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Premera Blue Cross October 2017 Medical Policy Updates
Click here to view the Premera Blue Cross October 2017 Medical Policy Updates »
Medical Policies Recent Updates
| Policy Title | Comments | Policy Number | Effective | Updated |
|---|---|---|---|---|
| 1.01.11 Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses | Annual review approved September 21, 2017. Policy updated with literature review through June 22, 2017; references 25-26 added. Policy statements unchanged. | 1.01.11 | 10/01/2017 | 09/30/2017 |
| 1.03.04 (effective Jan. 5, 2018) Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities | New policy approved September 12, 2017, effective January 5, 2018. Add to Durable Medical Equipment section. This service is considered investigational. | 1.03.04 | 01/05/2018 | 09/30/2017 |
| 12.04.122 Chromosomal Microarray Analysis for the Evaluation of Pregnancy Loss | Annual Review, approved Sept 21, 2017. Literature review through June 22, 2017; references 19-20 and 33 added. Removed CPT code 88271. Policy title and statement changed from “analysis” to “testing”. Policy statement otherwise unchanged. | 12.04.122 | 10/01/2017 | 09/30/2017 |
| 12.04.305 Preimplantation Genetic Testing in Embryos | Annual Review, approved September 21, 2017. Policy updated with literature review through June 22, 2017; references 4-5 added. Added CPT codes 89290 and 89291. Policy statements unchanged. *This policy varies slightly from the BCBSA reference policy. | 12.04.305 | 10/01/2017 | 09/30/2017 |
| 12.04.59 Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies | Annual Review, approved September 21, 2017. Policy updated with literature review through June 22, 2017; references 26-27 and 40 added; some references removed. Whole-exome sequencing is addressed in a separate policy. Policy statements unchanged. | 12.04.59 | 10/01/2017 | 09/30/2017 |
| 12.04.61 Multigene Expression Assay for Predicting Recurrence in Colon Cancer | Annual Review, approved September 21, 2017. Policy updated with literature review through June 22, 2017; references 20, 23, and 31 added; reference 2 updated. Policy statements unchanged. | 12.04.61 | 10/01/2017 | 09/30/2017 |
| 2.01.526 Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders | Interim Review, approved Sept 21, 2017. Clarifications added regarding medical necessity being determined on a case-by-case basis (see policy for more details). Also added that an abbreviated repeat course of TMS is also known as a “mini-intensive.” | 2.01.526 | 10/01/2017 | 09/30/2017 |
| 2.01.77 Automated Point-of-Care Nerve Conduction Tests | Annual Review, approved September 21, 2017. Policy updated with literature review through July 6, 2017; references 11-13, 22, and 25-26 added. Policy statement unchanged. | 2.01.77 | 10/01/2017 | 09/30/2017 |
| 2.02.18 Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia | Annual Review, approved September 21, 2017. Policy updated with literature review through June 22, 2017; references 10, 19, and 21-22 added. Removed CPT code33999. Policy statements unchanged. | 2.02.18 | 10/01/2017 | 09/30/2017 |
| 3.01.510 Applied Behavior Analysis (ABA) | Interim review approved Sept 5, 2017. Minor addition, allow for coverage of supervision conducted by Licensed Assistant Behavior Analysts in states where that function is within their legally-permitted scope of practice. | 3.01.510 | 10/01/2017 | 09/30/2017 |
| 4.01.21 Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA | Annual Review, approved September 21, 2017. Policy updated with literature review through June 22, 2017; references 10, 25-27, and 40-41 added; note 35 replaced. Removed CPT code 88271. Policy statements unchanged. | 4.01.21 | 10/01/2017 | 09/30/2017 |
| 5.01.10 Immune Prophylaxis for Respiratory Syncytial Virus | Annual Review, approved September 21, 2017. Policy updated with literature review through June 22, 2017; references 2, 9, 16, 19, and 22-24 added. Policy statements unchanged. | 5.01.10 | 10/01/2017 | 09/30/2017 |
