Florida Blue Cross Blue Shield April 2018 Medical Policy Updates

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April 2018 Medical Policy Updates:

Updated 4/15/2018;

New:

• Balloon Dilation of the Eustachian Tube

Revised:

• Abiraterone Acetate (Zytiga™) Tablet – Review and revision to guideline consisting of description section, position statement, precautions section, definitions, and references.
• Ado-trastuzumab emtansine (Kadcyla™) – Review and revision to guideline consisting of description section, position statement, dosage/administration section, precautions section, and references.
• Allogeneic Bone Marrow and Stem Cell Transplantation – Scheduled review. Revised crtieria for Hodgkin’s lymphoma. Revised Medicare Advantage program exception and definitions section. Updated references.
• Autologous Bone Marrow and Stem Cell Transplantation – Scheduled review. Revised criteria for germ cell tumor and list of conditions considered E/I. Revised Medicare Advantage program exception. Updated references.
• Bio-Engineered Skin and Soft Tissue Substitutes, Amniotic Membrane and Amniotic Fluid – Revision; description, position statements, coding, and references updated.
• Blinatumomab (Blincyto TM) IV – Review and revision; consisting of updating position statement, references.
• Cabazitaxel (Jevtana®) Injection – Review and revision to guideline consisting of updating the description section, position statement, dosage/administration, precautions, and references.
• Cabozantinib Capsules and Tablets (Cometriq®, Cabometyx®) – Revision to guideline; consisting of revising position statement, coding and references.
• Computed Tomography Angiography (CTA) Abdomen and Pelvis – Revision; revised position statement. Updated references.
• Computed Tomography Angiography (CTA) Brain (Head) – Revision; revised position statement. Updated references.
• Computed Tomography Angiography (CTA) Chest (non coronary) – Revision; revised position statement. Updated references.
• Computed Tomography Angiography (CTA) Lower Extremity – Revision; revised position statement. Updated references.
• Computed Tomography Angiography (CTA) Neck – Revision; revised position statement. Updated references.
• Computed Tomography Angiography (CTA) Upper Extremity – Revision; revised position statement. Updated references.
• Corneal Pachymetry – Review; position statements maintained, description and references updated.
• Denosumab (Prolia™, Xgeva™) Injection – Review and revision to guideline; consisting of updating position statement and references.
• Docetaxel (Taxotere®) IV – Review and revision to guidelines; updated position statement and references.
• Drug Testing in Pain Management and Substance Use Disorder Treatment – Review; Position maintained; policy title, description, position statements, coding, and references updated.
• Electroretinography – Scheduled review. Position statement maintained. Revised Medicare Advantage program exception. Updated references.
• Enzalutamide (Xtandi®) Capsules – Review and revision to guideline consisting of description section, precautions section, and references.
• Eribulin Mesylate (Halaven®) Injection – Review and revision; updated description, coding, position statement, references.
• External Insulin Infusion Pumps and Continuous Glucose Monitors – Scheduled review. Revised MCG title, description section, position statement (added criteria for external insulin infusion pumps), CPT and HCPCS coding, reimbursement information, program exceptions, definitions, and related guidelines. Updated references.
• High Resolution Anoscopy – Review; Update position statements, description, coding, and references.
• Human Papillomavirus (HPV) Testing – Review; Position statements maintained; description, program exception, and references updated; formatting changes.
• Hyperbaric Oxygen Therapy (Systemic & Topical) – Revision; description, position statements, coding, and references updated.
• Ibrutinib (Imbruvica™) – Revision to guideline consisting of updating the description section, position statement, dosage/administration section, billing/coding information, and references based on new NCCN guideline recommendations for B-cell lymphomas and new tablet strengths.
• Immune Globulin Therapy – Revision to guideline; consisting of updating position statement, coding and references.
• Ipilimumab (Yervoy™) Injection – Review and revision to guideline; consisting of revising position statement, description, coding and references.
• Lapatinib (Tykerb®) Tablets – Review and revision; updated position statement,description, references.
• Levoleucovorin (Fusilev®) IV – Review and revision to guideline consisting of updating references.
• Nab-Paclitaxel Injection (Abraxane) – Review and revision to guideline; consisting of updating position statement, coding and references.
• Neratinib (Nerlynx) – Review and revision; updated description, position statement, references.
• Nerve Block Injections – Scheduled review. Revised description section. Added coverage statement for imaging guidance for nerve block injections; added coverage statement for genicular nerve blocks (E/I). Revised Medicare Advantage program exception. Updated references.
• Niraparib (Zejula®) Capsule – Review and revision to guideline; consisting of updating references.
• Nivolumab (Opdivo®) – Review and revision to guideline; consisting of updating position statement, dosing, coding, and references.
• Olaparib (Lynparza TM) – Review and revision to guideline; consisting of updating position statement and references.
• Olaratumab (Lartruvo) – Review and revision to guideline; consisting of updating coding and references.
• Palbociclib (Ibrance TM) – Review and revision; description, position statement, references.
• Pembrolizumab (Keytruda®) Injection – Review and revision to guideline; consisting of updating position statement, description, coding and references.
• Pertuzumab (Perjeta™) Injection – Revision to guideline; consisting of updating position statement, references.
• Preventive Services – Revision; reformat position statement, updated immunization section and references.
• Radium Ra 223 (Xofigo®) Injection – Review and revision to guideline; updated description, position statement, coding, references.
• Ribociclib (Kisqali®) – Review and revision to guideline; updated description and references.
• Rucaparib (Rubraca) – Review and revision to guideline; consisting of updating position statement, coding and references.
• Sipuleucel-T (Provenge®) – Review and revision to guideline consisting of updating the description section, position statement, and references.
• Trastuzumab (Herceptin®) Injection – Review and revision; Updated description, position statement, references.
• Treatment of Tinnitus – Revision: added cognitive behavior therapy, self-help cognitive behavior therapy, acceptance and commitment therapy and psychological treatment to the position statement and biofeedback to investigational position statement. Updated references.
• Unclassified Codes and Compounded Drug Products – Review and revision; consisting of updating position statement.

Posted 4/1/2018;

• Axicabtagene Ciloleucel (Yescarta) Infusion – Addition of HCPCS code Q2041 and deletion of J9999.
• Benralizumab (Fasenra) – Addition of HCPCS code C9466.
• Clotting Factors and Coagulant Blood Products – Addition of HCPCS code C9468.
• Genetic Testing – Quarterly HCPCS/CPT update. Added codes 0036U, 0037U, 0040U.
• Granulocyte Colony Stimulating Factors – Revision to Q5101 code description.
• Infliximab Products [infliximab (Remicade®), infliximab-dyyb (Inflectra®), and infliximab-abda (Renflexis®)] – Addition of HCPCS codes Q5103 and Q5104 and removal of Q5102.
• NK-1 receptor antagonist injectable therapy (Emend®, Cinvanti®, Varubi®) – Addition of HCPCS codes C9463 and C9464.
• Orthotics – Quarterly HCPCS/CPT update. Added code K0903.
• Rituximab (Rituxan) and Rituximab hyaluronidase (Rituxan Hycela) – Addition of HCPCS code C9467 and deletion of C9399.
• Tumor/Genetic Markers – Quarterly HCPCS/CPT update. Added codes 0012M and 0013M.
• Viscosupplementation, Hyaluronan Injections (e.g. Synvisc®) – Addition of HCPCS code C9465 and J3490 for Durolane.

Click here to view the Florida Blue Cross Blue Shield Medical Policy Updates »

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