Krystexxa (pegloticase) Document Number: IC-0158
|
|
|
- Laurence Benson
- 6 years ago
- Views:
Transcription
1 Krystexxa (pegloticase) Document Number: IC-0158 Last Review Date: 06/27/2017 Date of Origin: 02/07/20103 Dates Reviewed: 11/2013, 08/2014, 07/2015, 07/2016, 09/2016, 12/2016, 03/2017, 06/2017 I. Length of Authorization Coverage is provided for six months and will be eligible for renewal. II. Dosing Limits A. Quantity Limit (max daily dose) [Pharmacy Benefit]: Krystexxa 8 mg/ml single-use vial: 2 vials (16 mg) every 28 days B. Max Units (per dose and over time) [Medical Benefit]: 16 billable units every 28 days III. Initial Approval Criteria Coverage is provided in the following conditions: Chronic Gout Patient is at least 18 years old; AND Patient has one of the following: o o At least 3 gout flares in the previous 18 months that were inadequately controlled by colchicine and/or nonsteroidal anti-inflammatory drugs (NSAIDS) or oral or injectable corticosteroids; OR At least 1 gout tophus or has chronic gouty arthritis; AND Documentation of baseline serum uric acid level > 8 mg/dl (current lab reports are required for renewal); AND Documented contraindication, intolerance, or clinical failure (inability to reduce serum uric acid to < 6 mg/dl) during a minimum (3) month trial on previous therapy with maximum tolerated dose of xanthine oxidase inhibitors (e.g., allopurinol or febuxostat); AND Patient is NOT receiving other urate lowering therapies such as allopurinol, febuxostat, probenecid, lesinurad, etc.; AND Patients at higher risk for glucose-6-phosphate dehydrogenase (G6PD) deficiency should be screened and found negative for G6PD before starting Krystexxa FDA-labeled indication(s) Moda Health Plan, Inc. Medical Necessity Criteria Page 1/7
2 IV. Renewal Criteria Authorizations can be renewed based on the following criteria: Patient continues to meet criteria identified in section III; AND Disease response with treatment (i.e., reduction of symptoms, reduction of tophi); AND Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include the following: anaphylaxis; infusion reactions; exacerbation of congestive heart failure; AND Documentation of serum uric acid level <6 mg/dl prior to scheduled infusion. V. Dosage/Administration Indication All indications Dose 8 mg given as an intravenous infusion every two weeks VI. Billing Code/Availability Information Jcode: J2507 Injection, pegloticase, 1 mg: 1 billable unit = 1mg NDC: Krystexxa 8 mg/ml single-use vial: xx VII. References 1. Krystexxa [package Insert]. Lake Forest, IL; Horizon Pharma Rheumatology, LLC; September Accessed May Khanna D, Fitzgerald JD, Khanna PP, et al American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia. Arthritis Care Res (Hoboken) Oct; 64(10): Khanna D, Khanna PP, Fitzgerald JD, et al American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res (Hoboken) Oct; 64(10): Richette P, Doherty M, Pascual E, et al updated EULAR evidence-based recommendations for the management of gout. Annals of the Rheumatic Diseases 2017;76: Appendix 1 Covered Diagnosis Codes ICD-10 M1A.00X0 M1A.00X1 M1A.0110 M1A.0111 M1A.0120 Idiopathic chronic gout, unspecified site, without tophus (tophi) Idiopathic chronic gout, unspecified site, with tophus (tophi) Idiopathic chronic gout, right shoulder, without tophus (tophi) Idiopathic chronic gout, right shoulder, with tophus (tophi) Idiopathic chronic gout, left shoulder, without tophus (tophi) Moda Health Plan, Inc. Medical Necessity Criteria Page 2/7
3 M1A.0121 M1A.0190 M1A.0191 M1A.0210 M1A.0211 M1A.0220 M1A.0221 M1A.0290 M1A.0291 M1A.0310 M1A.0311 M1A.0320 M1A.0321 M1A.0390 M1A.0391 M1A.0410 M1A.0411 M1A.0420 M1A.0421 M1A.0490 M1A.0491 M1A.0510 M1A.0511 M1A.0520 M1A.0521 M1A.0590 M1A.0591 M1A.0610 M1A.0611 M1A.0620 M1A.0621 M1A.0690 M1A.0691 M1A.0710 M1A.0711 M1A.0720 M1A.0721 M1A.0790 M1A.0791 Idiopathic chronic gout, left shoulder, with tophus (tophi) Idiopathic chronic gout, unspecified shoulder, without tophus (tophi) Idiopathic chronic gout, unspecified shoulder, with tophus (tophi) Idiopathic chronic gout, right elbow, without tophus (tophi) Idiopathic chronic gout, right elbow, with tophus (tophi) Idiopathic chronic gout, left elbow, without tophus (tophi) Idiopathic chronic gout, left elbow, with tophus (tophi) Idiopathic chronic gout, unspecified elbow, without tophus (tophi) Idiopathic chronic gout, unspecified elbow, with tophus (tophi) Idiopathic chronic gout, right wrist, without tophus (tophi) Idiopathic chronic gout, right wrist, with tophus (tophi) Idiopathic chronic gout, left wrist, without tophus (tophi) Idiopathic chronic gout, left wrist, with tophus (tophi) Idiopathic chronic gout, unspecified wrist, without tophus (tophi) Idiopathic chronic gout, unspecified wrist, with tophus (tophi) Idiopathic chronic gout, right hand, without tophus (tophi) Idiopathic chronic gout, right hand, with tophus (tophi) Idiopathic chronic gout, left hand, without tophus (tophi) Idiopathic chronic gout, left hand, with tophus (tophi) Idiopathic chronic gout, unspecified hand, without tophus (tophi) Idiopathic chronic gout, unspecified hand, with tophus (tophi) Idiopathic chronic gout, right hip, without tophus (tophi) Idiopathic chronic gout, right hip, with tophus (tophi) Idiopathic chronic gout, left hip, without tophus (tophi) Idiopathic chronic gout, left hip, with tophus (tophi) Idiopathic chronic gout, unspecified hip, without