| 5.01.500 Growth Hormone Therapy | Annual Review, approved September 21, 2017. Clarified criteria for reauthorization of adult growth hormone. Removed CPT codes 77072, 77073, and 96372. Removed ICD-10 codes. | 5.01.500 | 10/01/2017 | 09/30/2017 |
| 5.01.514 Trastuzumab and Other HER2 Inhibitors | Interim Review, approved September 21, 2017. Added criteria for Nerlynx. | 5.01.514 | 10/01/2017 | 09/30/2017 |
| 5.01.538 ALK Tyrosine Kinase Inhibitors | Interim review approved September 21, 2017. Alecensa, Zykadia, Alunbrig changed to first-line. | 5.01.538 | 10/01/2017 | 09/30/2017 |
| 5.01.539 5.01.539 Kalydeco® (ivacaftor) and Orkambi® (Lumacaftor / Ivacaftor) | Annual Review, approved Sept 12, 2017. Kalydeco®’s age criteria has changed from 6 to 2 years of age and older for treatment of cystic fibrosis, based on the FDA labeling. | 5.01.539 | 10/01/2017 | 09/30/2017 |
| 5.01.540 Miscellaneous Oral Oncology Drugs | Interim Review, approved September 21, 2017. Added coverage criteria for Idhifa®. | 5.01.540 | 10/01/2017 | 09/30/2017 |
| 5.01.550 Pharmacotherapy of Arthropathies | Interim review approved September 21, 2017. Clarified Taltz & Siliq criteria. Added criteria for Tremfya and Plivensia. | 5.01.550 | 10/01/2017 | 09/30/2017 |
| 5.01.560 Excessively High Cost Drug Products with Lower Cost Alternatives | Interim Review, approved September 21, 2017. Changed criteria for Differin, clarified criteria for auvi-q, added criteria for omePPi. | 5.01.560 | 10/01/2017 | 09/30/2017 |
| 5.01.562 Imlygic® (talimogene laherparepvec) | Annual Review, approved September 5, 2017. A literature search was conducted from 04/13/16 to 8/18/17. No new studies were found that would require changes to this policy. | 5.01.562 | 10/01/2017 | 09/30/2017 |
| 5.01.566 Pharmacotherapy of Thrombocytopenia | Annual Review, approved September 21, 2017. Updated dosage and quantity limits with specific age range of eltrombopag. | 5.01.566 | 10/01/2017 | 09/30/2017 |
| Pharmacotherapy of Type I and Type II Diabetes Mellitus | Interim Review, approved September 12, 2017. Added Symlin (pramlintide) and updated description and reference sections. | 5.01.569 | 10/01/2017 | 09/30/2017 |
| 6.01.38 Percutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation | Annual Review, approved September 21, 2017. Policy updated with literature review through June 22, 2017; references 20 and 22 added. Radiofrequency kyphoplasty added to title and investigational statement. | 6.01.38 | 10/01/2017 | 09/30/2017 |
| 7.01.104 Subtalar Arthroereisis | Annual Review, approved September 21, 2017. Policy updated with literature review through June 22, 2017; no references added. Removed CPT code 28899. Policy statement unchanged. | 7.01.104 | 10/01/2017 | 09/30/2017 |
| 7.01.144 Patient-Specific Cutting Guides and Custom Knee Implants | Annual Review, approved September 21, 2017. Policy updated with literature review through June 22, 2017; references 3-6 added; some references removed. Policy statement unchanged. | 7.01.144 | 10/01/2017 | 09/30/2017 |
| 7.01.48 (effective Jan. 5, 2018) Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions | New policy, approved Sept 12, 2017, effective Jan 5, 2018. Policy was previously archived, being reinstated. Autologous chondrocyte implantation may be considered medically necessary when criteria are met, considered investigational when criteria not met. | 7.01.48 | 01/05/2018 | 09/30/2017 |
| 7.01.542 Lumbar Spinal Fusion | Annual review approved September 12, 2017. Policy updated with literature review through February 23, 2017. References added: 22-26, reference 42 updated, some references removed. Clarifications made to policy statements. BCBSA references added. | 7.01.542 | 10/01/2017 | 09/30/2017 |
| 7.01.546 Spinal Cord Stimulation | Annual Review, approved Sept 12, 2017. Policy updated, added high-frequency stimulation, high frequency with burst, and dorsal root ganglion stimulators. Title changed. New HCPCS codes added. Replacement and upgrade device criteria added. Refs added. | 7.01.546 | 10/01/2017 | 09/30/2017 |
