Medical Policy and Coding Updates

Effective February 7, 2025

Gonadotropin Releasing Hormone (GnRH) Analogs, 5.01.625  PBC | Premera HMO
Drug added

• Synarel (nafarelin) to central precocious puberty, endometriosis and gender dysphoria criteria

Medical necessity criteria updated

• Initial gender dysphoria criteria updated to clarify that:
  • Puberty onset at Tanner stage 2 or higher is determined by serum testosterone level, serum estradiol level, serum estrone level, serum luteinizing hormone level, or serum follicle stimulating hormone for individuals assigned female at birth
  • Potential adverse effects have been discussed, including possible effects on fertility, bone mineralization and bone density
  • GnRH agonist is necessary to suppress characteristics of the gender assigned at birth that are not evident by observation or on physical examination in certain individuals aged 23 and older, or after reaching Tanner stage 5, or after irreversible physical/anatomic secondary sexual characteristics are developed
  • Documentation is required demonstrating that cross-sex hormone/gender affirming hormone treatment is not effective when starting a GnRH agonist
• Updated initial gender dysphoria criteria notes to clarify confirmation of Tanner stages due to overlapping values
• Initial authorization duration updated from up to 6 months to up to 12 months
• Re-authorization gender dysphoria criteria updated to clarify that:
  • Documentation of suppression of secondary sex characteristics based on physical examination OR documentation of suppression of characteristics of the gender assigned at birth that are not evident by observation or on physical examination is required
  • Documentation of annual testing of bone age or bone density is required in certain individuals
  • For the first re-authorization request, if the previous coverage was under a non-Company plan, documentation that the initial authorization requirements have also been met is required
• Updated re-authorization gender dysphoria criteria notes to clarify acceptable documentation of suppression of characteristics of the gender assigned at birth

Investigational criteria added

• Use of GnRH analogs that does not meet the age or diagnosis requirements within the Medical Necessity section is considered investigational
• Use of GnRH analogs that meets the age and diagnosis requirements within the Medical Necessity section but does not meet other policy criteria within the Medical Necessity section is considered not medically necessary

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

• CytoGam (cytomegalovirus immune globulin) for the prophylactic treatment of cytomegalovirus (CMV) disease or CMV pneumonitis associated with transplantation in certain individuals

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

• Brand bendamustine, Belrapzo (bendamustine), Bendeka (bendamustine), and Vivimusta (bendamustine) for the treatment of certain individuals with chronic lymphocytic leukemia or non-Hodgkin lymphoma
• Nipent (pentostatin) for the treatment of certain individuals with hairy cell leukemia
• Oncaspar (pegaspargase) for the treatment of certain individuals with acute lymphoblastic leukemia
• Vyxeos (cyatarabine-daunorubicin) coverage criteria for the treatment of certain individuals with acute myeloid leukemia

Effective January 3, 2025

Advanced Therapies for Pharmacological Treatment of Pulmonary Arterial Hypertension, 5.01.522  PBC | Premera HMO
Medical necessity criteria updated

• Remodulin (treprostinil injection; for subcutaneous [SC] or intravenous [IV] infusion) updated to require trial and failure or intolerance to generic treprostinil injection (SC or IV infusion)

Alpha1-Proteinase Inhibitor, 5.01.624  PBC | Premera HMO
Medical necessity criteria updated

• Glassia (alpha1-proteinase inhibitor (PI) [human]) IV
  • Updated from first-line to second-line product
  • Requires trial and failure or intolerance to Aralast NP (alpha1-PI [human]), Prolastin C (alpha1-PI [human]), or Zemaira (alpha1-PI [human])

Dupixent (dupilumab), 5.01.575  PBC | Premera HMO
Medical necessity criteria updated

• Blood eosinophil count in asthma criteria increased from 150 cells/mcL within the last 12 months to 300 cells/mcL within the last 12 months
• Asthma diagnostic criteria updated to:
  • One or more asthma exacerbations requiring a hospitalization, an emergency department visit, or an urgent care visit in the previous 12 months, or
  • Forced expiratory volume in 1 second (FEV1) less than 80% predicted

