Effective September 4, 2020
Folate Antimetabolites, 5.01.617
This is a new policy. The following drugs have been added and may be considered medically necessary when criteria are met:
Alimta® (pemetrexed)
- In combination with Keytruda® (pembrolizumab) and platinum chemotherapy for the initial treatment of metastatic non-squamous non-small cell lung cancer (NSCLC)
- In combination with cisplatin for the initial treatment of locally advanced or metastatic, non-squamous NSCLC
- As a single agent for the maintenance treatment of locally advanced or metastatic, non-squamous NSCLC in patients whose disease has not progressed after four cycles of platinum-based first-line chemotherapy
- As a single agent for the treatment of recurrent, metastatic non-squamous, NSCLC after prior chemotherapy
- Initial treatment, in combination with cisplatin, of malignant pleural mesothelioma in patients whose disease can’t be surgically treated or who are not candidates for curative surgery
Folotyn® (pralatrexate)
- Treatment of relapsed or refractory peripheral T-cell lymphoma (PTCL)
Pharmacologic Treatment of Gout, 5.01.616
This is a new policy. The following drug has been added and may be considered medically necessary when criteria are met:
Krystexxa® (pegloticase)
- Treatment of chronic gout in patients age 18 and older
Effective August 16, 2020
Updates to AIM Specialty Health® Clinical Appropriateness Guidelines
Effective for dates of service on and after August 16, 2020, the following updates by will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiology: Chest Imaging
Updates by section:
Tumor or Neoplasm
- Allowed follow up of nodules less than 6 mm in size seen on incomplete thoracic CT, in alignment with follow up recommendations for nodules of the same size seen on complete thoracic CT
- Added new criteria for which follow up is indicated for mediastinal and hilar lymphadenopathy
- Separated mediastinal/hilar mass from lymphadenopathy, which now has its own entry
Parenchymal Lung Disease – not otherwise specified
- Removed as it is covered elsewhere in the document (parenchymal disease in “Occupational lung diseases” and pleural disease in “Other thoracic mass lesions”)
Interstitial lung disease (ILD), non-occupational, including idiopathic pulmonary fibrosis (IPF)
- Defined criteria warranting advanced imaging for both diagnosis and management
Occupational lung disease (Adult only)
- Moved parenchymal component of asbestosis into this indication
- Added Berylliosis
Chest Wall and Diaphragmatic Conditions
- Removed screening indication for implant rupture due to lack of evidence indicating that outcomes are improved
- Limited evaluation of clinically suspected rupture to patients with silicone implants
Effective for dates of service on and after August 16, 2020, the following updates by will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiology: Oncology Imaging
Updates by section:
MRI breast
- New indication for BIA-ALCL
- New indication for pathologic nipple discharge
- Further define the population of patients most likely to benefit from preoperative MRI
Breast cancer screening
- Added new high risk genetic mutations appropriate for annual breast MRI screening
Lung cancer screening
- Added asbestos-related lung disease as a risk factor
Effective for dates of service on and after August 16, 2020, the following updates by will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Sleep Disorder Management
Updates by section:
Bi-Level Positive Airway Pressure Devices
- Change in BPAP FiO2 from 45 to 52 mmHg based on strong evidence and aligns with Medicare requirements for use of BPAP
Multiple Sleep Latency Testing and/or Maintenance of Wakefulness Testing
Effective August 7, 2020
IL-5 Inhibitors, 5.01.559
The following drug has been added and may be considered medically necessary when criteria are met:
Cinqair® (reslizumab)
- As an add-on maintenance treatment of severe asthma for patients ages 18 and older
Re-authorization criteria have been added
- A decrease in requirement for oral steroids, exacerbation frequency, ER and urgent care visits, and hospitalizations; or a decrease in the frequency and severity of asthma symptoms; or an increase in quality of life measures and ability to perform activities of daily living
Effective July 2, 2020
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.569
Removed from policy
- Site of service criteria and reference to policy, Site of Service: Select Surgery Procedures – 11.01.524, have been removed
- Site of service will be included in the medical necessity review for the primary procedure (knee arthroplasty, knee arthroscopy) using InterQual® criteria
Electrostimulation and Electromagnetic Therapy for Treating Wounds, 2.01.57
Policy Reinstated
- This policy was previously archived in 2018 and is being reinstated
- Electrical stimulation and electromagnetic therapy for the treatment of wounds is considered investigational
Erythroid Maturation Agents, 5.01.614
The following drug has been added and may be considered medically necessary when criteria are met:
Reblozyl® (luspatercept-aamt)
- Treatment of anemia in adults ages 18 and older with beta thalassemia
Meniscal Allografts and Other Meniscal Implants, 7.01.15
Removed from policy
- Site of service criteria and reference to policy, Site of Service: Select Surgery Procedures – 11.01.524, have been removed
- Site of service will be included within the medical necessity review for a knee arthroscopy procedure using InterQual® criteria
Miscellaneous Oncology Drugs, 5.01.540
The following drug has been added and may be considered medically necessary when criteria are met:
Padcev™ (enfortumab vedotin-ejfv)
- Treatment of locally advanced or metastatic urothelial cancer (mUC) in patients ages 18 and older
Effective June 5, 2020
Miscellaneous Oncology Drugs, 5.01.540
The following drug has been added and may be considered medically necessary when criteria are met:
Darzalex® (daratumumab)
- Treatment of multiple myeloma in adults when used as a combination treatment or monotherapy