teva – unbranded)
  • Single agent maintenance treatment of advanced or metastatic non-small cell lung cancer (NSCLC)
  • Single agent treatment of metastatic non-small cell lung cancer (NSCLC) after previous chemotherapy

Medical necessity criteria updated

• Alimta® (pemetrexed)
  Indication: Combination therapy with Keytruda® (pembrolizumab) and platinum chemotherapy for first-line treatment of non-squamous non-small cell lung cancer (NSCLC)
  • Now allows coverage while awaiting results of genomic testing

Immune Checkpoint Inhibitors, 5.01.591  PBC | Premera HMO
Drug added

• Imjudo® (tremelimumab-actl)
  • Combination treatment with Imfinzi® (durvalumab) for liver cancer that can't be treated with surgery

Drugs with new indications

• Imfinzi® (durvalumab)
  • Treatment with Imjudo® (tremelimumab-actl) for liver cancer that can't be treated with surgery
• Libtayo® (cemiplimab)
  • First-line treatment with platinum-based chemotherapy for advanced non-small cell lung cancer

Drug with indication removed

• Tecentriq® (atezolizumab)
  • Treatment of adults with locally advanced or metastatic urothelial carcinoma

Medical necessity criteria updated

• Keytruda® (pembrolizumab)
  Indication: Combination therapy with Alimta® (pemetrexed) and platinum chemotherapy for first-line treatment of non-squamous non-small cell lung cancer (NSCLC)
  • Now allows coverage while awaiting results of genomic testing

Medical Necessity Criteria for Pharmacy Edits, 5.01.605  PBC | Premera HMO
Angiotensin-Converting Enzyme Inhibitors (ACEIs), Brand
New policy section
Drugs added

• Accupril® (quinapril)
• Altace® (ramipril)
• Lotensin® (benazepril)
• Vasotec® (enalapril)
• Zestril® (lisinopril)

Angiotensin-Converting Enzyme Inhibitor (ACEI) Combinations, Brand
New policy section
Drugs added

• Accuretic® (quinapril/HCTZ)
• Lotensin HCT® (benazepril/HTCZ)
• Lotrel® (amlodipine/benazepril)
• Prestalia® (amlodipine/perindopril)
• Vaseretic® (enalapril/HCTZ)
• Zestoretic® (lisinopril/HCTZ)

Angiotensin II Receptor Blocker (ARB) Combinations, Brand
Drugs added

• Azor® (amlodipine/olmesartan)
• Exforge® (amlodipine/valsartan)
• Teveten® HCT (eprosartan/HCTZ)

Anticonvulsants
Drug added

• Ztalmy® (ganaxolone)
  • Treatment of seizures associated with CDKL5 deficiency disorder

Drugs removed

• Nayzilam® (midazolam nasal spray)
• Valtoco™ (diazepam nasal spray)

Medical necessity criteria updated

• Diacomit® (stiripentol)
  • The age requirement has been reduced from 2 years to 6 months

Antifungals, Topical Brand
New policy section
Drugs added

• Ciclodan (ciclopirox/urea)
• Ecoza (econazole)
• Ertaczo® (sertaconazole)
• Exelderm® (sulconazole)
• Extina (ketoconazole)
• Loprox® (ciclopirox)
• Luliconazole
• Luzu® (luliconazole)
• Mentax® (butenafine)
• Miconazole/Zinc Oxide/Petrolatum
• Naftin® (naftifine)
• Oxistat® (oxiconazole)
• Sulconazole nitrate
• Vusion® (miconazole/zinc/petrolatum)
• Xolegel® (ketoconazole)

Brand Oral NSAIDs
Section renamed
From "Brand Single Source Oral NSAIDs" to "Brand Oral NSAIDs"

Brand Topical Acne or Rosacea Products
Drugs added

• Avar®
• Avar® LS
• Avar-E®
• Avar-E® LS
• Benzamycin®
• Clenia® Plus
• Cleocin T®
• Evoclin®
• Metrocream® (metronidazole cream)
• Metrogel® (metronidazole gel)
• Noritate® (metronidazole cream)
• Plexion®
• Rosanil®
• Rosula®
• Sodium sulfacetamide-sulfur
• Sumadan®
• Sumaxin®
• Sumaxin® TS
• Vanoxide®-HC
• Ziana®

