Medical Policy and Coding Updates November 2023

Effective February 7, 2024

Botulinum Toxins, 5.01.512  PBC | Premera HMO
Medical necessity criteria updated

• Botox, Dysport, Myobloc, and Xeomin for the treatment of cervical dystonia requiring individual does not have acute cervical dystonia caused by exposure to dopamine receptor-blocking drugs

Effective January 1, 2024

Herceptin (trastuzumab) and Other HER2 Inhibitors, 5.01.514  PBC | Premera HMO
Medical necessity criteria updated

• Trazimera (trastuzumab-qyyp)
  • Updated to second-line agent

Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502  PBC | Premera HMO
Medical necessity criteria updated

• Ruxience (rituximab-pvvr)
  • Updated to a second-line product

Pharmacotherapy of Arthropathies, 5.01.550  PBC | Premera HMO
Medical necessity criteria updated

• Simponi Aria (golimumab) IV
  • Updated to a first-line product for all indications
• Avsola (IV)
  • Updated to a first-line product for all indications
  • Added to a list of preferred infliximab products to be tried and failed prior to trying non-preferred infliximab products
• Inflectra (infliximab-dyyb) IV
  • Updated to a second-line product for all indications
  • Removed from the list of preferred products to be tried and failed prior to trying non-preferred infliximab products

Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  PBC | Premera HMO
Medical necessity criteria updated

• Avsola (infliximab-axxq) IV
  • Updated to a first-line product for all indications
  • Added to a list of preferred infliximab products to be tried and failed prior to trying non-preferred infliximab products
• Inflectra (infliximab-dyyb) IV
  • Updated to a second-line product for all indications
  • Removed from the list of preferred products to be tried and failed prior to trying non-preferred infliximab products

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  PBC | Premera HMO
Medical necessity criteria updated

• Avsola (infliximab-axxq) IV
  • Updated to a first-line product for the treatment of pyoderma gangrenosum
  • Added to a list of preferred infliximab products to be tried and failed prior to trying non-preferred infliximab products
• Inflectra (infliximab-dyyb) IV
  • Updated to a second-line product for the treatment of pyoderma gangrenosum
  • Removed from the list of preferred products to be tried and failed prior to trying non-preferred infliximab products

Pharmacologic Treatment of Psoriasis, 5.01.629  PBC | Premera HMO
Medical necessity criteria updated

• Avsola (infliximab-axxq) IV
  • Updated to a first-line product
  • Added to a list of preferred infliximab products to be tried and failed prior to trying non-preferred infliximab products
• Inflectra (infliximab-dyyb) IV
  • Updated to a second-line product
  • Removed from the list of preferred products to be tried and failed prior to trying non-preferred infliximab products

Rituximab: Non-oncologic and Miscellaneous Uses, 5.01.556  PBC | Premera HMO
Medical necessity criteria updated

• Ruxience (rituximab-pvvr)
  • Updated to a second-line product

Use of Granulocyte Colony-Stimulating Factors (G-CSF), 5.01.551 PBC | Premera HMO
Medical necessity criteria updated

• Fulphila (pegfilgrastim-jmbd) and Nyvepria (pegfilgrastim-apgf)
  • Updated to a first-line product for individuals less than 18 years of age
  • Updated to a second-line product for individuals 18 years and older
• Udenyca (pegfilgrastim-cbqv) and Ziextenzo (pegfilgrastim-bmez)
  • Updated to a second-line product for individuals less than 18 years of age
  • Updated to a third-line product for individuals 18 years and older

Effective December 7, 2023

Dry Needling of Myofascial Trigger Points, 2.01.100  PBC | Premera HMO
New policy

• Reinstating previously archived policy
  • Dry needling of trigger points for the treatment of myofascial pain is considered investigational

Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
Drugs added

• Temodar (temozolomide) IV
  • For the treatment of newly diagnosed glioblastoma concomitantly with radiotherapy and then as maintenance treatment, or for refractory anaplastic astrocytoma in adult individuals who have experienced disease progression on a drug regimen containing nitrosourea and procarbazine
• Unituxin (dinutuximab) IV
  • For use in combination with granulocyte-macrophage colony-stimulating factor, interleukin-2, and 13-cis-retinoic acid, for the treatment of high-risk neuroblastoma in pediatric individuals who achieve at least a partial response to prior first-line multiagent, multimodality therapy

Site of Service: Infusion Drugs and Biologic Agents, 11.01.523  PBC | Premera HMO
Medical necessity criteria updated

• Monoclonal antibodies for the treatment of lymphoma and Rituximab may be delivered in the inpatient setting when medical necessity criteria for site of service are met

New medical policies

No updates this month.

