Medical Policy and Coding Updates January 2021

Effective April 7, 2021

Immune Globulin Therapy, 8.01.503

Site of service review added

• Xembify^®

Miscellaneous Oncology Drugs, 5.01.540

New drug added to policy

• Jelmyto™ (mitomycin)
  • Treatment of adult patients with low-grade upper tract urothelial cancer (LG-UTUC)

Site of Service Infusion Drugs and Biologic Agents, 11.01.523

Site of service review added

• Xembify^®

Effective March 14, 2021

Updates to AIM Specialty Health® Clinical Appropriateness Guidelines

Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging

Updates by section:

Brain Imaging

Ataxia, congenital or hereditary

• Combined with congenital cerebral anomalies to create one section

Acoustic neuroma

• More frequent imaging for a watch and wait or incomplete resection
• New indication for Neurofibromatosis type 2 (NF 2)
• More frequent imaging when MRI shows findings suspicious for recurrence
• Single post-operative MRI following gross total resection
• Included pediatrics with known acoustics (rare but NF 2)

Tumor – not otherwise specified

• Repurposed for surveillance imaging of low grade neoplasms

Seizure disorder and epilepsy

• Limited imaging for the management of established generalized epilepsy
• Required optimal medical management (aligning adult and pediatric language) prior to imaging for management in epilepsy

Headache

• Removed response to treatment as a primary headache red flag
• Included pregnancy as a red flag risk factor

Mental status change and encephalopathy

• Added requirement for initial clinical and lab evaluation to assess for a more specific cause

Brain Imaging and Head and Neck Imaging

Hearing loss

• Added CT temporal bone for evaluation of sensorineural hearing loss in any pediatric patients or in adults for whom MRI is nondiagnostic or unable to be performed
• Higher allowed threshold for consecutive frequencies to establish SNHL
• Removed CT brain as an alternative to evaluating hearing loss based on ACR guidance

Tinnitus

• Removed sudden onset symmetric tinnitus as an indication for advanced imaging

Chest Imaging and Head and Neck Imaging

Hoarseness, dysphonia, and vocal cord weakness/paralysis – primary voice complaint

• Required laryngoscopy for the initial evaluation of all patients with primary voice complaint

Head and Neck Imaging

Sinusitis/rhinosinusitis

• Added more flexibility for the method of conservative treatment in chronic sinusitis
• Required conservative management prior to repeat imaging for patients with prior sinus CT

Temporomandibular joint dysfunction

• Removed requirement for radiographs/ultrasound

Cerebrospinal fluid (CSF) leak of the skull base

• Added scenario for management of known leak with change in clinical condition

Oncologic Imaging

General content changes to align with current oncology recommendations

• Removal of indications/parameters not addressed by NCCN
• Average risk inclusion criteria for CT Colonography
• New allowances for MRI Abdomen and/or MRI Pelvis by tumor type, liver metastatic disease
• New indications for Acute Leukemia (CT, PET/CT), Multiple Myeloma (MRI, PET/CT), Ovarian Cancer surveillance (CT), Bone Sarcoma (PET/CT)
• Updated standard imaging pre-requisites prior to PET/CT for Bladder/Renal Pelvis/Ureter, Colorectal, Esophageal/GE Junction, Gastric and Non-Small Cell Lung Cancers
• Additional PET/CT management scenarios for Cervical Cancer, Hodgkin Lymphoma

Cancer screening

• New indication for Pancreatic Cancer screening

Breast cancer

• New PET/CT indication for restaging/treatment response for bone-only metastatic disease and limitation of post-treatment Breast MRI after breast conserving therapy or unilateral mastectomy

Prostate Cancer

• MRI pelvis: removal of TRUS biopsy requirement, allowance if persistent/unexplained elevation in PSA or suspicious DRE

Axumin PET/CT

• Updated inclusion criteria (removal of general MRI pelvis requirement, additional allowance for rising PSA with non-diagnostic mpMRI)

Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Advanced Imaging of the Heart

Updates by section:

Evaluation of patients with cardiac arrhythmias

• Updated repeat TTE criteria
• Added restrictions for patients whose initial echocardiogram shows no evidence of structural heart disease, and follow-up echocardiography is not appropriate for ongoing management of arrhythmia

