Prior Authorization Review Panel MCO Policy Submission
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1 Prior Authorization Review Panel MCO Policy Submission A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review. Plan: Aetna Better Health Submission Date: 11/01/2018 Policy Number: 0527 Policy Name: Intragastric Hypothermia Effective Date: Revision Date: Type of Submission Check all that apply: New Policy* Revised Policy Annual Review No Revisions *All revisions to the policy must be highlighted using track changes throughout the document. Please provide any clarifying information for the policy below: CPB 0527 Intragastric Hypothermia Policy is new to Aetna Better Health of Pennsylvania. Name of Authorized Individual (Please type or print): Signature of Authorized Individual: Dr. Bernard Lewin, M.D.
2 Intragastric Hypothermia - Medical Clinical Policy Bulletins Aetna Page 1 of 5 Intragastric Hypothermia Number: 0527 Policy *Please see amendment forpennsylvaniamedicaid at theend of this CPB. Aetna considers gastric freezing (intragastric hypothermia) experimental and investigational for chronic peptic ulcer disease or any other indications because there is insufficient evidence to support its effectiveness for these indications. Policy History Last Review: 10/10/2018 Effective: 06/15/2001 Next Review: 05/23/2019 Review History Definitions Background Gastric freezing for chronic peptic ulcer disease is a nonsurgical treatment which was popular about 20 years ago but now is seldom performed. It has been abandoned due to a high complication rate, only temporary improvement experienced by patients, and a lack of effectiveness when tested by double-blind, controlled clinical trials. The Center for Medicare and Medicaid Services (CMS) has concluded that this procedure is obsolete. Additional Information Clinical Policy Bulletin Notes CPT Codes / HCPCS Codes / ICD-10 Codes
3 Intragastric Hypothermia - Medical Clinical Policy Bulletins Aetna Page 2 of 5 Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+": Code Code Description HCPCS codes not covered for indications listed in the CPB: M0100 Intragastric hypothermia using gastric freezing ICD-10 codes not covered for indications listed in the CPB: (not all-inclusive) : K Chronic or unspecified peptic ulcer K27.9 The above policy is based on the following references: 1. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS). Gastric freezing. Medicare Coverage Issues Manual Baltimore, MD: CMS; Nasbeth DC, Nicholson AJ, Newman WH, et al. The influence of intragastric cooling on acute experimental pancreatitis. Surg Forum. 1960;11: Nasbeth DC, Goodale RL, Reif AE. Studies on the effect of intragastric cooling on acute experimental pancreatitis. Surgery. 1960;47: Ruffin JM, Grizzle JE, Hightower NC, et al. A co- operative double-blind evaluation of gastric 'freezing' in the treatment of duodenal ulcer. N Engl J Med. 1969;281 (1): McIntyre JA, Jalil S, Deitel M. Clinical course after gastric freezing: Long-term follow-up of 74 patients and a review of the literature. Can J Surg. 1969;12(2): Ruffin JM, Shingleton WM, McMillan WO Jr. Cold facts about gastric freezing. Postgrad Med. 1968;44(5):84-87.
