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Premera Blue Cross August 2017 Medical Policy Updates

Click here to view the Premera Blue Cross July 2017 Medical Policy Updates »

Medical Policies Recent Updates

August 2017

Policy Title Comments Policy Number Effective Updated
1.01.15 Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders Annual review, approved July 18, 2017. Literature review through April 25, 2017; reference 9 added. Other applications areconsidered not medically necessary when criteria are not met. 1.01.15 08/01/2017 07/31/2017
10.01.518 Clinical Trials Interim update, approved July 11, 2017. Policy clarification made; requirement for member consent form replaced with records demonstrating member agrees to participate in a clinical trial. No other changes. 10.01.518 08/01/2017 07/31/2017
12.04.108 Fetal RHD Genotyping Using Maternal Plasma Annual Review, approved July 11, 2017. Policy moved into new format. Policy updated with literature review through March 23, 2017; reference 9 added. Policy statement unchanged. 12.04.108 08/01/2017 07/31/2017
12.04.117 Genetic Testing for Mitochondrial Disorders Annual Review, approved July 18, 2017, new format. Literature review through April 25, 2017; references added. Policy statements revised regarding genetic testing restrictions. 12.04.117 08/01/2017 07/31/2017
12.04.131 Pharmacogenetic Testing for Pain Management Annual Review, approved July 11, 2017. Policy moved into new format. Policy updated with literature review through March 23, 2017; references 3 and 52- 53 added. Policy statement unchanged. 12.04.131 08/01/2017 07/31/2017
12.04.140 Proteogenomic Testing in Patients with Cancer (GPS Cancer™ Test) Annual Review, approved July 25, 2017. Policy updated with literature review through April 25, 2017; references 27-28 and 33 added. Policy statement unchanged. 12.04.140 08/01/2017 07/31/2017
Molecular Testing in the Management of Pulmonary Nodules New Policy, approved July 18, 2017. Literature review through March 30, 2017. Plasma-based proteomic screening (Xpresys® Lung) & Gene expression profiling on bronchial brushings (Percepta® Bronchial Genomic Classifier) considered investigational. 12.04.142 08/01/2017 07/31/2017
12.04.48 Genetic Testing for Initial Warfin Dosing Annual Review, approved July 25, 2017. Policy moved into new format. Policy updated with literature review through April 25, 2017; no references were added. Policy revised with updated genetics nomenclature; statement otherwise unchanged. 12.04.48 08/01/2017 07/31/2017
12.04.51 Genetic Testing for Tamoxifen Treatment Annual Review, approved July 25, 2017. Policy moved to new format. Policy updated with literature review through April 25, 2017; reference 64 added. Policy revised with updated genetics nomenclature; policy statement otherwise unchanged. 12.04.51 08/01/2017 07/31/2017
12.04.515 Genetic Testing for Mental Health Conditions Annual Review. Policy approved on July 25, 2017. No changes to policy statement. 12.04.515 08/01/2017 07/31/2017
12.04.517 CYP450 Genotyping to Determine Drug Metabolizer Status Annual review. Policy approved on July 25, 2017. Selection or Dosing of Tetrabenazine and Eliglustat were added to the Evidence Review section. No changes to policy statement. 12.04.517 08/01/2017 07/31/2017
12.04.81 Genetic Testing for Rett Syndrome Annual review. Literature review through March 23, 2017. Policy statements updated to define “genetic testing for Rett syndrome- associated genes. Removed “female” requirement of child for testing; Added 2 new medical necessity statements. 12.04.81 08/01/2017 07/31/2017
2.02.30 Transcatheter Mitral Valve Repair Annual Review, approved July 11, 2017. Policy moved into new format. Policy updated with literature review through March 23, 2017; references 27-28 and 36 added. “Cleared” changed to “approved” in the medically necessary policy statement. 2.02.30 08/01/2017 07/31/2017
2.02.510 Mobile Cardiac Outpatient Telemetry Annual review, approved July 11, 2017. No changes to policy statement. 2.02.510 08/01/2017 07/31/2017
3.01.510 Applied Behavior Analysis (ABA) Interim review, approved July 25, 2017. Clarifications made to policy statement. 3.01.510 08/01/2017 07/31/2017
5.01.560 Excessively High Cost Drug Products with Lower Cost Alternatives Interim review, approved July 25, 2017. Addition of excessively high cost kits. 5.01.560 08/01/2017 07/31/2017
5.01.605 Medical Necessity Criteria for Pharmacy Edits Interim review, approved July 25, 2017. Update ADHD drugs (add Mydayis); update reauthorization criteria for Xyrem. 5.01.605 08/01/2017 07/31/2017
6.01.25 Percutaneous Vertebroplasty and Sacroplasty Annual Review, approved July 18, 2017, in new format. Literature review through March 2017; references 9, 16, 26-27, and 30-31 added; vertebroplasty may be medically necessary when criteria met. 6.01.25 08/01/2017 07/31/2017
7.01.127 Bronchial Thermoplasty Annual Review, approved July 25, 2017. Policy moved into new format. Policy updated with literature review through April 25, 2017; references 14-17 and 22 added. Removed CPT code 31899. Policy statement unchanged. 7.01.127 08/01/2017 07/31/2017
7.01.128 Endobronchial Valves Annual Review, approved July 25, 2017. Policy moved to new format. Policy updated with literature review through April 25, 2017; reference 4 added. “Endobronchial” changed to “Bronchial” in policy and title. Policy statement otherwise unchanged. 7.01.128 08/01/2017 07/31/2017
7.01.149 Amniotic Membrane and Amniotic Fluid Injections Interim Review, approved July 18, 2017, in new format. Literature review through April 27, 2017; refs added. Sutured amniotic membrane grafts considered medically necessary when criteria met. Added HCPCS codes Q4131-Q4133, Q4145, and Q4154. 7.01.149 08/01/2017 07/31/2017
Sphenopalatine Ganglion Block for Headache New Policy, approved July 18, 2017, add to Surgery section. Literature review through March 23, 2017. Sphenopalatine ganglion blocks are considered investigational for all indications. 7.01.159 08/01/2017 07/31/2017
8.01.511 Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood Annual Review. Retinoblastoma was divided (metastatic [MN] vs without metastases [Inv]). HCT for late stage Wilms Tumor previously covered as med nec, now inv. Tandem auto HCT (high risk / relapsed neuroblastoma) now covered as medically necessary. 8.01.511 08/01/2017 07/31/2017
8.01.60 Extracorporeal Membrane Oxygenation for Adult Conditions Annual Review, approved July 11, 2017. Policy moved into new format. Policy updated with literature review through March 23, 2017; references 36, 51, 58, and 61 added. Policy statements unchanged. 8.01.60 08/01/2017 07/31/2017
8.01.61 Focal Treatments for Prostate Cancer Annual Review, approved July 11, 2017. Policy moved into new format. No changes to policy statement. 8.01.61 08/01/2017 07/31/2017
8.02.04 Lipid Apheresis Annual Review, approved July 11, 2017. Policy updated with literature review through March 23, 2017; references added. The investigational statement on LDL apheresis for all other uses expanded. Revised Definition of Terms. 8.02.04 08/01/2017 07/31/2017
8.03.08 Cardiac Rehabilitation in the Outpatient Setting Annual Review, approved July 18, 2017.Literature review through May 31, 2017; references added. Added statement that intensive cardiac rehabilitation with the Pritikin Program or the Ornish Program is considered investigational. 8.03.08 08/01/2017 07/31/2017

 

Click here to view the Premera Blue Cross July 2017 Medical Policy Updates »

 

 

 

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