Evaluation of signs, symptoms, or abnormal testing

• Added restrictions for TTE in evaluation of palpitation and lightheadedness based on literature

Effective for dates of service on and after March 14, 2021, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiation Oncology

Updates by section:

Special Treatment Procedure

• Removed IV requirement for chemotherapy

CNS cancer: IMRT for glioblastomas, other gliomas, brain metastases

• Eliminated the plan comparison requirement based on feedback from reviewers that essentially all cases were able to meet criteria - same change for high-grade and low-grade gliomas
• Added new indication for hippocampal sparing whole brain radiotherapy

Lung cancer: IMRT and SBRT for non-small cell, SBRT for small cell; fractionation for non-small cell

• Eliminated the plan comparison requirement for IMRT to treat stage III non-small cell lung cancer
• Removed “due to a medical contraindication” language
• Added new indication as an alternative to surgical resection when certain conditions apply
• Adjusted fractions of thoracic radiotherapy for non-small cell lung cancer

Proton Beam Therapy

• Added new indication for hepatocellular carcinoma and intrahepatic cholangiocarcinoma

Effective March 3, 2021

Medical Necessity Criteria for Pharmacy Edits, 5.01.605

New policy section

• Interferons

New drug added to policy

• Actimmune^® (interferon gamma-1b)
  • Reducing the frequency and severity of serious infections associated with Chronic Granulomatous Disease (CGD)
  • Delaying time to disease progression in patients with severe, malignant osteopetrosis (SMO)

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

New policy

The following brand drugs have been added and may be considered medically necessary when criteria are met:

• Beovu^® (brolucizumab-dbll)
  • Treatment of neovascular (wet) age-related macular degeneration (AMD)
• Eylea^® (aflibercept)
  • Treatment of neovascular (wet) age-related macular degeneration (AMD)
  • Treatment of macular edema following retinal vein occlusion (RVO)
  • Treatment of diabetic macular edema (DME)
  • Treatment of diabetic retinopathy (DR)
• Lucentis^® (ranibizumab)
  • Treatment of neovascular (wet) age-related macular degeneration (AMD)
  • Treatment of macular edema following retinal vein occlusion (RVO)
  • Treatment of diabetic macular edema (DME)
  • Treatment of diabetic retinopathy (DR)
  • Treatment of myopic choroidal neovascularization (mCNV)
• Macugen^® (pegaptanib)
  • Treatment of neovascular (wet) age-related macular degeneration (AMD)

Effective February 5, 2021

The following policies are being reinstated and used to review medical necessity for dates of service starting February 5, 2021 and after:

Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses, 1.01.11

Artificial Pancreas Device Systems, 1.01.30

Medical necessity criteria updated

• The age for an artificial pancreas device system has been lowered from age 14 to age 6 and older
• The age for a hybrid closed loop insulin delivery system has been lowered from age 7 to age 6 and older

Cochlear Implant, 7.01.05

Medical necessity criteria updated

• The age for bilateral hearing loss has been lowered from 12 months to 9 months or older

Continuous Passive Motion in the Home Setting, 1.01.10

Coronary Angiography for Known Suspected Coronary Artery Disease, 2.02.507

Deep Brain Stimulation, 7.01.63

Hip Arthroplasty in Adults, 7.01.573

Hospital Beds and Accessories, 1.01.520

Knee Arthroplasty in Adults, 7.01.550

Knee Arthroscopy in Adults, 7.01.549

Medical necessity criteria updated

• Knee arthroscopy for a partial meniscectomy is considered not medically necessary for a degenerative tear(s) that do not result in functional impairment symptoms

Knee Orthoses (Braces), Ankle foot Orthoses and Knee-Ankle-Foot-Orthoses, 1.03.501

