Medical Policy and Coding Updates January 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

    New 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

    Effective January 7, 2022

    Cervical Spine Surgeries: Discectomy, Laminectomy, and Fusion in Adults, 7.01.560

    Medical necessity criteria updated

    • Site of service (off campus-outpatient hospital/medical center, on campus-outpatient hospital/medical center, and ambulatory surgical center) has been added to the policy for medical necessity review for single-level cervical decompressions and single level cervical fusions (CPT codes 22551, 22554, 22600, 63020, and 63045)

    Hysterectomy for Non-Malignant Conditions, 7.01.548

    New policy

    • Hysterectomy, with or without salpingo-oophorectomy (removal of fallopian tubes and ovaries) is considered medically necessary when criteria are met
    • Conditions included in the criteria: abnormal uterine bleeding or uterine fibroids (leiomyomata), adenomyosis, endometriosis, genetic predisposition to cancer, symptomatic pelvic organ prolapse
    • Conditions excluded from review are hysterectomy for malignancies or conditions highly suspicious for malignancy (e.g., ovarian mass) and hysterectomy for gender-transition/affirming surgeries
    • Site of service review is included for laparoscopic-assisted vaginal hysterectomy and vaginal hysterectomy

    Lumbar Spinal Fusion in Adults, 7.01.542

    Medical necessity criteria updated

    • Site of service (off campus-outpatient hospital/medical center, on campus-outpatient hospital/medical center, and ambulatory surgical center) has been added to the policy for medical necessity review for single-level lumbar fusions (CPT codes 22553, 22558, 22612, 22630, and 22633)

    Site of Service: Select Surgical Procedures, 11.01.524

    • Single-level cervical discectomy and lumbar spinal fusions, along with some hysterectomy procedures, have been added to this policy as now requiring site of service review for medical necessity and are indicated by the following codes: 22533, 22551, 22554, 22558, 22600, 22612, 22630, 22633, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58294, 58550,58552, 58553, 58554,63020 and 63045. HCPCS code C1726 was removed.

    New medical policies

    Effective January 1, 2022

    Transcatheter Aortic-Valve Implantation for Aortic Stenosis, 7.01.585

    New policy

    This policy replaces Transcatheter Aortic-Valve Implantation for Aortic Stenosis, 7.01.132

    Investigational criteria added

    Use of a cerebral embolic protection device during transcatheter heart valve surgery is considered investigational

    Wilderness Therapy, 3.01.522

    New policy

    Wilderness therapy programs, also known as outdoor behavioral health residential wilderness programs, may be considered medically necessary for the following age groups when criteria are met:

    • Adults age 18 years and older (psychiatric)
    • Adolescents age 13 to 17 years (psychiatric)
    • Adolescents and adults age 18 years and older (substance use disorder)

    Revised medical policies

    Effective January 1, 2022

    Gender Transition/Affirmation Surgery, 7.01.557

    Policy renamed

    • From "Gender Reassignment Surgery" to "Gender Transition/Affirmation Surgery"

    Policy expanded

    • Non-binary has been added as a gender transition
    • Procedures that were previously considered cosmetic are now covered under Washington Senate Bill 5313 for the feminization, masculinization, or non-binary transition
    • Policy sections are now organized as follows:
      • Standard benefit
      • Enhanced benefit
      • Additional procedures after the initial surgery

    Policy coverage criteria updated

    Summaries for specific Plans have been added, including determination of coverage:

    • Standard benefit coverage: Alaska Individual Plans and Employer Sponsored Group Plans
    • Expanded benefit coverage: Washington Individual Plans and Select Employer Sponsored Group Plans
    • Other plan customizations

    Standard benefit coverage updated

    • Criteria for letters of recommendation from a licensed mental health professional and a surgeon have been added for requests prior to and after the surgery
    • Hair removal prior to genital surgery is no longer considered a cosmetic procedure and is now covered when medical necessity criteria are met

