Medical Policy and Coding Updates May 2018

  • Special notice: New medical policies effective in August

    Effective August 3, 2018

    Auditory Brainstem Implant, 7.01.83
    When criteria are met, a unilateral auditory brainstem implant may be considered medically necessary for patients 12 years old and older whose total deafness was caused by surgery to treat neurofibromatosis type 2.

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605
    Medical necessity criteria were added for Testopel®. This testosterone product may be considered medically necessary when the patient has failed a trial of a generic testosterone gel (1%) and AndroGel (1.62%).

    Special notice: Coding update

    Effective July 5, 2018

    Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease, 2.01.38
    The codes below have been reassigned to this more appropriate policy. These codes are now considered investigational for all uses. See this policy for details.

    43201 - Esophagoscopy, flexible, transoral; with directed submucosal injection(s), any substance

    43236 - Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance

    43257 - Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease

    Special notice: New medical policies effective in June

    Effective June 1, 2018

    Drugs for Rare Diseases, 5.01.576

    These drugs may be considered medically necessary when the criteria in the policy are met. The medical necessity criteria include review for site of service administration for the following drugs:

    • Cerezyme® (imiglucerase)
    • Elaprase® (idursulfase)
    • Fabrazyme® (agalsidase beta)
    • Lumizyme® (alglucosidase alfa)
    • Vimizim® (elosulfase alfa)
    • Vpriv® (velaglucerase alfa)

    Nonpharmacologic Treatment of Rosacea, 2.01.71
    Nonpharmacologic treatment of rosacea, including but not limited to laser and light therapy, dermabrasion, chemical peels, surgical debulking, and electrosurgery is considered investigational. Replaces policy 2.01.519.

    Site of Service, Select Surgical Procedures, 11.01.524
    Preferred medically necessary sites of service for elective surgical procedures are off-campus outpatient hospital/medical center, on-campus outpatient hospital/medical center, and ambulatory surgical center. When select elective procedures are requested at an inpatient hospital/medical center, the health plan will review the site of service to ensure this site is medically necessary. Consult the policy for the full list of elective surgical procedures and inpatient hospital/medical center inclusion criteria.

    Exondys 51® (eteplirsen), 5.01.570
    Exondys 51® (eteplirsen) is subject to review for site of service administration.

    New medical policies

    Effective May 1, 2018

    Balloon Dilation of the Eustachian Tube, 7.01.158
    Balloon dilation of the Eustachian tube for treatment of patients with chronic Eustachian tube dilatory dysfunction is considered investigational.

    Right-to-Try Laws and Coverage of Services, 10.01.525
    This benefit coverage guideline describes how the health plan may or may not cover investigational or routine services that are accessed under state or federal right-to-try laws.

    Revised medical policies

    Effective May 1, 2018

    Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer, 12.04.36
    The policy was revised to state that the MammaPrint, BluePrint, and Target tests, as well as any other gene expression assays for any indication, are considered investigational.
    Note: Effective January 4, 2019 the services originally described in this policy are reviewed by AIM Specialty Health®.

    Clinical Trials, 10.01.518
    This policy was updated with criteria for clinical trials, to be consistent with the Affordable Care Act and state laws.

    Molecular Markers in Fine Needle Aspirates of the Thyroid, 12.04.510
    The statement of medical necessity was revised to clarify when Afirma GEC is considered not medically necessary to reinforce the intent of the policy. Thyroid cancer targeted mutational analysis (PAX8/PPARgamma, PIK3CA, RA [HRAS, KRAS, NRAS], RET/PTC) is considered not medically necessary.
    Note: Effective January 4, 2019 the services originally described in this policy are reviewed by AIM Specialty Health®.

    Myoelectric Prosthetic Components for the Upper Limb, 1.04.502
    The policy was revised to include investigational statements for myoelectric orthoses and prostheses with both sensor and myoelectric control. A statement was also added that gloves for upper extremity prostheses are not medically necessary.

    Sinus Surgery, 7.01.559
    This policy was revised as follows:

    • The course of oral antibiotics was changed to 5–7 days
    • The duration of topical intranasal steroids or saline nasal irrigation was modified to 6 consecutive weeks
    • The requirement to use topical intranasal steroids for revision surgery was removed
    • Additional medically necessary diagnoses for functional endoscopic sinus surgery were added

    Revised pharmacy policies

    Effective April 4, 2018

    Quantity Limits for Opioid Drugs, 5.01.579
    The criterion for drug urine testing was revised to state the patient participates in drug urine testing as identified in provider’s opioid therapy plan, or a drug urine test has been completed within the last 6 months.
    Note: The services originally described in this policy are now found in policy 5.01.529 Management of Opioid Therapy

    Effective May 1, 2018

    BCR-ABL Kinase Inhibitors, 5.01.518
    The policy was revised to add the pediatric indication for Sprycel® (dasatinib). The criteria for Iclusig™ (ponatinib) and Synribo™ (omacetaxine) were updated.

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605
    Medical necessity statements and criteria were added for rho kinase inhibitor Rhopressa® (netarsudil) and topical antibiotic Xepi™ (ozenoxacin). In addition, see the notification about medical necessity criteria for Testopel® in the Special Notices section above.

    Multiple Receptor Tyrosine Kinase Inhibitors, 5.01.534
    The policy was revised to remove the required trial of antiangiogenic therapy for Cabometyx® (cabozantinib).

    An archived policy is one that's no longer active and is not used for reviews.

    Archived on April 30, 2018

    Retinal Prosthesis, 9.03.15

    Transtympanic Micropressure Applications as a Treatment of Meniere Disease, 1.01.23

    Added codes

    Effective May 1, 2018

    Implantable Bone Conduction and Bone-Anchored Hearing Aids, 7.01.547
    Now requires review for medical necessity, now requires prior authorization

    L8694 - Auditory osseointegrated device, transducer/actuator, replacement only, each

    Orthoptic Training for the Treatment of Vision or Learning Disabilities, 9.03.03
    Now requires review for medical necessity

    92065 - Orthoptic and/or pleoptic training, with continuing medical direction and evaluation

    Removed codes

    Effective May 1, 2018

    Chelation Therapy, 8.01.535
    No longer requires medical necessity review

    J3520 - Edetate disodium, per 150 mg

    Intracellular Micronutrient Analysis, 2.04.73
    No longer requires investigational review

    86353 - Lymphocyte transformation, mitogen (phytomitogen) or antigen induced blastogenesis

    88348 - Electron microscopy, diagnostic

    Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure, 6.01.56
    No longer requires investigational review

    A9582 - Iodine I-123 iobenguane, diagnostic, per study dose, up to 15 millicuries

    Retinal Prosthesis, 9.03.15
    No longer requires investigational review

    0100T - Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy

    Transtympanic Micropressure Applications as a Treatment of Meniere Disease, 1.01.23
    No longer requires investigational review

    A4638 - Replacement battery for patient-owned ear pulse generator, each

    E2120 - Pulse generator system for tympanic treatment of inner ear endolymphatic fluid

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