tophus (tophi) Idiopathic chronic gout, unspecified hip, with tophus (tophi) Idiopathic chronic gout, right knee, without tophus (tophi) Idiopathic chronic gout, right knee, with tophus (tophi) Idiopathic chronic gout, left knee, without tophus (tophi) Idiopathic chronic gout, left knee, with tophus (tophi) Idiopathic chronic gout, unspecified knee, without tophus (tophi) Idiopathic chronic gout, unspecified knee, with tophus (tophi) Idiopathic chronic gout, right ankle and foot, without tophus (tophi) Idiopathic chronic gout, right ankle and foot, with tophus (tophi) Idiopathic chronic gout, left ankle and foot, without tophus (tophi) Idiopathic chronic gout, left ankle and foot, with tophus (tophi) Idiopathic chronic gout, unspecified ankle and foot, without tophus (tophi) Idiopathic chronic gout, unspecified ankle and foot, with tophus (tophi) Moda Health Plan, Inc. Medical Necessity Criteria Page 3/7
4 M1A.08X0 M1A.08X1 M1A.09X0 M1A.09X1 M1A.30X0 M1A.30X1 M1A.3110 M1A.3111 M1A.3120 M1A.3121 M1A.3190 M1A.3191 M1A.3210 M1A.3211 M1A.3220 M1A.3221 M1A.3290 M1A.3291 M1A.3310 M1A.3311 M1A.3320 M1A.3321 M1A.3390 M1A.3391 M1A.3410 M1A.3411 M1A.3420 M1A.3421 M1A.3490 M1A.3491 M1A.3510 M1A.3511 M1A.3520 M1A.3521 M1A.3590 M1A.3591 M1A.3610 M1A.3611 M1A.3620 Idiopathic chronic gout, vertebrae, without tophus (tophi) Idiopathic chronic gout, vertebrae, with tophus (tophi) Idiopathic chronic gout, multiple sites, without tophus (tophi) Idiopathic chronic gout, multiple sites, with tophus (tophi) Chronic gout due to renal impairment, unspecified site, without tophus (tophi) Chronic gout due to renal impairment, unspecified site, with tophus (tophi) Chronic gout due to renal impairment, right shoulder, without tophus (tophi) Chronic gout due to renal impairment, right shoulder, with tophus (tophi) Chronic gout due to renal impairment, left shoulder, without tophus (tophi) Chronic gout due to renal impairment, left shoulder, with tophus (tophi) Chronic gout due to renal impairment, unspecified shoulder, without tophus (tophi) Chronic gout due to renal impairment, unspecified shoulder, with tophus (tophi) Chronic gout due to renal impairment, right elbow, without tophus (tophi) Chronic gout due to renal impairment, right elbow, with tophus (tophi) Chronic gout due to renal impairment, left elbow, without tophus (tophi) Chronic gout due to renal impairment, left elbow, with tophus (tophi) Chronic gout due to renal impairment, unspecified elbow, without tophus (tophi) Chronic gout due to renal impairment, unspecified elbow, with tophus (tophi) Chronic gout due to renal impairment, right wrist, without tophus (tophi) Chronic gout due to renal impairment, right wrist, with tophus (tophi) Chronic gout due to renal impairment, left wrist, without tophus (tophi) Chronic gout due to renal impairment, left wrist, with tophus (tophi) Chronic gout due to renal impairment, unspecified wrist, without tophus (tophi) Chronic gout due to renal impairment, unspecified wrist, with tophus (tophi) Chronic gout due to renal impairment, right hand, without tophus (tophi) Chronic gout due to renal impairment, right hand, with tophus (tophi) Chronic gout due to renal impairment, left hand, without tophus (tophi) Chronic gout due to renal impairment, left hand, with tophus (tophi) Chronic gout due to renal impairment, unspecified hand, without tophus (tophi) Chronic gout due to renal impairment, unspecified hand, with tophus (tophi) Chronic gout due to renal impairment, right hip, without tophus (tophi) Chronic gout due to renal impairment, right hip, with tophus (tophi) Chronic gout due to renal impairment, left hip, without tophus (tophi) Chronic gout due to renal impairment, left hip, with tophus (tophi) Chronic gout due to renal impairment, unspecified hip, without tophus (tophi) Chronic gout due to renal impairment, unspecified hip, with tophus (tophi) Chronic gout due to renal impairment, right knee, without tophus (tophi) Chronic gout due to renal impairment, right knee, with tophus (tophi) Chronic gout due to renal impairment, left knee, without tophus (tophi) Moda Health Plan, Inc. Medical Necessity Criteria Page 4/7
5 M1A.3621 M1A.3690 M1A.3691 M1A.3710 M1A.3711 M1A.3720 M1A.3721 M1A.3790 M1A.3791 M1A.38X0 M1A.38X1 M1A.39X0 M1A.39X1 M1A.40X0 M1A.40X1 M1A.4110 M1A.4111 M1A.4120 M1A.4121 M1A.4190 M1A.4191 M1A.4210 M1A.4211 M1A.4220 M1A.4221 M1A.4290 M1A.4291 M1A.4310 M1A.4311 M1A.4320 M1A.4321 M1A.4390 M1A.4391 M1A.4410 M1A.4411 M1A.4420 M1A.4421 M1A.4490 M1A.4491 Chronic gout due to renal impairment, left knee, with tophus (tophi) Chronic gout due to renal impairment, unspecified knee, without tophus (tophi) Chronic gout due to renal impairment, unspecified knee, with tophus (tophi) Chronic gout due to renal impairment, right ankle and foot, without tophus (tophi) Chronic gout due to renal impairment, right ankle and foot, with tophus (tophi) Chronic gout due to renal impairment, left ankle and foot, without tophus (tophi) Chronic gout due to renal impairment, left ankle and foot, with tophus (tophi) Chronic gout due to renal impairment, unspecified ankle and foot, without tophus (tophi) Chronic gout due to renal impairment, unspecified ankle and foot, with tophus (tophi) Chronic gout due to renal impairment, vertebrae, without tophus (tophi) Chronic gout due to renal impairment, vertebrae, with tophus (tophi) Chronic gout due to renal impairment, multiple sites, without tophus (tophi) Chronic gout due to renal impairment, multiple sites, with tophus (tophi) Other secondary chronic gout, unspecified site, without tophus (tophi) Other secondary chronic gout, unspecified site, with tophus (tophi) Other secondary chronic gout, right shoulder, without tophus (tophi) Other secondary chronic gout, right shoulder, with tophus (tophi) Other secondary chronic gout, left shoulder, without tophus (tophi) Other secondary chronic gout, left shoulder, with tophus (tophi) Other secondary chronic gout, unspecified shoulder, without tophus (tophi) Other secondary chronic gout, unspecified shoulder, with tophus (tophi) Other secondary chronic gout, right elbow, without tophus (tophi) Other secondary chronic gout, right elbow, with tophus (tophi) Other secondary chronic gout, left elbow, without tophus (tophi) Other secondary chronic gout, left elbow, with tophus (tophi) Other secondary chronic gout, unspecified elbow, without tophus (tophi) Other secondary chronic gout, unspecified elbow, with tophus (tophi) Other secondary chronic gout, right wrist, without tophus (tophi) Other secondary chronic gout, right wrist, with tophus (tophi) Other secondary chronic gout, left wrist, without tophus (tophi) Other secondary chronic gout, left wrist, with tophus (tophi) Other secondary chronic gout, unspecified wrist, without tophus (tophi) Other secondary chronic gout, unspecified wrist, with tophus (tophi) Other secondary chronic gout, right hand, without tophus (tophi) Other secondary chronic gout, right hand, with tophus (tophi) Other secondary chronic gout, left hand, without tophus (tophi) Other secondary chronic gout, left hand, with tophus (tophi) Other secondary chronic gout, unspecified hand, without tophus (tophi) Other secondary chronic gout, unspecified hand, with tophus (tophi) Moda Health Plan, Inc. Medical Necessity Criteria Page 5/7
6 M1A.4510 M1A.4511 M1A.4520 M1A.4521 M1A.4590 M1A.4591 M1A.4610 M1A.4611 M1A.4620 M1A.4621 M1A.4690 M1A.4691 M1A.4710 M1A.4711 M1A.4720 M1A.4721 M1A.4790 M1A.4791 M1A.48X0 M1A.48X1 M1A.49X0 M1A.49X1 M1A.9XX0 M1A.9XX1 Other secondary chronic gout, right hip, without tophus (tophi) Other secondary chronic gout, right hip, with tophus (tophi) Other secondary chronic gout, left hip, without tophus (tophi) Other secondary chronic gout, left hip, with tophus (tophi) Other secondary chronic gout, unspecified hip, without tophus (tophi) Other secondary chronic gout, unspecified hip, with tophus (tophi) Other secondary chronic gout, right knee, without tophus (tophi) Other secondary chronic gout, right knee, with tophus (tophi) Other secondary chronic gout, left knee, without tophus (tophi) Other secondary chronic gout, left knee, with tophus (tophi) Other secondary chronic gout, unspecified knee, without tophus (tophi) Other secondary chronic gout, unspecified knee, with tophus (tophi) Other secondary chronic gout, right ankle and foot, without tophus (tophi) Other secondary chronic gout, right ankle and foot, with tophus (tophi) Other secondary chronic gout, left ankle and foot, without tophus (tophi) Other secondary chronic gout, left ankle and foot, with tophus (tophi) Other secondary chronic gout, unspecified ankle and foot, without tophus (tophi) Other secondary chronic gout, unspecified ankle and foot, with tophus (tophi) Other secondary chronic gout, vertebrae, without tophus (tophi) Other secondary chronic gout, vertebrae, with tophus (tophi) Other secondary chronic gout, multiple sites, without tophus (tophi) Other secondary chronic gout, multiple sites, with tophus (tophi) Chronic gout, unspecified, without tophus (tophi) Chronic gout, unspecified, with tophus (tophi) Appendix 2 Centers for Medicare and Medicaid Services (CMS) Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub ), Chapter 15, 50 Drugs and Biologicals. In addition, National Coverage Determination (NCD) and Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. They can be found at: Additional indications may be covered at the discretion of the health plan. Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD): N/A Medicare Part B Administrative Contractor (MAC) Jurisdictions Jurisdiction Applicable State/US Territory Contractor E (1) CA, HI, NV, AS, GU, CNMI Noridian Healthcare Solutions, LLC F (2 & 3) AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ Noridian Healthcare Solutions, LLC Moda Health Plan, Inc. Medical Necessity Criteria Page 6/7
7 Medicare Part B Administrative Contractor (MAC) Jurisdictions Jurisdiction Applicable State/US Territory Contractor 5 KS, NE, IA, MO Wisconsin Physicians Service Insurance Corp (WPS) 6 MN, WI, IL National Government Services, Inc. (NGS) H (4 & 7) LA, AR, MS, TX, OK, CO, NM Novitas Solutions, Inc. 8 MI, IN Wisconsin Physicians Service Insurance Corp (WPS) N (9) FL, PR, VI First Coast Service Options, Inc. J (10) TN, GA, AL Cahaba Government Benefit Administrators, LLC M (11) NC, SC, WV, VA (excluding below) Palmetto GBA, LLC L (12) DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA) Novitas Solutions, Inc. K (13 & 14) NY, CT, MA, RI, VT, ME, NH National Government Services, Inc. (NGS) 15 KY, OH CGS Administrators, LLC Moda Health Plan, Inc. Medical Necessity Criteria Page 7/7
Eylea (aflibercept) Document Number: IC-0026
Eylea (aflibercept) Document Number: IC-0026 Last Review Date: 3/1/2018 Date of Origin: 02/07/2013 Dates Reviewed: 03/07/2013, 06/2013, 09/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 04/2015,