    Expanded benefit coverage updated

    • All procedures that were previously considered cosmetic are now covered when medical necessity criteria are met
    • Criteria have been expanded for revision of appearance after previous gender transition/affirmation surgery
    • Criteria have been expanded for correction of incomplete or incorrectly done non-breast/chest surgeries, genital and non-genital surgeries, and additional breast augmentation

    Other gender transition/affirmation services updated

    • A non-surgical gender transition/affirmation services reference section has been added

    Recommendations by licensed mental health professionals updated

    • Minimum content requirements have been expanded for mental health recommendation letters
    • Timing requirements for surgery and mental health recommendation letters have been added

    Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty,  Biacuplasty, and Intraosseous Basivertebral Nerve Ablation, 7.01.72

    Policy renamed

    From “Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty” to “Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty, and Intraosseous Basivertebral Nerve Ablation”

    Investigational criteria updated

    • Intraosseous radiofrequency ablation of the basivertebral nerve (eg, Intracept®) for the treatment of vertebrogenic back pain has been added to the list of investigational procedures

    Speech Therapy, 8.03.505

    Medical necessity criteria updated

    • Criteria have been added for voice therapy for gender transition/affirmation

    Revised pharmacy policies 

    Effective January 1, 2022 

    Antibody-Drug Conjugates, 5.01.582

    New drugs added

    • Padcev® (enfortumab vedotin-ejfv)
      • Treatment of locally advanced or metastatic urothelial cancer (mUC) in patients age 18 years and older
      • This drug and identical medical necessity criteria have been moved to this policy from Miscellaneous Oncology Drugs, 5.01.54 
    • Tivdak™ (tisotumab vedotin-tftv)
      • Treatment of recurrent or metastatic cervical cancer

    C3 and C5 Complement Inhibitors, 5.01.571

    New drug added 

    • Tavneos® (avacopan)
      • Treatment of adult patients with active anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis

    CGRP Inhibitors for Migraine Prophylaxis, 5.01.584

    New drugs added 

    • Nurtec® ODT (rimegepant)
      • Preventive treatment of episodic migraines in patients age 18 years and older
    • Qulipta™ (atogepant)
      • Preventive treatment of episodic migraines in patients age 18 years and older

    Medical necessity criteria updated 

    • Aimovig™ (erenumab)
    • Ajovy™ (fremanezumab)
    • Emgality™ (galcanezumab)
    • Vyepti™ (eptinezumab-jjmr)
      • These drugs require documentation that their use is for the preventive treatment of migraines

    Drugs for Weight Management, 5.01.621

    Drugs with new indications

    • Saxenda® (liraglutide)
    • Xenical® (orlistat)
      • Chronic weight management in pediatric patients ≥ 12 years of age and < 18 years

    Initial authorization period updated

    • Contrave® (naltrexone/bupropion) 
    • Saxenda® (liraglutide)
      • 4 months 
    • Wegovy™ (semaglutide)
      • 7 months

    Re-authorization criteria updated

    • Contrave® (naltrexone/bupropion)
      • Weight loss ≥ 5% after 15 weeks of treatment
    • Qsymia® (phentermine/topiramate extended-release)
      • Weight loss ≥ 5% after 26 weeks of treatment
    • Saxenda® (liraglutide)
      • Weight loss of  ≥ 4% after 16 weeks of treatment in adults age 18 years and older
      • Weight loss of ≥ 1% after 16 weeks of treatment in pediatric patients ≥ 12 years of age and < 18 years
    • Wegovy™ (semaglutide)
      • Weight loss ≥ 5% after 7 months of treatment
    • Xenical® (orlistat)
      • Weight loss of ≥ 5% after 6 months of treatment

    Medical necessity criteria updated

    • All drugs in policy require that the patient has engaged in a trial of behavioral modification and dietary restrictions
    • All drugs in policy now contain cardiovascular disease as a weight-related comorbid condition for patients with a BMI of ≥ 27 kg/m2
    • Symptomatic osteoarthritis of the lower extremities (knee or hip) has been removed as a weight-related comorbid condition for patients with a BMI of ≥ 27 kg/m2

