Revised medical policies
Effective May 1, 2017
Genetic Testing for Muscular Dystrophies, 12.04.86
Added policy statement for Duchenne muscular dystrophy. Testing is now considered medically necessary for asymptomatic male offspring of female carriers and asymptomatic brothers of affected
siblings.
Note: Effective January 4, 2019, the services originally described in this policy are reviewed by AIM Specialty Health®.
Gene Expression Profiling for Uveal Melanoma, 12.04.120
For patients with primary, localized uveal melanoma, changed the policy statement from investigational to medically necessary for the DecisionDx-UM test.
Note: Effective January 4, 2019, the services originally described in this policy are reviewed by AIM Specialty Health®.
New pharmacy policies
Effective May 1, 2017
Pharmacotherapy of Atopic Dermatitis, 5.01.575
Dupixent (dupilumab) may be considered medically necessary for moderate to severe atopic dermatitis (eczema) for adults 18 and older when eczema covers 10 percent or more of the body and a topical
calcineurin inhibitor and two topical corticosteroids failed. Read the full policy.
Revised pharmacy policies
Effective April 10, 2017
Pharmacotherapy of Arthropathies, 5.01.550
Updated criteria for Remicade (infliximab), which is now considered first-line biologic treatment for ankylosing spondylitis, rheumatoid arthritis, plaque psoriasis, and psoriatic arthritis when criteria
are met. Inflectra (infliximab-dyyb) remains second-line treatment for these indications. Site-of-service criteria continue to apply to Remicade and Inflectra. Read the full policy.
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
Updated criteria for Remicade (infliximab) and Entyvio (vedolizumab). These are now considered first-line treatment for Crohn's disease and ulcerative colitis when criteria are met.
Inflectra (infliximab-dyyb) remains second-line treatment for these indications. Site-of-service criteria continue to apply to Remicade, Entyvio, and Inflectra. Read the full policy.
Effective May 1, 2017
ALK Tyrosine Kinase Inhibitors, 5.01.538
Initial approval for drugs listed in the policy will be for three months. Continued approval beyond the first three months requires documentation of objective response to therapy. Read the full policy.
Bcr‐Abl Kinase Inhibitors, 5.01.518
Initial approval for drugs listed in the policy will be for three months. Continued approval beyond the first three months requires documentation of objective response to therapy. Read the full policy.
Cutaneous T‐Cell Lymphomas (CTCL): Systemic Therapies, 5.01.532
Targretin gel may be considered medically necessary for cutaneous T-cell lymphomas when at least three previous therapies failed, including but not limited to phototherapy, topical
imiquimod, topical corticosteroids, and/or local radiation. Initial approval for drugs listed in the policy will be for three months. Continued approval beyond the first three months requires documentation of objective response to therapy. Read the full policy.
Miscellaneous Oncology Drugs, 5.01.540
Initial approval for oral drugs listed in the policy will be for three months. Continued approval beyond the first three months requires documentation of objective response to therapy. Read the full policy.
Pharmacotherapy of Multiple Sclerosis, 5.01.565
Ocrevus (ocrelizumab) may be considered medically necessary as a first-line treatment for primary progressive multiple sclerosis, and second-line treatment for relapsing forms of multiple sclerosis
when there has been an inadequate response to at least two first-line drugs. Read the full policy.
Prostate Cancer Targeted Therapies, 5.01.544
Initial approval for drugs listed in the policy will be for three months. Continued approval beyond the first three months requires documentation of objective response to therapy. Read the full policy.
Venclexta® (venetoclax) BCL-2 Inhibitor, 5.01.568
Initial approval for drugs listed in the policy will be for three months. Continued approval beyond the first three months requires documentation of objective response to therapy.
Read the full policy.
Archived policy
An archived policy is no longer active and is not used for reviews.
Archived on April 30, 2017
Genetic Testing for CHARGE Syndrome, 12.04.106
Coding updates
Removed code
Effective May 1, 2017
Genetic Testing for PTEN Hamartoma Tumor Syndrome, 12.04.88
No longer reviewed for medical necessity; prior authorization is no longer required
81322 PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant
81323 PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant
Sacral Nerve Neuromodulation/Stimulation, 7.01.69
No longer reviewed for medical necessity; prior authorization is no longer required
64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver