Clinical UM Guidelines for Indiana, Kentucky, Missouri, Ohio and Wisconsin

Transcription

1 10/4/2018 State: State CG number CG title CG Category Date implemented CG-ADMIN-02 Clinically Equivalent Cost Effective Services Targeted Immune Modulators Admin 7/1/2018 CG-ANC-04 Ambulance services Air and Water Ancillary Services prior to 1/1/16 CG-ANC-06 Ambulance Services Ground Non-emergent Ancillary Services prior to 1/1/16 CG-DRUG-01 Off Label Drug and Approved Orphan Drug Use Drugs prior to 1/1/16 CG-DRUG-03 Beta Interferons or Glatiramer Acetate for Treatment of Multiple Sclerosis Drugs prior to 1/1/16 CG-DRUG-05 Recombinant Erythropoietin Products Drugs prior to 1/1/16 CG-DRUG-08 Pharmacotherapy for Gaucher Disease Drugs prior to 1/1/16 CG-DRUG-09 Immune Globulin Therapy (Ig) Drugs prior to 1/1/16 CG-DRUG-11 Infertility Drugs Drugs prior to 1/1/16 CG-DRUG 16 White Blood Cell Growth Factors Drugs prior to 1/1/16 CG-DRUG-24 Repository Corticotropin Injection Drugs prior to 1/1/16 CG-DRUG-25 IV vs. Oral Drug Administration in the Outpatient and Home Sett Drugs prior to 1/1/16 CG-DRUG-27 Clostridial Collagenase Histolyticum Injection Drugs 9/15/2016 CG-DRUG-28 Alglucosidase Alfa Drugs prior to 1/1/16 CG-DRUG-29 Hyaluronan Injections Drugs 12/1/2017 CG-DRUG-38 Pemetrexed Disodium (Alimta) Drugs prior to 1/1/16 CG-DRUG-42 Asparagine Specific Enzymes (Asparaginase) Drugs prior to 1/1/16 CG-DRUG-43 Natalizumab (Tysabri ) Drugs 1/1/2017 CG-DRUG-45 Octreotide acetate (Sandostatin ; Sandostatin LAR Depot) Drugs prior to 1/1/16 CG-DRUG-47 Level of Care: Specialty Pharmaceuticals Drugs 7/18/2016 CG-DRUG-49 Doxorubicin Hydrochloride Liposome Injection Drugs 1/1/2017 CG-DRUG-50 Paclitaxel, protein-bound (Abraxane ) Drugs 1/1/2017 CG-DRUG-51 Romidepsin (Istodax ) Drugs 1/1/2017 CG-DRUG-53 Drug Dosage, Frequency, and Route of Administration Drugs 9/1/2017 CG-DRUG-54 Agalsidase beta (Fabrazyme ) Drugs 5/1/2017 CG-DRUG-55 Elosulfase alfa (Vimizim ) Drugs 5/1/2017 CG-DRUG-56 Galsulfase (Naglazyme ) Drugs 5/1/2017 CG-DRUG-57 Idursulfase (Elaprase ) Drugs 5/1/2017 CG-DRUG-58 Laronidase (Aldurazyme ) Drugs 5/1/2017 CG-DRUG-61 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications Drugs 12/28/2016 CG-DRUG-62 Fulvestrant (FASLODEX ) Drugs 5/1/2017 CG-DRUG-63 Levoleucovorin Calcium (Fusilev ) Drugs 5/1/2017 CG-DRUG-64 FDA - Approved Biosimilar Products Drugs 6/1/2017 CG-DRUG-65 Tumor Necrosis Factor Antagonists Drugs 12/27/2017 CG-DRUG-66 Panitumumab (Vectibix ) Drugs 12/27/2017 CG-DRUG-67 Cetuximab (Erbitux ) Drugs 6/28/2018 CG-DRUG-68 Bevacizumab (Avastin ) for Non-Ophthalmologic Indications Drugs 12/27/2017 CG-DRUG-69 Ustekinumab (Stelara ) Drugs 12/27/2017 CG-DRUG-70 Eribulin mesylate (Halaven ) Drugs 12/27/2017 CG-DRUG-71 Ziv-aflibercept (Zaltrap ) Drugs 12/27/2017 CG-DRUG-72 Pertuzumab (Perjeta ) Drugs 12/27/2017 CG-DRUG-73 Denosumab (Prolia, Xgeva ) Drugs 12/27/2017 CG-DRUG-74 Canakinumab (Ilaris ) Drugs 12/27/2017 CG-DRUG-75 Romiplostim (Nplate ) Drugs 12/27/2017 CG-DRUG-76 Plerixafor Injection (Mozobil ) Drugs 12/27/2017 CG-DRUG-77 Radium Ra 223 Dichloride (Xofigo ) Drugs 12/27/2017 CG-DRUG-78 Antihemophilic Factors and Clotting Factors Drugs 12/27/2017 CG-DRUG-79 Siltuximab (Sylvant ) Drugs 12/27/2017 CG-DRUG-80 Cabazitaxel (Jevtana ) Drugs 12/27/2017 CG-DRUG-81 Tocilizumab (Actemra ) Drugs 12/27/2017 CG-DRUG-82 Prostacyclin Infusion Therapy and Inhalation Therapy for Treatment of Pulmonary Arterial Hypertension Drugs 5/1/2018 CG-DRUG-83 Growth Hormone Drugs 5/1/2018 CG-DRUG-84 Belimumab (Benlysta ) Drugs 5/1/2018