4 Intragastric Hypothermia - Medical Clinical Policy Bulletins Aetna Page 3 of 5 7. Zikria BA, De Jesus RS, Cunnick WR, Ferrer JM Jr. Gastric 'freezing'--a clinical double-blind study. Am J Gastroenterol. 1967;47(3): Barner HB, Collins CH, Jones TI, Garlick TB. Clinical gastric 'freezing'. Am J Dig Dis. 1966;11(8): Marx FW Jr, Kolig G. The hazards of gastric freezing. Am J Dig Dis. 1966;11(4): Lubos MC, Viril LC, Klotz AP. A controlled study of outpatient gastric freezing. Am J Dig Dis. 1966;11(4): Wangensteen SL, Smith RB 3, Barker HG. Gastric cooling and gastric 'freezing'. Surg Clin North Am. 1966;46(2): Hitchcock CR, Ruiz E, Sutherland D, Bitter JE. Eighteenmonth follow-up of gastric freezing in 173 patients with duodenal ulcer. JAMA. 1966;195(2): Fuson RL, Shingleton WW. Technical considerations in gastric freezing. Cryobiology. 1965;2(3): Scott HW Jr, O'Neill JA Jr, Snyder HE, Shull HJ. An evaluation of the long term results of gastric freezing for duodenal ulcer. Surg Gynecol Obstet. 1965;121(4): Rose H, Fordtran JS, Harrell R, Friedman B. A controlled study of gastric freezing for the treatment of duodenal ulcer. Gastroenterol. 1964;47: Perry GT, Dunphy JV, Fruin RC, Littman A. Gastric freezing for duodenal ulcer, a double blind study. Gastroenterol. 1964:47: Goodale RL Jr, Ghanem M, Borner JW, et al. Improved technology and enhanced accomplishment of gastric freezing. An experimental study. Arch Surg. 1972;104 (3): Miao LL. Gastric freezing: An example of the evaluation of medical therapy by randomized clinical trials. In: Bunker JR, Barnes BA, Mostelloer F, eds. Cost, Risks and Benefits of Therapy. New York, NY: Oxford University Press:1977; Ch.12, pp
5 Intragastric Hypothermia - Medical Clinical Policy Bulletins Aetna Page 4 of Fineberg HV. Gastric freezing: A study of diffusion of a medical innovation. In: Medical Technology and the Health Care System. National Academy of Sciences. Washington, DC: U.S. Government Printing Office; 1979, pp Edmonson JM. Gastric freezing: The view a quarter century later. J Lab Clin Med. 1989;114(5):
6 Intragastric Hypothermia - Medical Clinical Policy Bulletins Aetna Page 5 of 5 Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change. Copyright Aetna Inc.
7 AETNA BETTER HEALTH OF PENNSYLVANIA Amendment to Aetna Clinical Policy Bulletin Number: 0527 Intragastric Hypothermia There are no amendments for Medicaid. new 11/01/2018
Prior Authorization Review Panel MCO Policy Submission
Prior Authorization Review Panel MCO Policy Submission A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.
Prior Authorization Review Panel MCO Policy Submission
Prior Authorization Review Panel MCO Policy Submission A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.
Clinical Policy Bulletin: Nusinersen (Spinraza)
Clinical Policy Bulletin: Nusinersen (Spinraza) Number: 0915 Policy *Pleasesee amendment forpennsylvaniamedicaidattheendofthiscpb. Note: REQUIRES PRECERTIFICATION.Footnotes for Precertification of nusinersen
Number: Policy *Please see amendment for Pennsylvania Medicaid at the end. Last Review 06/09/2016 Effective: 08/14/2001 Next Review: 06/08/2017
1 of 6 Number: 0552 Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB. Aetna considers laser peripheral nerve block (laser neurolysis) experimental and investigational for any
Number: Last Review 06/23/2016 Effective: 09/25/2001 Next Review: 06/22/2017. Review History
1 of 8 Number: 0566 Policy Aetna considers strabismus repair medically necessary for adults 18 years of age or older only if both of the following criteria are met: Last Review 06/23/2016 Effective: 09/25/2001
Clinical Policy: DNA Analysis of Stool to Screen for Colorectal Cancer
Clinical Policy: to Screen for Colorectal Cancer Reference Number: CP.MP.125 Last Review Date: 07/18 See Important Reminder at the end of this policy for important regulatory and legal information. Coding
Number: Policy *Please see amendment for Pennsylvania Medicaid at the end. Last Review 01/26/2017 Effective: 10/23/1995 Next Review: 01/25/2018
1 of 9 Number: 0062 Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB. Aetna considers burn garments and associated physical and occupational therapy medically necessary when
Clinical Policy: Digital Breast Tomosynthesis Reference Number: CP.MP.90
Clinical Policy: Reference Number: CP.MP.90 Effective Date: 01/18 Last Review Date: 12/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and
Clinical Policy Bulletin: Naltrexone Implants
Naltrexone Implants Page 1 of 5 Clinical Policy Bulletin: Naltrexone Implants Number: 0878 Policy Aetna considers naltrexone implants experimental and investigational for treatment of alcohol addiction,
Prior Authorization Review Panel MCO Policy Submission
Prior Authorization Review Panel MCO Policy Submission A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.
