Medical Policy and Coding Updates September 2024

Effective December 5, 2024

Pharmacotherapy of Arthropathies, 5.01.550  PBC | Premera HMO
Drugs added
Site of service review added

• Site of service review was added to Cosentyx (secukinumab) IV and Tofidence (tocilizumab-bavi) IV throughout the policy

Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  PBC | Premera HMO
Drug added
Site of service review added

• Site of service review was added to Tyruko (natalizumab-sztn) throughout the policy

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  PBC | Premera HMO
Drug added
Site of service review added

• Site of service review is added to Tofidence (tocilizumab-bavi) IV throughout the policy

Site of Service: Infusion Drugs and Biologic Agents, 11.01.523  PBC | Premera HMO
Drugs added

• The following will be reviewed for site of service when requested in an inpatient setting:
  • Alyglo (immune globulin intravenous, human-stwk)
  • Cosentyx IV (secukinumab)
  • Spevigo IV (spesolimab-sbzo)
  • Tofidence IV (tocilizumab-bavi)
  • Tyruko (natalizumab-sztn)

Effective November 1, 2024

Alpha-1 Proteinase Inhibitors, 5.01.624  PBC | Premera HMO
Site of service review added

• The following will be reviewed for site of service when requested in an inpatient setting:
  • Aralast NP
  • Glassia
  • Prolastin-C
  • Zemaira

Site of Service: Infusion Drugs and Biologic Agents, 11.01.523  PBC | Premera HMO
Drugs added

• The following will be reviewed for site of service when requested in an inpatient setting:
  • Aralast NP
  • Glassia
  • Prolastin-C
  • Zemaira

Effective October 20, 2024

Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
(formerly AIM Specialty Health).

Effective for dates of service on and after October 20, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Radiology Clinical Appropriateness Guidelines. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

Updates by section

Brain Imaging

• Added indications for Magnetic Resonance Imaging (MRI) and amyloid beta positron emission tomography (PET) imaging in Alzheimer disease to address patients considering or receiving lecanemab

Spine Imaging

• Changed “Perioperative and Periprocedural Imaging” to “Postoperative and Postprocedural Imaging;” pre-procedure requests should be reviewed based on more specific indication

Extremity Imaging

• Separated criteria for osteomyelitis and septic arthritis into separate indications
• Ultrasound or arthrocentesis as preliminary tests were placed only in the “septic arthritis” indication

Vascular Imaging

• Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) Head addition for chronic posterior circulation Stroke/TIA presentations (CTA/MRA neck already allowed, intracranial eval needed for full extent of anatomy)
• Lower Extremity peripheral artery disease: Updated physiologic testing parameters and added allowance for ischemic signs/symptoms at presentation, in alignment with American College of Radiology Appropriateness Criteria
• Suboptimal imaging option downgrades/removals in Brain, Head and Neck and Abdomen/Pelvis

Effective for dates of service on and after October 20, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Cardiology Clinical Appropriateness Guidelines. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

Updates by section

Imaging of the Heart

• Resting Transthoracic Echocardiography (TTE)
  • Expanded frequency of echocardiographic evaluation in patients on mavacamten for treatment of hypertrophic obstructive cardiomyopathy
  • Expanded criteria for echocardiographic evaluation to allow a single screening for cardiac disease in patients undergoing evaluation for solid organ or hematopoietic cell transplant

Effective for dates of service on and after October 20, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Genetic Testing Clinical Appropriateness Guidelines. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

Updates by section

Chromosomal Microarray Analysis

• Clarified recommendations for Genetic Counseling
• Clarified requirements for postnatal evaluation of individuals with:
  • Congenital or early onset epilepsy (before age 3 years) without suspected environmental causes
  • Autism spectrum disorder, developmental delay, or intellectual disability with no identifiable cause (idiopathic)
• Clarified prenatal evaluation of a fetus with a structural fetal anomaly noted on ultrasound