2 CG-DRUG-85 Tesamorelin (Egrifta ) Drugs 5/1/2018 CG-DRUG-86 Ocriplasmin (Jetrea ) Intravitreal Injection Treatment Drugs 5/1/2018 CG-DRUG-87 Vedolizumab (Entyvio ) Drugs 5/1/2018 CG-DRUG-88 Dupilumab (Dupixent ) Drugs 5/1/2018 CG-DRUG-89 Implantable and Extended-Release Buprenorphine-Containing Products Drugs 6/22/2018 CG-DRUG-90 Intravitreal Treatment for Retinal Vascular Conditions Drugs 6/28/2018 CG-DRUG-91 Intravitreal Treatment for Retinal Vascular Conditions Drugs 6/28/2018 CG-DRUG-92 Alpha-1 Proteinase Inhibitor Therapy Drugs 6/28/2018 CG-DRUG-93 Sarilumab (Kevzara ) Drugs 6/28/2018 CG-DRUG-94 Rituximab (Rituxan ) for Non-Oncologic Indications Drugs 6/28/2018 CG-DRUG-95 Belatacept (Nulojix ) Drugs 6/28/2018 CG-DRUG-96 Ado-trastuzumab emtansine (Kadcyla ) Drugs 6/28/2018 CG-DRUG-97 Rilonacept (Arcalyst ) Drugs 6/28/2018 CG-DRUG-98 Bendamustine Hydrochloride Drugs 6/28/2018 CG-DRUG-99 Elotuzumab (Empliciti ) Drugs 6/28/2018 CG-DRUG-100 Interferon gamma-1b (Actimmune ) Drugs 6/28/2018 CG-DRUG-101 Ixabepilone (Ixempra ) Drugs 6/28/2018 CG-DRUG-102 Olaratumab (Lartruvo ) Drugs 6/28/2018 CG-DRUG-103 Botulinum Toxin Drugs 9/20/2018 CG-DRUG-104 Omalizumab (Xolair ) Drugs 9/20/2018 CG-DRUG-105 Abatacept (Orencia ) Drugs 9/20/2018 CG-DRUG-106 Brentuximab Vedotin (Adcetris ) Drugs 9/20/2018 CG-DRUG-107 Pharmacotherapy for Hereditary Angioedema Drugs 9/20/2018 CG-DRUG-108 Enteral Carbidopa and Levodopa Intestinal Gel Suspension Drugs 9/20/2018 CG-DRUG-109 Asfotase Alfa (Strensiq ) Drugs 9/20/2018 CG-DRUG-110 Naltrexone Implantable Pellets Drugs 9/20/2018 CG-DRUG-111 Sebelipase alfa (KANUMA ) Drugs 9/20/2018 CG-DRUG-112 Abaloparatide (Tymlos ) Injection Drugs 9/20/2018 CG--06 Pneumatic Compression Devices for Lymphedema prior to 1/1/16 CG--07 Augmentative and Alternative Communication prior to 1/1/16 CG--10 Durable Medical Equipment prior to 1/1/16 CG--15 Hospital Beds and Accessories prior to 1/1/16 CG--16 Pressure Reducing Support Surfaces prior to 1/1/16 CG--24 Manual Wheeled Mobility Devices prior to 1/1/16 CG--31 Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) prior to 1/1/16 Wheeled Mobility Devices: Manual Wheelchairs-Ultra CG--33 Lightweight prior to 1/1/16 CG--40 Electrical Bone Growth Stimulation 12/27/2017 CG--41 Ultraviolet Light Therapy Delivery Devices for Home Use 12/27/2017 Non-implantable Insulin Infusion and Blood Glucose Monitoring CG--42 Devices 5/1/2018 High Frequency Chest Compression Devices for Airway CG--43 Clearance 5/1/2018 CG--45 Ultrasound Bone Growth Stimulation 9/20/2018 CG-GENE-01 Janus Kinase 2 (JAK2) V617F Gene Mutation Assay Gene 12/27/2017 CG-GENE-02 Analysis of KRAS Status Gene 12/27/2017 CG-GENE-03 BRAF Mutation Analysis Gene 12/27/2017 CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules Gene 12/27/2017 Screening for Vitamin D Deficiency in Average Risk Individuals CG-LAB-11 LAB 6/1/2018 CG-LAB-13 Skin Nerve Fiber Density Testing LAB 6/28/2018 CG-MED-19 Custodial Care Medicine prior to 1/1/16 CG-MED-23 Home Health Medicine 3/1/2018 CG-MED-26 Neonatal Levels of Care Medicine prior to 1/1/16 CG-MED- 37 Pediatric Feeding Programs Medicine prior to 1/1/16 CG-MED-38 Inpatient Admission for Radiation Therapy Medicine prior to 1/1/16