Intravitreal Avastin (Bevacizumab)
Intravitreal Avastin (Bevacizumab) Date of Origin: 10/18/2018 Last Review Date: 10/18/2018 Effective Date: 10/18/2018 Dates Reviewed: 10/2018 Developed By: Medical Criteria Committee I. Length of Authorization
Dates Reviewed: 12/2012, 3/2013, 6/2013, 9/2013, 11/2013, 12/2013, 3/2014, 6/2014, 9/2014, 12/2014,
Perjeta (pertuzumab) Last Review Date: 5/30/2017 Date of Origin: 11/01/2012 Document Number: IC-0096 Dates Reviewed: 12/2012, 3/2013, 6/2013, 9/2013, 11/2013, 12/2013, 3/2014, 6/2014, 9/2014, 12/2014,
Tecentriq (atezolizumab) (Intravenous)
Tecentriq (atezolizumab) (Intravenous) Last Review Date: 06/01/2018 Date of Origin: 06/28/2016 Document Number: IC-0278 Dates Reviewed: 06/2016, 08/2016, 10/2016, 02/2017, 04/2017, 08/2017, 11/2017, 02/2018,
Imfinzi (durvalumab) (Intravenous)
Imfinzi (durvalumab) (Intravenous) Last Review Date: 09/05/2018 Date of Origin: 05/30/2017 Dates Reviewed: 05/2017, 08/2017, 11/2017, 02/2018, 05/2018, 09/2018 Document Number: IC-0301 I. Length of Authorization
Velcade (bortezomib) Document Number: IC-0137
Velcade (bortezomib) Document Number: IC-0137 Last Review Date: 11/21/2017 Date of Origin: 11/28/2011 Dates Reviewed: 12/2011, 03/2012, 06/2012, 09/2012, 12/2012, 03/2013, 06/2013, 09/2013, 12/2013, 03/2014,
Document Number: IC I. Length of Authorization. Dosing Limits
Hyaluronic Acid Derivatives: Durolane, Euflexxa, Gel-One, GelSyn-3, GenVisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/Supartz FX, Synojoynt, Synvisc, & Synvisc-One, TriVisc, Visco-3 (Intra-articular)
Cyramza (ramucirumab) (Intravenous)
Cyramza (ramucirumab) (Intravenous) Document Number: IC 0199 Last Review Date: 5/1/2018 Date of Origin: 06/24/2014 Dates Reviewed: 09/2014, 01/2015, 05/2015, 11/2015, 04/2016, 08/2016, 11/2016, 05/2017,
Rituxan Hycela (rituximab and hyaluronidase human) (Subcutaneous)
Rituxan Hycela (rituximab and hyaluronidase human) (Subcutaneous) Document Number: IC-0322 Last Review Date: 02/06/2018 Date of Origin: 7/20/2010 Dates Reviewed: 09/2010, 12/2010, 02/2011, 03/2011, 05/2011,
Ilaris (canakinumab) (Subcutaneous)
Ilaris (canakinumab) (Subcutaneous) Last Review Date: 08/02/2018 Date of Origin: 11/07/2013 Dates Reviewed: 08/2014, 07/2015, 07/2016, 10/2016, 10/2017, 08/2018 Document Number: IC-0177 I. Length of Authorization
Yervoy (ipilmumab) Last Review Date: 03/25/2014 Date of Origin: 11/28/2011. Prior Auth Available: Post-Service Edit:
Yervoy (ipilmumab) Date of Origin: 11/28/2011 Prior Auth Available: Post-Service Edit: Dates Reviewed: 12/13/2011, 03/2012, 06/19/2012, 09/06/2012, 12/06/2012, 05/16/2013, 06/06/2013, 09/05/2013, 12/05/2013,
Trelstar (triptorelin) (Intramuscular)
Trelstar (triptorelin) (Intramuscular) Last Review Date: 02/06/2018 Date of Origin: 11/28/2011 Document Number: IC-0131 Dates Reviewed: 12/2011, 03/2012, 06/19/2012, 09/2012, 12/2012, 03/2013, 06/2013,
Colony Stimulating Factors: Zarxio (filgrastim sndz) (Subcutaneous/Intravenous)
Colony Stimulating Factors: Zarxio (filgrastim sndz) (Subcutaneous/Intravenous) Document Number: IC 0245 Last Review Date: 5/1/2018 Date of Origin: 03/31/2015 Dates Reviewed: 03/2015, 05/2015, 08/2015,
Colony Stimulating Factors: Nivestym (filgrastim-aafi) (Subcutaneous/Intravenous)
Colony Stimulating Factors: Nivestym (filgrastim-aafi) (Subcutaneous/Intravenous) Document Number: MODA-0375 Last Review Date: 08/06/2018 Date of Origin: 08/06/2018 Dates Reviewed: 08/2018 I. Length of
Simponi ARIA (golimumab) (Intravenous)
Simponi ARIA (golimumab) (Intravenous) Last Review Date: 10/31/2017 Date of Origin: 09/05/2013 Document Number: MODA-0176 Dates Reviewed: 12/2013, 8/2014, 3/2015, 6/2015, 9/2015, 12/2015, 3/2016, 6/2016,
Trelstar Depot (triptorelin)
Dates Reviewed: 12/13/2011, 03/2012, 06/19/2012, 09/06/2012, 12/06/2012, 03/07/2013, 06/06/2013, Date of Origin: 11/28/2011 09/05/2013, 12/05/2013, 03/25/2014 Prior Auth Available: Post-service edit: The
Erythropoiesis Stimulating Agents (ESAs): Aranesp (darbepoetin alfa) (Subcutaneous/Intravenous) *NON DIALYSIS* Document Number: IC 0242
Erythropoiesis Stimulating Agents (ESAs): Aranesp (darbepoetin alfa) (Subcutaneous/Intravenous) *NON DIALYSIS* Document Number: IC 0242 Last Review Date: 05/01/2018 Date of Origin: 10/17/2008 Dates Reviewed:
Alimta (pemetrexed) Document Number: IC 0007
Alimta (pemetrexed) Document Number: IC 0007 Last Review Date: 05/01/2018 Date of Origin: 07/20/2010 Dates Reviewed: 09/2010, 12/2010, 03/2011, 06/2011,0 9/2011, 12/2011, 03/2012, 06/2012, 09/2012, 12/2012,
Prolia /Xgeva (denosumab) Document Number: IC-0098
/ (denosumab) Document Number: IC-0098 Last Review Date: 5/30/2017 Date of Origin: 11/28/2011 Dates Reviewed: 12/2011, 03/2012, 06/2012, 09/2012, 12/2012, 03/2013, 06/2013, 03/2014, 06/2014, 09/2014, 12/2014,
Federation of State Boards of Physical Therapy Jurisdiction Licensure Reference Guide Topic: Retaking NPTE
The table below lists the requirements for retaking the National Physical Therapy Exam (NPTE) for each jurisdiction. Summary Number of attempts on NPTE limited? 16 27 Number of attempts allowed before
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Krystexxa) Reference Number: CP.PHAR.115 Effective Date: 06.01.13 Last Review Date: 02.19 Line of Business: Commercial, Medicaid Coding Implications Revision Log See Important Reminder
Federation of State Boards of Physical Therapy Jurisdiction Licensure Reference Guide Topic: Direct Access