Pharmacogenomic Testing

• Added Apolipoprotein E (APOE) testing

Polygenic Risk Scores renamed Predictive and Prognostic Polygenic Testing

• Broadened guideline scope to include polygenic expression prognostic testing and multivariable prognostic genetic testing (essentially clarifications)
  • Moved these tests to exclusions as they are considered not medically necessary
• Retitled guideline to Predictive and Prognostic Polygenic Testing to address the change in scope

Somatic Testing of Solid Tumors

• Clarified gene expression profiling is to guide adjuvant therapy for localized Breast Cancer

Whole Exome and Whole Genome Sequencing

• Expanded whole exome sequencing (WES) criteria to include congenital or early onset epilepsy (before age 3) without suspected environmental etiology and added other clarifications
• Clarified well-delineated genetic syndrome in criterion for multiple anomalies
• Clarified Genetic Counseling details for WES

Effective for dates of service on and after October 20, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Radiation Oncology Clinical Appropriateness Guidelines. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

Updates by section

Radiation Therapy (excludes Proton)

• Removed criteria for hyperthermia
• Clarified inclusion criteria of the RTOG 1112 protocol

Effective for dates of service on and after October 20, 2024, the following updates will apply to the Carelon Medical Benefits Management, Inc. Sleep Clinical Appropriateness Guidelines. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

Updates by section

Sleep Disorder Management

• Expanded definitions and terminology
• Expanded documentation of hypoventilation
• Expanded criteria for home and in-lab sleep studies
• Added contraindication to automatic positive airway pressure titration for use of supplemental oxygen
• Removed home sleep apnea testing as an option in medical necessity of multiple sleep latency test/maintenance of wakefulness test for suspected narcolepsy
• Management of obstructive sleep apnea (OSA) using Implanted Hypoglossal Nerve Stimulators (HNS):
  • Narrowed age range (raised lower limit to 13) for HNS in individuals with Down syndrome and OSA to align with age range suggested by Food and Drug Administration (FDA)
• Miscellaneous Devices section added:
  • Electronic positional therapy and neuromuscular electrical training of the tongue musculature are considered not medically necessary due to lack of high-quality evidence

For questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines.

Effective October 8, 2024

Surgical Treatment of Femoral Acetabular Impingement, 7.01.592 PBC | Premera HMO
New policy

• Surgical treatment of femoral acetabular impingement is considered medically necessary when criteria are met.

New medical policies

Vagus Nerve Stimulation, 7.01.593 PBC | Premera HMO
Policy renumbered from 7.01.20 (see Deleted policies)
Vagus Nerve Stimulation for Major Depression Disorder

• Added “not bipolar depression” after “unipolar depression”
• Added a new criterion: “No acute or chronic psychotic symptoms”
• Added, “or TMS was stopped due to intolerable, incapacitating, or potentially dangerous adverse effects” to the item for a course of transcranial magnetic stimulation
• Added “or ECT was stopped due to intolerable, incapacitating, or potentially dangerous adverse effects” to the item for a course of electroconvulsive therapy

Revised medical policies
Effective September 1, 2024

Facet Joint Denervation, 7.01.555  PBC | Premera HMO
Medical necessary criteria updated

• Added time requirement to the criterion for radiographic imaging that it must have been performed within the past 12 months

Hysterectomy for Non-Malignant Conditions, 7.01.548  PBC | Premera HMO
Hysterectomy, with or without salpingo-oophorectomy
Medical necessity criteria updated

• Update made within Abnormal Uterine Bleeding – Premenopausal, expanding on criterion for endometrial sampling, indicating it must have been performed within the past 12 months, and adding allowance for when it cannot be performed due to technical reasons or has been attempted but was unsuccessful
• Update made within Uterine Fibroids (leiomyomata), expanding on criterion for endometrial sampling, indicating it must have been performed within the past 12 months, and adding allowance for when it cannot be performed due to technical reasons or has been attempted but was unsuccessful or dilation and curettage (D&C) in the setting of menometrorrhagia  was performed

Related information updated

• Definition of menometrorrhagia added

New pharmacy policies

No updates this month.