Mastectomy for Gynecomastia, 7.01.521

Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions, 1.01.15

Panniculectomy and Excision of Redundant Skin, 7.01.523

Patient Lifts, Seat Lifts, and Standing Devices, 1.01.519

Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation, 2.02.26

Power Operated Vehicle (Scooters) (excluding motorized wheelchairs), 1.01.527

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

Reduction Mammoplasty for Breast-Related Symptoms, 7.01.503

Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy, 7.01.143

Rhinoplasty, 7.01.558

Semi-Implantable and Fully Implantable Middle Ear Hearing Aids, 7.01.84

Spinal Cord and Dorsal Root Ganglion Stimulation, 7.01.546

Transcatheter Aortic Valve Implantation for Aortic Stenosis, 7.01.132

Treatment of Varicose Veins, 7.01.519

Upper GI Endoscopy, 2.01.533

Medical necessity criteria updated

• Routine preoperative UGI is considered not medically necessary for individuals scheduled for bariatric surgery unless they meet the clinical criteria

Vagus Nerve Stimulation, 7.01.20

Wearable Cardioverter Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement , 2.02.506

Wheelchairs (Manual or Motorized), 1.01.501

New medical policies

Effective January 1, 2021

ASAM Criteria: Services Reviewed for Medical Necessity, 10.01.532

New policy

• Effective for dates of service on and after January 1, 2021, American Society of Addiction Medicine (ASAM) criteria will be used to review for medical necessity for inpatient substance use disorder services for adults and adolescents
• This policy only applies to Washington fully-insured groups, except (student insurance) GAIP and ISHIP

Revised medical policies

Effective January 1, 2021

Immune Globulin Therapy, 8.01.503

Removed from site of service review

• Carimune^® NF
• GamaSTAN^® S/D

Investigational criteria updated

• The following has been updated from medically necessary to investigation for the treatment of the following impaired immunity states:
  • Preventive treatment after hematopoietic stem cell transplantation (HCT)
  • Preventive use in chronic lymphocytic leukemia (CLL)
  • Preventive use in lymphoma
  • Preventive use in multiple myeloma (MM)
  • Preventive use in solid organ transplant
  • Patients at high risk of antibody-mediated rejection including highly sensitized patients and those receiving an ABO-incompatible organ prior to solid organ transplant

Humoral immunodeficiency states

Medical necessity criteria updated

• The category “Individual who is undergoing/undergone hematopoietic cell transplantation or CAR-T cell therapy” has been renamed “Humoral immunodeficiency states”
• Statement has been revised from “IVIG therapy may be considered medically necessary when IgG levels are less than 400 mg/dL” to the following: “IVIG therapy may be considered medically necessary for therapeutic use in humoral immunodeficiency states such as chronic lymphocytic leukemia (CLL), lymphoma, or multiple myeloma on anti-B cell immunotherapy (eg, Rituximab, CAR-T, or hematopoietic stem cell transplant [HCT]) when the IgG level is less than 400 mg/dL and there are persistent or recurrent infections.”

Autoimmune mucocutaneous blistering diseases

Medical necessity criteria updated

• The list of autoimmune mucocutaneous blistering diseases has been expanded to include: bullous pemphigoid, mucous membrane pemphigoid, immunoglobulin A (IgA) pemphigus, and paraneoplastic pemphigus
• Mycophenolate is now included in the list of standard treatments

Lambert Eaton myasthenic syndrome

Medical necessity criteria updated

• The following drug has been added: amifampridine (ie, Firdapse^® in adults, Ruzurgi^® in children <18 years of age)

Severe refractory myasthenia gravis

Medical necessity criteria updated

• Examples of cholinesterase inhibitors have been added: Mestinon and Regonol^®

Warm antibody hemolytic anemia

Medical necessity criteria updated

• First-line therapies now include the drugs corticosteroids with/without rituximab

New pharmacy policies

Effective January 1, 2021

Drugs for Weight Management, 5.01.621

New policy

• This policy only applies to groups that have coverage for weight loss drugs

The following brand drugs have been added and may be considered medically necessary when criteria are met:

• Contrave^® (naltrexone/bupropion)
  • Treatment of chronic weight management in patients age 18 and older
• Qsymia^® (phentermine/topiramate extended-release)
  • Treatment of chronic weight management in patients age 18 and older
• Saxenda^® (liraglutide)
  • Treatment of chronic weight management in patients 12 and older
• Xenical^® (orlistat)
  • Treatment of chronic weight management in patients 12 and older