3 CG-Med-46 Ambulatory and Inpatient Video Electroencephalography Medicine 7/1/2017 CG-Med-55 Level of Care - Advanced Radiologic Imaging Medicine 6/28/2017 CG-Med-58 Coronary Artery Imaging: Contrast-Enhanced CT Angiography, Fractional Flow Reserve derived from CT, Coronary MRA, and Cardiac MRI Medicine 9/15/2017 CG-Med-59 Upper Gastrointestinal Endoscopy in Adults Medicine 11//1/2018 CG-MED-63 Treatment of Hyperhidrosis Medicine 12/27/2017 CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation) Medicine 12/27/2017 CG-MED-65 Manipulation Under Anesthesia of the Spine and Joints other than the Knee Medicine 12/27/2017 CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue Medicine 12/27/2017 CG-MED-67 Melanoma Vaccines Medicine 12/27/2017 CG-MED-68 Therapeutic Apheresis Medicine 12/27/2017 CG-MED-69 Inhaled Nitric Oxide Medicine 6/28/2018 CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule Medicine 6/28/2018 CG-MED-72 Hyperthermia for Cancer Therapy Medicine 6/28/2018 CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical) Medicine 9/20/2018 CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry Medicine 9/20/2018 CG-MED-75 Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome Medicine 9/20/2018 CG-MED-76 Magnetic Source Imaging and Magnetoencephalography Medicine 9/20/2018 CG-MED-77 SPECT/CT Fusion Imaging Medicine 9/20/2018 CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices Orthotics-Prosthetics prior to 1/1/16 CG-REHAB-03 Pulmonary Rehabilitation Rehabilitation prior to 1/1/16 CG-REHAB-04 Physical Therapy Rehabilitation prior to 1/1/16 CG-REHAB-05 Occupational Therapy Rehabilitation prior to 1/1/16 CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services Rehabilitation prior to 1/1/16 CG-REHAB-08 Private Duty Nursing in the Home Setting Rehabilitation prior to 1/1/16 CG-REHAB-10 Level of Care: Outpatient Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services (*Note - Adopted for KY sold plans only) Rehabilitation 7/1/2017 CG-REHAB-11 Cognitive Rehabilitation Rehabilitation 9/20/2018 CG-SURG-03 Blepharoplasty, Blepharoptosis Repair and Brow Lift Surgery prior to 1/1/16 CG-SURG-05 MAZE Procedure (effective 1/1/2013) Surgery prior to 1/1/16 CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Surgery prior to 1/1/16 CG-SURG-09 Temporomandibular Disorders Surgery prior to 1/1/16 CG-SURG-12 Penile Prosthesis Implantatation Surgery prior to 1/1/16 CG-SURG-18 Septoplasty Surgery prior to 1/1/16 CG-SURG-24 Functional Endoscopic Sinus Surgery Surgery prior to 1/1/16 CG-SURG-27 Sex Reassignment Surgery Surgery prior to 1/1/16 CG-SURG-28 Transcatheter Uterine Artery Embolization Surgery prior to 1/1/16 CG-SURG-30 Tonsillectomy for Children with or without Adenoidectomy Surgery prior to 1/1/16 CG-SURG-33 Lumbar Fusion and Lumbar Artificial Intervertebral Disc (LAID) Surgery prior to 1/1/16 CG-SURG-38 Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and or DSurgery prior to 1/1/16 CG-SURG-42 Cervical Fusion Surgery 6/28/2016 CG-SURG-43 Knee Arthroscopy Surgery 4/4/2016 CG-SURG-44 Coronary Angiography and Cardiac Catheterization in the OutpatSurgery prior to 1/1/16 CG-SURG-47 Surgical Interventions for Scoliosis and Spinal Deformity Surgery 5/2/2016 CG-SURG-48 Elective Percutaneous Coronary Interventions (PCI) Surgery prior to 1/1/16 CG-SURG-53 Elective Total Hip Arthroplasty Surgery 7/1/2016 CG-SURG-54 Elective Total Knee Arthroplasty Surgery 7/1/2016 CG-SURG-60 Cervical Total Disc Arthroplasty Surgery 9/22/2017 CG-SURG-61 Cryosurgical Ablation of Solid Tumors Outside the Liver Surgery 12/27/2017 CG-SURG-62 Radiofrequency Ablation to Treat Tumors Outside the Liver Surgery 12/27/2017

