Medical Policy Updates

New policy developed.  Amevive® (alefacept) injection for the treatment of psoriasis requires prior plan approval. Benefits for an initial 3 month period of time may be considered medically neces¬sary: 1) In patients who are 18 years of age or older; and 2) In situations where the patient has already been treated with phototherapy (i.e., PUVA or broadband or narrowband UVB) unless the patient is not a candidate for phototherapy or phototherapy is not available to the patient; and 3) In situations where the patient has already been treated with or is not a candidate for any other systemic treatments such as methotrexate (oral or IM), cyclosporin, and acitretin (Soriatane®).

Continuation of coverage may be provided (in situations where treatment is continuing to provide improvement in the plaque psoriasis) for an additional 3 months following a 3-month period of time where the patient is not receiving Amevive® (alefacept).

Coverage is provided for up to two 3-month treatment cycles per lifetime.

Amevive® (alefacept) is not covered when the criteria stated above are not met.  Coverage is not provided for the simultaneous use of more than one biologic drug.  Amevive®(alefacept) is contraindicated in and should not be administered to patients infected with HIV.  Amevive®(alefacept) reduces CD4+ lymphocyte counts, which might accelerate disease progression or increase complications of disease in these patients.  Amevive®(alefacept) is contraindicated in and should not be administered to patients with known hypersensitivity to Amevive®(alefacept) or any of its components.

Notification given 3/30/09.  Effective date 7/1/09.

New policy adopted. Reviewed with Senior Medical Director 2/24/2009. Gene expression profiling using the Pathwork® Tissue of Origin test to evaluate the site of origin of a tumor of unknown primary, and to distinguish a primary from a metastatic tumor because it is considered investigational. Notice given 3/30/09. Effective date of policy 7/6/2009.

Policy adopted from the BCBS Association. Senior Medical Director review 3/25/09. " 1) Chronic home use of a device for pulsed irrigation may be medically necessary in patients with neuropathic bowel who have failed conservative techniques of bowel retraining , as evidenced by repeated episodes of impaction requiring physician intervention or hospitalization. 2) Pulsed irrigation may be medically necessary as a treatment of fecal impaction in the hospital, outpatient, and clinic setting." "Pulsed irrigation is not covered for indications that do not meet the criteria listed above." Notification given 3/30/09. Policy effective 7/1/09.