Revised pharmacy policies
Effective September 1, 2024

C3 and C5 Complement Inhibitors, 5.01.571  PBC | Premera HMO
Drug added 
Medical necessity criteria added
Piasky (crovalimab-akkz)

• Added coverage for treatment of paroxysmal nocturnal hemoglobinuria in individuals aged 13 years or older 
• Must have completed at least 3 months of therapy with Soliris or Ultomiris
• Must have experienced residual anemia (hemoglobin <10.5 g/dL and lactic acid dehydrogenase level 1.5 times the upper limit) while undergoing treatment on Soliris or Ultomiris
• Must have received Streptococcus pneumoniae, Neisseria meningitis, and Hemophilus influenzae at least 2 weeks prior to first does

Drug removed

• Removed Ultomiris SC on body injector since it is removed from the market

Hereditary Angioedema, 5.01.587  PBC | Premera HMO
Medical necessity criteria updated
Berinert (pdC1-INH) IV

• Added requirement that individual must have tried and had an inadequate response or intolerance to generic icatibant or Sajazir (icatibant)

Cinryze (pdC1-INH) IV

• Removed requirement for males 18 years and older to have tried and had an inadequate response or intolerance to Danocrine or another androgen

Haegarda (pdC1-INH) SC

• Removed requirement for males 18 years and older to have tried and had an inadequate response or intolerance to Danocrine or another androgen

Kalbitor (ecallantide) SC

• Removed requirement for males 18 years and older to have tried and had an inadequate response or intolerance to Danocrine or another androgen

Orladeyo (berotralstat) oral

• Removed requirement for males 18 years and older to have tried and had an inadequate response or intolerance to Danocrine or another androgen

Ruconest (rhC1-INH) IV

• Added requirement that individual must have tried and had an inadequate response or intolerance to generic icatibant or Sajazir (icatibant)

Takhzyro (lanadelumab-lyo) SC

• Removed requirement for males 18 years and older to have tried and had an inadequate response or intolerance to Danocrine or another androgen

Immune Checkpoint Inhibitors, 5.01.591  PBC | Premera HMO
Medical necessity criteria updated
Imfinzi

• Added treatment of primary advanced or recurrent endometrial cancer that is mismatch repair deficient when administered as a single agent following combination therapy with carboplatin and paclitaxel

Keytruda (pembrolizumab) IV

• Added treatment of hepatocellular carcinoma secondary to hepatitis B in individuals who have received prior systemic therapy other than a PD-1/PD-L1 containing regimen
• Added treatment of primary advanced or recurrent endometrial carcinoma when administered as a single agent following combination therapy with carboplatin and paclitaxel

Pharmacologic Treatment of Hemophilia, 5.01.581  PBC | Premera HMO
Drugs added
Medical necessity criteria added
Beqvez (findanacogene elaparvovec-dzkt)

• Added coverage for treatment of hemophilia in individuals aged 18 years and older who are assigned male at birth
  • Must have severe or moderately severe hemophilia B as defined by a plasma Factor IX (FIX) activity level of 2% or less
  • Must have either current or historical life threatening hemorrhage OR repeated serious spontaneous bleeding episodes OR is currently receiving a FIX prophylaxis that will be discontinued following Beqvez administration
  • Must not have a history of FIX inhibitors or a positive screen result of 0.6 or greater Bethesda Units
  • Must have received a liver health assessment including enzyme testing and an hepatic ultrasound and elastography
  • Must have been assessed by an hepatologist if radiological liver abnormalities or sustained liver enzyme elevations are present
  • Must be human immunodeficiency virus (HIV) negative or have HIV controlled infection
  • Must not have an active hepatitis B or hepatitis C infection
  • Must not have neutralizing antibodies to adeno-association virus serotype Rh74var capsid
  • Must be prescribed by or in consultation with a physician specializing in hemophilia B or a hematologist

Investigational criteria updated
Beqvez (findanacogene elaparvovec-dzkt)

• Considered investigational for all other uses not outlined in policy or for repeat treatment

