Medical Policy and Coding Updates October 2023

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

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

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

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 October 1, 2023

Artificial Pancreas Device System, 1.01.30  PBC | Premera HMO
Device added

• Artificial pancreas device system with a closed-loop insulin delivery system (iLet Bionic pancreas) for individuals with type 1 diabetes may be considered medically necessary

Electrical Stimulation Devices, 1.01.507  PBC | Premera HMO
Investigational criteria added

• Multimodal devices that incorporate interferential current stimulation, neuromuscular electrical stimulation, and transcutaneous electrical nerve stimulation are considered investigational for all indications (e.g., NexWave)

Upper Gastrointestinal (UGI) Endoscopy for Adults, 2.01.533  PBC | Premera HMO
Medical necessity criteria added

• UGI endoscopy is considered medically necessary when performed for endoscopic ultrasound guided fine needle aspiration/biopsy(s) of adjacent organs or structures (e.g., esophagus, stomach, duodenum, pancreas, liver, etc.)

Rhinoplasty and Other Nasal Procedures, 7.01.558  PBC | Premera HMO
Medical necessity criteria added

• Nasal swell body reduction by any method is considered investigational for the treatment of nasal obstruction or other sinonasal disease

Gender Transition/Affirmation Surgery and Related Services, 7.01.557  PBC | Premera HMO
Medical necessity criteria added

• For hair removal related to genital surgery
  • Added a requirement for documentation that hair removal will be from existing genital sites where surgery will be performed or from donor tissue that will be utilized to form female or male genitals
  • Added a requirement for documentation that hair removal is intended to reduce the individual’s gender dysphoria
• For correction/repair, revision, or reversal surgeries
  • Added requirement for documentation indicating that the original surgery was medically necessary
• See policy for additional additions

Medical necessity criteria updated

• For surgery or procedures requiring a mental health recommendation
  • Changed the time requirement for mental health recommendation/support from 6 to 12 months prior to the request for consistency
  • Changed the requirement for mental health recommendation/support for genital surgery from two letters or medical record documentation to one
• See policy for additional updates

Medical necessity criteria removed

• For augmentation mammoplasty and genital surgeries
  • Removed the prerequisite of hormone therapy
• For all surgery and procedures
  • Removed the requirement for a pre-surgery or pre-procedure surgeon’s or other provider’s evaluation
• See policy for additional removals

Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy, 7.01.588  PBC | Premera HMO
Policy renumbered

• This policy replaces Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy 7.01.29, which is now deleted

New pharmacy policies

No updates this month

Revised pharmacy policies
Effective October 1, 2023

Migraine and Cluster Headache Medications, 5.01.503  PBC | Premera HMO
Medical necessity criteria added

• For calcitonin gene-related peptides (CGRPs), for acute use, updated requirement that trial and failure of one triptan
• For CGRPs, for preventive use, updated requirement that trial and failure of two prophylactic medications

Prostate Cancer Targeted Therapies, 5.01.544  PBC | Premera HMO
Medical necessity criteria/drug added

• Akeega (niraparib and abiraterone Acetate) oral for the treatment of adult individuals with deleterious or suspected deleterious BRCA-mutated metastatic castration-resistant prostate cancer

Pharmacotherapy of Multiple Sclerosis, 5.01.565  PBC | Premera HMO
Medical necessity criteria removed

• Removed the requirement of trial and failure of Ocrevus step therapy before trying Kesimpta

Pharmacologic Treatment of Duchenne Muscular Dystrophy, 5.01.570  PBC | Premera HMO
Medical necessity criteria added

• Elevidys (delandistrogene moxeparvovec-rokl) IV for the treatment of ambulatory pediatric individuals aged 4 through 5 years with Duchenne muscular dystrophy with a confirmed mutation in the DMD gene

C3 and C5 Complement Inhibitors, 5.01.571  PBC | Premera HMO
Medical necessity criteria added

