Loading...Loading...In addition to the summary of monthly changes below, please also review our monthly Bulletin for recent and upcoming changes to our medical and reimbursement policies, Clinical Position Statements and associated changes to pre-authorization requirements. The Medical Policy Manual includes a list of recent updates and archived policies. Monthly change summaries are added to our website within 10 business days of our newsletter publication.
Review other monthly changes for 2022.
We publish updates to medical and reimbursement policies in our monthly publication, The Bulletin. Read issues of The Bulletin or subscribe to receive an email notification when issues are published.
Medical policy updates
We provided 90-day notice in the June 2022 issue of The Bulletin about the following medical policies, which are effective September 1, 2022:
- Gender Affirming Interventions for Gender Dysphoria (#MED153) - Intensity Modulated Radiotherapy (IMRT) for Breast Cancer (#MED166)
- Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and Extremities (#MED165)
Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants (#SUR40)
Reimbursement policy updates
We provided 90-day notice in the June 2022 issue of The Bulletin about the following reimbursement policy, which is effective September 1, 2022:
Reimbursement of Facility Room and Board (Facility #103)
Effective September 1, 2022, the following changes will made to our pre-authorization lists:
Commercial & Medicare Advantage
Joint management—eviCore healthcare (eviCore)
- 23000, 23020, 23120, 23130, 23410, 23412, 23420, 23430, 23440, 23455, 23462, 23466, 23700, 27332-27334, 27403, 27405, 27415, 27418, 27420, 27422, 27425, 27427-27429, 27430, 27570
Please review our pre-authorization lists for all updates and pre-authorize services accordingly. You can submit standard medical pre-authorizations through Availity Essentials. Learn more about electric authorizations.
Effective September 1, 2022, HCPCS J1627, J9304 and J9370 will require pre-authorization for CHG Healthcare Services (group #70000004), IEC Group (group #70000000) and Alsco Inc. (group #70000002) members.
View the complete list of specialty medications that require pre-authorization for these members.
Effective September 1, 2022, we will make the following changes to concurrent review time frames:
- We will decrease the time frame in which in-network diagnosis-related group (DRG) facilities must submit clinical information. Upon receipt of the admission notification, we will respond with an acknowledgment fax that includes the date clinical information will be due.
We will require concurrent review for newborn intensive care unit (NICU) and pediatric intensive care unit (PICU) notifications within 24 hours.
These changes apply to commercial, Medicare Advantage and UMP members.
Effective September 1, 2022, we will require concurrent review for newborn intensive care unit (NICU) and pediatric intensive care unit (PICU) notifications within 24 hours. We are making this change to align with our concurrent review requirements for other admissions.
This change applies to commercial, Medicare Advantage and UMP members.
Effective September 1, 2022, eviCore healthcare (eviCore) will revise the advanced musculoskeletal clinical guidelines below for several components of our Physical Medicine program:
- Pain management
- Joint surgery
Spine surgery
These upcoming guidelines revisions are posted on eviCore’s website under the Future tab in the Musculoskeletal: Advanced Procedures section.
Effective September 11, 2022, AIM Specialty Health (AIM) will revise its radiology and sleep disorder management guidelines. AIM announces upcoming revised guidelines in the Coming Soon section below each set of current guidelines.
Effective September 1, 2022, we will add 43 DME-related HCPCS codes to our non-reimbursable services (NRS) list for commercial and UMP claims and 21 codes for Medicare Advantage claims.
These NRS codes will be added to the Clinical Edits by Code List.
Read more in the June, 2022 issue of our newsletter.
Effective September 1, 2022, we will update the following medication policies:
Revised medication policies effective September 1, 2022
- Cholbam, cholic acid, dru402
- Complement Inhibitors, dru348
- Corlanor, ivabradine, dru413
- Cost-Share Exception Criteria for Preventative Medications, dru399
- Direct Acting Antivirals for HCV, dru599
- Dupixent, dupilumab, dru493
- Enzyme Replacement Therapies (dru426) Adding generic carglumic acid to the policy
- High-Cost Medications for Chronic Constipation (dru519)
- High-cost medications for overactive bladder, dru460
- lapatinib (generic, Tykerb), dru145
- Medications for Multiple Myeloma, other cancers, and other hematologic disorders, dru672
- Medications for thrombocytopenia, dru648
- Non-Preferred GLP1-AgonistContaining Medications, dru347
- Non-Preferred Inhaled Corticosteroid (ICS)-Containing and Muscarinic-Antagonist (LAMA)-Containing Medications, dru380
- Non-preferred Oral Medications for Inflammatory Bowel Disease, dru473
- Radicava, edaravone, dru510
Scenesse, afamelanotide, dru625
New medication policies effective September 1, 2022
- Camzyos, mavacamten, dru720
- Hyftor, sirolimus 0.2% topical gel, dru721
- Pyrukynd, mitapivat, dru719
- Tarpeyo, budesonide, dru712
Vonjo, pacritinib, dru717
Archived medication policies effective September 1, 2022
- Aemcolo, rifamycin, dru601
- Helixate FS, antihemophilic Factor (recombinant), dru537
Stivarga, regorafenib, dru284
Read more in the June and August 2022 issues of our newsletter.