Medical Policy and Coding Updates February 2022

  • Updates for both non-individual and individual plans

  • Effective March 13, 2022

    Updates to AIM Specialty Health® Clinical Appropriateness Guidelines

    Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging.

    Updates by section

    Brain imaging

    Acoustic neuroma

    • Removed indication for CT brain and replaced with CT temporal bone

    Meningioma

    • Added new guideline for follow-up intervals

    Pituitary adenoma

    • Removed allowance for CT following nondiagnostic MRI in macroadenoma

    Tumor, not otherwise specified

    • Added indication for management; excluded surveillance for lipoma and epidermoid without suspicious features

    Chest imaging

    Pneumonia

    • Removed indication for diagnosis of COVID-19 due to availability and accuracy of lab testing

    Pulmonary nodule

    • Revised criteria for follow-up of nodules detected on lung cancer screening CT based on Lung-RADS

    Head and neck imaging

    Parathyroid adenoma

    • Added situations where surgery is recommended based on American Association of Endocrine Surgeons guidelines

    Temporomandibular joint dysfunction

    • Added duration of required conservative management

    Abdominal and pelvic imaging

    Azotemia

    • Removed this indication

    Hematuria

    • Revised criteria for asymptomatic microhematuria based on American Urological Association guideline

    Intussusception

    • Removed this indication

    Jaundice

    • Added requirement for ultrasound prior to advanced imaging in pediatric patients

    Sacroiliitis

    • Added situations where advanced imaging is indicated (predisposing condition or equivocal radiographs)

    Uterine leiomyomata (fibroids)

    • Added requirement for ultrasound prior to MRI
    • Expanded indication to include most other fertility-sparing procedures

    Oncologic imaging

    • Updated recommendations based on the National Comprehensive Cancer Network (NCCN) for the following:
      • Breast cancer
      • Hodgkin lymphoma
      • Non-Hodgkin lymphoma
      • Melanoma
      • Neuroendocrine tumors
      • Soft tissue sarcoma
      • Testicular cancer
      • Thyroid cancer

    Breast cancer

    • Updated clinical scenarios in chart for diagnostic breast MRI and PET/CT for management

    Cancer screening

    • Added indication for hepatocellular carcinoma screening
    • Added age criteria for pancreatic cancer

    Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging of the Heart

    Updates by section

    Cardiac imaging

    Coronary CT Angiography 

    • Removed indication for patients undergoing evaluation for transcatheter aortic valve implantation/replacement who are at moderate coronary artery disease risk

    Effective for dates of service on and after March 13, 2022, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiation Oncology

    • Removed Eastern Cooperative Oncology Group (ECOG) status as definition for performance status throughout guidelines

    Effective February 4, 2022

    Adjunctive Techniques for Screening and Surveillance of Barrett Esophagus and Esophageal Dysplasia, 7.01.167
    New policy

    • Wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS3D) is considered investigational for all indications, including but not limited to the screening and surveillance of Barrett esophagus and esophageal dysplasia

    Drugs for Rare Diseases, 5.01.576
    Site of service review added

    • Adakveo® (crizanlizumab-tmca)
    • Aldurazyme® (laronidase)
    • Kanuma® (sebelipase alfa)

    Hereditary Angioedema, 5.01.587
    Site of service review added

    • Cinryze® (pdC1-INH)

    IL-5 Inhibitors, 5.01.559
    Site of service review added

    • Cinqair® (reslizumab)

    Medical necessity criteria updated

    • Nucala® (mepolizumab)
      Indication: Treatment of adults with eosinophilic granulomatosis with polyangiitis (EGPA)
      • Requirement added that patient has been taking prednisone or prednisolone
      Indication: Treatment of adults and children age 12 years and older with hypereosinophilic syndrome (HES)
      • Genetic testing is required to confirm that the patient does not have FIP1L1-PDGFRA kinase-positive HES
      • Requirement has been added that the patient has been taking background HES therapy prior to treatment with this drug

    Immune Globulin Therapy, 8.01.503
    Site of service review added

    • Asceniv™ (immune globulin intravenous, human - slra)