Exception Request to Utilization Management Restrictions for Washington State Fully Insured Members, 5.01.622

New policy

• Policy only applies to Washington fully-insured members (does not apply to member plans outside of Washington state or to those enrolled in a self-insured plan)
• Exception requests have been added for a substitute drug, to continue with current drug, and for a higher drug dosage
• Exception requests may be considered medically necessary when criteria are met

Revised pharmacy policies

Effective January 1, 2021

Drugs for Rare Diseases, 5.01.576

New drug added to policy

• Sucraid^® (sacrosidase)
  • Treatment of genetically determined sucrase deficiency

Medical Necessity Criteria for Pharmacy Edits, 5.01.605

Irritable Bowel Syndrome with Diarrhea (IBS-D)

New policy section

New drug added to policy

• Viberzi^® (eluxadoline)
  • Treatment of irritable bowel syndrome with diarrhea (IBS-D) in patients age 18 and older

Ulcerative Colitis Agents

New policy section

New drugs added to policy

• Apriso^® (mesalamine)
  • Treatment of ulcerative colitis
• Asacol^® HD (mesalamine)
  • Treatment of ulcerative colitis
• Colazal^® (balsalazide)
  • Treatment of ulcerative colitis
• Delzicol^® (mesalamine)
  • Treatment of ulcerative colitis
• Dipentum^® (olsalazine)
  • Treatment of ulcerative colitis
• Giazo^® (balsalazide)
  • Treatment of ulcerative colitis
• Lialda^® (mesalamine)
  • Treatment of ulcerative colitis
• Pentasa^® (mesalamine)
  • Treatment of ulcerative colitis

Miscellaneous Oncology Drugs, 5.01.540

Medical necessity criteria updated

• Kyprolis^® (carfilzomib)
  • Daratumumab plus dexamethasone has been added as another drug combination that can be used

Pharmacologic Treatment of High Cholesterol, 5.01.558

Drug added to preferred

• Repatha^® (evolocumab)
  • Treatment of adults with clinical atherosclerotic cardiovascular disease (ASCVD)
  • Treatment of patients age 13 and older with homozygous familial hypercholesterolemia (HoFH)

Drug added to non-preferred

• Praluent^® (alirocumab)
  • Treatment of adults with clinical atherosclerotic cardiovascular disease (ASCVD)
  • Treatment of patients age 13 and older with homozygous familial hypercholesterolemia (HoFH)

Medical necessity criteria updated

• Praluent^® (alirocumab)
  • Patient has tried Repatha^® (evolocumab) first and had an inadequate response or intolerance to Repatha^®

Pharmacotherapy of Arthropathies, 5.01.550

Ankylosing spondylitis

Medical necessity criteria updated

• Taltz^® (ixekizumab) has been moved from a second-line treatment to a first-line treatment
• Cosentyx^® (secukinumab) has been moved from a first-line treatment to a second-line treatment
• Cimzia^® (certolizumab pegol), Simponi^® (golimumab) and Simponi Aria^® (golimumab)
  • Taltz^® (ixekizumab) has been added to the list of first-line therapies

Polyarticular juvenile idiopathic arthritis

Medical necessity criteria updated

• Simponi Aria^® (golimumab)
  • Second-line therapy for the treatment of polyarticular juvenile idiopathic arthritis
• Xeljanz^® (tofacitinib)
  • First-line therapy for the treatment of polyarticular juvenile idiopathic arthritis

Medical necessity criteria updated

• Actemra^® (tocilizumab)
  • Sulfasalazine and leflunomide have been added to the list of as initial treatment options
  • This drug must be prescribed by or in consultation with a rheumatologist
• Enbrel^® (etanercept)
  • This drug must be prescribed by or in consultation with a rheumatologist
• Humira^® (adalimumab)
  • This drug must be prescribed by or in consultation with a rheumatologist
• Orencia^® (abatacept)
  • Patient must have had an inadequate response or intolerance to leflunomide, methotrexate, or sulfasalazine
  • Xeljanz^® (tofacitinib) has been added to the list of first-line therapies
  • This drug must be prescribed by or in consultation with a rheumatologist