Medical Necessity Criteria for Pharmacy Edits, 5.01.605  PBC | Premera HMO
Medical necessity criteria updated
Motpoly XR (lacosamide extended release)

• Added treatment of primary generalized tonic-clonic seizures in individuals weighing at least 50 kg

Sirturo (bedaquiline)

• Update criterion to indicate diagnosis requirement of pulmonary tuberculosis due to Mycobacterium tuberculosis resistant to at least rifampin and isoniazid

Palforzia [peanut (arachis hypogaea) allergen powder-dnfp]

• Age requirement updated from those aged 4 years or older to those aged 1 year and older

Drug added
Medical necessity criteria added
Vigafyde (vigabatrin)

• Added coverage for treatment of infantile spasms when used alone in individuals aged 1 months to 2 years
  • Must have tried and had inadequate response or intolerance to generic vigabatrin, Vigpoder (vigabatrin), or Vigadrone (vigabatrin)

Drugs added 
Medical necessity criteria added
Durysta (bimatoprost)

• Added coverage for use to reduce intraocular pressure in individuals diagnosed with open-angle glaucoma or ocular hypertension
  • Must have tried and had an inadequate response or intolerance to two generic ophthalmic prostaglandin analogs

Envarsus XR (tacrolimus extended-release)

• Added as a transplant agent for individuals who have received a kidney transplant
  • Must have tied generic immediate-release tacrolimus
  • Must be prescribed by or in consultation with a nephrologist or transplant specialist

Opill (norgestrel)

• Added to Contraceptives with a quantity limit of 30 tables per 30 days

Drugs added
Brand Oral NSAIDs

• Anaprox (naproxen)
• Arthrotec (diclofenac-misoprostol)
• Celebrex (celecoxib)
• Daypro (oxaprozin)
• Feldene (piroxicam)
• Lodine (etodolac)
• Mobic (melaxicam)
• Naprosyn (naproxen)
• Voltaren (diclofenac)

Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
Drugs added
Medical necessity criteria added
Casodex (bicalutamide)

• Added coverage for the treatment of metastatic carcinoma of the prostate in individuals aged 18 years and older
  • Must be used in combination with gonadotropin releasing hormone (GnRH) analogs
  • Must have tried and had inadequate response or intolerance to generic bicalutamide
  • Must limit dosing to 50 mg daily

Eulexin (flutamide) oral

• Added coverage for the treatment of locally confined or metastatic carcinoma of the prostate in individuals aged 18 years and older
  • Must be used in combination with gonadotropin releasing hormone (GnRH) analogs
  • Must have tried and had inadequate response or intolerance to generic bicalutamide
  • Must limit dosing to 750 mg daily

Nilandron (nilutamide) oral and generic nilutamide oral

• Added coverage for the treatment of metastatic prostate cancer in individuals aged 18 years and older
  • Must be used in combination with a bilateral orchiectomy
  • Must have tried and had an inadequate response or intolerance to generic bicalutamide
  • Must limit dosing to 300 mg daily for 30 days followed by 150 mg daily

Dacogen (decitabine) IV

• Added coverage for the treatment of myelodysplastic syndromes (MDS) in individuals aged 18 years and older
  • Must have been diagnosed with MDS, including previously treated and untreated, de novo and secondary MDS of all French-American-British subtypes
  • Must have tried and had an inadequate response to generic decitabine
• Added coverage for generic decitabine IV for the treatment of myelodysplastic syndromes (MDS) in individuals aged 18 years and older
  • Must have been diagnosed with MDS, including previously treated and untreated, de novo and secondary MDS of all French-American-British subtypes

Elitek (rasburicase) IV

• Added coverage for the initial management of plasma uric acid levels in individuals with leukemia, lymphoma, or solid tumor malignancies
  • Must be receiving anticancer therapy expected to result in tumor lysis and subsequent elevation of plasma uric acid

