Medical Policy and Coding Updates September 2023

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

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 MiscellaneousAutoimmune 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

New medical policies
Effective September 1, 2023

Laboratory Testing Investigational Services, 2.04.520  PBC | Premera HMO
New policy

• Modified version of Blue Cross and Blue Shield Association policy
  • All tests listed in this policy are investigational

Leadless Cardiac Pacemakers, 2.02.515  PBC | Premera HMO
New policy

• This policy replaces Leadless Cardiac Pacemakers 2.02.32, which is now deleted
  • Dual chamber leadless pacemakers are considered investigational

Revised medical policies
Effective September 1, 2023

Orthognathic Surgery, 9.02.501  PBC | Premera HMO
Medical necessity criteria added

• Criteria added for significant transverse maxillary arch deficiency

New pharmacy policies
Effective September 1, 2023

Omisirge (Omidubicel), 5.01.638  PBC | Premera HMO
New policy

• Omisirge (omidubicel-onlv)
  • Medical necessity criteria provided for individuals 12 years of age and older for the treatment of hematologic malignancies who are planned for umbilical cord blood transplantation following myeloablative conditioning to reduce the time to neutrophil recovery and the incidence of infection

Pharmacologic Treatment of Alopecia, 5.01.637  PBC | Premera HMO
New policy

• Olumiant (baricitinib) and Lifulo (ritlecitinib)
  • Medical necessity criteria provided for the treatment of severe alopecia areata

Revised pharmacy policies
Effective September 1, 2023

Drugs for Rare Diseases, 5.01.576  PBC | Premera HMO
Drug added

• Bylvay (avatrombopag) oral
  • For the treatment of cholestatic pruritus in individuals 12 months of age and older with Alagille syndrome

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

• Zylet (tobramycin-loteprednol)
  • May be considered medically necessary when the individual has tried and failed generic ophthalmic tobramycin and generic ophthalmic loteprednol

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

• Lynparza (olaparib)
  • Added coverage criteria for the treatment of deleterious or suspected deleterious BRCA-mutated metastatic castration-resistant prostate cancer (mCRPC) in adult individuals when used in combination with abiraterone and prednisone or prednisolone
• Talzenna (talazoparib)
  • Added coverage criteria when used in combination with enzalutamide, for the treatment of homologous recombination repair (HRR) gene-mutated mCRPC in adult individuals
• Leukine (sargramostim) IV, SC
  • In combination with Unituxin, for the treatment high-risk neuroblastoma in of pediatric individuals who achieve at least a partial response to prior first-line multiagent, multimodality therapy

Medical necessity criteria removed

• Gavreto (pralsetinib)
  • Removed indication of advanced or metastatic RET-mutant medullary thyroid cancer who require systemic therapy for adult and pediatric patients 12 years of age and older per Food and Drug Administration (FDA) label changes

Drugs added

• Matulane (procarbazine hydrochloride) oral
  • For the treatment of stage III and IV Hodgkin’s disease, when used in combination with other anticancer drugs
• Lysodren (mitotane)
  • For the treatment of adrenal cortical carcinoma when the tumor is inoperable
• Generic temozolamide oral
  • 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
• Vistogard (uridine triacetate) oral
  • For the emergency treatment of fluorouracil or capecitabine overdose, or severe or life-threatening toxicity within 96 hours following the end of fluorouracil or capecitabine administration
• Brand paclitaxel protein-bound particles (American regent-unbranded) IV
  • Added to Abraxane criteria
• Epkinly (epcoritamab-bysp)
  • For the treatment of relapsed or refractory diffuse large B-cell lymphoma (DLBCL), not otherwise specified, including DLBCL arising from indolent lymphoma, and high-grade B-cell lymphoma after two or more lines of systemic therapy in adult individuals
• Generic bortezomib IV
  • Added to the criteria of Velcade (bortezomib) IV

Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502  PBC | Premera HMO
Drug removed

• Lumoxiti (moxetumomab pasudotox)
  • Astrazenenca has decided to permanently discontinue Lumoxiti from the US market and will not be available after August 2023

