Effective June 5, 2020
Miscellaneous Oncology Drugs, 5.01.540
Darzalex® (daratumumab) has been added to the policy and may be considered medically necessary for the treatment of multiple myeloma in adults when used as a combination treatment or monotherapy when criteria are met.
Effective May 17, 2020
Effective for dates of service on and after May 17, 2020, the following updates by will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiology: Vascular Imaging
Updates by section:
- Aneurysm of the abdominal aorta or iliac arteries:
- Added new indication for asymptomatic enlargement by imaging
- Clarified surveillance intervals for stable aneurysms as follows:
- Treated with endografts, annually
- Treated with open surgical repair, every 5 years
- Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified:
- Added surveillance indication and interval for surgical bypass grafts
Effective April 3, 2020
Herceptin® (trastuzumab) and Other HER2 Inhibitors, 5.01.514
Trazimera™ (trastuzumab-qyyp), a biosimilar to Herceptin® (trastuzumab), has been changed to a first-line biosimilar for the treatment of HER2-postive breast cancer, HER2-postive metastatic gastric cancer, and HER2-postive gastroesophageal junction adenocarcinoma when criteria are met. The biosimilars Herzuma® (trastuzumab-pkrb), Kanjinti™ (trastuzumab-anns), Ogivri™ (trastuzumab-dkst) and Ontruzant® (trastuzumab-dttb) are second-line biosimilars and require an inadequate response or intolerance to Herceptin® or Trazimera™ when criteria are met.
IL-5 Inhibitors, 5.01.559
Nucala® (mepolizumab) medical necessity criteria has been updated for the treatment of patients with severe eosinophilic asthma. Age criterion has changed from age 12 to age 6 and older. Nucala® (mepolizumab) medical necessity criteria have also been updated for the treatment of eosinophilic granulomatosis with polyangiitis (EGPA) in adults to include blood eosinophil levels and documented evidence of polyangiitis, vasculitis, mononeuritis, or systemic symptoms.
Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502
Polivy™ (polatuzumab vedotin-piiq) has been added to the policy and may be considered medically necessary for the treatment of diffuse large B-cell lymphoma (DLBCL) in adults when criteria are met. Ruxience™ (rituximab-pvvr), a biosimilar to Rituxan® (rituximab), has been added to the policy as a first-line biosimilar and may be considered medically necessary for non-Hodgkin’s lymphoma and chronic lymphocytic leukemia. Truxima® (rituximab-abbs) is a second-line biosimilar and requires an inadequate response or intolerance to Rituxan® or Ruxience™ when criteria are met.
Pharmacotherapy of Arthropathies, 5.01.550
Ruxience™ (rituximab-pvvr) has been added to the policy and may be considered medically necessary as a second-line anti-CD20 agent when criteria are met.
Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564
Ruxience™ (rituximab-pvvr) has been added to the policy and may be considered medically necessary as a first-line treatment for systemic lupus erythematosus when criteria are met.
Pharmacotherapy of Thrombocytopenia, 5.01.566
Ruxience™ (rituximab-pvvr) and Truxima® (rituximab-abbs) have been added to the policy and may be considered medically necessary as anti-CD20 agents in for the treatment of chronic immune thrombocytopenia when criteria are met.
Rituximab: Non-oncologic and Miscellaneous Uses, 5.01.556
Ruxience™ (rituximab-pvvr), a biosimilar to Rituxan® (rituximab), has been added to the policy as a first-line biosimilar and may be considered medically necessary when criteria are met. Truxima® (rituximab-abbs) is a second-line biosimilar and requires an inadequate response or intolerance to Rituxan® or Ruxience™ when criteria are met.
Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology, 5.01.517
Zirabev™ (bevacizumab-bvzr), a biosimilar to Avastin® (bevacizumab), has been changed to a first-line biosimilar and may be considered medically necessary when criteria are met. Mvasi™ (bevacizumab-awwb) is a second-line biosimilar and requires an inadequate response or intolerance to Avastin® (bevacizumab) or Zirabev™ (bevacizumab-bvzr) when criteria are met.
Effective March 5, 2020
Knee Arthroplasty in Adults, 7.01.550
A description of Kellgren-Lawrence grade 3 is added to the medical necessity statement of radiographic evidence. The conservative management section is modified to now include a requirement of both medical measures and physical measures.
Pharmacotherapy for Multiple Sclerosis, 5.01.565
Medical necessity of Ocrevus® (ocrelizumab) intravenous will now include site of service review. See policy for more details.
Site of Service: Infusion Drugs and Biologic Agents, 11.01.523
Medical necessity of Ocrevus® (ocrelizumab) intravenous will now include site of service review. See policy for more details.