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

• Kanjinti (trastuzumab-anns) and Trazimera (trastuzumab-qyyp) updated to preferred trastuzumab products
• Herceptin (trastuzumab), Herceptin Hylecta (trastuzumab and hyaluronidase-oysk), and Ogivri (trastuzumab-dkst) updated to non-preferred trastuzumab products
• Herceptin, Herceptin Hylecta, Hercessi (trastuzumab-strf), Herzuma (trastuzumab-pkrb), Ogivri, and Ontruzant (trastuzumab-dttb) updated to require the individual to have had an adequate trial and failure with Kanjinti or Trazimera

IL-5 Inhibitors, 5.01.559  PBC | Premera HMO
Medical necessity criteria updated

• Nucala (mepolizumab), Fasenra (benralizumab), and Cinqair (reslizumab) asthma criterion on blood eosinophil count updated from greater than 150 cells/mcL to greater than 300 cells/mcL
• Nucala asthma and eosinophilic granulomatosis with polyangiitis criteria updated to include prescriber requirement
• Fasenra and Cinqair asthma criteria updated to include a prescriber requirement
• Nucala, Fasenra, and Cinqair asthma diagnostic criteria updated to:
  • Two or more asthma exacerbations in the previous 12 months requiring use of oral corticosteroids, or
  • One or more asthma exacerbations requiring a hospitalization, an emergency department visit, or an urgent care visit in the previous 12 months, or
  • FEV1 <80% predicted

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

• Ruxience (rituximab-pvvr) updated to a preferred rituximab product
• Rituxan (rituximab) and Rituxan Hycela (rituximab and hyaluronidase human) updated to non-preferred rituximab products
• Riabni (rituximab-arrx), Rituxan, and Rituxan Hycela updated to require that the individual has had an adequate trial and failure with Ruxience or Truxima

Pharmacologic Treatment in Assisted Reproduction, 5.01.610  PBC | Premera HMO
Drugs/medical necessity criteria added

• Ganirelix SC for use in assisted reproduction when the individual has had an inadequate response or intolerance to Generic cetrorelix or Cetrotide (cetrorelix), and Generic ganirelix or Fyremadel (ganirelix)
• Generic ganirelix SC, and Fryremadel (ganirelix) SC for use in assisted reproduction when the individual has had tried and failed, or has intolerance to generic cetrorelix or brand Cetrotide (cetrorelix)

Pharmacological Treatment of Multiple Sclerosis, 5.01.565  PBC | Premera HMO
Policy reformatted

• Policy section 2 added to include criteria specific to Individual/Small Group/Student/International Student Metallic Formulary Plans (Rx Plan M1, M2, and M4) for the following drugs:
  • Lemtrada (alemtuzumab), Avonex (interferon-beta 1a), Rebif (interferon-beta 1a), Plegridy (interferon-beta 1a), Betaseron (interferon-beta 1b), Extavia (interferon-beta 1b), generic glatiramer, Glatopa (glatiramer), Copaxone (glatiramer), Aubagio (teriflunomide), generic teriflunomide, Bafiertam (monomethyl fumarate), generic dimethyl fumarate, Tecfidera (dimethyl fumarate), Vumerity (diroximel fumarate), generic fingolimod, Gilenya (fingolimod), Tascenso ODT (fingolimod), Tyruko (natalizumab-sztn), Tysabri (natalizumab), Briumvi (ublituximab-xiiy), Kesimpta (ofatumumab), Ocrevus (ocrelizumab), Mavenclad (cladribine), Mayzent (siponimod), Ponvory (ponesimod), and Zeposia (ozanimod)

Drugs/medical necessity criteria updated

• Ocrevus (ocrelizumab) and Tysabri (natalizumab) added to site of service administration