    Immune Checkpoint Inhibitors, 5.01.591

    Drug with new indications

    • Keytruda® (pembrolizumab)
      • Adjuvant treatment of adult and pediatric (age 12 years and older) patients with Stage IIB, IIC, or III melanoma after surgery
      • Adjuvant treatment of patients with renal cell carcinoma (RCC) at intermediate-high or high risk of recurrence after kidney and/or metastatic lesion removal

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605

    Antipsychotics, Second Generation

    New drug added

    • Lybalvi™ (olanzapine and samidorphan)

    Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and Combinations

    New drug added

    • Generic ibuprofen + famotidine (two-drug combination)

    Generic ivermectin, Stromectol® (ivermectin)

    Quantity limits added

    • 20 tablets per 30 days

    Miscellaneous Oncology Drugs, 5.01.540

    Drug added

    • Generic nelarabine
      • Treatment of patients with T-cell acute lymphoblastic leukemia (T-ALL) and T-cell lymphoblastic lymphoma (T-LBL) in adult and pediatric patients age 1 year and older 

    Drugs with new indications

    • Darzalex Faspro™ (daratumumab and hyaluronidase-fihj)
      • Treatment of multiple myeloma in combination with Kyprolis® (carfilzomib) and dexamethasone
    • Jakafi® (ruxolitinib)
      • Treatment of chronic graft-versus-host disease
    • Kyprolis® (carfilzomib)
      • Treatment of multiple myeloma in combination with Darzalex Faspro (daratumumab and hyaluronidase-fihj) and dexamethasone
    • Verzenio™ (abemaciclib)
      • Treatment of early breast cancer at high risk of recurrence and Ki-67 score ≥ 20%

    Drugs removed

    • Padcev (enfortumab vedotin-ejfv)
      • Drug and identical medical necessity criteria moved to Antibody-Drug Conjugates, 5.01.582
    • Pepaxto (melphalan flufenamide)
      • This drug has been withdrawn from the market

    Pharmacologic Treatment of HIV/AIDS, 5.01.588

    New drugs added

    • Descovy® (emtricitabine and tenofovir alafenamide)
    • Truvada® (emtricitabine and tenofovir disoproxil fumarate)
      • Treatment of HIV-1 infection and prevention (PrEP) of HIV-1 infection when generic emtricitabine and tenofovir disoproxil fumarate were tried first

    Pharmacotherapy of Arthropathies, 5.01.550

    Ankylosing Spondylitis

    Medical necessity criteria updated

    • Avsola™ (infliximab-axxq)
    • Cimzia® (certolizumab pegol)
    • Enbrel® (etanercept)
    • Humira® (adalimumab)
    • Inflectra® (infliximab-dyyb)
    • Remicade® (infliximab)
    • Renflexis™ (infliximab-abda)
    • Simponi (golimumab)
    • Simponi Aria® (golimumab)
    • Taltz® (ixekizumab)
      • These drugs must be prescribed by or in consultation with a rheumatologist

    Polyarticular Juvenile Idiopathic Arthritis

    Medical necessity criteria updated

    • Enbrel® (etanercept)
    • Humira® (adalimumab)
      • Leflunomide and sulfasalazine have been added to the list of drugs that may be used concurrently

    • Xeljanz® (tofacitinib)
    • Xeljanz® Oral Solution (tofacitinib)
      • The patient must have had an inadequate response or intolerance to one or more TNF blockers

    Rheumatoid Arthritis

    Medical necessity criteria updated

    • Avsola™ (infliximab-axxq)
    • Cimzia® (certolizumab pegol)
    • Enbrel® (etanercept)
    • Humira® (adalimumab)
    • Inflectra® (infliximab-dyyb)
    • Kevzara® (sarilumab)
    • Kineret® (anakinra)
    • Olumiant® (baricitinib)
    • Orencia® (abatacept)
    • Remicade® (infliximab)
    • Renflexis™ (infliximab-abda)
    • Simponi® (golimumab)
    • Simponi Aria® (golimumab)
      • These drugs must be prescribed by or in consultation with a rheumatologist

