Medical Policy and Coding Updates July 2023

Effective September 1, 2023

Intraarticular Corticosteroids, 5.01.633  PBC | Premera HMO
New policy
Drug added

• Zilretta® (triamcinolone acetonide extended-release injectable suspension) Intra-articular
  • Added as medically necessary for moderate to severe osteoarthritis pain of the knee in adults and may be approved once per knee per lifetime
  • Considered investigational for all other indications

Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures), 7.01.14  PBC | Premera HMO
New policy
Maze or modified maze procedure
Medical necessity criteria added

• For the treatment of atrial fibrillation or flutter when performed on a non-beating heart during cardiopulmonary bypass

Stand-alone minimally invasive, off-pump maze procedures
Investigational criteria added

• For the treatment of atrial fibrillation and flutter, including when done via mini thoracotomy

Hybrid ablation
Investigational criteria added

• For the treatment of atrial fibrillation and flutter

Effective August 4, 2023

Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
Miscellaneous intramuscular/intravenous/subcutaneous agents
Drug added

• Xgeva® (denosumab)
  • For the prevention of skeletal-related events in individuals with bone metastases from solid tumors
  • For the prevention of skeletal-related events in individuals with multiple myeloma

New medical policies
Effective July 1, 2023

Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes, 2.04.152  PBC | Premera HMO
New policy
Investigational criteria added

• Use of serum biomarker tests with or without additional algorithmic analysis for prediction of preeclampsia or for prediction of spontaneous preterm birth is considered investigational

Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions, 1.01.539  PBC | Premera HMO
Policy renumbered
This policy replaces Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions, 1.01.15
Investigational criteria added

• Oscillation and lung expansion devices are considered investigational

Revised medical policies
Effective August 1, 2023

Psychiatric and Other Specified Evaluations in Inpatient and Residential Behavioral Health Treatment, 3.01.521  PBC | Premera HMO
Inpatient mental health treatment, inpatient eating disorder treatment, and inpatient substance use disorder treatment
Medical necessity criteria updated

• Specified that initial psychiatric evaluation must be done within one day after admission versus within one day of for the purpose of aligning with 2023 InterQual updates
• Added requirement for a medical history and physical examination within one day after admission versus one day within to align with 2023 InterQual updates

Mental health residential treatment, eating disorder residential treatment, substance abuse residential treatment
Note added

• Clarification made that weekly summaries are not the same as and do not count as psychiatric or psychiatric medical evaluations

Inpatient mental health treatment, inpatient eating disorder treatment, inpatient substance use disorder treatment
Medical necessity criteria updated

• Added requirement for a nursing assessment upon admission and then a nursing staff observation 24 hours per day

Wilderness Therapy/Outdoor Behavioral Healthcare Residential Wilderness Programs, 3.01.522  PBC | Premera HMO
Psychiatric/mental health disorders; adults (18 years and older)
Medical necessary criteria updated

• Admission criteria
  • Added criterion of very problematic sexual behavior
• Continued stay criteria
  • Updated to include the criterion of socially withdrawn or interacting with others in very strange or angry or threatening ways, or with very problematic sexual behavior, in or including in the treatment program
• Minimum service requirements
  • Added inclusion criterion that treatment is taking place in a licensed wilderness therapy/outdoor behavioral healthcare residential wilderness program

Psychiatric/mental health disorders; adolescents (13 to 17 years old)
Medical necessity criteria updated

• Admission criteria
  • Clarification made to include problematic or abusive sexual behavior
• Continued stay criteria
  • Added tantrums, severe irritability, or rage; problematic sexual behavior; psychomotor agitation; symptoms interfering with functioning in school and unresponsible to staff intervention; and, interacting with others in a very angry or threatening way, including in the treatment program to the list of qualifying criteria
• Minimum service requirements
  • Added inclusion criterion that treatment is taking place in a licensed wilderness therapy/outdoor behavioral healthcare residential wilderness program

Substance use disorders; adolescents and adults (13 years old and older)
Medical necessity criteria updated