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

• Inflectra (infliximab-dyyb) updated to a first-line agent
• Avsola (infliximab-axxq) updated to a second-line agent
• Avsola and Renflexis updated to require the individual to have an adequate trial and failure with Inflectra, Infliximab (Janssen – unbranded), or Remicade
• Hyrimoz (Sandoz) (adalimumab-adaz) [NDCs starting with 61314] updated to a non-preferred product
• Humira (AbbVie) (adalimumab) [NDCs starting with 00074] updated to require that the individual has had an inadequate response or intolerance to a preferred product for new starts

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

• Inflectra (infliximab-dyyb) updated to a first-line agent
• Avsola (infliximab-axxq) updated to a second-line agent
• Avsola and Renflexis updated to require the individual to have an adequate trial and failure with Inflectra, Infliximab (Janssen – unbranded), or Remicade
• Hyrimoz (Sandoz) (adalimumab-adaz) [NDCs starting with 61314] updated to a non-preferred product
• Humira (AbbVie) (adalimumab) [NDCs starting with 00074] updated to require that the individual has had an inadequate response or intolerance to a preferred product for new starts

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

• Inflectra (infliximab-dyyb) updated to a first-line agent
• Avsola (infliximab-axxq) updated to a second-line agent
• Avsola and Renflexis updated to require the individual to have an adequate trial and failure with Inflectra, Infliximab (Janssen – unbranded), or Remicade
• Hyrimoz (Sandoz) (adalimumab-adaz) [NDCs starting with 61314] updated to a non-preferred product
• Humira (AbbVie) (adalimumab) [NDCs starting with 00074] updated to require that the individual has had an inadequate response or intolerance to a preferred product for new starts

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

• Inflectra (infliximab-dyyb) updated to a first-line agent
• Avsola (infliximab-axxq) updated to a second-line agent
• Avsola and Renflexis criteria updated to require the individual to have an adequate trial and failure with Inflectra, Infliximab (Janssen – unbranded), or Remicade
• Rystiggo criteria updated to require for AChR antibody positive myasthenia gravis the individual has tried and failed Soliris, Ultomiris, Vyvgart, or Vyvgart Hytrulo
• Hyrimoz (Sandoz) (adalimumab-adaz) [NDCs starting with 61314] updated to a non-preferred product
• Humira (AbbVie) (adalimumab) [NDCs starting with 00074] updated to require that the individual has had an inadequate response or intolerance to a preferred product for new starts

Rituxan (rituximab): Non-oncologic and Miscellaneous, 5.01.556  PBC | Premera HMO
Medical necessity criteria updated

• Ruxience (rituximab-pvvr) updated to a preferred product
• Rituxan (rituximab) and Rituxan Hycela (rituximab and hyaluronidase human) updated to non-preferred products
• Riabni (rituximab-arrx), Rituxan, and Rituxan Hycela updated to require the individual has had an adequate trial and failure with Ruxience or Truxima
• Hyrimoz (Sandoz) (adalimumab-adaz) [NDCs starting with 61314] updated to a non-preferred product

Shoulder Arthroplasty, 7.01.590  PBC | Premera HMO
New policy

• Total shoulder arthroplasty, reverse total shoulder arthroplasty, and shoulder hemiarthroplasty may be considered medically necessary in certain individuals

Thymic Stromal Lymphopoietin (TSLP) Inhibitors, 5.01.627  PBC | Premera HMO
Medical necessity criteria updated

• Tezspire (tezepelumab-ekko) updated to include a prescriber requirement
• Diagnostic criteria updated to include the following alternatives:
  • One or more asthma exacerbations requiring a hospitalization, an emergency department visit, or an urgent care visit in the previous 12 months, or
  • FEV1 less than 80% predicted

Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment, 5.01.517 PBC | Premera HMO
Medical necessity criteria updated

• Mvasi (bevacizumab-awwb) updated to a preferred product
• Avastin (bevacizumab) updated to a non-preferred product
• Alymsys (bevacizumab-maly), Avastin, Avzivi (bevacizumab-tnjn) and Vegzelma (bevacizumab-adcd) updated to require the individual has had an adequate trial and failure with Mvasi or Zirabev

Xolair (omalizumab), 5.01.513  PBC | Premera HMO
Medical necessity criteria updated