Clinical Policy: Fecal Calprotectin Assay Reference Number: CP.MP.135
Clinical Policy: Reference Number: CP.MP.135 Effective Date: 11/16 Last Review Date: 11/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and
Policy. ( Number: *Pleasesee amendment forpennsylvaniamedicaidatthe endofthis CPB.
1 of 11 (https://www.aetna.com/) Number: 0889 Policy *Pleasesee amendment forpennsylvaniamedicaidatthe endofthis CPB. Aetna considers levoleucovorin (Fusilev) medically necessary for the following indications,
Clinical Policy: Homocysteine Testing Reference Number: CP.MP.121
Clinical Policy: Reference Number: CP.MP.121 Effective Date: 08/16 Last Review Date: 08/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and
Clinical Policy: Iron Sucrose (Venofer) Reference Number: CP.PHAR.167
Clinical Policy: (Venofer) Reference Number: CP.PHAR.167 Effective Date: 03/16 Last Review Date: 03/17 Revision Log Coding Implications See Important Reminder at the end of this policy for important regulatory
Vertebral Axial Decompression
Close (https://www.aetna.com/) Vertebral Axial Decompression Number: 0180 Policy History Policy Aetna considers vertebral axial decompression (e.g., by means of the VAX-D Spinal Decompression System, the
Clinical Policy: Helicobacter Pylori Serology Testing Reference Number: CP.MP.153
Clinical Policy: Reference Number: CP.MP.153 Effective Date: 12/17 Last Review Date: 12/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and
Clinical Policy: Total Artificial Heart Reference Number: CP.MP.127
Clinical Policy: Reference Number: CP.MP.127 Effective Date: 12/16 Last Review Date: 12/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and
Clinical Policy: Implantable Miniature Telescope for Age Related Macular Degeneration Reference Number: CP.MP.517
Clinical Policy: Implantable Miniature Telescope for Age Related Macular Reference Number: CP.MP.517 Effective Date: 11/16 Last Review Date: 11/17 See Important Reminder at the end of this policy for important
Clinical Policy: Trigger Point Injections for Pain Management
Clinical Policy: for Pain Management Reference Number: CP.MP.169 Last Review Date: 08/18 See Important Reminder at the end of this policy for important regulatory and legal information. Coding Implications
Clinical Policy: Cochlear Implant Replacements Reference Number: CP.MP.14
Clinical Policy: Reference Number: CP.MP.14 Effective Date: 02/09 Last Review Date: 09/17 Revision Log Coding Implications See Important Reminder at the end of this policy for important regulatory and
Clinical Policy: Laser Therapy for Skin Conditions Reference Number: CP.MP.123 Last Review Date: 08/17
Clinical Policy: Laser Therapy for Skin Conditions Reference Number: CP.MP.123 Last Review Date: 08/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
Clinical Policy: Gastric Electrical Stimulation
Clinical Policy: Reference Number: CP.MP.40 Last Review Date: 08/18 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description
Clinical Policy: Electric Tumor Treating Fields (Optune) Reference Number: CP.MP.145
Clinical Policy: Electric Tumor Treating Fields (Optune) Reference Number: CP.MP.145 Effective Date: 05/17 Last Review Date: 06/17 See Important Reminder at the end of this policy for important regulatory
Clinical Policy: Cochlear Implant Replacements
Clinical Policy: Reference Number: CP.MP.14 Last Review Date: 07/18 Revision Log Coding Implications See Important Reminder at the end of this policy for important regulatory and legal information. Description
Clinical Policy: Gastric Electrical Stimulation Reference Number: CP.MP.40
Clinical Policy: Reference Number: CP.MP.40 Effective Date: 09/09 Last Review Date: 10/16 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and
Clinical Policy: Radial Head Implant Reference Number: CP.MP.148
Clinical Policy: Reference Number: CP.MP.148 Effective Date: 08/17 Last Review Date: 08/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and