    • Rinvoq™ (upadacitinib)
    • Xeljanz® (tofacitinib)
    • Xeljanz® XR (tofacitinib extended-release)
      • The patient must have had an inadequate response or intolerance to one or more TNF blockers

    • Cimzia® (certolizumab pegol)
    • Kevzara® (sarilumab)
    • Kineret® (anakinra)
    • Olumiant® (baricitinib)
    • Orencia® (abatacept)
    • Simponi® (golimumab)
    • Simponi Aria® (golimumab)
      • The patient must have had an inadequate response or intolerance to methotrexate, leflunomide, sulfasalazine, or hydroxychloroquine

    Plaque Psoriasis

    Medical necessity criteria updated

    • Avsola™ (infliximab-axxq)
    • Cimzia® (certolizumab pegol)
    • Cosentyx® (secukinumab)
    • Enbrel® (etanercept)
    • Humira® (adalimumab)
    • Ilumya™ (tildrakizumab-asmn)
    • Inflectra® (infliximab-dyyb)
    • Otezla® (apremilast)
    • Remicade® (infliximab)
    • Renflexis™ (infliximab-abda)
    • Stelara® (ustekinumab)
      • Patient age criteria added for these drugs

    • Avsola™ (infliximab-axxq)
    • Enbrel® (etanercept)
    • Humira® (adalimumab)
    • Inflectra® (infliximab-dyyb)
    • Otezla® (apremilast)
    • Remicade® (infliximab) 
    • Renflexis™ (infliximab-abda)
    • Stelara® (ustekinumab)
      • These drugs must be prescribed by or in consultation with a dermatologist

    Psoriatic Arthritis

    Medical necessity criteria updated

    • Avsola™ (infliximab-axxq)
    • Cimzia® (certolizumab pegol)
    • Enbrel® (etanercept)
    • Humira® (adalimumab)
    • Inflectra® (infliximab-dyyb)
    • Orencia® (abatacept)
    • Remicade® (infliximab)
    • Renflexis™ (infliximab-abda)
    • Simponi® (golimumab)
    • Simponi Aria® (golimumab)
    • Stelara® (ustekinumab)
      • These drugs must be prescribed by or in consultation with a rheumatologist

    • Avsola™ (infliximab-axxq)
    • Cimzia® (certolizumab pegol)
    • Enbrel® (etanercept)
    • Humira® (adalimumab)
    • Inflectra® (infliximab-dyyb)
    • Orencia® (abatacept)
    • Otezla® (apremilast)
    • Remicade® (infliximab)
    • Renflexis™ (infliximab-abda)
    • Simponi® (golimumab)
    • Simponi Aria® (golimumab)
      • The use of a conventional DMARD (eg, lefluomide, methotrexate, sulfasalazine) requirement has been removed for these drugs

    • Rinvoq™ (upadacitinib)
    • Xeljanz® (tofacitinib)
    • Xeljanz® XR (tofacitinib extended-release)
      • The patient must have had an inadequate response or intolerance to one or more TNF blockers

    Reauthorization criteria updated

    • The re-authorization period for all drugs in the policy has been increased from 1 year to 3 years

    Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564

    Bechet’s disease

    Medical necessity criteria updated

    • Otezla® (apremilast)
      • The patient must have tried at least one other systemic therapy
      • This drug must be prescribed by or in consultation with a rheumatologist or dermatologist

    Giant cell arteritis

    Medical necessity criteria updated

    • Actemra® (tocilizumab)
      • The patient must have tried at least one systemic corticosteroid
      • This drug must be prescribed by or in consultation with a rheumatologist

    Hidradenitis suppurativa

    Medical necessity criteria updated

    • Humira® (adalimumab)
      • The patient must have tried at least one other therapy
      • This drug must be prescribed by or in consultation with a dermatologist

