Medical Policy and Coding Updates May 2022

  • Updates for both non-individual and individual plans

  • Effective August 5, 2022

    Drugs for Rare Diseases, 5.01.576

    Pompe Disease

    Site of service review added

    • Nexviazyme™ (avalglucosidase alfa-ngpt) IV

    Thyroid Eye Disease (TED)

    Medical necessity criteria updated

    • Tepezza™ (teprotumumab-trbw)
      • The patient must have tried glucocorticoids before this drug can be prescribed
      • This drug will be given within 9 months of completing the glucocorticoid trial
      • This drug must be prescribed by an ophthalmologist with expertise in TED treatment or endocrinologist with expertise in TED treatment
      • This drug is not being used in combination with another biologic drug that can be used to treat TED

    Effective July 7, 2022

    Immune Checkpoint Inhibitors, 5.01.591

    Site of service review added

    • Keytruda® (pembrolizumab)
    • Opdivo® (nivolumab)

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523

    Site of service review added

    • Keytruda® (pembrolizumab)
    • Opdivo® (nivolumab)

    Effective June 3, 2022

    Phosphoinositide 3-kinase (PI3K) Inhibitors, 5.01.592

    Indication removed

    • Aliqopa® (copanlisib)
      • Treatment of chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) with this drug is not FDA-approved or supported by the National Comprehensive Cancer Network (NCCN)

    New medical policies

    Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.569

    New policy

    • This policy replaces Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.48
    • All other policy statements remain unchanged

    Revised medical policies
    Effective May 1, 2022

    Amniotic Membrane and Amniotic Fluid, 7.01.583

    Medical necessity criteria updated

    Specific ophthalmic conditions have been removed and replaced with a general statement about eye conditions

    Investigational criteria updated

    • The use of other human amniotic products (from amnion, chorion, amniotic fluid, umbilical cord, or Wharton’s jelly) is considered investigational
    • The use of human amniotic products for repair following Mohs micrographic surgery is considered investigational
    • AmnioBind®, Enverse, MLG-CompleteTM, and Relese™ have been added to the list of investigational products

    Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis, 7.01.168

    Policy renamed

    From “Cryoablation for Chronic Rhinitis” to “Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis”

    Investigational criteria updated

    • Radiofrequency ablation
    • Laser ablation
      • The procedures listed above have been added to the list of investigational treatments

    Prescription Digital Therapeutics, 13.01.500

    Investigational criteria updated

    • d-Nav® Insulin Management Program
    • Insulia® Diabetes Management Companion
    • Leva® Pelvic Digital Health System
    • MindMotion™ GO
      • The prescription digital therapeutics listed above have been added to the list of investigational software applications

    Temporomandibular Joint Disorder, 2.01.535

    Investigational criteria updated

    Dextrose prolotherapy has been added to the list of investigational nonsurgical treatments

    Wilderness Therapy/Outdoor Behavioral Healthcare Residential Wilderness Programs, 3.01.522

    Minimum service requirements updated

    • Added requirement that treatment is taking place in a licensed residential program that provides 24-hour individualized interdisciplinary treatment
    • Added note that registered and certified clinicians are not considered licensed clinical practitioners

    New pharmacy policies

    No updates this month

    Revised pharmacy policies
    Effective May 1, 2022

    Drugs for Rare Diseases, 5.01.576

    Achondroplasia (ACH)

    Medical necessity criteria updated

    • Voxzogo™ (vosoritide)
      • Added specific dosing based on patient's actual body weight

    Cold Agglutinin Disease (CAD)

    New policy section

    Drug added

    • Enjaymo™ (sutimlimab-jome)
      • To decrease the need for red blood cell transfusion due to hemolysis in adults age 18 years and older with cold agglutinin disease (CAD)

    Pyruvate Kinase Deficiency (PKD)

    New policy section

    Drug added

    • Pyrukynd® (mitapivat)
      • Treatment of hemolytic anemia in adults age 18 years and older with pyruvate kinase deficiency