Systemic juvenile idiopathic arthritis

Medical necessity criteria updated

• Actemra^® (tocilizumab)
  • Corticosteroid, leflunomide, methotrexate, and sulfasalazine have been added to the list as initial treatment options
  • This drug must be prescribed by or in consultation with a rheumatologist

Rheumatoid arthritis

Medical necessity criteria updated

• Actemra^® (tocilizumab)
  • Hydroxychloroquine, sulfasalazine, and leflunomide have been added to the list as initial treatment options
  • This drug must be prescribed by or in consultation with a rheumatologist

Plaque psoriasis

Medical necessity criteria updated

• Cimzia^® (certolizumab pegol)
  • Enbrel^® (etanercept) and Taltz^® (ixekizumab) have been added to the list of first-line therapies
  • This drug must be prescribed by or in consultation with a dermatologist
• Cosentyx^® (secukinumab)
  • Second-line therapy for the treatment of moderate to severe plaque psoriasis
  • Enbrel^® (etanercept) and Taltz^® (ixekizumab) have been added to the list of first-line therapies
• Enbrel^® (etanercept)
  • First-line therapy for the treatment of plaque psoriasis
• Ilumya™ (tildrakizumab-asmn)
  • Enbrel^® (etanercept) and Taltz^® (ixekizumab) have been added to the list of first-line therapies
  • This drug must be prescribed by or in consultation with a dermatologist
• Siliq™ (brodalumab)
  • Enbrel^® (etanercept) and Taltz^® (ixekizumab) have been added to the list of first-line therapies
• Taltz^® (ixekizumab)
  • First-line therapy for the treatment of moderate to severe plaque psoriasis
  • This drug must be prescribed by or in consultation with a dermatologist

Psoriatic arthritis

Medical necessity criteria updated

• Cimzia^® (certolizumab pegol)
  • Taltz^® (ixekizumab) and Tremfya^® (guselkumab) have been added to the list of first-line therapies
• Cosentyx^® (secukinumab)
  • Second-line therapy for the treatment of active psoriatic arthritis
  • Taltz^® (ixekizumab) and Tremfya^® (guselkumab) have been added to the list of first-line therapies
• Orencia^® (abatacept)
  • Taltz^® (ixekizumab) and Tremfya^® (guselkumab) have been added to the list of first-line therapies
• Simponi^® (golimumab)
  • Taltz^® (ixekizumab) and Tremfya^® (guselkumab) have been added to the list of first-line therapies
• Simponi Aria^® (golimumab)
  • Taltz^® (ixekizumab) and Tremfya^® (guselkumab) have been added to the list of first-line therapies
• Taltz^® (ixekizumab)
  • First-line therapy for the treatment of active psoriatic arthritis
  • This drug must be prescribed by or in consultation with a dermatologist or a rheumatologist
• Tremfya^® (guselkumab)
  • First-line therapy for the treatment of active psoriatic arthritis
  • This drug must be prescribed by or in consultation with a dermatologist or a rheumatologist

Non-radiographic axial spondyloarthritis

New drugs added to policy

• Cosentyx^® (secukinumab)
  • Second-line therapy for the treatment of non-radiographic axial spondyloarthritis in adults
• Taltz^® (ixekizumab)
  • First-line therapy for the treatment of non-radiographic axial spondyloarthritis in adults

Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563

Medical necessity criteria updated

• The following Crohn’s disease drugs require an adequate trial and treatment failure with one corticosteroid or one other agent for Crohn's disease:
  • Avsola ™ (infliximab-axxq)
  • Cimzia^® (certolizumab pegol)
  • Entyvio^® (vedolizumab)
  • Humira^® (adalimumab)
  • Inflectra^® (infliximab-dyyb)
  • Remicade^® (infliximab)
  • Renflexis^® (infliximab-abda)
  • Stelara^® (ustekinumab)
  • Tysabri^® (natalizumab)
• The following ulcerative colitis drugs require an adequate trial and treatment failure with a systemic agent:
  • Avsola ™ (infliximab-axxq)
  • Entyvio^® (vedolizumab)
  • Humira^® (adalimumab)
  • Inflectra^® (infliximab-dyyb)
  • Remicade^® (infliximab)
  • Renflexis^® (infliximab-abda)
  • Stelara^® (ustekinumab)
  • Simponi^® (golimumab)
• Stelara^® (ustekinumab) is now a first-line therapy for the treatment of ulcerative colitis