| 7.01.557 Gender Reassignment Surgery | Interim Review, approved September 12, 2017. Removed the requirement for meeting DSM diagnostic criteria and instead only requiring that an evaluating mental health professional confirm that the diagnosis applies. | 7.01.557 | 10/01/2017 | 09/30/2017 |
| 7.01.560 Anterior Cervical Spine Decompression and Fusion in Adults | Annual Review, approved September 5, 2017. No changes to policy statement, no new references. | 7.01.560 | 10/01/2017 | 09/30/2017 |
| 7.03.04 Intestinal and Multivisceral Organ Transplant Surgery | Interim Review, approved September 5, 2017. Policy updated with literature review. Policy statements unchanged. | 7.03.04 | 10/01/2017 | 09/30/2017 |
| 7.03.12 Islet Transplantation | Annual Review, approved September 21, 2017. Policy updated with literature review through June 22, 2017; clinical trials section added; reference 14 added; reference 17 updated. Removed CPT code 48999. Policy statements unchanged. | 7.03.12 | 10/01/2017 | 09/30/2017 |
| 7.03.13 Composite Tissue Allotransplantation of the Hand and Face | Annual Review, approved September 21, 2017. Policy updated with literature review through June 22, 2017; references 2 and 7 added. Policy statement unchanged. | 7.03.13 | 10/01/2017 | 09/30/2017 |
| 8.01.25 Hematopoietic Cell Transplantation for Autoimmune Diseases | Annual Review, approved Sept 5, 2017, new format. Policy updated with literature review through June 2, 2017; references 14-16, 26, 31-32, 36, and 38 added. “Stem” removed from title and Policy. Policy statement unchanged. | 8.01.25 | 10/01/2017 | 09/30/2017 |
| 8.01.26 Hematopoietic Cell Transplantation for Acute Myeloid Leukemia | Annual Review, approved Sept 5, 2017, new format. Literature review through June 2, 2017; references added. “Stem” removed from title and policy. Policy statements otherwise unchanged. | 8.01.26 | 10/01/2017 | 09/30/2017 |
| 8.01.505 Transcatheter Arterial Chemoembolization as a Treatment for Primary or Metastatic Liver Malignancies | Annual Review, approved Sept 5, 2017. References updated and added. Minor addition to policy statement, no changes to intent. | 8.01.505 | 10/01/2017 | 09/30/2017 |
| 8.01.533 Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma | Annual Review, approved September 5, 2017. Policy updated with literature review through June 2, 2017; references 9 and 19 added; no change in policy statements. | 8.01.533 | 10/01/2017 | 09/30/2017 |
| 8.03.01 Functional Neuromuscular Electrical Stimulation | Annual Review, approved September 21, 2017. Policy moved into new format. Policy updated with literature review through June 22, 2017; reference 1 added. Policy statement unchanged. *This policy varies slightly from the BCBSA Reference Policy. | 8.03.01 | 10/01/2017 | 09/30/2017 |
| 5.01.605 Medical Necessity Criteria for Pharmacy Edits | Interim Review, approved September 12, 2017, effective September 15, 2017. Added Flolipid and Nikita, added brand oral acne products, updated Solodyn, Xyrosa, & Minolara criteria, added Ingrezza & Austedo, added Carospir. | 5.01.605 | 09/15/2017 | 09/14/2017 |
| 5.01.606 Hepatitis C Antiviral Therapy | Interim Review, approved September 22, 2017, effective September 25, 2017. Modified step therapy criteria. Harvoni re-incorporated into policy as a preferred treatment agent; length of therapy information included. | 5.01.606 | 09/25/2017 | 09/14/2017 |
| 1.01.05 (effective for dates of service before Dec. 21, 2017) Ultrasound Accelerated Fracture Healing Device | Annual Review, approved 8/15/17. Policy eff. 12/21/17. Literature review through Jan. 2017; references added. Fresh fractures and nonunion/delayed union fractures changed from med necessary to not med necessary. | 1.01.05_2017-12-21 | 12/21/2017 | 08/31/2017 |
| 1.01.05 Ultrasound Accelerated Fracture Healing Device | Note added that this policy has been revised. Added link to revised policy that will become effective December 21, 2017. | 1.01.05 | 06/01/2016 | 08/31/2017 |