    Pyoderma gangrenosum

    Medical necessity criteria updated

    • Avsola™ (infliximab-axxq)
    • Enbrel® (etanercept)
    • Humira® (adalimumab) 
    • Inflectra® (infliximab-dyyb)
    • Remicade® (infliximab)
    • Renflexis® (infliximab-abda)
      • These drugs must be prescribed by or in consultation with a dermatologist

    Uveitis

    Medical necessity criteria updated

    • Humira® (adalimumab)
      • The patient must have tried at least one other therapy
      • This drug must be prescribed by or in consultation with an ophthalmologist

    Spravato® (esketamine) Nasal Spray, 5.01.609

    New indication added

    • Treatment of major depressive disorder (MDD) with acute suicidal ideation or behavior in patients age 18 years and older

    Investigational criteria updated

    • Use of this drug along with any type of neuromodulation, including but not limited to transcranial magnetic stimulation (TMS), electroconvulsive therapy (ECT), and vagus nerve stimulation (VNS), is considered investigational

    Initial authorization criteria updated

    • Criteria added for the use of this drug for the treatment of major depressive disorder with acute suicidal ideation or behavior

    Reauthorization criteria updated

    • Indication: Depression
      • This drug must be used along with an oral antidepressant
      • The maintenance dose is limited to 84 mg once a week
    • Indication: Major depressive disorder (MDD) with acute suicidal ideation or behavior
      • New criteria and dosing requirements added

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

    No updates this month. 

    Effective January 1, 2022

    Transcatheter Aortic-Valve Implantation for Aortic Stenosis, 7.01.132

    • This policy has been replaced by Transcatheter Aortic-Valve Implantation for Aortic Stenosis, 7.01.585

    Added codes

    Effective February 4, 2022

    The following codes will require review for medical necessity and prior authorization for services on or after February 4, 2022

    American Society of Addiction Medicine (ASAM), 10.01.532

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

    Effective January 7, 2022

    Hysterectomy for Non-Malignant Conditions, 7.01.548

    Now requires review for medical necessity and prior authorization.

    58150, 58152, 58180, 58541, 58542, 58543, 58544, 58570, 58571, 58572, 58573

    Hysterectomy for Non-Malignant Conditions, 7.01.548

    Now requires review for medical necessity and prior authorization, including site of service.

    58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58294, 58550, 58552, 58553, 58554

    Effective January 1, 2022

    Amniotic Membrane and Amniotic Fluid, 7.01.583

    Now requires review for investigational.

    A2001, Q4199

    Amyloid Antibodies for the Treatment of Alzheimer’s Disease, 5.01.626

    Now requires review for medical necessity and prior authorization.

    J0172

    Bioengineered Skin and Soft Tissue Substitute, 7.01.113

    Now requires review for investigational.

    A2002, A2003, A2004, A2005, A2006, A2007, A2008, A2009, A2010

    CGRP Inhibitors for Migraine Prophylaxis, 5.01.584

    Now requires review for medical necessity and prior authorization.

    J3031

    Chimeric Antigen Receptor Therapy for Multiple Myeloma, 8.01.66

    Now requires review for medical necessity and prior authorization.

    Q2055

    Cryoablation for Chronic Rhinitis, 7.01.168

    Now requires review for investigational.

    30117, C9771

    Drugs for Rare Diseases, 5.01.576

    Now requires review for medical necessity.

    C9085

    Epidermal Growth Factor Receptor (EGFR) Inhibitors, 5.01.603

    Now requires review for medical necessity and prior authorization.

    J9061

    Gender Transition/Affirmation Surgery, 7.01.557

    Now requires review for medical necessity and prior authorization.

    11960, 15788, 15789, 15792, 15793, 21087, 21210, 40500, 40510, 40520, 40525, 40527, 53430, 54520

    Gender Transition/Affirmation Surgery, 7.01.557

    Will require review for WA members when submitted for gender transition/affirmation surgery unless otherwise specified by contract.

    15775, 15776, 17380, 54400, 54401, 54405, C1813, C2622

    Gonadotropin Releasing Hormone (GnRH) Analogs, 5.01.625

    Now requires review for medical necessity and prior authorization.

