Medical Policies and Clinical Utilization Management Guidelines update
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1 Medical Policies and Clinical Utilization Management Guidelines update Medical Policies update Summary: On July 26, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Simply Healthcare Plans, Inc. These policies were developed or revised to support clinical coding edits. Several policies were revised to provide clarification only and are not included in the below listing. The Medical Policies were made publicly available on the Simply provider website on the effective date listed below. Visit to search for specific policies. Please note: AIM Musculoskeletal (MSK) Level of Care (LOC) Guidelines, AIM Sleep Study Guidelines and AIM Radiology Guidelines will be effective 11/1/2018 for clinical reviews. When requesting services for a patient, including medical procedures and medications, the Precertification Look-up Tool (PLUTO) located on the provider website under Quick Tools may indicate that No Pre-Certification is required but this does not guarantee payment for services rendered. Services may state No Pre-Certification is required but the Medical Policy or Clinical UM Guideline may still deem the services investigational or not medically necessary. Please ensure that the applicable Clinical Criteria is reviewed prior to rendering services in order to determine if they qualify for payment. Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff. Please note: For markets with pharmacy services carved out, the applicable listings below would be informational only. Publish Date Medical Policy Number Medical Policy Title or DRUG Ibalizumab-uiyk (Trogarzo ) GENE Circulating Tumor DNA Testing for Cancer (Liquid Biopsy) ADMIN Immunizations DRUG Ipilimumab (Yervoy ) DRUG Eculizumab (Soliris ) 8/2/2018 DRUG Ramucirumab (Cyramza ) 8/2/2018 DRUG Pembrolizumab (Keytruda ) DRUG Nivolumab (Opdivo )
2 DRUG Atezolizumab (Tecentriq ) DRUG Lutetium Lu 177 dotatate (Lutathera ) GENE Epidermal Growth Factor Receptor (EGFR) Testing 8/2/2018 GENE Gene Expression Profiling for Managing Breast Cancer Treatment GENE Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignant Tumors GENE Genetic Testing for Breast and/or Ovarian Cancer Syndrome 8/2/2018 MED "Tisagenlecleucel (Kymriah ) 8/2/2018 SURG Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures 8/2/2018 SURG Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention Page 2 of 5
3 Clinical Utilization Management Guidelines update Summary: On July 26, 2018, the MPTAC approved the following Clinical Utilization Management (UM) Guidelines applicable to Amerigroup. These clinical guidelines were developed or revised to support clinical coding edits. Several guidelines were revised to provide clarification only and are not included in the following listing. This list represents the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division on August 31, On July 26, 2018, the clinical guidelines were made publicly available on the Simply Medical Policies and Clinical UM Guidelines subsidiary website. Visit to search for specific guidelines. Please note: AIM Musculoskeletal (MSK) Level of Care (LOC) Guidelines will be effective 11/1/2018 for clinical reviews. Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff. Please note: For markets with pharmacy services carved out, the applicable listings below would be informational only. Publish Date Clinical UM Guideline number Clinical UM Guideline title or 9/20/2018 CG-DME-45 Ultrasound Bone Growth Stimulation 9/20/2018 CG-DRUG-103 Botulinum Toxin 9/20/2018 CG-DRUG-104 Omalizumab (Xolair ) 9/20/2018 CG-DRUG-105 Abatacept (Orencia ) 9/20/2018 CG-DRUG-106 Brentuximab Vedotin (Adcetris ) 9/20/2018 CG-DRUG-107 Pharmacotherapy for Hereditary Angioedema 9/20/2018 CG-DRUG-108 Enteral Carbidopa and Levodopa Intestinal Gel Suspension 9/20/2018 CG-DRUG-109 Asfotase Alfa (Strensiq ) 9/20/2018 CG-DRUG-110 Naltrexone Implantable Pellets 9/20/2018 CG-DRUG-111 Sebelipase alfa (KANUMA ) 9/20/2018 CG-DRUG-112 Abaloparatide (Tymlos ) Injection 9/20/2018 CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical) Page 3 of 5
4 9/20/2018 CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry 9/20/2018 CG-MED-75 Medical and Other Non- Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome 9/20/2018 CG-MED-76 Magnetic Source Imaging and Magnetoencephalography 9/20/2018 CG-MED-77 SPECT/CT Fusion Imaging 9/20/2018 CG-REHAB-11 Cognitive Rehabilitation 9/20/2018 CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants 9/20/2018 CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids 10/31/2018 CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity 9/20/2018 CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery 10/31/2018 CG-SURG-85 Hip Resurfacing 10/31/2018 CG-SURG-86 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring 9/20/2018 CG-SURG-87 Previous title: Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring 9/20/2018 CG-SURG-88 Mastectomy for Gynecomastia 9/20/2018 CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia CG-ADMIN-02 Clinically Equivalent Cost Effective Services Targeted Immune Modulators CG-DRUG-09 Immune Globulin (Ig) Therapy Page 4 of 5
5 CG-DRUG-65 Tumor Necrosis Factor Antagonists CG-DRUG-68 Bevacizumab (Avastin ) for Non-Ophthalmologic Indications CG-DRUG-73 Denosumab (Prolia, Xgeva ) CG-DRUG-81 Tocilizumab (Actemra ) CG-GENE-03 BRAF Mutation Analysis CG-MED-35 Retinal Telescreening Systems CG-MED-71 Wound Care in the Home Setting Functional Endoscopic Sinus 8/2/2018 CG-SURG-24 Surgery (FESS) CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities 8/2/2018 CG-SURG-73 Balloon Sinus Ostial Dilation 74792MUPENMUB 10/16/2018 Simply Healthcare Plans, Inc. is a Medicare-contracted coordinated care plan that has a Medicaid contract with the State of Florida Agency for Health Care Administration to provide benefits or arrange for benefits to be provided to enrollees. Enrollment in Simply Healthcare Plans, Inc. depends on contract renewal. Page 5 of 5
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