Each licensing authority indicates the level of direct access allowed in the jurisdiction and the type of limitations that apply to this access. There are two tables: Types and Limits Referrals TYPES AND
Federation of State Boards of Physical Therapy Jurisdiction Licensure Reference Guide Topic: Direct Access
Each licensing authority indicates the level of direct access allowed in the jurisdiction and the type of limitations that apply to this access. There are two tables: Types and Limits Referrals TYPES AND
Krystexxa. Krystexxa (pegloticase) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.14 Subject: Krystexxa Page: 1 of 5 Last Review Date: March 16, 2018 Krystexxa Description Krystexxa
HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES
Generic Brand HICL GCN Exception/Other PEGLOTICASE KRYSTEXXA 37154 GUIDELINES FOR USE 1. Does the patient have a diagnosis of symptomatic chronic gout (prior to initiating Krystexxa therapy) with clinical
Coverage Summary. Wound Treatments
Coverage Summary Wound Treatments Policy Number: W-001 Products: UnitedHealthcare Medicare Advantage Plans Original Approval Date: 02/18/2009 Approved by: UnitedHealthcare Medicare Benefit Interpretation
Workforce Data The American Board of Pediatrics
Workforce Data 2009-2010 The American Board of Pediatrics Caution. Before using this report as a resource, please read the information below! Please use caution when comparing data in this version of the
Financial Impact of Lung Cancer in West Virginia
Financial Impact of Lung Cancer in West Virginia John Deskins, Ph.D. Christiadi, Ph.D. Sara Harper November 2018 Bureau of Business & Economic Research College of Business & Economics West Virginia University
Federation of State Boards of Physical Therapy Jurisdiction Licensure Reference Guide Topic: Foreign Educated PTs and PTAs
PT Requirements for Licensure Summary: Number of Jurisdictions that Require: Educational Credentials Review 50 from a program equivalent to CAPTE 37 Eligibility to practice in the country in which education
BY-STATE MENTAL HEALTH SERVICES AND EXPENDITURES IN MEDICAID, 1999
STATE-BY BY-STATE MENTAL HEALTH SERVICES AND EXPENDITURES IN MEDICAID, 1999 James Verdier,, Ann Cherlow,, and Allison Barrett Mathematica Policy Research, Inc. Jeffrey Buck and Judith Teich Substance Abuse
Federation of State Boards of Physical Therapy Jurisdiction Licensure Reference Guide Topic: Direct Access
Each licensing authority indicates the level of direct access allowed in the jurisdiction and the type of limitations that apply to this access. There are three tables: Types and Limits Specific Limits
Renflexis (infliximab-abda)
Renflexis (infliximab-abda) Last Review Date: 04/25/2017 Date of Origin: 04/25/2017 Dates Reviewed: 04/2017 Document Number: MODA-0300 I. Length of Authorization Coverage is provided for 6 months and may
2016 COMMUNITY SURVEY
1 Epilepsy Innovation Institute (Ei ) 016 COMMUNITY SURVEY INTRODUCTION From September 8th to November 9th, 016, epilepsy.com hosted a survey that asked the community the following: What are the aspects
Federation of State Boards of Physical Therapy Jurisdiction Licensure Reference Guide Topic: Foreign Educated Physical Therapists
Requirements for Licensure Summary: Number of Jurisdictions that Require: Educational Credentials Review 50 Graduation from a program equivalent to CAPTE 37 Eligibility to practice in the country in which
Subject: Krystexxa (pegloticase) Original Effective Date: 06/26/13. Policy Number: MCP-138. Revision Date(s):
Subject: Krystexxa (pegloticase) Original Effective Date: 06/26/13 Policy Number: MCP-138 Revision Date(s): Review Date(s): 12/16/15; 6/15/2016; 3/21/2017 DISCLAIMER This Molina Clinical Policy (MCP) is
Cimzia (certolizumab pegol) (Subcutaneous)
Cimzia (certolizumab pegol) (Subcutaneous) Last Review Date: 06/01/2018 Date of Origin: 11/28/2011 Document Number: IC-0028 Dates Reviewed: 12/2011, 11/2012, 11/2013, 12/2013, 08/2014, 03/2015, 06/2015,
Stelara (ustekinumab)
Stelara (ustekinumab) Last Review Date: 03/01/2018 Date of Origin: 02/15/2011 Document Number: MODA-0117 Dates Reviewed: 03/2011, 06/2011, 09/2011, 12/2011, 03/2012, 06/2012, 09/2012, 03/2013, 06/2013,
Radiologic Therapeutic Procedures
Coverage Summary Radiologic Therapeutic Procedures Policy Number: R-003 Products: UnitedHealthcare Medicare Advantage Plans Original Approval Date: 04/02/2008 Approved by: UnitedHealthcare Medicare Benefit
Sleep Apnea: Diagnosis and Treatment
Coverage Summary Sleep Apnea: Diagnosis and Treatment Policy Number: S-003 Products: UnitedHealthcare Medicare Advantage Plans Original Approval Date: 08/23/2007 Approved by: UnitedHeatlhcare Medicare
RECOVERY SUPPORT SERVICES IN STATES
RECOVERY SUPPORT SERVICES IN STATES An analysis of State recovery support services using the 16 17 Substance Abuse Block Grant (SABG) Behavioral Health Assessment and Plan THIS PROJECT IS BEING SUPPORTED
Transcranial Magnetic Stimulation
Transcranial Magnetic Stimulation Date of Origin: 7/24/2018 Last Review Date: 7/24/2018 Effective Date: 08/01/18 Dates Reviewed: 7/24/2018 Developed By: Medical Necessity Criteria Committee I. Description
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Krystexxa) Reference Number: CP.CPA.57 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Medicaid Medi-Cal Revision Log See Important Reminder at the end of this policy
The Affordable Care Act and HIV: What are the Implications?