Corticosteroids, Topical Brand
Drugs added

• Ala-Scalp HP®
• Analpram-HC®
• Clobex®
• Diprolene®
• Halobetasol proprionate
• Hydrocortisone/pramoxine
• Locoid®
• Luxiq®
• Neo-Synalar®
• Pramosone®
• Proctocort®
• Psorcon®
• Temovate®
• Tridesilon™
• Vanos™

Gout Agents, Brand
New policy section
Drugs added

• Gloperba® (colchicine)
• Mitigare™ (colchicine)
• Uloric® (allopurinol)
• Zyloprim® (allopurinol)

Gastrointestinal Stimulants
New policy section
Drug added

• Gimoti™ (metoclopramide nasal spray)

Nonsteroidal Anti-inflammatory Drugs (NSAIDs) and Combinations
Drugs added

• Brand diclofenac epolamine
• Flector® (diclofenac epolamine)
• Licart™ (diclofenac epolamine)

Testosterone Replacement Products
Drug added

• Methitest™ (methyltestosterone tablets)

Topical Antivirals, Brand
New policy section
Drugs added

• Denavir® (penciclovir)
• Xerese® (acyclovir/hydrocortisone)
• Zovirax® (acyclovir cream)
• Zovirax® (acyclovir ointment)

Topical Seborrheic Dermatitis Agents, Brand
New policy section
Drugs added

• Klaron® (sulfacetamide)
• Ovace® Plus Cream (sulfacetamide)
• Ovace® Plus Lotion (sulfacetamide)
• Ovace® Plus Shampoo (sulfacetamide)
• Ovace® Plus Wash (sulfacetamide)
• Ovace® Plus Wash Cleansing Gel (sulfacetamide)
• Ovace® Wash (sulfacetamide)
• Plexion® NS (sulfacetamide)
• Selrx® (selenium sulfide)
• Tersi™ (selenium sulfide)

Topical Wart Agents, Brand
New policy section
Drugs added

• Condylox® (podofilox)
• Veregen® (sinecatechins)

Quantity Limits
New drugs added
Epinephrine Injection

• Auvi-Q® auto-injector
• Epinephrine auto-injector
• EpiPen® auto-injector
• EpiPen Jr® auto-injector
• Symjepi® syringe

Ketorolac

Dosing limits updated

• Xofluza™ (baloxavir marboxil)

Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
Drugs added

• Rezlidhia™ (olutasidenib)
  • Treatment of adults with acute myeloid leukemia (AML) with a change in the IDH1 gene that has returned or can't be treated with surgery
• Tecvayli™ (teclistamab-cqyv)
  • Treatment of adults with multiple myeloma that has returned or can't be treated with surgery

Drug removed

• Blenrep™ (belantamab mafodotin-blmf)
  • This drug is being withdrawn from the market by the manufacturer

Pharmacotherapy of Arthropathies, 5.01.550  PBC | Premera HMO
Non-radiographic axial spondyloarthritis
Drug added

• Rinvoq® (upadacitinib)

No updates this month

No updates this month

Added codes
Effective January 1, 2023

Amniotic Membrane and Amniotic Fluid, 7.01.583  PBC | Premera HMO
Now requires review for investigational.

Q4236, Q4262, Q4263, Q4264

Now requires review for investigational and prior authorization.

22860

Bariatric Surgery, 7.01.516  PBC | Premera HMO
Now requires review for investigational.

43290, 43291

Coronary Angiography for Known or Suspected Coronary Artery Disease, 2.02.507  PBC | Premera HMO
Now requires review for medical necessity.

C7516, C7517, C7518, C7519, C7520, C7521, C7522, C7523, C7524, C7525, C7526, C7527, C7528, C7529, C7552, C7553

Cranial Electrotherapy Stimulation and Auricular Electrostimulation, 8.01.58  PBC | Premera HMO
Now requires review for investigational.

0783T

Focal Treatments for Prostate Cancer, 8.01.61  PBC | Premera HMO
Now requires review for investigational.

0738T, 0739T

Folate Antimetabolites, 5.01.617  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J9314

Implantable Bone-Conduction and Bone-Anchored Hearing Aids, 7.01.03  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

69729, 69730

Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J9046, J9048, J9049

Non-covered Experimental/Investigational Services, 10.01.533  PBC | Premera HMO
Now requires review for investigational.