Clinical Policy: Ferumoxytol (Feraheme) Reference Number: CP.PHAR.165
Clinical Policy: (Feraheme) Reference Number: CP.PHAR.165 Effective Date: 03/16 Last Review Date: 03/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
Clinical Policy: EEG in the Evaluation of Headache Reference Number: CP.MP.155
Clinical Policy: EEG in the Evaluation of Headache Reference Number: CP.MP.155 Effective Date: 12/17 Last Review Date: 12/17 Coding Implications Revision Log See Important Reminder at the end of this policy
Clinical Policy: Measurement of Serum 1,25-dihydroxyvitamin D
Clinical Policy: Reference Number: CP.MP.152 Last Review Date: 12/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description
Clinical Policy: Ferric Carboxymaltose (Injectafer) Reference Number: CP.PHAR.234
Clinical Policy: (Injectafer) Reference Number: CP.PHAR.234 Effective Date: 06/16 Last Review Date: 03/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important
Clinical Policy: Posterior Tibial Nerve Stimulation for Voiding Dysfunction Reference Number: CP.MP.133
Clinical Policy: Reference Number: CP.MP.133 Effective Date: 10/16 Last Review Date: 10/16 See Important Reminder at the end of this policy for important regulatory and legal information. Coding Implications
Clinical Policy: Cardiac Biomarker Testing for Acute Myocardial Infarction Reference Number: CP.MP.156
Clinical Policy: Reference Number: CP.MP.156 Effective Date: 12/17 Last Review Date: 12/17 See Important Reminder at the end of this policy for important regulatory and legal information. Description The
Clinical Policy: Digital EEG Spike Analysis
Clinical Policy: Reference Number: CP.MP.105 Last Review Date: 01/18 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description
Clinical Policy: Essure Removal Reference Number: CP.MP.131
Clinical Policy: Reference Number: CP.MP.131 Effective Date: 11/16 Last Review Date: 11/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and
Clinical Policy: Ambulatory Electroencephalography Reference Number: CP.MP.96
Clinical Policy: Ambulatory Electroencephalography Reference Number: CP.MP.96 Effective Date: 09/15 Last Review Date: 09/17 See Important Reminder at the end of this policy for important regulatory and
SUBJECT: LIMB PNEUMATIC COMPRESSION EFFECTIVE DATE: 06/27/13 DEVICES FOR VENOUS REVISED DATE: 06/26/14 THROMBOEMBOLISM PROPHYLAXIS
MEDICAL POLICY SUBJECT: LIMB PNEUMATIC COMPRESSION PAGE: 1 OF: 5 If the member's subscriber contract excludes coverage for a specific service it is not covered under that contract. In such cases, medical
Clinical Policy: Aflibercept (Eylea) Reference Number: CP.PHAR.184
Clinical Policy: (Eylea) Reference Number: CP.PHAR.184 Effective Date: 03/16 Last Review Date: 03/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
Clinical Policy: Functional MRI Reference Number: CP.MP.43
Clinical Policy: Reference Number: CP.MP.43 Effective Date: 09/09 Last Review Date: 10/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and
Clinical Policy: Robotic Surgery Reference Number: CP.MP. 207
Clinical Policy: Robotic Surgery Reference Number: CP.MP. 207 Effective Date: 03/05 Last Review Date: 10/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important
Clinical Policy: Growing Rods Spinal Surgery Reference Number: CP.MP.354
Clinical Policy: Growing Rods Spinal Surgery Reference Number: CP.MP.354 Effective Date: 06/07 Last Review Date: 10/16 Coding Implications Revision Log See Important Reminder at the end of this policy
Payment Policy: Urine Specimen Validity Testing Reference Number: CC.PP.056 Product Types: ALL Effective Date: 11/01/2017 Last Review Date:
Payment Policy: Reference Number: CC.PP.056 Product Types: ALL Effective Date: 11/01/2017 Last Review Date: Coding Implications Revision Log See Important Reminder at the end of this policy for important