Revised medical policies
Effective November 1, 2023

Botulinum Toxins, 5.01.512  PBC | Premera HMO
Medical necessity criteria added

• Botox (onabotulinumtoxinA) for the treatment of primary focal axillary or palmar hyperhidrosis in adult individuals (moved policy criteria from Treatment of Hyperhidrosis, 8.01.519)
• Daxxify (daxibotulinumtoxinA-lanm) for the treatment of cervical dystonia in adult individuals

Immune Prophylaxis for Respiratory Syncytial Virus, 5.01.639  PBC | Premera HMO
Policy renumbered

• This policy replaces Immune Prophylaxis for Respiratory Syncytial Virus, 5.01.10, which is now deleted

Medical necessity criteria updated

• Provided policy statement that concurrent use of Beyfortus (nirsevimab-alip) and Synagis (palivizumab) within the same respiratory syncytial virus season is considered not medically necessary

Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain, 7.01.574  PBC | Premera HMO
Title change

• Policy title changed to “Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain and Other Conditions”

Investigational criteria updated

• Policy statement modified to include treatment of chronic pain and "other conditions" to cover new background information on eCoin implantable tibial nerve stimulation

Prescription Digital Therapeutics, 13.01.500  PBC | Premera HMO
Investigational criteria removed

• Removed Pear Therapeutics products, including ReSet, ReSet-O, and Somryst, as they are longer in business

Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.101  PBC | Premera HMO
Medical necessity criteria updated

• Hypoglossal nerve stimulation in adults with obstructive sleep apnea increased body mass index from ≤ 32 kg/m², to ≤ 40 kg/m² to align with expanded Food and Drug Administration indication approved on June 8, 2023

Treatment of Hyperhidrosis, 8.01.519 PBC | Premera HMO
Title change

• Policy title changed to “Surgical Treatment of Hyperhidrosis”

Medical necessity criteria removed

• Removed content on botulinum toxin as it is now included in policy Botulinum Toxins, 5.01.512

New pharmacy policies
Effective November 1, 2023

Chronic Hepatitis B, 5.01.636 PBC | Premera HMO
New policy

• Provided coverage criteria for Baraclude, Epivir-HBV, Hepsera, and Vemlidy for the treatment of chronic hepatitis B
• Moved Pegasys (peginterferon alfa-2a) policy criteria for the treatment of chronic hepatitis B from Hepatitis C Antiviral Therapy, 5.01.606, to this policy

Revised pharmacy policies
Effective November 1, 2023

Amyotrophic Lateral Sclerosis (ALS) Medications, 5.01.578  PBC | Premera HMO
Medical necessity criteria/drug added

• Exservan (riluzole) and Tiglutik (riluzole) for the treatment of amyotrophic lateral sclerosis

Drugs for Rare Diseases, 5.01.576  PBC | Premera HMO
Medical necessity criteria/drug added

• Added coverage for Sohonos (palovarotene) for the reduction in the volume of new heterotopic ossification in adults and children with fibrodysplasia ossificans progressiva

Erythroid Maturation Agents, 5.01.614  PBC | Premera HMO
Medical necessity criteria/drug added

• Reblozyl (luspatercept-aamt) for the treatment of anemia in erythropoiesis stimulating agent (ESA) naïve adults with very low- to intermediate-risk myelodysplastic syndromes

Medical Necessity Criteria for Pharmacy Edits, 5.01.605  PBC | Premera HMO
Medical necessity criteria added

• Use of generic lisdexamfetamine dimesylate required prior to brand Vyvanse for the treatment of attention deficit hyperactive disorder
• Rexulti (brexpiprazole) for the treatment of agitation associated with dementia due to Alzheimer’s disease