0357U, 0743T, 0744T, 0745T, 0746T, 0747T, 0748T, 0749T, 0750T, 0764T, 0765T, 0766T, 0767T, 0768T, 0769T, 0770T, 0771T, 0772T, 0773T, 0774T, 0775T, 0776T, 0777T, 0778T, 0781T, 0782T

Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation, 6.01.38  PBC | Premera HMO
Now requires review for medical necessity.

C7507, C7508

Percutaneous Vertebroplasty and Sacroplasty, 6.01.25  PBC | Premera HMO
Now requires review for medical necessity.

C7504, C7505

Pharmacologic Treatment of Transthyretin-Mediated Amyloidosis, 5.01.593  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J0225

Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J2327

Plasma-based Proteomic Screening in the Management of Pulmonary Nodules, 2.04.515  PBC | Premera HMO
Now requires review for investigational.

0360U

Prescription Digital Therapeutics, 13.01.500  PBC | Premera HMO
Now requires review for investigational.

0740T, 0741T

Prescription Digital Therapeutics for Substance Use Disorder, 5.01.35  PBC | Premera HMO
Now requires review for investigational.

98978

Rhinoplasty and Other Nasal Procedures, 7.01.558 PBC | Premera HMO
Now requires review for investigational.

30469

Spinal Cord and Dorsal Root Ganglion Stimulation, 7.01.546  PBC | Premera HMO
Now requires review for medical necessity.

C1826, C1827

Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment, 5.01.517  PBC | Premera HMO

Now requires review for medical necessity and prior authorization.

Q5126

AIM Specialty Health® Genetic Testing
Now reviewed by AIM Specialty Health® for medical necessity and prior authorization.

0355U, 0356U, 0362U, 0363U, 81418, 81441, 81449, 81451, 81456

Removed codes
Effective January 1, 2023

Bariatric Surgery, 7.01.516 PBC | Premera HMO
No longer requires review.

0312T, 0313T, 0314T, 0315T, 0316T, 0317T

Bioengineered Skin and Soft Tissue Substitutes, 7.01.113  PBC | Premera HMO
No longer requires review.

C1849

Implantable Bone-Conduction and Bone-Anchored Hearing Aids, 7.01.03  PBC | Premera HMO
No longer requires review.

69715, 69718

Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
No longer requires review.

J9037

Non-covered Experimental/Investigational Services, 10.01.533  PBC | Premera HMO
No longer requires review.

0470T, 0471T, 0487T, C1841, C1842

Prescription Digital Therapeutics for Substance Use Disorder, 5.01.35  PBC | Premera HMO
No longer requires review.

0702T, 0703T

Rhinoplasty and Other Nasal Procedures, 7.01.558  PBC | Premera HMO
No longer requires review.

30117

Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment, 5.01.517  PBC | Premera HMO
No longer requires review.

C9142

Effective January 6, 2023

Services Reviewed Using InterQual® Criteria, 10.01.530  PBC
Acute adult
See InterQual® for medical necessity criteria
Services added

• Electroconvulsive therapy (ECT)
• Total ankle replacement

Total Ankle Replacement, 7.01.577
Policy deleted
Now included in Services Reviewed Using InterQual® Criteria, 10.01.530

Effective January 1, 2023

Services Reviewed Using InterQual® Criteria, 10.01.530 PBC
Acute adult
See InterQual® for medical necessity criteria
Service added
Cardiac defibrillator, subcutaneous implantable

Durable medical equipment
See InterQual® for medical necessity criteria
Equipment added

• Home oxygen therapy
• Spinal orthoses

Home Oxygen Therapy, 1.01.535
Cardiac Defibrillator, Subcutaneous Implantable, 2.02.512
Spinal Orthosis, 1.03.502

These policies deleted and are now included in Services Reviewed Using InterQual® Criteria, 10.01.530

Added codes
Effective January 6, 2023

See also the Special notices section above

Services Reviewed Using InterQual® Criteria, 10.01.530  PBC
Now requires review for medical necessity and prior authorization.

90870

Removed codes
Effective January 6, 2023

Total Ankle Replacement, 7.01.577
No longer requires review.

27703