Clinical Policy: Refractive Surgery Reference Number: CP.MP. 391
Clinical Policy: Refractive Surgery Reference Number: CP.MP. 391 Effective Date: November 2007 Last Review Date: January 2016 Coding Implications Revision Log See Important Reminder at the end of this
Clinical Policy: Transcatheter Closure of Patent Foramen Ovale Reference Number: CP.MP.151
Clinical Policy: Reference Number: CP.MP.151 Effective Date: 12/17 Last Review Date: 12/17 See Important Reminder at the end of this policy for important regulatory and legal information. Coding Implications
Clinical Policy: Donor Lymphocyte Infusion Reference Number: CP.MP.101 Last Review Date: 11/17
Clinical Policy: Reference Number: CP.MP.101 Last Review Date: 11/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description
Coding Implications Revision Log. See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Eylea) Reference Number: CP.PHAR.184 Effective Date: 03.16 Last Review Date: 02.18 Line of Business: Commercial, Medicaid Coding Implications Revision Log See Important Reminder at the
Clinical Policy: Low-Frequency Ultrasound Therapy for Wound Management Reference Number: CP.MP.139 Last Review Date: 01/18
Clinical Policy: Low-Frequency Ultrasound Therapy for Wound Management Reference Number: CP.MP.139 Last Review Date: 01/18 See Important Reminder at the end of this policy for important regulatory and
Clinical Policy: Multiple Sleep Latency Testing
Clinical Policy: Reference Number: CP.MP.24 Last Review Date: 04/18 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Reference Number: AZ.CP.PHAR.10.11.8 Effective Date: 07.2016 Last Review Date: 09.12.18 Line of Business: Arizona Medicaid Revision Log See Important Reminder at the end of this policy
Clinical Policy: Phototherapy and Photochemotherapy for Dermatological Conditions Reference Number: CP.MP. 441
Clinical Policy: Phototherapy and Photochemotherapy for Dermatological Conditions Reference Number: CP.MP. 441 Effective Date: November 2008 Last Review Date: January 2017 See Important Reminder at the
Clinical Policy: Implantable Hormone Pellets Reference Number: CA.CP.MP.507
Clinical Policy: Reference Number: CA.CP.MP.507 Effective Date: 1/12 Last Review Date: 7/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and
Premier Health Plan considers Oral Appliances for Obstructive Sleep Apnea (OSA) medically necessary for the following indications:
Premier Health Plan POLICY AND PROCEDURE MANUAL MP.063.PH - al Appliances for Obstructive Sleep Apnea This policy applies to the following lines of business: Premier Commercial Premier Employee Premier
Clinical Policy: Bone-Anchored Hearing Aid Reference Number: CP.MP.93
Clinical Policy: Reference Number: CP.MP.93 Effective Date: 12/13 Last Review Date: 12/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Portrazza) Reference Number: CP.PHAR.320 Effective Date: 03.01.17 Last Review Date: 11.18 Line of Business: Medicaid, HIM-Medical Benefit Coding Implications Revision Log See Important
Clinical Policy: Dabrafenib (Tafinlar) Reference Number: CP.PHAR.239 Effective Date: 07/16 Last Review Date: 07/17 Line of Business: Medicaid
Clinical Policy: (Tafinlar) Reference Number: CP.PHAR.239 Effective Date: 07/16 Last Review Date: 07/17 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of
Clinical Policy: Thryoid Hormones and Insulin Testing in Pediatrics Reference Number: CP.MP.154
Clinical Policy: Thryoid Hormones and Insulin Testing in Pediatrics Reference Number: CP.MP.154 Effective Date: 12/17 Last Review Date: 12/17 See Important Reminder at the end of this policy for important
Prior Authorization Review Panel MCO Policy Submission
Prior Authorization Review Panel MCO Policy Submission A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.
Clinical Policy: Buprenorphine-Naloxone (Bunavail, Suboxone, Zubsolv) Reference Number: CP.PMN.81 Effective Date: Last Review Date: 02.