Pharmacotherapy of Multiple Sclerosis, 5.01.565

New drug added to policy

• Kesimpta^® (ofatumumab)
  • Treatment of relapsing forms of multiple sclerosis, including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease

Medical necessity criteria updated

• Tecfidera^® (dimethyl fumarate)
  • The patient must have tried generic dimethyl fumarate first for 3 months and had an inadequate response or intolerance to this drug

Site of Service Infusion Drugs and Biologic Agents, 11.01.523

Removed from site of service review

• Carimune^® NF
• GamaSTAN^® S/D
• Simponi^®

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

Archived policies

Effective January 1, 2021

Automated Point-of-Care Nerve Conduction Tests, 2.01.77

Added codes

Effective January 1, 2021

Absorbable Nasal Implant for Treatment of Nasal Valve Collapse, 7.01.163
Now requires review for investigative.

30468

Balloon Dilation of the Eustachian Tube, 7.01.158
Now requires review for medical necessity and prior authorization.

69705, 69706

Chimeric Antigen Receptor Therapy for Hematologic Malignancies, 8.01.63
Now requires review for medical necessity.

C9073

Focal Treatments for Prostate Cancer, 8.01.61
Now requires review for medical necessity and prior authorization.

55880

Granulocyte Colony-Stimulating Factor (G-CSF) Use in Adult Patients, 5.01.551
Now requires review for medical necessity and prior authorization.

Q5122

Herceptin® (trastuzumab) and Other HER2 Inhibitors, 5.01.514
Now requires review for medical necessity and prior authorization.

J9316

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

J7352

Miscellaneous Oncology Drugs, 5.01.540
Now requires review for medical necessity and prior authorization.

J9144, J9223, J9317

Miscellaneous Oncology Drugs, 5.01.540
Now requires review for medical necessity.

C9069

Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502
Now requires review for medical necessity.

C9070

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564
Now requires review for medical necessity and prior authorization.

J0638, J1823

Pharmacologic Treatment of Duchenne Muscular Dystrophy, 5.01.570
Now requires review for medical necessity.

C9071

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

J2323

Spravato™ (esketamine) Nasal Spray, 5.01.609
Now requires review for medical necessity and prior authorization.

S0013

Total Artificial Hearts and Implantable Ventricular Assist Device, 7.03.11
Now requires review for investigative.

33995, 33997

Effective for dates of service on and after January, 1, 2021, the following will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Genetic Testing.

Now reviewed by AIM^® Specialty Health and requires prior authorization.

0228U, 0229U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 71271, 81168, 81191, 81192, 81193, 81194, 81278, 81279, 81338, 81339, 81347, 81348, 81351, 81352, 81353, 81357, 81360, 81419, 81529, 81546, 81554

Revised codes

Effective January 1, 2021

Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
Now requires review for site of service. Currently requires review for medical necessity and prior authorization.

Q5121

Removed codes

Effective January 1, 2021

Automated Point-of-Care Nerve Conduction Tests, 2.01.77
No longer requires review. Policy archived.

95905, G0255

Growth Hormone Therapy, 5.01.500
No longer requires review.

S9558

Reconstructive Breast Surgery/Management of Breast Implants, 7.01.533
No longer requires review.

J1562

Reconstructive Breast Surgery/Management of Breast Implants, 7.01.533
No longer requires review.

19324, 19366

Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis, 2.02.16
No longer requires review for investigative.

0126T

Effective February 5, 2021

InterQual® Criteria: Services Reviewed for Medical Necessity, 10.01.531

This policy is updated to remove reference to services replaced with individual policies that address medical procedures and durable medical equipment. See the Special notices (above) under the Updates for non-individual and individual plans for the specific policies.

No updates this month

Effective February 5, 2021

Services Reviewed Using InterQual® Criteria, 10.01.530

This policy is updated to remove reference to services replaced with individual policies that address medical procedures and durable medical equipment. See the Special notices (above) under the Updates for non-individual and individual plans for the specific policies.

No updates this month