The Affordable Care Act and HIV: What are the Implications? 2013 National Black AIDS Institute Webinar Series September 18, 2013 Jen Kates, Kaiser Family Foundation The Challenge Figure 1 30 years into
Federation of State Boards of Physical Therapy Jurisdiction Licensure Reference Guide Topic: License Renewal. License Renewal on Birthdays
The table below lists information on the term and renewal date for each jurisdiction. Summary License Term 1 26 2 Renewal Date One date 31 Birthdays 6 Half in even years 4 4 License Term AL AK AZ AR CA
USA National Mental Healthcare Nonprofit Exempt Organization Financial Analysis as of December 14, 2015 January 24, 2016 ANSA-H2
USA National Mental Healthcare Nonprofit Exempt Organization Financial Analysis as of December 14, 2015 January 24, 2016 ANSA-H2 Prepared by David Yoo, HanaSoul Consulting, Omaha, Nebraska dcyoo@cox.net
MEDICAL POLICY PEGLOTICASE (KRYSTEXXA ) POLICY NUMBER MP POLICY TITLE. Original Issue Date (Created): January 1, 2011
Original Issue Date (Created): January 1, 2011 Most Recent Review Date (Revised): September 24, 2013 Effective Date: November 1, 2013 I. POLICY PREAUTHORIZATION REQUIRED Note: Requests for pegloticase
Arkansas Prescription Monitoring Program
Arkansas Prescription Monitoring Program FY 2016 Third Quarter Report January-March 2016 Arkansas Prescription Monitoring Program Quarterly Report January March, Fiscal year 2016 Act 304 of 2011 authorized
Intrathecal Opioid Therapy for Management of Chronic Pain
Intrathecal Opioid Therapy for Management of Chronic Pain Date of Origin: 01/2000 Last Review Date: 09/27/2017 Effective Date: 09/27/2017 Dates Reviewed: 11/2002, 12/2003, 12/2004, 12/2005, 12/2006, 12/2007,
Consensus and Collaboration
Consensus and Collaboration John Morton, MD, MPH, FACS, FASMBS Chief, Bariatric & Minimally Invasive Surgery Stanford School of Medicine Past-President, American Society of Metabolic and Bariatric Surgery,
Arkansas Prescription Monitoring Program
Arkansas Prescription Monitoring Program FY 2017 Second Quarter Report October December 2016 Arkansas Prescription Monitoring Program Quarterly Report October December, Fiscal year 2017 Act 304 of 2011
Continuous Glucose Monitoring (CGM)
Continuous Glucose Monitoring (CGM) Date of Origin: 02/2001 Last Review Date: 07/26/2017 Effective Date: 07/26/2017 Dates Reviewed: 04/2004, 04/2005, 03/2006, 11/2006, 12/2007, 03/2008, 09/2008, 04/2009,
Dental ER Visits: Evidence of a Failed System. Shelly Gehshan AACDP Conference April 29, 2012
Dental ER Visits: Evidence of a Failed System Shelly Gehshan AACDP Conference April 29, 2012 Overview of Pew s s findings Preventable dental conditions were the primary diagnosis in 830,590 visits to hospital
Strategies to Increase Hepatitis C Treatment Within ADAPs
Strategies to Increase Hepatitis C Treatment Within ADAPs Amanda Bowes National Alliance of State & Territorial AIDS Directors (NASTAD) Disclosures Presenter(s) has no financial interest to disclose. Learning
Considerations for State Obesity Policy
Considerations for State Obesity Policy Scott Kahan, MD, MPH Faculty, Johns Hopkins Bloomberg School of Public Health Director, National Center for Weight & Wellness Clinical Director, STOP Obesity Alliance,
How to Get Paid for Doing EBD
How to Get Paid for Doing EBD Robert D. Compton, DDS President Robert Compton, DDS Executive Director DentaQuest Institute Disclosure DentaQuest Institute President DentaQuest Benefits Senior VP & CDO
State of California Department of Justice. Bureau of Narcotic Enforcement
State of California Department of Justice Bureau of Narcotic Enforcement Prescription Drugs in the U.S. At least half of all Americans take one prescription drug regularly, with one in six taking three
Overview of the HHS National Network of Quitlines Initiative
Overview of the HHS National Network of Quitlines Initiative Prepared for the 2005 National Oral Health Conference 6th Joint Meeting of ASTDD and AAPHD Barbara Z. Park, RDH, MPH May 2, 2005 Background
Improving Oral Health:
Improving Oral Health: New Tools for State Policy Makers Cassie Yarbrough, MPP Lead Public Policy Analyst Health Policy Institute Lansing, MI June 1, 2017 The ADA Health Policy Institute 2017 American
Anesthesia for Routine Gastrointestinal Endoscopic Procedures (Additional description)
Anesthesia for Routine Gastrointestinal Endoscopic Procedures (Additional description) Date of Origin: 05/2012 Last Review Date: 12/06/2017 Effective Date: 01/01/2018 Dates Reviewed: 12/2013, 11/2014,
Black Women s Access to Health Insurance
FACT SHEET Black Women s Access to Health Insurance APRIL 2018 Data released by the U.S. Census Bureau show that, despite significant health insurance gains since the Affordable Care Act (ACA) was implemented,
Fusilev (levoleucovorin) Document Number: IC-0183
Fusilev (levoleucovorin) Document Number: IC-0183 Last Review Date: 2/1/2018 Date of Origin: 01/02/2014 Dates Reviewed: 08/2014, 03/2015, 05/2015, 08/2015, 11/2015, 02/2016, 05/2016, 08/2016, 11/2016,
AMERICAN IMMUNIZATION REGISTRY ASSOCIATION A L I S O N C H I, P R O G R A M D I R E C T O R
AMERICAN IMMUNIZATION REGISTRY ASSOCIATION A L I S O N C H I, P R O G R A M D I R E C T O R WHAT IS AIRA A way to work together to develop standards, best practices, develop and share strategies and provide
