Medical policies update
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- Morgan Fisher
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1 On February 5, 2015, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following medical policies which are applicable to BlueChoice HealthPlan Medicaid. These medical policies were developed or revised to support clinical coding edits. The medical policies were made publicly available on the BlueChoice HealthPlan Medicaid provider website on the effective date listed below. Visit to search for specific policies. Existing precertification requirements have not changed. effective date number April 7, 2015 DRUG Alpha-1 Proteinase Inhibitor Therapy April 7, 2015 DRUG Rilonacept (Arcalyst ) April 7, 2015 DRUG Alemtuzumab (Lemtrada ) April 7, 2015 GENE Genetic Testing of an Individual s Genome for Inherited Diseases April 7, 2015 MED Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management April 7, 2015 MED Near-Infrared Spectroscopy Brain Screening for Hematoma Detection February 9, 2015 DRUG Enteral Carbidopa and Levodopa Intestinal Gel Suspension BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. Healthy Connections is administered for BlueChoice HealthPlan by WellPoint Partnership Plan, LLC, an independent company. BSCPEC
2 Page 2 of 7 February 9, 2015 GENE Genetic Testing for Hereditary Pancreatitis February 9, 2015 SURG Intraocular Telescope April 7, 2015 ADMIN Medical Policy Formation April 7, 2015 GENE Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status April 7, 2015 GENE Cell-Free Fetal DNA-Based Prenatal Screening for Fetal Aneuploidy April 7, 2015 DRUG Omalizumab (Xolair ) April 7, 2015 DRUG Belimumab (Benlysta ) April 7, 2015 MED Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems April 7, 2015 MED Autologous Cell Therapy for the Treatment of Damaged Myocardium April 7, 2015 SURG Treatments for Urinary Incontinence April 7, 2015 SURG Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty
3 Page 3 of 7 April 7, 2015 SURG Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention April 7, 2015 SURG Interspinous Process Fixation Devices April 7, 2015 GENE Analysis of Fecal DNA for Colorectal Cancer Screening and Surveillance April 7, 2015 SURG Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting The following existing Clinical Utilization Management Guideline was adopted through the Medical Operations Committee on April 23, 2015: CG-DME-20 Orthopedic Footwear On May 7, 2015, MPTAC approved the following medical policies which are applicable to BlueChoice HealthPlan Medicaid. These medical policies were developed or revised to support clinical coding edits. The medical policies were made publicly available on the provider website on the effective date listed below. Visit to search for specific policies. Existing precertification requirements have not changed. effective date number May 11, 2015 DRUG Nivolumab (Opdivo ) July 7, 2015 DRUG Blinatumomab (Blincyto ) July 7, 2015 LAB Advanced Lipoprotein Testing in Cardiac Disease Risk Assessment and Management July 7, 2015 MED Continuous Monitoring of Intraocular Pressure
4 Page 4 of 7 July 7, 2015 SURG.0140 Peripheral Nerve Blocks for Treatment of Neuropathic Pain May 11, 2015 DRUG Botulinum Toxin May 11, 2015 DRUG Intravitreal and Periocular Injection Treatment for Retinal Vascular Conditions May 11, 2015 DRUG Bevacizumab (Avastin ) for Non-Ophthalmologic Indications May 11, 2015 DRUG Brentuximab Vedotin (Adcetris ) May 11, 2015 DRUG Eribulin mesylate (Halaven ) July 7, 2015 DRUG Pertuzumab (Perjeta ) May 11, 2015 DRUG Denosumab (Prolia, Xgeva ) May 11, 2015 DRUG Romiplostim (Nplate ) May 11, 2015 DRUG Antihemophilic Factors and Clotting Factors May 11, 2015 DRUG Ramucirumab (Cyramza ) May 11, 2015 DRUG Pembrolizumab (Keytruda ) July 7, 2015 GENE Gene Expression Profiling of Melanomas July 7, 2015 RAD Positron Emission Tomography (PET) and PET/CT Fusion July 7, 2015 RAD Brachytherapy for Oncologic Indications May 11, 2015 SURG Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting May 11, 2015 SURG Implantable Cardioverter-Defibrillator (ICD) May 11, 2015 SURG Mechanical Embolectomy for Treatment of Acute Stroke May 11, 2015 TRANS Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