    Folate Antimetabolites, 5.01.617

    Drug added

    • Pemfexy™ (pemetrexed)
      • First treatment of locally advanced or metastatic, non-squamous non-small cell lung cancer (NSCLC) when used in combination with platinum chemotherapy
      • As a single agent for the maintenance treatment of locally advanced or metastatic, non-squamous NSCLC without disease progression after four cycles of platinum chemotherapy
      • As a single agent for the treatment of patients with recurrent, metastatic non-squamous NSCLC who have already had chemotherapy
      • First treatment of cancerous pleural mesothelioma that cannot be treated with surgery when used in combination with cisplatin 

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605

    Anticonvulsants

    Drug with new indication

    • Fintepla® (fenfluramine)
      • Treatment of seizures associated with Lennox-Gastaut syndrome in patients age 2 years and older

    Heart Failure Agents

    Medical necessity criteria updated

    • Jardiance® (empagliflozin)
      • The requirement for a reduced ejection fraction of 40% or less has been removed

    Muscle Relaxants

    Drug added

    • Brand baclofen oral solution

    mTOR Kinase Inhibitors, 5.01.533

    Drug added

    • Generic everolimus tablet for oral suspension
      • Treatment of adults and children age 1 year and older with tuberous sclerosis complex (TSC) who have subependymal giant cell astrocytoma (SEGA)
      • Treatment of adults and children age 2 years and older with TSC-associated partial-onset seizures

    Medical necessity criteria updated

    • Afinitor® (everolimus tablet)
      • The patient must have tried generic everolimus tablet first before the above drug can be prescribed
    • Afinitor Disperz® (everolimus tablet for oral suspension)
      • The patient must have tried generic everolimus tablet for oral suspension first before the above drug can be prescribed

    Pharmacotherapy of Cushing’s Disease and Acromegaly, 5.01.548

    Drug added

    • Recorlev® (levoketoconazole)
      • Treatment of high cortisol in patients age 18 years and older with Cushing's syndrome

    Medical necessity criteria updated

    • Isturisa® (osilodrostat)
    • Signifor® (pasireotide)
    • Signifor® LAR (pasireotide)
      • The requirement to use the drugs carbergoline and Metopirone® (metyrapone) or Lysodren® (mitotane) has been removed
      • The patient must have tried generic ketoconazole before the above drugs can be prescribed

    Policy statement added

    Definition of gastroenteropancreatic neuroendocrine tumor (GEP-NET)

    Tadalafil Products for Benign Prostatic Hyperplasia, 5.01.545

    Drug added

    • Entadfi™ (finasteride and tadalafil)
      • Treatment of symptoms of benign prostatic hyperplasia (BPH)

    Vascular Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders, 5.01.620

    Drug added

    • Vabysmo™ (faricimab-svoa)
      • Treatment of neovascular (wet) age-related macular degeneration (AMD)
      • Treatment of diabetic macular edema (DME)

    Medical necessity criteria updated

    • Beovu® (brolucizumab-dbll)
    • Byooviz™ (ranibizumab-nuna)
    • Eylea® (aflibercept)
    • Lucentis® (ranibizumab)
    • Macugen® (pegaptanib)
    • Susvimo™ (ranibizumab)
      • Revised statement that combination treatment includes each eye treated
      • Vabysmo™ (faricimab-svoa) has been added to the list of drugs that may not be used in combination treatment

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

    Effective May 1, 2022

    Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery, 7.01.140

    Effective May 1, 2022

    Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.48

    • This policy has been replaced by Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.569

    Added codes

    Effective May 1, 2022

    Folate Antimetabolites, 5.01.617

    Now requires review for medical necessity and prior authorization.

    J9304

    Revised codes
    Effective May 1, 2022

    Amniotic Membrane and Amniotic Fluid, 7.01.583

    No longer requires review for medical necessity or prior authorization. Now requires review for investigational.

    Q4145, Q4168

    Removed codes
    Effective May 1, 2022

    Chelation Therapy, 8.01.535

    No longer requires review.

    G0068

    Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery, 7.01.140

    No longer requires review. Policy archived.

    0546T

     

  • Updates for non-individual plans only

  • No updates this month
    No updates this month

  • Updates for individual plans only

  • No updates this month

    No updates this month

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