Erythropoiesis Stimulating Agents (ESAs): Epogen/Procrit (epoetin alfa)
Erythropoiesis Stimulating Agents (ESAs): Epogen/Procrit (epoetin alfa) Last Review Date: 02/01/2018 Date of Origin: 10/17/2008 Document Number: IC-0243 Dates Reviewed: 11/2008, 06/2009, 12/2009, 09/2010,
Pulmonary Rehabilitation
Pulmonary Rehabilitation Date of Origin: 06/2005 Last Review Date: 10/25/2017 Effective Date: 10/25/2017 Dates Reviewed: 05/2006, 05/2007, 05/2008, 11/2009, 02/2011, 01/2012, 08/2013, 07/2014, 09/2015,
Voluntary Mental Health Treatment Laws for Minors & Length of Inpatient Stay. Tori Lallemont MPH Thesis: Maternal & Child Health June 6, 2007
Voluntary Mental Health Treatment Laws for Minors & Length of Inpatient Stay Tori Lallemont MPH Thesis: Maternal & Child Health June 6, 2007 Introduction 1997: Nearly 300,000 children were admitted to
Kadcyla (ado-trastuzumab emtansine) Document Number: IC-0092
Kadcyla (ad-trastuzumab emtansine) Dcument Number: IC-0092 Last Review Date: 2/6/2018 Date f Origin: 05/16/2013 Dates Reviewed: 7/2013, 11/2013, 12/2013, 3/2014, 6/2014, 9/2014, 12/2014, 5/2015, 8/2015,
Herniated Disc Treatment Non-covered Procedures
Herniated Disc Treatment Non-covered Procedures Date of Origin: 03/2004 Last Review Date: 03/22/2017 Effective Date: 03/22/2017 Dates Reviewed: 02/2005, 02/2006, 02/2007, 03/2008, 01/2009, 04/2009, 02/2011,
Director s Update Brief novel 2009-H1N1. Tuesday 21 JUL EDT Day 95. Week of: Explaining the burden of disease and aligning resources
Director s Update Brief novel 9-H1N1 Tuesday 1 JUL 9 815 EDT Day 95 Week of: Explaining the burden of disease and aligning resources Key Events novel 9-H1N1 Declarations WHO: Pandemic Phase (11 JUN 9 1
CHILDHOOD ALLERGIES IN AMERICA
CHILDHOOD ALLERGIES IN AMERICA Severe Allergic Reactions Causing More Emergency Room Visits for U.S. Children PUBLISHED MARCH 13, 2018 ( 2 ) EXECUTIVE SUMMARY In this report, the Blue Cross Blue Shield
Evidence-Based Policymaking: Investing in Programs that Work
Evidence-Based Policymaking: Investing in Programs that Work August 4, 2015 The Policy Challenge Though policymakers want to make the best choices, the process often relies on inertia and anecdote Very
A National and Statewide Perspective on the Opioid Crisis
Insert CIO Name Here A National and Statewide Perspective on the Opioid Crisis Amy Peeples, MPA Deputy Director, National Center for Injury Prevention and Control Centers for Disease Control and Prevention
Who is paying pharmacists? Network inclusion Standard and simplified processes
From the 950 s. Increase access points Enhanced and consistent communications / education Documentation / Quality Measures (outcomes) Interface between primary care, public health and pharmacists Documentation
Mexico. April August 2009: first wave
Partners in Prepare edness Conference H1N1 Planning, Re esponse, Recovery April 6, 2010 Overview H1N1 Event April 24: first cases appeared in US and Mexico April 26: public health emergency declared April
Improving Cancer Surveillance and Mortality Data for AI/AN Populations
Improving Cancer Surveillance and Mortality Data for AI/AN Populations Melissa A. Jim, MPH (Diné) Epidemiologist, Cancer Surveillance Branch Assigned to IHS Division of Epidemiology and Disease Prevention
Using Cancer Registry Data to Estimate the Percentage of Melanomas Attributable to UV Exposure
Using Cancer Registry Data to Estimate the Percentage of Melanomas Attributable to UV Exposure Meg Watson, MPH Epidemiologist NAACCR Annual Conference June 16, 2016 National Center for Chronic Disease
Inflectra (infliximab-dyyb) Document Number: MODA-0275
Inflectra (infliximab-dyyb) Document Number: MODA-0275 Last Review Date: 09/19/2017 Date of Origin: 04/26/2016 Dates Reviewed: 04/2016, 09/2016, 12/2016, 03/2017, 06/2017, 09/2017 I. Length of Authorization
MEDICAID FINANCING OF HPV VACCINE: Access for Low-Income Women
MEDICAID FINANCING OF HPV VACCINE: Access for Low-Income Women For the American Public Health Association s 135 th Annual Meeting Alexandra Stewart, JD Department of Health Policy November 7, 2007 1 The
THREE BIG IMPACT ISSUES
THREE BIG IMPACT ISSUES Tim McAfee, MD, MPH Director CDC Office on Smoking and Health Presented at the National Cancer Policy Forum Workshop on Reducing Tobacco-Related Cancer Incidence and Mortality June
LaTanya Runnells, Ph.D Program Manager December 6, 2016
LaTanya Runnells, Ph.D Program Manager December 6, 2016 Mental Health First Aid USA is coordinated by the National Council for Behavioral Health, the Maryland Department of Health and Mental Hygiene, and
Women s Health Coverage: Stalled Progress
FACT SHEET Women s Health Coverage: Stalled Progress SEPTEMBER 2018 New data from the U.S. Census Bureau show that 1 in 10 women lack access to health insurance. This year, progress in reducing the number
Medicaid Expansion & Adult Dental Benefits: Access to Dental Care among Low-Income Adults
Medicaid Expansion & Adult Dental Benefits: Access to Dental Care among Low-Income Adults Astha Singhal BDS, MPH, PhD Assistant Professor, Health Policy & Health Services Research Boston University Henry
What is the Objective of the DQA in Developing Performance Measures. Robert Compton, DDS Executive Director