• Removed requirement for asthma to be a current non-smoker or be enrolled in a smoking cessation program
• Asthma diagnostic criteria updated to:
  • Two or more asthma exacerbations in the previous 12 months requiring use of oral corticosteroids, or
  • One or more asthma exacerbations requiring a hospitalization, an emergency department visit, or an urgent care visit in the previous 12 months, or
  • FEV1 less than 80% predicted, or
  • Dependence on oral corticosteroids of at least 5 mg per day of prednisone or equivalent

Effective December 5, 2024

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

• Cosentyx (secukinumab) IV and Tofidence (tocilizumab-bavi) IV will be reviewed for site of service

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

• Tyruko (natalizumab-sztn) will be reviewed for site of service

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

• Tofidence (tocilizumab-bavi) IV will be reviewed for site of service

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

• Tyruko (natalizumab-sztn) will be reviewed for site of service

Site of Service: Infusion Drugs and Biologic Agents, 11.01.523  PBC | Premera HMO
Drugs added

• Alyglo (immune globulin intravenous, human-stwk), Cosentyx IV (secukinumab), Spevigo IV (spesolimab-sbzo), Tofidence IV (tocilizumab-bavi), and Tyruko (natalizumab-sztn) will be reviewed for site of service

Effective November 1, 2024

Alpha-1 Proteinase Inhibitors, 5.01.624  PBC | Premera HMO
Medical necessity criteria updated

• Aralast NP, Glassia, Prolastin-C, and Zemaira will be reviewed for site of service

Site of Service: Infusion Drugs and Biologic Agents, 11.01.523  PBC | Premera HMO
Drugs added

• Aralast NP, Glassia, Prolastin-C, and Zemaira will be reviewed for site of service

New medical policies

No updates this month.

Revised medical policies

No updates this month.

New pharmacy policies

No updates this month.

Revised pharmacy policies
Effective November 1, 2024

Drugs for Rare Diseases, 5.01.576  PBC | Premera HMO
Drug/medical necessity criteria added

• Yorvipath (palopegteriparatide) for the treatment of certain individuals with hypoparathyroidism

Medical necessity criteria updated

• Brineura (cerliponase alfa) updated from individuals 3 years of age and older diagnosed with late infantile neuronal ceroid lipofuscinosis type 2 (CLN2) to individuals aged less than 18 years diagnosed with CLN2
• Livmarli (maralixibat) progressive familial intrahepatic cholestasis coverage criteria age requirement updated from 5 years and older to 12 months and older

Immune Checkpoint Inhibitors, 5.01.591  PBC | Premera HMO
Medical necessity criteria added

• Imfinzi (durvalumab) updated to add criteria for certain individuals with non-small cell lung cancer used in combination with platinum-containing chemotherapy
• Jemperli (dostarlimab-gxly) updated to include coverage criteria for adults with primary advanced or recurrent endometrial cancer regardless of whether the cancer is mismatch repair deficient or microsatellite instability-high
• Opdivo (nivolumab) updated to add criteria for certain individuals with stage I or II Hodgkin lymphoma with one or more high-risk features
• Opdivo (nivolumab) updated to add criteria for certain individuals with stage IIb through IV Hodgkin lymphoma
• Clarified that Tecentriq (atezolizumab) use for hepatocellular carcinoma is limited to adult individuals

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

• Onyda XR (clonidine) to Brand Attention Deficit Hyperactivity Disorder Drugs
• Symbyax to Antipsychotics (Second Generation “Atypicals”)
• Cortifoam (hydrocortisone) and Dexonto (dexamethasone) to Brand Topical Corticosteroids
• Ambien CR to Hypnotics
• Crexont (carbidopa-levodopa) to Parkinson’s Disease Agents
• Brand esomeprazole and Brand rabeprazole to Proton Pump Inhibitors
• Neuac (benzoyl peroxide-clindamycin) to Brand Topical Acne or Rosacea Products
• Centany (mupirocin) to Topical Antibiotics
• Neffy (epinephrine nasal spray) to Epinephrine Agents