4 Cardiac Resynchronization Therapy (CRT) with or without an CG-SURG-63 Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure Surgery 12/27/2017 CG-SURG-65 Recombinant Human Bone Morphogenetic Protein Surgery 12/27/2017 CG-SURG-66 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS) Surgery 12/27/2017 CG-SURG-67 Treatment of Osteochondral Defects Surgery 12/27/2017 CG-SURG-68 Surgical Treatment of Femoracetabular Impingement Syndrome Surgery 12/27/2017 CG-SURG-69 Meniscal Allograft Transplantation of the Knee Surgery 12/27/2017 CG-SURG-70 Gastric Electrical Stimulation Surgery 5/1/2018 CG-SURG-71 Reduction Mammaplasty Surgery 5/1/2018 CG-SURG-72 Endothelial Keratoplasty Surgery 5/1/2018 CG-SURG-73 Balloon Sinus Ostial Dilation Surgery 6/28/2018 CG-SURG-74 Total Ankle Replacement Surgery 6/28/2018 CG-SURG-75 Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions Surgery 6/28/2018 CG-SURG-76 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty Surgery 6/28/2018 CG-SURG-77 Refractive Surgery Surgery 6/28/2018 CG-SURG-78 Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies Surgery 6/28/2018 CG-SURG-79 Implantable Transcatheter Infusion Arterial Pumps Chemoembolization (TACE) and Surgery 6/28/2018 Transcatheter Arterial Embolization (TAE) for Treating Primary CG-SURG-80 or Metastatic Liver Tumors Surgery 6/28/2018 CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants Surgery 9/20/2018 CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids Surgery 9/20/2018 CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity Surgery 10/31/2018 CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery Surgery 9/20/2018 CG-SURG-85 Hip Resurfacing Surgery 10/31/2018 CG-SURG-86 CG-SURG-87 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection Surgery 10/31/2018 Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring Surgery 9/20/2018 CG-SURG-88 Mastectomy for Gynecomastia Surgery 9/20/2018 CG-SURG-89 CG-THER-RAD-03 CG-THER-RAD-04 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia Surgery 9/20/2018 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy Ther-Rad 7/1/2018 Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver Tumors Ther-Rad 7/1/2018 CG-THER-RAD-07 Intravascular Brachytherapy (Coronary and Non-Coronary) Ther-Rad 6/28/2018 CG-TRANS-03 Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation Transplant 9/20/2018 THIRD PARTY CRITERIA ADOPTED: The health plan may use guidelines developed by third parties to perform utilization management services of some procedures for certain health plan members. AIM Specialty Health (AIM). For more detail please visit the AIM Specialty Health site with links to Anthem programs You may also call AIM toll free at (800) (Hours 7:30a - 6p CT M-F)

5 AIM provides benefits management for the following listed programs Radiology Benefit Management including Imaging Level of Care Genetic Testing Cardiology - Cardiovascular Services Outpatient Sleep Testing and Therapy Services Specialty Pharmacy Drugs Radiation Oncology Cancer Care Quality Program Musculoskeletal Clinical Appropriateness Guidelines: Spine Surgery, Joint Surgery, and Interventional Pain Management Upper Gastrointestinal Endoscopy in Adults.The AIM Surgical GI program (using CG-MED-59) for upper endoscopy procedures will be effective 11/1/18. Prior authorization will be managed by AIM for Local Fully Insured members. For dates of service 11/1/2018 and after please contact AIM.