What is the Objective of the DQA in Developing Performance Measures Robert Compton, DDS Executive Director EBD Champions Conference May 9-10, 2014 DISCLOSURE Disclosure on DentaQuest Benefits ~ 20 million
AMERICA S OPIOID EPIDEMIC AND ITS EFFECT ON THE NATION S COMMERCIALLY-INSURED POPULATION PUBLISHED JUNE 29, 2017
AMERICA S OPIOID EPIDEMIC AND ITS EFFECT ON THE NATION S COMMERCIALLY-INSURED POPULATION PUBLISHED JUNE 29, 2017 America s Opioid Epidemic and Its Effect on the Nation s Commercially-Insured Population
Overview and Findings from ASTHO s IIS Interstate Data Sharing Meeting
Overview and Findings from ASTHO s IIS Interstate Data Sharing Meeting Kim Martin Association of State and Territorial Health Officials (ASTHO) May 12, 2015 The Need for IIS Interstate Data Exchange States,
Uloric Step Therapy Program
Uloric Step Therapy Program Policy Number: 5.01.584 Last Review: 7/2017 Origination: 7/2014 Next Review: 7/2018 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will provide coverage for brand
Hospice in ESRD: To Withdraw or Not to Withdraw
Hospice in ESRD: To Withdraw or Not to Withdraw Access to Hospice for Patients with ESRD Rebecca J. Schmidt, DO, FACP October 2005 In which scenario may the hospice benefit be engaged? ESRD patient with
ADEA Survey of Dental School Seniors, 2015 Graduating Class Tables Report
ADEA Survey of Dental School Seniors, 2015 Graduating Class Tables Report Published March 2016 Suggested Citation American Dental Education Association. (March 2016). ADEA Survey of Dental School Seniors,
ANNUAL REPORT EXECUTIVE SUMMARY. The full report is available at DECEMBER 2017
ANNUAL REPORT EXECUTIVE SUMMARY DECEMBER 2017 The full report is available at www.americashealthrankings.org EXECUTIVE SUMMARY OVERVIEW America s Health Rankings presents its 28th Annual Report, providing
The Growing Health and Economic Burden of Older Adult Falls- Recent CDC Research
The Growing Health and Economic Burden of Older Adult Falls- Recent CDC Research Gwen Bergen, PhD gjb8@cdc.gov Division of Unintentional Injury Prevention National Center for Injury Prevention and Control
Report to Congressional Defense Committees
Report to Congressional Defense Committees The Department of Defense Comprehensive Autism Care Demonstration Quarterly Report to Congress Second Quarter, Fiscal Year 2017 In Response to: Senate Report
Pragmatic Trial Design to Study Health Policy Interventions: Lessons Learned from ARTEMIS Tracy Y. Wang, MD, MHS, MSc, FACC, FAHA
Pragmatic Trial Design to Study Health Policy Interventions: Lessons Learned from ARTEMIS Tracy Y. Wang, MD, MHS, MSc, FACC, FAHA Associate Professor of Medicine, Duke University Director of Health Services
Xeomin (incobotulinumtoxina) (Intramuscular/Intradetrusor/Intradermal)
Xeomin (incobotulinumtoxina) (Intramuscular/Intradetrusor/Intradermal) Last Review Date: 6/1/2018 Date of Origin: 06/21/2011 Document Number: IC-0241 Dates Reviewed: 9/2011, 12/2011, 3/2012, 6/2012, 9/2012,
Xeomin (incobotulinumtoxina) Document Number: IC-0241
Xeomin (incobotulinumtoxina) Document Number: IC-0241 Last Review Date: 3/1/2018 Date of Origin: 06/21/2011 Dates Reviewed: 9/2011, 12/2011, 3/2012, 6/2012, 9/2012, 12/2012, 2/2013, 3/2013, 6/2013, 9/2013,
How Often Do Americans Eat Vegetarian Meals? And How Many Adults in the U.S. Are Vegetarian? Posted on May 29, 2015 by The VRG Blog Editor
How Often Do Americans Eat Vegetarian Meals? And How Many Adults in the U.S. Are Vegetarian? Posted on May 29, 2015 by The VRG Blog Editor The Vegetarian Resource Group asks in a 2015 National Survey Conducted
Clinical Policy: Colchicine (Colcrys) Reference Number: CP.PMN.123 Effective Date: Last Review Date: 05.18
Clinical Policy: (Colcrys) Reference Number: CP.PMN.123 Effective Date: 05.01.11 Last Review Date: 05.18 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important
Khapzory (levoleucovorin) (Intravenous)
Khapzory (levoleucovorin) (Intravenous) Last Review Date: 12/04/2018 Date of Origin: 12/04/2018 Dates Reviewed: 12/2018 Document Number: IC-0408 I. Length of Authorization Coverage will be provided for
High Frequency Chest Wall Oscillating Devices (HFCWO) (Airway Clearance Systems)
High Frequency Chest Wall Oscillating Devices (HFCWO) (Airway Clearance Systems) Date of Origin: 05/2015 Last Review Date: 07/26/2017 Effective Date: 07/26/2017 Dates Reviewed: 07/2016 Developed By: Medical
OREGON MEDICAL MARIJUANA PROGRAM STATISTICAL SNAPSHOT JANUARY, 2015 (REVISED 02/26/2015)
Statistical Snapshot January, 2015 OREGON MEDICAL MARIJUANA PROGRAM STATISTICAL SNAPSHOT JANUARY, 2015 (REVISED 02/26/2015) PUBLIC HEALTH DIVISION Oregon Medical Marijuana Program PO Box 14450 Portland,
PS : Comprehensive HIV Prevention Programs for Health Departments
PS12-1201: Comprehensive HIV Prevention Programs for Health Departments Program Overview Erica K. Dunbar, MPH Program Leader, Health Department Initiatives National Center for HIV/AIDS, Viral Hepatitis,
Present value cost-savings to Medicaid over 25 years
cost-savings from switching would be realized 2 relies on assumptions about the fraction of aggregate medical expenditures avoided and the rate at which they are realized over a 25-year period. In particular,