• Minimum service requirements
  • Clarified that treatment must take place in a program that is licensed for substance use disorder outdoor behavioral healthcare residential treatment or licensed for residential substance use

Effective July 1, 2023

Intraoperative Neurophysiologic Monitoring, 7.01.562  PBC | Premera HMO
Medical necessity criteria updated

• Considered medically necessary during location of the hypoglossal nerve during implantation of a hypoglossal nerve stimulator, previously considered not medically necessary

Medical necessity criteria added

• Considered not medically necessary during decompression, neurectomy, radiosurgery, or rhizotomy of the trigeminal nerve

Prescription Digital Therapeutics, 13.01.500  PBC | Premera HMO
Investigational criteria updated

• Added Regulora™ and Luminopia One to the list of FDA-approved prescription digital therapeutics that are considered investigational

Wheelchairs (Manual or Motorized), 1.01.501  PBC | Premera HMO
Medical necessity criteria removed

• Powered seat elevation systems and seat lift mechanisms indications were removed and are now covered due to changes in CMS guidelines 

New pharmacy policies
Effective July 1, 2023

Pharmacologic Treatment of Epidermolysis Bullosa, 5.01.635  PBC | Premera HMO
New policy
Drug added

• Vyjuvek^TM (beremagene geoerpavec-svdt) topical
  • Added medical necessity criteria for treatment of dystrophic epidermolysis bullosa for those aged 6 months and older
  • Not to exceed maximum weekly dose based on age
  • All other indications are considered investigational

Revised pharmacy policies
Effective July 1, 2023

Bruton’s Kinase Inhibitors, 5.01.590  PBC | Premera HMO
Medical necessity criteria updated

• Imbruvica® (ibrutinib)
  • Removed indications for Mantle cell lymphoma and marginal zone lymphoma

Drugs for Rare Diseases, 5.01.576  PBC | Premera HMO
Fabry disease
Drug added

• Elfabrio® (pegunigalsidase alfa-iwxj) IV
  • Added medical necessity criteria for treatment of adults with Fabry disease
  • May not be used in combination with Galafold® (migalastat) and Fabrazyme® (agalsidase beta)
  • May be approved for up to one year, with an additional year of approval when criteria are met

Medical necessity criteria updated

• Fabrazyme® (agalsidase beta) IV
  • Added Fabrazyme is not being used in combination with Galafold® (migalastat) and Elfabrio® (pegunigalsidase alfa-iwxj)
• Galafold® (migalastat) oral
  • Added Galafold is not being used in combination with Fabrazyme® (agalsidase beta) and Elfabrio® (pegunigalsidase alfa-iwxj)

Periodic paralysis
Drug added

• Generic dichlorphenamide oral
  • Added medical necessity criteria for treatment of adults with primary hyperkalemic or hypokalemic periodic paralysis when there are documented episodes of weakness at least once per week
  • Maximum dose may not exceed 200 mg daily

Medical necessity criteria updated

• Keveyis® (dichlorphenamide) oral
  • Added medical necessity criterion requiring trial and failure of, or intolerance to, generic dichlorphenamide

Medical Necessity Criteria for Pharmacy Edits, 5.01.605  PBC | Premera HMO
Muscle relaxants
Drug added

• Brand baclofen oral suspension
  • Added and considered medically necessary to treat individuals who have trouble swallowing baclofen tablets

Vasomotor Symptoms
Drug added

• Veozah™ (fexolinetant)
  • Added medical necessity criteria for the treatment of moderate to severe vasomotor symptoms due to menopause in those aged 18 years and older
  • Maximum dose is 45 mg per day

Pharmacologic Treatment of Psoriasis, 5.01.629  PBC | Premera HMO
Second-line tyrosine kinase 2 (TYK2) inhibitors
Medical necessity criteria updated

• Sotyku™ (deucravacitinib) oral
  • Expanded trial and failure criteria to three of the listed agents, instead of two

Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  PBC | Premera HMO
First-line Janus kinase (JAK) inhibitors
Drug added

• Rinvoq® (upadacitinib)
  • Added medical necessity criteria for treatment of moderate to severely active Crohn’s disease when there has been trial and failure of certain medications, enterocutaneous or rectovaginal fistulas are present, or ileocolonic resection has been performed

