Revised medical policies
Effective June 1, 2017
Cosmetic and Reconstructive Services, 10.01.514
Added a statement that Rhofade (oxymetazoline hydrochloride) topical cream is considered cosmetic. Read the full policy.
Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies, 12.04.89
Added medically necessary policy statement for suspected inherited motor and sensory neuropathies when the diagnosis can't be made without the genetic test. Test
is investigational for all other indications.
Note: Effective January 4, 2019, the services originally described in this policy are reviewed by AIM Specialty Health®.
Review for Coverage in the Absence of a Medical Policy, Pharmacy Policy or Utilization Management Guideline, 10.01.520
Added a notation that FDA-approved drug package insert is used as a resource for review. Read the full policy.
Revised pharmacy policies
Effective June 1, 2017
Epidermal Growth Factor Receptor (EGFR) Inhibitors, 5.01.603
Added a statement specifying the length of prior authorization approval for the agents described in this policy. Read the full policy.
Medical Necessity Criteria for Pharmacy Edits, 5.01.605
Updated policy statement for Entresto (sacubitril/valsartan) to remove the requirement for treatment with beta blocker; added requirement that Entresto is prescribed by or in consultation
with a cardiologist or cardiac care specialist. Read the full policy.
Miscellaneous Oncology Drugs, 5.01.540
Odomzo (sonidegib) may be considered medically necessary for adult patients with locally advanced basal cell carcinoma when criteria are met. Updated Ibrance (palbociclib) and Tecentriq (atezolizumab)
policy statements. Read the full policy.
mTOR Kinase Inhibitors, 5.01.533
Added a statement specifying the length of prior authorization approval for the agents described in this policy. Read the full policy.
Multiple Receptor Tyrosine Kinase Inhibitors, 5.01.534
Stivarga (regorafenib) is considered medically necessary for hepatocellular carcinoma following previous treatment with Nexavar (sorafenib). Added a statement specifying the length of
prior authorization approval for the agents described in this policy. Read the full policy.
Opioid Analgesics, 5.01.529
Added a statement that medical records history is required when submitting prior authorization for drugs discussed in this policy. Read the full policy.
Pharmacotherapy of Arthropathies, 5.01.550
Added a notation that Xeljanz (tofacitinib) is considered investigational for alopecia. Added a medically necessary policy statement for Kevzara (sarilumab) as a second-line treatment for moderate
to severe rheumatoid arthritis when criteria are met. Read the full policy.
Trastuzumab and Other HER2 Inhibitors, 5.01.514
Added a statement specifying the length of prior authorization approval for the agents described in this policy. Read the full policy.
Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Patients, 5.01.517
Added a statement specifying the length of prior authorization approval for the agents described in this
policy. Added notation that Avastin (bevacizumab) is considered standard of care for eye-related injections. Read the full policy.
Archived policies
An archived policy is no longer active and is not used for reviews.
Archived on May 31, 2017
Patient-Controlled End Range Motion Stretching Devices, 1.03.05
Sensory and Auditory Integration Therapy, 8.03.500
Coding updates
Added Codes
Effective June 1, 2017
Keratoprosthesis, 9.03.01
Now reviewed for medical necessity; now requires prior authorization
L8609 Artificial cornea
Removed code
Effective June 1, 2017
Patient-Controlled End Range of Motion Stretching Device, 1.03.05
No longer reviewed as investigative
E1801 Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1806 Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories
E1811 Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1816 Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories
E1818 Static progressive stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and accessories
E1831 Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1841 Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories
Physical Therapy Evaluation/Occupational Therapy Evaluation (Managed by Evicore)
No longer reviewed for outpatient rehabilitation
97161 Physical therapy evaluation: Low complexity
97162 Physical therapy evaluation: Moderate complexity
97163 Physical therapy evaluation: High complexity
97165 Occupational therapy evaluation: Low complexity
97166 Occupational therapy evaluation: Moderate complexity
97166 Occupational therapy evaluation: High complexity
Revised Codes
Effective June 1, 2017
Patient Lifts, Seat Lifts, and Standing Devices, 1.01.519
Removed from medical necessity review; added to non-covered; prior authorization no longer required
E0627 Seat-lift mechanism, electric, any type
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers, 1.01.18
Currently reviewed for medical necessity; now requires prior authorization
E0670 Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk
Skilled Hourly Nursing Care in the Home, 11.01.522
Removed from medical necessity review; added to non-covered; prior authorization no longer required
T1000 Private duty/independent nursing service(s), licensed, up to 15 minutes