• Veopoz (pozelimab-bbfg) for the treatment of adult and pediatric individuals 1 year of age and older with CD55-deficient protein-losing enteropathy, also known as CHAPLE disease

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

• Cholbam (cholic acid) capsule for the indication of either bile acid synthesis disorders due to single enzyme defects or for the adjunctive treatment of peroxisomal disorders including Zellweger spectrum disorders

Medical/pharmacy benefit updated

• Crysvita (burosumab) moved from medical/pharmacy benefits to medical benefits

Pharmacologic Treatment of Hemophilia, 5.01.581  PBC | Premera HMO
Medical necessity criteria added

• Roctavian for the treatment of severe hemophilia A in adults without pre-existing antibodies to adeno-associated virus serotype 5

CGRP Inhibitors for Migraine Prophylaxis, 5.01.584  PBC | Premera HMO
Medical necessity criteria added

• CGRPs for preventive use. For preventive use, updated requirement that trial and failure of 2 prophylactic medications

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

• Opvee (nalmefene) for the emergency treatment of known or suspected overdose induced by natural or synthetic opioids in adults and pediatric individuals aged 12 years and older, as manifested by respiratory and/or central nervous system depression
• Ingrezza for the treatment of chorea associated with Huntington’s disease
• Jesduvroq (daprodustat) for the treatment of anemia due to chronic kidney disease in adults who have been receiving dialysis for at least four months

Medical necessity criteria removed

• Removed Farxiga requirement of a reduced ejection fraction of 40% or less

No updates this month

Effective October 1, 2023

Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy, 7.01.29
This policy is replaced with Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy, 7.01.588

Added codes
Effective October 1, 2023

Amniotic Membrane and Amniotic Fluid, 7.01.583  PBC | Premera HMO
Now requires review for investigational.

Q4285, Q4286

Amyotrophic Lateral Sclerosis (ALS) Medications, 5.01.578  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

C9157

Bioengineered Skin and Soft Tissue Substitutes, 7.01.113  PBC | Premera HMO
Now requires review for investigational.

A2022, A2023, A2024, A2025

C3 and C5 Complement Inhibitors, 5.01.571  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J2781

Immune Checkpoint Inhibitors, 5.01.591  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J9345

Laboratory Testing Investigational Services, 2.04.520  PBC | Premera HMO
Now requires review for investigational.

0406U, 0415U, 0418U

Medical Necessity Criteria for Pharmacy Edits, 5.01.605  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J0889, J7353

Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

C9155, J9051

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

0019M, C9790, C9792, E0490, E0491, L5991, 0404U

Non-covered Services and Procedures, 10.01.517  PBC | Premera HMO
No longer covered.

A9268, A9269, H2040, H2041, V2526

Pharmacologic Treatment of Hemophilia, 5.01.581  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J1411

Prescription Digital Therapeutics, 13.01.500  PBC | Premera HMO
Now requires review for investigational.

A9292

Repository Corticotropin Injection, 5.01.561  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J0801, J0802

Stationary Ultrasonic Diathermy Devices, 7.01.174  PBC | Premera HMO
Now requires review for investigational.

K1036

Carelon Genetic Testing
Now requires review for medical necessity and prior authorization.

0403U, 0405U, 0409U, 0410U, 0411U, 0413U, 0414U, 0417U, 0419U

Revised codes
Effective October 1, 2023

Site of Service: Infusion Drugs and Biologic Agents, 11.01.523  PBC | Premera HMO
Now requires review for site of service. Currently requires review for medical necessity and prior authorization.

Q5123

Revised codes

No updates this month

Removed codes
Effective October 1, 2023

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

98978

Non-covered Experimental/Investigational Services, 10.01.533  PBC | Premera HMO
Code terminated

0357U

C5 Complement Inhibitors, 5.01.571  PBC | Premera HMO
Code terminated

C9151

Repository Corticotropin Injection, 5.01.561  PBC | Premera HMO
Code terminated

J0800

Carelon Genetic Testing
Code terminated

0397U

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