    Intravitreal Corticosteroids, 5.01.619
    New policy
    Drugs added

    • Iluvien® (fluocinolone acetonide intravitreal implant)
      • Treatment of diabetic macular edema (DME) in patients age 18 years and older
    • Ozurdex® (dexamethasone intravitreal implant)
      • Treatment of macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO) in patients age 18 years and older
      • Treatment of non-infectious uveitis of the posterior segment of the eye in patients age 18 years and older
      • Treatment of diabetic macular edema (DME) in patients age 18 years and older
    • Retisert® (fluocinolone acetonide intravitreal implant)
      • Treatment of chronic non-infectious uveitis affecting the posterior segment of the eye in patients age 12 years and older
    • Yutiq® (fluocinolone acetonide intravitreal implant)
      • Treatment of chronic non-infectious uveitis of the posterior segment of the eye in patients age 18 years and older

    Pharmacologic Treatment of Duchenne Muscular Dystrophy, 5.01.570
    Site of service review added

    • Amondys 45® (casimersen)

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
    Site of service review added

    • Stelara® (ustekinumab) IV
    • Stelara® (ustekinumab) SC

    Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564
    Site of service review added

    • Uplizna™ (inebilizumab-cdon)

    Pharmacotherapy of Arthropathies, 5.01.550
    Site of service review added

    • Stelara® (ustekinumab)

    Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers, 1.01.18
    Policy statement added

    • The use of lymphedema pumps applied to the head and neck to treat lymphedema has been added to the list of investigational conditions

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523
    New drugs added

    • Adakveo® (crizanlizumab-tmca)
    • Aldurazyme® (laronidase)
    • Amondys 45™ (casimersen)
    • Asceniv™ (immune globulin intravenous, human – slra)
    • Cinqair® (reslizumab)
    • Cinryze® (C1 esterase inhibitor [human])
    • Kanuma® (sebelipase alfa)
    • Stelara® (ustekinumab) IV
    • Stelara® (ustekinumab) SC
    • Uplizna® (inebilizumab-cdon)

    Total Artificial Hearts and Implantable Ventricular Assist Devices, 7.03.11
    Medical necessity criteria updated

    • For implantable ventricular assist devices (VADs) for end-stage heart failure, criteria updated based on the 2020 MOMENTUM 3 clinical trial
      • Criterion added of cardiac index while patient is not on inotropes
      • Heart transplant ineligibility criteria removed

    Xolair® (omalizumab), 5.01.513
    Medical necessity criteria updated

    • Indication: Treatment of moderate to severe asthma in adults and children age 6 years and older
      • Requirement added that an adult patient is not a smoker, or is enrolled in a smoking cessation program
      • Requirement added that the patient weighs between 44 and 330 pounds
    • Indication: Treatment of severe chronic idiopathic urticaria in adults and adolescents age 12 years and older
      • The requirement of failure to respond to two therapeutic regimens has been reduced to one
    • Indication: Treatment of adult patients with inadequately controlled nasal polys
      • Requirement added for a pre-treatment IgE antibody score greater than or equal to 30 IU/mL
      • Requirement added that the patient weighs between 66 and 330 pounds

    No updates this month

    Revised pharmacy policies

    Effective February 1, 2022

    BCR-ABL Kinase Inhibitors, 5.01.518
    New drug added

    • Scemblix® (asciminib)
      • Treatment of adults with Philadelphia chromosome positive chronic myeloid leukemia (Ph+ CML) in chronic phase after resistance or intolerance to prior therapy with imatinib and an additional tyrosine kinase inhibitor
      • Treatment of T3151-positive Philadelphia chromosome positive chronic myeloid leukemia (Ph+ CML) in chronic phase

    Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma, 8.01.63
    Drug with new indication

    • Tecartus™ (brexucabtagene autoleucel)
      • Treatment of patients with relapsed or refractory B-cell acute lymphoblastic leukemia

    Epidermal Growth Factor Receptor (EGFR) Inhibitors, 5.01.603
    New drug added

    • Exkivity™ (mobocertinib)
      • Treatment of adults patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) exon 20 insertion mutations, whose disease has progressed on or after platinum-based chemotherapy