Imdelltra (tarlatamab-dlle) IV

• Added coverage for the treatment of extensive stage small cell lung (ES-SCLC) cancer in individuals aged 18 years and older
  • Must have relapsed or refractory ES-SCLC
  • Must have had disease progression on or after treatment with platinum-based chemotherapy
  • Must be prescribed by or in consultation with an oncologist

Pharmacologic Treatment of Atopic Dermatitis, 5.01.628  PBC | Premera HMO
Drug added 
Medical necessity criteria added
Zoryve (roflumilast) 0.15% cream, topical

• Added coverage for treatment of atopic dermatitis in individuals aged 6 years and older
  • Must have tried and had an inadequate response or intolerance to one topical corticosteroid medication
  • In individual is aged 2 years and older, must have tried and had an inadequate response or intolerance to one topical calcineurin inhibitor medication
  • Considered investigational for all other conditions

Pharmacologic Treatment of Chronic Non-Infectious Liver Diseases, 5.01.615  PBC | Premera HMO
Drug added
Medical necessity criteria added
Iqirvo (elafibranor) oral

• Added coverage for treatment of primary biliary cholangitis (PBC) when used in combination with ursodeoxycholic acid (UDCA) in individuals aged 18 years and older who have had inadequate response to UDCA, or as monotherapy in those unable to tolerate UDCA
  • Must have PBC without cirrhosis or PBC with compensated cirrhosis and no evidence of portal hypertension
  • Must have confirmed diagnosis by consistently elevated alkaline phosphatase for at least 6 months AND positive antimitochondrial (AMA) test OR presence of sp100 or gp210 autoantibodies if AMA-negative OR liver biopsy consistent with PBC
  • Must not be a diagnosis associated with cholestatic drug reaction, complete biliary obstruction, sarcoidosis, or primary sclerosing cholangitis
  • Must have tried and had inadequate response to at least 1 year of UDCA therapy or had intolerance to UDCA therapy
  • Must not be used in combination with Ocaliva (obeticholic acid)
  • Must be prescribed by or in consultation with a gastroenterologist or hepatologist
  • Must not exceed 80 mg once daily

Investigational criteria updated

• Added Iqirvo (elafibranor) as investigation for all other conditions not outlined in policy

Medical necessity criteria updated
Ocaliva (obeticholic acid)

• Added requirement that must be prescribed by or in consultation with a gastroenterologist or hepatologist
  • Must not be used in combination with Iqirvo (elafibranor)
  • Must not exceed 10 mg once daily

Pharmacologic Treatment of Interstitial Lung Disease, 5.01.555  PBC | Premera HMO
Drug added

• Add Tyenne (tocilizumab-aazg) IV/SC for treatment of moderate to severe rheumatoid arthritis with current criteria for Actemra (tocilizumab) IV

Pharmacologic Treatment of Sleep Disorders, 5.01.599  PBC | Premera HMO
Medical necessity criteria updated
Wakix (pitolisant)

• Age requirement updated from adults to those aged 6 and older

Pharmacotherapy of Arthropathies, 5.01.550  PBC | Premera HMO
Drugs added
First-line IL-6 Inhibitors

• Added Tyenne (tocilizumab-aazg) IV/SC for treatment of polyarticular juvenile idiopathic arthritis with current criteria for Actemra (tocilizumab) IV
• Added Tyenne (tocilizumab-aazg) IV/SC for treatment of systemic juvenile idiopathic arthritis with current criteria for Actemra (tocilizumab) IV
• Added Tyenne (tocilizumab-aazg) IV/SC for treatment of moderate to severe rheumatoid arthritis with current criteria for Actemra (tocilizumab) IV

Second-line IL-6 Inhibitors

• Added Kevzara (sarilumab) SC for treatment of polyarticular juvenile idiopathic arthritis with current criteria for Actemra (tocilizumab) IV
  • Must have had inadequate response or intolerance to leflunomide, methotrexate, or sulfasalazine
  • Must have had an inadequate response or intolerance to two of the drugs as listed within the policy
  • Must be prescribed by or in consultation with a rheumatologist