| 1.01.05 (effective for dates of service before Dec. 21, 2017) Ultrasound Accelerated Fracture Healing Device | Note added that this policy has been revised. Added link to revised policy that will become effective December 21, 2017. | 1.01.05 | 12/21/2017 | 08/31/2017 |
| 11.01.523 Site of Service: Infusion Drugs and Biologic Agents | Interim review, approved August 15, 2017. Added Renflexis to coverage criteria and to the coding section. | 11.01.523 | 09/01/2017 | 08/31/2017 |
| 12.04.121 Miscellaneous Genetic and Molecular Diagnostic Tests | Annual review, approved August 22, 2017. Literature review through July 2016; references added. Several guidelines updated with current versions. Policy statements updated for clarity; all tests remain investigational. Removed CPT codes 83520 and 86021. | 12.04.121 | 09/01/2017 | 08/31/2017 |
| 12.04.512 Genetic Testing for Li-Fraumeni Syndrome | Annual Review, approved August 22, 2017. No changes to policy statement. Removed CPT code 81479. | 12.04.512 | 09/01/2017 | 08/31/2017 |
| 12.04.52 PathFinder TG® Molecular Testing | Annual Review, approved Aug 22, 2017. Literature review through June 20, 2017; references added. Policy statements unchanged. Title of this policy was changed to “Molecular Testing for the Management of Pancreatic Cysts or Barrett Esophagus.” | 12.04.52 | 09/01/2017 | 08/31/2017 |
| 2.01.40 Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions | Annual Review, approved August 1, 2017. Policy moved into new format. Policy updated with literature review through April 25, 2017; references 5-6, 18, 27, 34-35, 41-43, 51-53, 56-58, 61, 64, and 68. Policy statement unchanged. Added CPT code 20999. | 2.01.40 | 09/01/2017 | 08/31/2017 |
| 2.01.82 Bioimpedance Devices for Detection and Management of Lymphedema | Annual Review, approved August 1, 2017. Policy moved into new format. Policy updated with literature review through April 25, 2017; references 3, 9, and 11 added. Policy statement unchanged. | 2.01.82 | 09/01/2017 | 08/31/2017 |
| 2.01.90 Navigated Transcranial Magnetic Stimulation | Annual Review, approved August 1, 2017. Policy moved into new format. Policy updated with literature review through April 25, 2017; reference 19 added. Policy statement unchanged. | 2.01.90 | 09/01/2017 | 08/31/2017 |
| 2.04.07 Urinary Tumor Markers for Bladder Cancer | Annual Review, approved August 1, 2017. Policy moved into new format. Policy updated with literature review through April 25, 2017; references 1 and 20 added. Policy statement unchanged. | 2.04.07 | 09/01/2017 | 08/31/2017 |
| 2.04.119 Vectra® DA Blood Test for Rheumatoid Arthritis | Annual Review, approved August 1, 2017. Policy moved into new format. Policy updated with literature review through April 25, 2017; references 16, 18, 20, and 23-24 added. Policy statement unchanged. Removed unlisted CPT code 84999. | 2.04.119 | 09/01/2017 | 08/31/2017 |
| 2.04.123 Serum Biomarker Panel Testing for Systemic Lupus Erythematosus | Annual Review, approved August 22, 2017. Policy updated with literature review through April 25, 2017; references 10 and 15 added. The phrase “and other connective tissue diseases” added to policy statement and title. | 2.04.123 | 09/01/2017 | 08/31/2017 |
| 4.02.503 Infertility and Reproductive Services | Interim review, approved August 22, 2017. No changes to coverage guidelines. | 4.02.503 | 09/01/2017 | 08/31/2017 |
| 5.01.527 Dalfampridine (Ampyra™) | Annual Review, approved August 22, 2017. A literature search was conducted from 12/6/16 to 8/14/17. No new studies were found that would require changes to this policy. Title changed from Dalfampridine (Ampyra™) to Ampyra™ (Dalfampridine). | 5.01.527 | 09/01/2017 | 08/31/2017 |
| 5.01.530 Tesamorelin (Egrifta®) | Annual Review, approved August 22, 2017. Title changed to Egrifta® (tesamorelin). Policy updated with literature review; no changes to policy statements. | 5.01.530 | 09/01/2017 | 08/31/2017 |