5 Clinical Utilization Management Guidelines update BlueChoice HealthPlan Medicaid Page 5 of 7 On February 5, 2015, MPTAC approved the following Clinical Utilization Management (UM) Guidelines which are applicable to BlueChoice HealthPlan Medicaid. These clinical guidelines were developed or revised to support clinical coding edits. The Clinical UM Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee on February 23, Clinical guidelines are publicly available on the BlueChoice HealthPlan Medicaid Medical Policies and Clinical UM Guidelines website. To access this site: Go to Select Providers from the left menu bar. Select Resources from the right menu bar. Select Policies & Guidelines from the menu. Select Medical Policies and UM Guidelines. Existing precertification requirements have not changed. Effective date Clinical UM Guideline number Clinical UM Guideline title or new April 7, 2015 CG-DRUG-43 Natalizumab (Tysabri ) April 7, 2015 CG-DRUG-44 Pegloticase (Krystexxa ) April 7, 2015 CG-SURG-46 Myringotomy and Tympanostomy Tube Insertion February 9, 2015 CG-ANC-04 Ambulance Services: Air and Water February 9, 2015 CG-DME-21 External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings February 9, 2015 CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthotics) April 7, 2015 CG-BEH-07 Psychological Testing April 7, 2015 CG-DME-19 Therapeutic Shoes, Inserts or Modifications for Individuals with Diabetes April 7, 2015 CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs Standard, Heavy Duty, Lightweight April 7, 2015 CG-DME-31 Wheeled Mobility Devices: Wheelchairs Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) April 7, 2015 CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs Ultra Lightweight April 7, 2015 CG-DRUG-07 Hepatitis C Pegylated Interferon Antiviral Therapy
6 Page 6 of 7 April 7, 2015 CG-DRUG-14 Dihydroergotamine Mesylate (DHE) Injection for the Treatment of Migraine or Cluster Headaches in Adults April 7, 2015 CG-DRUG-21 Naltrexone (Vivitrol ) Injections for the Treatment of Alcohol and Opioid Dependence April 7, 2015 CG-LAB-09 Drug Testing or Screening in the Context of Substance Abuse and Chronic Pain April 7, 2015 CG-MED-22 Neuropsychological Testing April 7, 2015 CG-MED-32 Ancillary Services for Pregnancy Complications April 7, 2015 CG-MED-46 Ambulatory and Inpatient Video Electroencephalography April 7, 2015 CG-SURG-33 Lumbar Fusion and Lumbar Artificial Intervertebral Disc (LAID April 7, 2015 CG-SURG-39 Pain Management: Epidural Steroid Injections April 7, 2015 CG-SURG-41 Surgical Strabismus Correction April 7, 2015 CG-SURG-44 Coronary Angiography and Cardiac Catheterization in the Outpatient Setting On May 7, 2015, MPTAC approved the following Clinical UM Guidelines which are applicable to BlueChoice HealthPlan Medicaid. These clinical guidelines were developed or revised to support clinical coding edits. The Clinical UM Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee on May 18, Clinical guidelines are publicly available on the BlueChoice HealthPlan Medicaid Medical Policies and Clinical UM Guidelines subsidiary website. To access this site: Go to Select Providers from the left menu bar. Select Resources from the right menu bar. Select Policies & Guidelines from the menu. Select Medical Policies and UM Guidelines. Existing precertification requirements have not changed. Effective date Clinical UM Guideline number Clinical UM Guideline title or new July 7, 2015 CG-DRUG-45 Octreotide acetate (Sandostatin ; Sandostatin LAR Depot) July 7, 2015 CG-DRUG-46 Fosaprepitant (Emend ) June 15, 2015 CG-SURG-47 Surgical Interventions for Scoliosis and Spinal Deformity
7 Page 7 of 7 May 11, 2015 CG-BEH-05 Eating and Feeding Disorder Treatment July 7, 2015 CG-DRUG-09 Immune Globulin (Ig) Therapy May 11, 2015 CG-DRUG-15 Gonadotropin Releasing Hormone (GnRH) Analogs May 11, 2015 CG-DRUG-16 White Blood Cell Growth Factors July 7, 2015 CG-MED-46 Ambulatory and Inpatient Video Electroencephalography July 7, 2015 CG-MED-47 Fundus Photography July 7, 2015 CG-REHAB-08 Private Duty Nursing in the Home Setting July 7, 2015 CG-SURG-01 Colonoscopy July 7, 2015 CG-SURG-17 Trigger Point Injections May 11, 2015 CG-SURG-44 Coronary Angiography and Cardiac Catheterization in the Outpatient Setting The following Medical Policies and Clinical UM guidelines have been archived on the date listed below. Effective date Clinical UM Guideline number Clinical UM Guideline title April 7, 2015 GENE Diagnostic Genetic Testing of a Potentially Affected Individual (Adult or Child) April 7, 2015 GENE Predictive Genetic Testing for Non-Malignant Diseases April 7, 2015 CG-DRUG-32 HCV and HIV-AIDS Anti-Viral Drug Treatment Regimens May 11, 2015 DRUG Recombinant Coagulation Factor IX, Fc Fusion Protein (Alprolix ) May 11, 2015 DRUG Recombinant Antihemophilic Factor, Fc Fusion Protein (Eloctate ) May 15, 2015 RAD Real-Time Intra-Fraction Target Tracking during Radiation Therapy July 7, 2015 CG-MED-43 Multiple Sleep Latency Testing (MSLT) and Maintenance of Wakefulness Testing (MWT) Guideline
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