Second-line T-Cell Costimulation Modulators

• Orencia (abatacept) IV/SC: Updated list of drugs which individual must have inadequate response or intolerance to include Tyenne and Rinvoq or Rinvoq LQ

Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563  PBC | Premera HMO
Drug added

• Add Tyruko (natalizumab-sztn) for treatment Crohn’s disease with current criteria for Tysabri (natalizumab)

Drug added
Medical necessity criteria added

• Site of service review is added to Skyrizi (risankizumab-rzaa) IV and Skyrizi (risankizumab-rzaa) SC on-body injector
• Add Skyrizi (risankizumab-rzaa) IV for treatment of ulcerative colitis prescribed by or in consultation with a gastroenterologist and used only for induction therapy
• Add Skyrizi (risankizumab-rzaa) SC on-body injector for treatment of ulcerative colitis when prescribed by or in consultation with a gastroenterologist and individual has received induction therapy with Skyrizi IV

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  PBC | Premera HMO
Medical necessity criteria updated

• Clarify use of Lupkynis (voclosporin) in policy with no changes to the statement

Drugs added
Giant cell arteritis

• Added Tyenne (tocilizumab-aazg) SC and IV and  Tofidence (tocilizumab-bavi) IV for treatment of giant cell arteritis with current Actemra criteria
• Added Tyenne (tocilizumab-aazg) SC and IV and  Tofidence (tocilizumab-bavi) IV for treatment of cytokine release syndrome with current Actemra criteria

Drugs added
Medical necessity criteria added
Chronic inflammatory demyelinating polyneuropathy (CIDP)

• Added coverage of Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) for treatment of chronic inflammatory demyelinating polyneuropathy (CIDP) in individuals aged 18 and older
  • Must have experienced progressive or relapsing motor and/or sensory symptoms of more than one limb and hyporeflexia or areflexia in affected limbs for at least 2 months
  • Must have electrophysiologic findings that meet at least 3 of the 4 American Academy of Neurology criteria indicating demyelinating neuropathy
  • Must have excluded any other causes of demyelinating neuropathy
  • Must have result of other testing to support diagnosis, if available, and as outlined in the policy
  • Must have tried and had an inadequate response or intolerance to intravenous or subcutaneous immune globulin
  • Must be prescribed by or in consultation with a neurologist

Sarcoidosis
First-line agents

• Added first-line agents adalimumab-adaz (Hyrimoz unbranded), adalimumab-adbm, (Cyltezo unbranded), adalimumab-ryvk (Simlandi unbranded), Cyltezo (adalimumab-adbm), Humira (adalimumab) (AbbVie) [NDCs starting with 00074], Hyrimoz (adalimumab-adaz), (Sandoz) [NDCs starting with 61314], and Simlandi (adalimumab-ryvk) for treatment of sarcoidosis when individual has tried and had an inadequate response or intolerance to one corticosteroid
  • Must have tried and had an inadequate response or intolerance to one immunosuppressive medication
  • Must be prescribed by or in consultation with a pulmonologist, ophthalmologist, or dermatologist
• Added first-line TNF-α antagonists Avsola (infliximab-axxq), Infliximab (Janssen-unbranded), and Remicade (infliximab) for treatment of sarcoidosis when individual has tried and had an inadequate response or intolerance to one corticosteroid
  • Must have tried and had an inadequate response or intolerance to one immunosuppressive medication
  • Must be prescribed by or in consultation with a pulmonologist, ophthalmologist, or dermatologist

