Medical Policy and Coding Updates April 2022

  • Updates for both non-individual and individual plans

  • 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
    Effective April 1, 2022

    Hyperbaric Oxygen Therapy, 2.01.505

    Policy renumbered

    • From Hyperbaric Oxygen Therapy, 2.01.04, to 2.01.505

    Indication added

    • Central retinal artery occlusion

    Revised medical policies
    Effective April 1, 2022

    No updates this month

    New pharmacy policies

    Effective April 1, 2022

    No updates this month


    Revised pharmacy policies
    Effective April 1, 2022

    Drugs for Rare Diseases, 5.01.576

    New drugs added

    • Besremi (ropeginterferon alfa-2b-njft)
      • Treatment of polycythemia vera in patients age 18 years and older
    • Voxzogo™ (vosoritide)
      • Treatment of achondroplasia in patients between age 5 and 18 years

    Medical necessity criteria updated

    • Firdapse® (amifampridine)
      • The requirement for a trial of the drug Ruzurgi® (amifampridine) has been removed
    • Oxbryta™ (voxelotor)
      • The age requirement has been reduced from 12 years to 4 years and older

    Drug removed

    • Ruzurgi® (amifampridine)
      • This drug has been withdrawn from the market

    Dupixent®, 5.01.575

    Medical necessity criteria updated

    • Indication: Atopic dermatitis
      • The requirement for a trial of two topical corticosteroids has been reduced to one
      • This drug must be prescribed by or in consultation with an allergist, immunologist, or dermatologist

    Immune Checkpoint Inhibitors, 5.01.591

    Indication removed

    • Keytruda® (pembrolizumab)
      • Third-line single agent therapy for patients with PD-L1-positive gastric or gastroesophageal junction cancer

    Pharmacotherapy of Arthropathies, 5.01.550

    Atopic Dermatitis

    New policy section

    New drugs added

    • Adbry™ (tralokinumab-ldrm)
    • Cibinqo™ (abrocitinib)
    • Rinvoq® (upadacitinib)

    Psoriatic Arthritis

    New drug added

    • Skyrizi® (risankizumab-rzaa)

    Medical necessity criteria updated

    • Cimzia® (certolizumab pegol) SC
    • Cosentyx® (secukinumab)
    • Orencia® (abatacept) IV/SC
    • Simponi® (golimumab) SC
    • Simponi Aria® (golimumab) IV
      • Skyrizi® (risankizumab-rzaa) has been added to the list of drugs that must be tried before the above drugs can be prescribed

    Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564

    New drugs added

    • Orencia® (abatacept)
      • Prevention of acute graft versus host disease
    • Vyvgart™ (efgartigimod alfa-fcab)
      • Treatment of myasthenia gravis in adult patients age 18 years and older

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

    No updates this month. 

    Hyperbaric Oxygen Therapy, 2.01.04

    • This policy has been replaced by Hyperbaric Oxygen Therapy, 2.01.505

    Added codes

    Effective April 1, 2022

    Amniotic Membrane and Amniotic Fluid, 7.01.583

    Now requires review for investigational.

    Q4224, Q4225, Q4256, Q4257, Q4258

    Antibody-Drug Conjugates, 5.01.582

    Now requires review for medical necessity and prior authorization.

    J9273, J9359

    Bioengineered Skin and Soft Tissue Substitutes, 7.01.113

    Now requires review for investigational.

    A2011, A2012, A2013

    Drugs for Rare Diseases, 5.01.576

    Now requires review for medical necessity.

    C9090

    Drugs for Rare Diseases, 5.01.576

    Now requires review for medical necessity and prior authorization.

    J0219

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605

    Now requires review for medical necessity and prior authorization.

    J0879

    mTOR Kinase Inhibitors, 5.01.533

    Now requires review for medical necessity.

    C9091

    Non-covered Services and Procedures, 10.01.517

    Not covered.

    H2038, T2050, T2051

    Non-covered Experimental/Investigational Services, 10.01.533

    Now requires review for investigational.

    0489T, 0490T, K1028, K1029

    Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564

    Now requires review for medical necessity and prior authorization.

    J0491

    Prescription Digital Therapeutics, 13.01.500

    Now requires review for investigational.

    A9291

    Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases, 2.04.123

    Now requires review for investigational.

    0312U

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

    Now requires review for medical necessity.

    C9093

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

    Now requires review for medical necessity and prior authorization.

    Q5124

    AIM Specialty Health® Genetic Testing

    Now reviewed by AIM Specialty Health® for medical necessity and prior authorization.

    0306U, 0307U, 0313U, 0314U, 0315U, 0317U, 0318U, 0319U, 0320U


    Revised codes
    Effective April 1, 2022

    Electrostimulation and Electromagnetic Therapy for Treating Wounds, 2.01.57

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

    E0761


    Removed codes
    Effective April 1, 2022

    Antibody-Drug Conjugates, 5.01.582

    No longer requires review. Code terminated.

    C9084

    Drugs for Rare Diseases, 5.01.576

    No longer requires review. Code terminated.

    C9085

    Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564

    No longer requires review. Code terminated.

    C9086

    Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564

    No longer requires review for medical necessity and prior authorization.

    Q5109

  • Updates for only non-individual plans

  • No updates this month
    No updates this month
  • Updates for only individual plans

  • No updates this month

    No updates this month

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