Second-line sphingosine 1-phosphate receptor modulators
Medical necessity criteria updated

• Zeposia® (ozanimod) oral
  • Added separately called out criterion requiring trial and failure with Stelara® (ustekinumab) and requiring trial and failure with either Humira or Amjevita

Phosphoinositide 3-kinase (PI3K) Inhibitors, 5.01.592  PBC | Premera HMO
Drug added

• Joenja® (leniolisib) oral
  • Added medical necessity criteria for the treatment of activated phosphoinositide 3-kinase delta syndrome (APDS) in those aged 12 years and older with a document APDS associated PI3K delta gene mutation with documented variant in either PIK3CD or PIK3R1
  • The maximum dose is limited to 140 mg per day

Effective July 1, 2023

No updates this month

Effective July 1, 2023

Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions, 1.01.15
This policy is replaced with Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions, 1.01.539

Added codes
Effective July 1, 2023

Amniotic Membrane and Amniotic Fluid, 7.01.583  PBC | Premera HMO
Now requires review for investigational.

Q4272, Q4273, Q4274, Q4275, Q4276, Q4277, Q4278, Q4280, Q4281, Q4282, Q4283, Q4284

Antibody Drug Conjugates, 5.01.582  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J9063

Bariatric Surgery, 7.01.516  PBC | Premera HMO
Now requires review for investigational.

C9784, C9785

C3 and C5 Complement Inhibitors, 5.01.571  PBC | Premera HMO
Now requires review for medical necessity.

C9151

Carelon Medical Benefits Management, Genetic Testing Guidelines
Now reviewed by Carelon for medical necessity and prior authorization.

0388U, 0389U, 0391U, 0392U, 0396U, 0397U, 0400U, 0401U

Diagnosis and Treatment of Sacroiliac Joint Pain, 6.01.527  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

0809T

Folate Antibodies, 5.01.617  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J9322, J9323

Immune Checkpoint Inhibitors, 5.01.591  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J9347

Immune Globulin Therapy, 8.01.503  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J1576

Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes, 2.04.152  PBC | Premera HMO
Now requires review for investigational.

0243U, 0247U, 0390U

Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J9380

Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J9350

Non-covered Experimental/Investigational Services, 10.01.533  PBC | Premera HMO
Now requires review for investigational.

0795T, 0796T, 0797T, 0801T, 0802T, 0803T, 0810T, 0393U, 0395U, 0398U, 0793T, 0794T, 0807T, 0808T, C9785, C9787, K1024, K1025, K1031, K1032, K1033

Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome, 2.01.106  PBC | Premera HMO
Now requires review for investigational.

0720T

Pharmacologic Prevention and Treatment of HIV/AIDS, 5.01.588  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J1961

Pharmacologic Treatment of Bladder Cancer, 5.01.632  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J9029

Pharmacologic Treatment of Clostridioides Difficile, 5.01.631  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J1440

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

Q5131

Pharmacotherapy of Multiple Sclerosis, 5.01.565  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

J2329

Site of Service: Select Surgical Procedures, 11.01.524  PBC | Premera HMO
Now requires review for medical necessity, including site of service and prior authorization.

63052

Revised codes
Effective July 1, 2023

Site of Service: Select Surgical Procedures, 11.01.524  PBC | Premera HMO
No longer requires review for site of service. Review for medical necessity and prior authorization still required.

63053

Removed codes
Effective July 1, 2023

Antibody Drug Conjugates, 5.01.582  PBC | Premera HMO
Code terminated.

C9146

Immune Checkpoint Inhibitors, 5.01.591  PBC | Premera HMO
Code terminated.

C9148

Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
Code terminated.

C9147

Pharmacotherapy of Type I and Type II Diabetes Mellitus, 5.01.569  PBC | Premera HMO
Code terminated.

C9149

Wheelchairs (Manual or Motorized), 1.01.501  PBC | Premera HMO
Now covered without review.

E0985, E2300, E2310, E2311, K0830, K0831

No updates this month

No updates this month