Second-line agents

• Added second-line TNF-α antagonists Abrilada (adalimumab-afzb), adalimumab-aacf (Idacio unbranded), adalimumab-aaty (Yuflyma unbranded), adalimumab-fkjp (Hulio unbranded), Amjevita (adalimumabatto), Hadlima (adalimumab-bwwd), Hulio (adalimumab-fkjp), Humira (adalimumab) (Cordavis) [NDCs starting with 83457], Hyrimoz (adalimumab-adaz) (Cordavis) [NDCs starting with 83457], Idacio (adalimumab-aacf), Yuflyma (adalimumabaaty), and Yusimry (adalimumab-aqvh) for treatment of sarcoidosis when individual has tried and had an inadequate response or intolerance to one corticosteroid
  • Must have tried and had an inadequate response or intolerance to one immunosuppressive medication
  • Must have inadequate response or intolerance to all agents as listed within the policy
  • Must be prescribed by or in consultation with a pulmonologist, ophthalmologist, or dermatologist
• Added second-line TNF-α antagonists Renflexis (infliximab-abda) and Inflectra (infliximab-dyyb) for treatment of sarcoidosis when individual has tried and had an inadequate response or intolerance to one corticosteroid
  • Must have tried and had an inadequate response or intolerance to one immunosuppressive medication
  • Must have inadequate response or intolerance to Avsola (infliximab-axxq), Infliximab (Janssen – unbranded) or Remicade (infliximab)
  • Must be prescribed by or in consultation with a pulmonologist, ophthalmologist, or dermatologist

Site of Service: Infusion Drugs and Biologic Agents, 11.01.523  PBC | Premera HMO
Drugs added
Site of service review added

• The following will be reviewed for site of service when requested in the inpatient setting:
  • Skyrizi (risankizumab-rzaa) IV
  • Skyrizi (risankizumab-rzaa) SC on-body injector)

No updates this month.

Vagus Nerve Stimulation, 7.01.20
Policy deleted; renumbered and replaced with Vagus Nerve Stimulation, 7.01.593 PBC | Premera HMO

Added codes
Effective September 1, 2024

Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain and Other Conditions, 7.01.574  PBC | Premera HMO
Now requires review for medical necessity.

A4438, C1816

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

J0894, J2783

Non-covered Services and Procedures, 10.01.517  PBC | Premera HMO
No longer covered.

92065, 92066

Revised codes
Effective September 1, 2024

No updates this month.

Removed codes
Effective September 1, 2024

Chelation Therapy, 8.01.535
No longer requires review.

M0300, S9355

Effective December 5, 2024

Services Reviewed Using InterQual Criteria, 10.01.530  PBC
Services added
Durable Medical Equipment

• The following modules were added and will be used to review for medical necessity:
  • Continuous glucose monitors, insulin pumps, and automated insulin delivery technology
  • Home mechanical ventilation devices: Invasive, noninvasive, and multifunction

Procedures

• The following modules were added and will be used to review for medical necessity:
  • Arthrotomy, shoulder arthroscopy or arthroscopically assisted surgery, shoulder
  • Arthrotomy, shoulder
  • Electrophysiology (EP) testing +/- radiofrequency (RFA) or cryothermal ablation, cardiac
  • Mastectomy, prophylactic, total or simple
  • Osteotomy, proximal, first metatarsal (MT) (Bunionectomy)
  • Prostatectomy, radical
  • Salpingectomy
  • Tendon sheath incision or excision, hand, flexor
  • Video electroencephalographic (EEG) monitoring

No updates this month.

No updates this month.

Surgical Treatment for Wound Care, 9.01.511

Added codes
Effective September 1, 2024

Applied Behavior Analysis (ABA), 3.01.510 PBC
Now requires review for medical necessity and prior authorization.

0373T

Removed codes
Effective September 1, 2024

Surgical Dressings and Wound Care Supplies, 9.01.511
No longer requires review.

A4450, A4452, A4461, A4463, A4649, A6010, A6011, A6021, A6022, A6023, A6024, A6154, A6196, A6197, A6198, A6199, A6023-A6029, A6210-A6224, A6231-A6248, A6251-A6259, A6261, A6262, A6266, A6402-A6204, A6025, A6207, A6228-A6230, A6250, A6260, A6410-A6413, A6441-A6457, A6501-A6513, A6545

Effective October 8, 2024

Surgical Treatment of Femoral Acetabular Impingement, 7.01.592 PBC
New policy

• Surgical treatment of femoral acetabular impingement is considered medically necessary when criteria are met.

No updates this month.