    J1952

    Immune Checkpoint Inhibitors, 5.01.591

    Now requires review for medical necessity and prior authorization.

    J9272

    Implantable Bone-Conduction and Bone-Anchored Hearing Aids, 7.01.03

    Now requires review for medical necessity and prior authorization.

    69716, 69719

    Lumbar Spinal Fusion in Adults, 7.01.542

    Now requires review for medical necessity and prior authorization.

    63052, 63053

    Miscellaneous Oncology Drugs, 5.01.540

    Now requires review for medical necessity and prior authorization.

    J9021

    Non-covered Experimental/Investigational Services, 10.01.533

    Now requires review for investigational.

    0295U, 0672T, 0674T, 0675T, 0676T, 0677T, 0678T, 0679T, 0680T, 0681T, 0682T, 0683T, 0684T, 0685T, 0686T, 0687T, 0688T, 0689T, 0690T, 0691T, 0692T, 0693T, 0694T, 0695T, 0696T, 0697T, 0698T, 0700T, 0701T, 0704T, 0705T, 0706T, 0707T, 0708T, 0709T, 0710T, 0711T, 0712T, 0713T, K1027, 33267, 33268, 33269, 61736, 61737

    Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty, and Intraosseous Basivertebral Nerve Ablation, 7.01.72

    Now requires review for investigational.

    64628, 64629

    Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia, 2.01.91

    Now requires review for investigational.

    43497

    Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564

    Now requires review for medical necessity.

    C9086

    Prescription Digital Therapeutics for Substance Use Disorder, 5.01.35

    Now requires review for investigational.

    0702T, 0703T

    Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors, 7.01.95

    Now requires review for investigational.

    0673T

    Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.101

    Now requires review for medical necessity and prior authorization.

    64582, 64583, 64584

    Transcatheter Aortic Valve Implantation for Aortic Stenosis, 7.01.585

    Now requires review for investigational.

    33370, C1884

    Use of Granulocyte Colony-Stimulating Factors (G-CSF), 5.01.551

    Now requires review for medical necessity and prior authorization.

    J2506

    AIM® Specialty Health Genetic Testing

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

    0285U, 0286U, 0287U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0296U, 0297U, 0298U, 0299U, 0300U, 81349, 81523

    Revised codes

    Effective January 7, 2022

    Cervical Spine Surgeries: Discectomy, Laminectomy, and Fusion in Adults, 7.01.560

    Currently requires review for medical necessity, now requires review for site of service.

    22551, 22554, 22600, 63020, 63045

    Lumbar Spinal Fusion in Adults, 7.01.542

    Currently requires review for medical necessity, now requires review for site of service.

    22533, 22558, 22612, 22630, 22633, 63052, 63053

    Removed codes

    Effective January 1, 2022

    Chimeric Antigen Receptor Therapy for Multiple Myeloma, 8.01.66

    No longer requires review. Code terminated.

    C9081

    Epidermal Growth Factor Receptor (EGFR) Inhibitors, 5.01.603

    No longer requires review. Code terminated.

    C9083

    Immune Checkpoint Inhibitors, 5.01.591

    No longer requires review. Code terminated.

    C9082

    Implantable Bone-Conduction and Bone-Anchored Hearing Aids, 7.01.03

    No longer requires review. Code terminated.

    69715, 69718

    Non-covered Experimental/Investigational Services, 10.01.533

    No longer requires review. Code terminated.

    C9752, C9753

    Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.101

    No longer requires review. Code terminated.

    0466T, 0467T

    Use of Granulocyte Colony-Stimulating Factors (G-CSF), 5.01.551

    No longer requires review. Code terminated.

    J2505

    Wilderness Therapy/Outdoor Behavioral Healthcare Residential Wilderness Programs, 3.01.522

    Now requires review for medical necessity and prior authorization.

    T2036, T2037

    AIM® Specialty Health Genetic Testing

    No longer requires review. Code terminated.

    0208U

  • Updates for only non-individual plans

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  • Updates for only individual plans

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