Drug/medical necessity criteria added

• Generic oxcarbazepine ER for the treatment of partial-onset seizures in certain individuals aged 6 years and older
• Oravig (miconazole) for the treatment of fungal infections in certain individuals with inadequate response or intolerance to generic oral clotrimazole or generic oral nystatin
• Anusol-HC (hydrocortisone), brand hydrocortisone-pramoxine, Proctocort (hydrocortisone), and Zypram (hydrocortisone-pramoxine) to Brand Suppository Corticosteroids
• Generic ivabradine for the treatment of stable, symptomatic heart failure in certain adult individuals
• Generic apomorphine for the intermittent treatment of OFF episodes in certain individuals with Parkinson’s disease
• Sofdra (sofpironium) for the treatment of primary axillary hyperhidrosis in certain individuals aged 9 years and older
• Pivya (pivmecillinam) for the treatment of uncomplicated urinary tract infections in certain adult individuals

Medical necessity criteria updated

• Oxtellar XR (oxcarbazepine extended release) updated from trial and failure with another generic antiseizure medication to trial with generic oxcarbazepine ER
• Corlanor (ivabradine) updated to require trial with generic ivabradine first
• Qbrexza (glycopyrronium cloth) updated criteria to require interference with activities of daily living for at least 6 months, and not due to a secondary cause
• Xepi (ozenoxacin) updated from trial with mupirocin to generic mupirocin

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

• Abraxane (paclitaxel protein-bound particles), brand paclitaxel protein-bound particles (American Regent – unbranded), and brand paclitaxel protein-bound particles (Teva – unbranded) updated to include treatment of certain adult individuals who have tried paclitaxel
• Darzalex Faspro (daratumumab-hyaluronidase-fihj) updated to include treatment of certain adults with multiple myeloma in combination with bortezomib, lenalidomide, and dexamethasone
• Boruzu (bortezomib) for the treatment of certain individuals with mantle cell lymphoma and multiple myeloma

Drug/medical necessity criteria added

• Voranigo (vorasidenib) for the treatment of certain individuals with Grade 2 astrocytoma or oligodendroglioma

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

• Age requirement for Elevidys (delandistrogene moxeparvovec-rokl) updated from 4 to 5 years of age to 4 years of age and older

Investigational criteria updated

• Clarified that use of Elevidys (delandistrogene moxeparvovec-rokl) in individuals who are non-ambulatory is considered investigational

Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  PBC | Premera HMO
Drug/medical necessity criteria added

• Tremfya (guselkumab) IV/SC for the treatment of ulcerative colitis

Pharmacotherapy of Type I and Type II Diabetes Mellitus, 5.01.569  PBC | Premera HMO
Drug added

• Brand liraglutide to Injectable/Oral Noninsulin Products as a non-preferred Glucagon-like Peptide-1 Receptor agonist

Spravato (esketamine) Nasal Spray, 5.01.609  PBC | Premera HMO
Investigational criteria updated

• Clarified that use of Spravato (esketamine) that does not meet the age or diagnosis requirements within the Medical Necessity section is considered investigational
• Clarified that use of Spravato (esketamine) that meets the age and diagnosis requirements within the Medical Necessity section but does not meet other policy criteria within the Medical Necessity section is considered not medically necessary

No updates this month.

No updates this month.

Added codes
Effective November 1, 2024

Amyloid Antibodies for the Treatment of Alzheimer’s Disease, 5.01.626  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J0175

Knee Arthroplasty in Adults, 7.01.550  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

27440, 27442, 27443, 27445

Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J1628

Selective Estrogen Receptor Modulators and Down Regulators, 5.01.618  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J9395

Revised codes
Effective November 1, 2024

Alpha-1 Proteinase Inhibitors, 5.01.624  PBC | Premera HMO
Now requires review for site of service. Currently requires review for medical necessity and prior authorization.

J0256, J0257

Removed codes

No updates this month.