    Gonadotropin Releasing Hormone (GnRH) Analogs, 5.01.625
    Drugs with new indications

    • Lupron Depot® (leuprolide acetate)
    • Trelstar® (triptorelin pamoate)
      • Palliative treatment of advanced breast cancer in pre- and perimenopausal women

    •  Lupron Depot® (leuprolide acetate)
    • Trelstar® (triptorelin pamoate)
    • Zoladex® (goserelin)
      • Additional treatment of early breast cancer in pre- and perimenopausal women
      • Combination treatment of HR+/HER2-negative, lymph-node positive, early breast cancer at high risk of recurrence and a Ki-67 score of ≥ 20% in pre- and perimenopausal women

    Medical necessity criteria updated

    • Fensolvi® (leuprolide acetate)
    • Generic leuprolide
    • Lupron Depot® (leuprolide acetate)
    • Lupron Depot PED® (leuprolide acetate)
    • Supprelin LA® (histrelin implant)
    • Triptodur® (triptorelin)
    • Trelstar® (triptorelin pamoate)
    • Vantas® (histrelin implant)
      • Providers in an adolescent medicine gender clinic have been added to the list of specialists who can prescribe or consult on the use of these drugs

    Policy statements added

    • Definition of advanced prostate cancer
    • Pre- and perimenopausal status documentation requirements
    • Dosing requirements for Lupron Depot® (leuprolide acetate), Trelstar® (triptorelin pamoate)
    • Definition of high-risk in Verzenio™ (abemaciclib) clinical trial for breast cancer indication

    Re-authorization criteria added

    • Lupron Depot® (leuprolide acetate)
    • Trelstar® (triptorelin pamoate)
    • Zoladex® (goserelin)
      • 12 months for additional treatment of early breast cancer in pre- and perimenopausal women

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605
    Kappa Opioid Receptor (KOR) Agonist
    New drug added

    • Korsuva™ (difelikefalin)
      • Treatment of pruritus associated with chronic kidney disease (CKD)
      • This drug is managed through the patient's medical benefit

    GnRH Receptor Antagonist Products
    Section and drugs removed

    • Oriahnn® (elagolix, estradiol, and norethindrone acetate; elagolix)
    • Orilissa® (elagolix)
      • These drugs have been moved to policy Gonadotropin Releasing Hormone (GnRH) Analogs, 5.01.625

    Migraine and Cluster Headache Medications, 5.01.503
    New drug added

    • Elyxyb® (celecoxib oral solution)
      • Acute treatment of migraine with our without aura in patients age 18 years or older

    Appendix updated

    • Ergotamine preparations have been removed from preventive headache therapies

    mTOR Kinase Inhibitors, 5.01.533
    New drug added

    • Fyarro™ (sirolimus protein-bound particles)
      • Treatment of adult patients with locally advanced inoperable or metastatic malignant perivascular epithelioid cell tumor (PEComa)

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

    No updates this month. 

    No updates this month

    Added codes

    Effective February 4, 2022

    Adjunctive Techniques for Screening and Surveillance of Barrett Esophagus and Esophageal Dysplasia, 7.01.167
    Now requires review for investigational.

    88104, 88305, 88312, 88361

    American Society of Addiction Medicine (ASAM), 10.01.532
    *Applies to fully insured plans only
    Now requires review for medical necessity and prior authorization.

    H0031, H0032, H2014, H2019, S5108, S5109, S5110 and S5111

    Intravitreal Corticosteroids, 5.01.619
    Now requires review for medical necessity and prior authorization.

    J7311, J7312, J7313, J7314

    Site of Service: Infusion Drugs and Biologic Agents, 11.01.523
    Now requires review for Site of Service; currently requires review for Medical Necessity and prior authorization.

    J0791, J3357, J3358, J1931, J1426, J1554, J2786, J0598, J2840, J1823

  • Updates for only non-individual plans

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

  • No updates this month

    Added codes

    February 01, 2022

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

    0014M, 81596

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