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

• Hemgenix (etranacogene dezaparvovec-drlb)
  • Criteria updated to state that individual meets one of the following: Current or historical life-threatening hemorrhage OR repeated, serious spontaneous bleeding episodes OR individual is currently receiving FIX prophylaxis
  • Removed separate bullet point “Individual is currently receiving FIX prophylaxis”
  • Changes based on the FDA approval for Hemgenix and Pharmacy & Therapeutic committee in February 2023

Pharmacologic Treatment of Psoriasis, 5.01.629  PBC | Premera HMO
Drugs added

• Humira biosimilars Idacio (adalimumab-aacf) SC and Adalimumab-fkjp (biocon-unbranded) SC
  • Added as non-preferred products with similar criteria as Amjevita (adalimumab-atto) [NDCs starting with 72511]

Medical necessity criteria updated

• Cosentyx (secukimumab) SC
  • Changed the requirement of trying four products to two products, and removed the requirement of trying agents from two or more different drug classes

Pharmacotherapy of Arthropathies, 5.01.550  PBC | Premera HMO
Drugs added

• Humira biosimilars Idacio (adalimumab-aacf) and Adalimumab-fkjp (biocon-unbranded)
  • Added coverage as non-preferred products with similar criteria as Amjevita (adalimumab-atto) [NDCs starting with 72511]

Medical necessity criteria update

• Cosentyx (secukimumab) SC
  • For ankylosing spondylitis, added Rinvoq as a qualifier
  • For active psoriatic arthritis, changed the requirement of trying three products to two products, and removed the requirement of trying agents from two or more different drug classes
  • For non-radiographic axial spondylarthritis, added Rinvoq as a qualifier and added requirement of trying two of the three agents

Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  PBC | Premera HMO
Drugs added

• Humira biosimilars Idacio (adalimumab-aacf) SC and Adalimumab-fkjp (biocon-unbranded) SC
  • Added as non-preferred products with similar criteria as Amjevita (adalimumab-atto) [NDCs starting with 72511]

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  PBC | Premera HMO
Drugs added

• Humira biosimilars Idacio (adalimumab-aacf) SC and Adalimumab-fkjp (biocon-unbranded) SC
  • Added as non-preferred products with similar criteria as Amjevita (adalimumab-atto) [NDCs starting with 72511]

Pharmacotherapy of Thrombocytopenia, 5.01.566  PBC | Premera HMO
Medical necessity criteria removed

• Dopletet (avatrombopag) oral
  • Removed the step therapy requirement requiring individual to have an insufficient response to Promacta (eltrombopag) or Nplate (romiplostim) based on the formulary and guideline

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

• Xtandi (enzalutamide) oral
  • Treatment of HRR gene-mutated mCRPC when used in combination with Talzenna in adult individuals based on the updated Talzenna FDA labeling

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

• Humira biosimilars Amjevita (adalimumab-atto) [NDCs starting with 55513], Cyltezo LCF (adalimumab-adbm), Hyrimoz HCF (adalimumab-adaz) and Adamilumab- adaz HCF (sandoz–unbranded)
  • Added to the list of preferred products to be tried and failed prior to using Rituxan and Truxima as second-line therapy for the indication of rheumatoid arthritis

No updates this month

Effective September 1, 2023

Leadless Cardiac Pacemakers, 2.02.32
This policy is replaced with Leadless Cardiac Pacemakers 2.02.32

Added codes
Effective September 1, 2023

Intraarticular Corticosteroids, 5.01.633  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J3304

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

0112U

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

J9259, J9328

Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures), 7.01.587  PBC | Premera HMO
Now requires review for investigational.

33254, 33255, 33256, 33258, 33265 and 33266

Rituxan (rituximab): Non-oncologic and Miscellaneous Uses, 5.01.556  PBC | Premera HMO
Now requires review for investigational.

Q5123

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

Q5123

Revised codes

No updates this month

Removed codes

No updates this month

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