Effective December 5, 2024

Services Reviewed Using InterQual Criteria, 10.01.530  PBC
Services added
Durable Medical Equipment

• The following modules were added and will be used to review for medical necessity:
  • Continuous glucose monitors, insulin pumps, and automated insulin delivery technology
  • Home mechanical ventilation devices: Invasive, noninvasive, and multifunction

Procedures

• The following modules were added and will be used to review for medical necessity:
  • Arthrotomy, shoulder arthroscopy or arthroscopically assisted surgery, shoulder
  • Arthrotomy, shoulder
  • Electrophysiology testing +/- radiofrequency or cryothermal ablation, cardiac
  • Mastectomy, prophylactic, total or simple
  • Osteotomy, proximal, first metatarsal (Bunionectomy)
  • Prostatectomy, radical
  • Salpingectomy
  • Tendon sheath incision or excision, hand, flexor
  • Video electroencephalographic monitoring

No updates this month.

No updates this month.

Added codes
Effective November 1, 2024

No updates this month.

Revised codes
Effective January 3, 2025

Biofeedback for Incontinence, 2.01.540  PBC
Now requires review for medical necessity and prior authorization.

90901, 90912, 90913

Continuous Home Pulse Oximetry, 1.01.533  PBC
Now requires review for medical necessity and prior authorization.

A4606, E0445

Endometrial Ablation, 7.01.578  PBC
Now requires review for medical necessity and prior authorization.

58353, 58356, 58563

External Counterpulsation Therapy, 2.02.514  PBC
Now requires review for medical necessity and prior authorization.

G0166

Eye-Anterior Segment Optical Coherence Tomography, 9.03.509  PBC
Now requires review for medical necessity and prior authorization.

92132

Fundus Photography, 9.03.507  PBC
Now requires review for medical necessity and prior authorization.

92250

Glaucoma, Invasive Procedures, 9.03.510  PBC
Now requires review for medical necessity and prior authorization.

66174, 66175, 66183

High-Resolution Anoscopy, 2.01.539  PBC
Now requires review for medical necessity and prior authorization.

46601, 46607

Home Apnea Monitoring, 1.01.534  PBC
Now requires review for medical necessity and prior authorization.

94774, 94775, 94776, 94777

Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring, 1.01.536  PBC
Now requires review for medical necessity and prior authorization.

93792, 93793, G0248, G0249, G0250

Laryngeal Injection for Vocal Cord Augmentation, 2.01.541  PBC
Now requires review for medical necessity and prior authorization.

31513, 31570, 31571, 31573, 31574

Noninvasive Tests for Hepatic Fibrosis, 2.01.536  PBC
Now requires review for medical necessity and prior authorization.

76981, 76982, 76983

Posterior Tibial Nerve Stimulators, 7.01.579  PBC
Now requires review for medical necessity and prior authorization.

64566

Presbyopia Correcting Intraocular Lenses (PIOLs) and Astigmatism Correcting Intraocular Lenses (ACIOLs), 9.03.511  PBC
Now requires review for medical necessity and prior authorization.

66982, 66983, 66984, V2630, V2631, V2632

Rabies Vaccine, Home Setting, 9.01.508  PBC
Now requires review for medical necessity and prior authorization.

90375, 90376, 90377, 90675, 90676

Services Reviewed Using InterQual Criteria, 10.01.530  PBC
Now requires review for medical necessity and prior authorization.

34701, 34702, 34703, 34704, 34705, 34706, 34707, 34708, 34709, 34710, 34711, 34712, 34713, 34714, 34715, 34716, 34808, 34812, 34813, 34820, 34833, 34834, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 58720, 58940, A4633, E0424, E0431, E0433, E0434, E0439, E0441, E0442, E0443, E0444, E1390, E1391, E1392, E1405, E1406, K0378

Supervised Exercise Therapy for Peripheral Artery Disease, 8.01.537  PBC
Now requires review for medical necessity and prior authorization.

93668

Ultraviolet B Light Therapy in the Home to Treat Skin Conditions, 2.01.542  PBC
Now requires review for medical necessity and prior authorization.

E0691, E0692, E0693, E0694

Visual Evoked Response Test, 9.03.512  PBC
Now requires review for medical necessity and prior authorization.

95930

No updates this month.

No updates this month.