| 5.01.541 Medical Necessity Exception Criteria for Closed Formulary Benefits and for Dispense as Written (DAW) Exception Reviews | Annual Review, approved August 22, 2017. No updates made to the existing policy criteria. | 5.01.541 | 09/01/2017 | 08/31/2017 |
| 5.01.542 Medical Necessity Criteria for Medication Safety: Controlled Substances Utilization Service Program | Annual Review, approved August 22, 2017. No changes to coverage guidelines. | 5.01.542 | 09/01/2017 | 08/31/2017 |
| 5.01.543 General Medical Necessity Criteria for Approval of Drugs with Companion Diagnostics | Annual Review, approved August 22, 2017. No changes to policy statements. Minor change to title for clarification. | 5.01.543 | 09/01/2017 | 08/31/2017 |
| 5.01.546 Medical Necessity Criteria for Compounded Medications | Annual Review, approved August 22, 2017. No changes to policy statements. Statement added to intro “This policy is not intended to apply to infused admixtures.” | 5.01.546 | 09/01/2017 | 08/31/2017 |
| 5.01.555 Pharmacologic Treatment of Idiopathic Pulmonary Fibrosis | Annual Review, approved August 22, 2017. A literature search was conducted from 4/2/16 to 8/18/17. No new studies were found that would require changes to this policy. | 5.01.555 | 09/01/2017 | 08/31/2017 |
| 5.01.559 Mepolizumab (Nucala) | Annual review approved Aug 22, 2017. No changes to policy statement Literature search from 1/1/16 to 8/15/17. No new studies were found that would change policy. Removed HCPCS code J3490. Title changed from Mepolizumab (Nucala®) to Nucala® (mepolizumab). | 5.01.559 | 09/01/2017 | 08/31/2017 |
| 5.01.563 Pharmacotherapy of Inflammatory Bowel Disorder | Interim review, approved August 15, 2017 Added coverage criteria for Xeljanz (tofacitinib) in Ulcerative Colitis. Clarified second line status of Stelara in Crohn’s. Added Renflexis coding. | 5.01.563 | 09/01/2017 | 08/31/2017 |
| 5.01.564 Pharmacotherapy of Miscellaneous Autoimmune Diseases | Interim review, approved August 15, 2017. Added Infliximab-abda (Renflexis) to coverage criteria and coding section. Clarified pydoderma gangrenosum first-line/second-line treatment. | 5.01.564 | 09/01/2017 | 08/31/2017 |
| 5.01.579 Quantity Limits for Opioid Drugs | Interim update, approved August 1, 2017. Quantity limits added for Arymo, Arymo ER, Bunavail, and Morphabond ER. No other changes. Updated criteria for coverage. | 5.01.579 | 09/01/2017 | 08/31/2017 |
| 7.01.109 Magnetic Resonance Imaging‒Guided Focused Ultrasound | Interim review, approved August 22, 2017. Policy updated with literature review through June 2, 2017; references 2, 12, 18, 23, and 27-29 added. Removed CPT code 19499. Policy statements unchanged. | 7.01.109 | 09/01/2017 | 08/31/2017 |
| 8.01.52 Orthopedic Applications of Stem-Cell Therapy (Including Allograft and Bone Substitute Products Used with Autologous Bone Marrow) | Annual Review, approved August 22, 2017. Policy updated with literature review through June 9, 2017; references 1, 4, 12-13, 25, and 27-29 were added. Policy statements unchanged. | 8.01.52 | 09/01/2017 | 08/31/2017 |
| 8.01.53 Cellular Immunotherapy for Prostate Cancer | Annual Review, approved August 22, 2017. Policy updated with literature review through June 6, 2017; references 5 and 14-15 added. Policy statement unchanged. | 8.01.53 | 09/01/2017 | 08/31/2017 |
| 8.01.55 Stem-Cell Therapy for Peripheral Arterial Disease | Annual Review, approved August 22, 2017. Policy updated with literature review through June 4, 2017; references 3 and 14 added. Policy statement updated to describe specific sources of stem cells. | 8.01.55 | 09/01/2017 | 08/31/2017 |
| 8.01.62 Electronic Brachytherapy for Nonmelanoma Skin Cancer | Annual Review, approved August 22, 2017. Policy created with literature review through June 6, 2017; reference 6 added. Policy statement unchanged. | 8.01.62 | 09/01/2017 | 08/31/2017 |
Click here to view the Premera Blue Cross October 2017 Medical Policy Updates »
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