Drugs added

• Humatin (paromomycin) for the treatment of intestinal amebiasis and management of hepatic coma to Antiparasitic Agents
• Pancreaze (pancrelipase) and Pertzye (pancrelipase) for the treatment of exocrine pancreatic insufficiency to Digestive Enzymes
• Miebo (perfluorohexyloctane ophthalmic solution) to Dry Eye Treatment
• Cequa, Tyrvaya, Vevye, Xiidra to require that individual has tried and failed generic cyclosporine ophthalmic emulsion 0.05%
• Gocovri (amantadine) for the treatment of dyskinesia and treatment of “off” episodes in Parkinson’s disease to Parkinson’s Disease Agents
• Osmolex ER (amantadine) for the treatment of Parkinson’s disease and drug-induced extrapyramidal reactions to Parkinson’s Disease Agents
• Lokelma (sodium zirconium cyclosilicate) and Veltassa (patiromer) for the treatment of hyperkalemia to Potassium Binders
• Thiola (tiopronin), Thiola EC (tiopronin delayed-release), and generic tiopronin for the prevention of cystine stone formation to Cystine Binding Drugs

Medical necessity criteria updated

• Vyvanse criteria for BED adding requirement individual has tried and failed or is intolerant to generic lisdexamfetamine dimesylate
• Trulance, Motegrity, Pizensy, Linzess, Movantik, and Amitiza to require the individual has tried and failed or is intolerant to generic lubiprostone

Medical necessity criteria removed

• Vyvanse exception to use of a generic stimulant when the individual has a history of drug abuse or dependence due to the available use of generic lisdexamfetamine dimesylate

Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
Medical necessity criteria updated

• Arranon added as first-line treatment when incorporated into the augmented Berlin Frankfurter Muenster (ABFM) regimen in intermediate to high-risk individuals or ABFM regimen induction failures

Medical necessity criteria added

• Talvey and Elrexfio for the treatment of adult individuals with relapsed or refractory multiple myeloma where individual has tried at least four lines of prior therapies
• Brand bortezomib with identical coverage criteria as generic bortezomib and Velcade (bortezomib)

Pharmacologic Treatment of Postpartum Depression, 5.01.608  PBC | Premera HMO
Drug added

• Zurzuvae (zuranolone) for the treatment of postpartum depression in adults

Vascular Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders, 5.01.620  PBC | Premera HMO
Medical necessity criteria/drug added

• Eylea HD (aflibercept), a higher dose and longer acting formulation of Eylea, for the treatment of age-related macular degeneration, diabetic macular edema, and diabetic retinopathy

Medical necessity criteria updated

• Beovu, Byooviz, Cimerli, Lucentis, Macugen, Susvimo, and Vabysmo to include use is not in combination with Eylea HD

Pharmacologic Treatment of Sleep Disorders, 5.01.599  PBC | Premera HMO
Medical necessity criteria/drug added

• Brand sodium oxybate added to Xyrem (sodium oxybate) criteria

Medical necessity criteria added

• Lumryz (sodium oxybate) for the treatment of cataplexy or excessive daytime sleepiness in adults with narcolepsy

Medical necessity criteria updated

• Updated coverage criteria for Xyrem, Xywav, Sunosi, and Wakix regarding concurrent use with Lumryz

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  PBC | Premera HMO
Medical necessity criteria updated

• Actemra (tocilizumab) for the treatment of cytokine release syndrome to require documentation confirming the diagnosis

Effective November 1, 2023

Prescription Digital Therapeutics for Substance Use Disorders, 5.01.35
Archive policy

• The products in this policy are no longer available on the market

Effective November 1, 2023

Immune Prophylaxis for Respiratory Syncytial Virus, 5.01.10
This policy is replaced with Immune Prophylaxis for Respiratory Syncytial Virus 5.01.639

Added codes
Effective November 1, 2023

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

C9789

Surgical Treatment of Hyperhidrosis, 8.01.519  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

11450, 11451, 69676

Revised codes
Effective November 1, 2023

Non-covered Services and Procedures, 10.01.517  PBC | Premera HMO
Now reviewed by Carelon Medical Benefits Management for medical necessity and prior authorization.

K1027

Removed codes
Effective November 1, 2023

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

A9291, 98978

Added codes

No updates this month

Effective December 7, 2023

Services Reviewed Using InterQual Criteria, 10.01.530
This policy updated to reflect additional services

No updates this month.

Effective December 7, 2023

Digital Breast Tomosynthesis, 6.01.526
This policy is replaced with InterQual criteria

No updates this month.