Clinical Policy: (Bunavail, Suboxone, Zubsolv) Reference Number: CP.PMN.81 Effective Date: 09.01.17 Last Review Date: 02.18 Line of Business: Medicaid See Important Reminder at the end of this policy for
Clinical Policy: Sacroiliac Joint Interventions for Pain Management
Clinical Policy: for Pain Management Reference Number: CP.MP.166 Last Review Date: 08/18 See Important Reminder at the end of this policy for important regulatory and legal information. Coding Implications
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Imfinzi) Reference Number: CP.PHAR.339 Effective Date: 07.01.17 Last Review Date: 05.18 Line of Business: Medicaid, HIM-Medical Benefit Coding Implications Revision Log See Important
Premier Health Plan considers Negative Pressure Wound Therapy (NPWT) in the home setting medically necessary for the following indications:
Premier Health Plan POLICY AND PROCEDURE MANUAL PA.009.PH Negative Pressure Wound Therapy This policy applies to the following lines of business: Premier Commercial Premier Employee Premier Health Plan
Clinical Policy: Naltrexone (Vivitrol) Reference Number: CP.PHAR.96 Effective Date: Last Review Date: Line of Business: Medicaid
Clinical Policy: (Vivitrol) Reference Number: CP.PHAR.96 Effective Date: 03.01.12 Last Review Date: 02.19 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Kadcyla) Reference Number: CP.PHAR.229 Effective Date: 06.01.16 Last Review Date: 05.18 Line of Business: Commercial, HIM-Medical Benefit, Medicaid Coding Implications Revision Log See
Clinical Policy: Fractional Exhaled Nitric Oxide Reference Number: CP.MP.103
Clinical Policy: Reference Number: CP.MP.103 Effective Date: 01/16 Last Review Date: 01/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and
Clinical Policy: Naltrexone (Vivitrol) Reference Number: CP.PHAR.96 Effective Date: Last Review Date: Line of Business: Medicaid
Clinical Policy: (Vivitrol) Reference Number: CP.PHAR.96 Effective Date: 03.01.12 Last Review Date: 02.18 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Thyrogen) Reference Number: CP.PHAR.95 Effective Date: 03.12 Last Review Date: 08.18 Line of Business: Medicaid, HIM-Medical Benefit Revision Log See Important Reminder at the end of
Clinical Policy: Facet Joint Interventions
Clinical Policy: Reference Number: CP.MP.171 Last Review Date: 07/18 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description
Sympathetic Electrical Stimulation Therapy for Chronic Pain
Sympathetic Electrical Stimulation Therapy for Chronic Pain Policy Number: 015M0076A Effective Date: April 01, 015 RETIRED 5/11/017 Table of Contents: Page: Cross Reference Policy: POLICY DESCRIPTION COVERAGE
Applies to: All Aetna plans, except Traditional Choice plans. All Innovation Health plans, except indemnity plans
BRCA Precertification Information Request Form Applies to: All Aetna plans, except Traditional Choice plans All Innovation Health plans, except indemnity plans All Health benefits and health insurance
Clinical Policy: Atezolizumab (Tecentriq) Reference Number: CP.PHAR.235 Effective Date: 06/16 Last Review Date: 05/17
Clinical Policy: (Tecentriq) Reference Number: CP.PHAR.235 Effective Date: 06/16 Last Review Date: 05/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Trogarzo) Reference Number: CP.PHAR.378 Effective Date: 04.17.18 Last Review Date: 05.18 Line of Business: Commercial, HIM-Medical Benefit, Medicaid Coding Implications Revision Log See
MedStar Health considers External Counterpulsation Therapy (ECP) medically necessary for the following indications:
MedStar Health, Inc. POLICY AND PROCEDURE MANUAL MP.107.MH External Counterpulsation Therapy This policy applies to the following lines of business: MedStar Employee (Select) MedStar MA DSNP CSNP MedStar
Clinical Policy: Trabectedin (Yondelis) Reference Number: CP.PHAR.204 Effective Date: Last Review Date: Line of Business: Medicaid
Clinical Policy: (Yondelis) Reference Number: CP.PHAR.204 Effective Date: 05.01.16 Last Review Date: 02.18 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Nuedexta) Reference Number: CP.PMN.93 Effective Date: 12.05.17 Last Review Date: 02.19 Line of Business: Commercial, HIM, Medicaid Revision Log See Important Reminder at the end of this
MedStar Health considers Cough Assist Devices medically necessary for the following indications:
MedStar Health, Inc. POLICY AND PROCEDURE MANUAL MP.047.MH Cough Assist Devices This policy applies to the following lines of business: MedStar Employee (Select) MedStar MA DSNP CSNP MedStar CareFirst
Common Diagnosis Codes and Tips for Coding Nicotine Use/
ICD-10 Tobacco Billing Guide ICD-10 and Tobacco Common Diagnosis Codes and Tips for Coding Nicotine Use/ Dependence Tobacco use is the leading cause of preventable disease and death in the United States,
Clinical Policy: Rivastigmine (Exelon) Reference Number: CP.PMN.101 Effective Date: Last Review Date: 02.18
Clinical Policy: (Exelon) Reference Number: CP.PMN.101 Effective Date: 03.01.17 Last Review Date: 02.18 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important
Clinical Policy: Oxygen Therapy in the Home Reference Number: CP.MP.485
Clinical Policy: Reference Number: CP.MP.485 Effective Date: 09/04 Last Review Date: 09/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and
Clinical Policy: Nusinersen (Spinraza) Reference Number: CP.PHAR.327
Clinical Policy: (Spinraza) Reference Number: CP.PHAR.327 Effective Date: 03/17 Last Review Date: 03/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) Reference Number: CP.PHAR.228 Effective Date: 07.01.18 Last Review Date: 05.18 Line of Business: Oregon Health Plan Coding Implications
Clinical Policy: Discography Reference Number: CP.MP.115
Clinical Policy: Reference Number: CP.MP.115 Effective Date: 08/16 Last Review Date: 08/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and
Clinical Policy: Obinutuzumab (Gazyva) Reference Number: CP.PHAR.305 Effective Date: Last Review Date: Line of Business: Medicaid
Clinical Policy: (Gazyva) Reference Number: CP.PHAR.305 Effective Date: 02.01.17 Last Review Date: 11.17 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Xeomin) Reference Number: CP.PHAR.231 Effective Date: 07.01.16 Last Review Date 05.18 Line of Business: Commercial, HIM, Medicaid Coding Implications Revision Log See Important Reminder
Clinical Policy: Fluticasone/Salmeterol (Advair Diskus, Advair HFA) Reference Number: CP.PMN.31 Effective Date: 08/16 Last Review Date: 08/17
Clinical Policy: (Advair Diskus, Advair HFA) Reference Number: CP.PMN.31 Effective Date: 08/16 Last Review Date: 08/17 Line of Business: Medicaid Revision Log See Important Reminder at the end of this
Prior Authorization Review Panel MCO Policy Submission
Prior Authorization Review Panel MCO Policy Submission A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.
Clinical Policy: Vedolizumab (Entyvio) Reference Number: CP.PHAR.265
Clinical Policy: (Entyvio) Reference Number: CP.PHAR.265 Effective Date: 07/16 Last Review Date: 07/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
Clinical Policy: Dalteparin (Fragmin) Reference Number: CP.PHAR.225
Clinical Policy: (Fragmin) Reference Number: CP.PHAR.225 Effective Date: 05/16 Last Review Date: 05/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
Clinical Policy: Discography
Clinical Policy: Reference Number: CP.MP.115 Last Review Date: 06/18 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description
FDA Approved Indication(s) Firmagon is indicated for treatment of advanced prostate cancer.
Clinical Policy: (Firmagon) Reference Number: CP.PHAR.170 Effective Date: 10.01.16 Last Review Date: 11.17 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end
Clinical Policy: Vilazodone (Viibryd) Reference Number: CP.PMN.145 Effective Date: Last Review Date: Line of Business: HIM, Medicaid
Clinical Policy: (Viibryd) Reference Number: CP.PMN.145 Effective Date: 08.01.12 Last Review Date: 08.18 Line of Business: HIM, Medicaid Revision Log See Important Reminder at the end of this policy for
Clinical Policy: Mifepristone (Korlym) Reference Number: CP.PHAR.101
Clinical Policy: (Korlym) Reference Number: CP.PHAR.101 Effective Date: 05/12 Last Review Date: 04/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Fluticasone/Salmeterol (Advair Diskus, Advair HFA) Reference Number: CP.PMN.31 Effective Date: 10.01.18 Last Review Date: 07.13.18 Line of Business: Oregon Health Plan See Important Reminder
See Important Reminder at the end of this policy for important regulatory and legal information.
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