Medical Policy Updates

Notification of Policy Revisions Effective April 1, 2011 (Posted December 30, 2010)

Medical Policy	Revision
Natalizumab (Tysabri) "Notification"	New medical policy issued. Natalizumab (Tysabri) may be considered medically necessary for the treatment of multiple sclerosis and Crohn's disease when the medical criteria and guidelines are met. Notification date 1/1/2011 for effective date 4/1/2011.
Pulmonary Hypertension, Drug Management "Notification"	Under Description section under Advanced Therapy and Prostacyclin Analogues-added Tyvaso as approved inhalation treatment. Moved PAH (Who Group I) statement paragraph that begins "The diagnosis of PAH requires confirmation with a complete right heart catheterization" from the Description section to Policy Guidelines. Also moved non-pulmonary arterial hypertension PH (Who Groups 2-5) statement paragraph that begins "PH associated with elevated left heart filling pressures are more prevalent than PAH" from the Description section to Policy Guidelines. Moved statement paragraph that begins "Treatment with epoprostenol requires three steps as follows" from Policy Guidelines to Description section. Under When Covered section, added Tadalafil (ADCIRCA), oral as medically necessary oral therapy for PAH conditions. Under When Not Covered section, added Tadalafil as investigational for the treatment of non-PAH PH conditions. Added new HCPCS code J7686 for 2011. HCPCS codes J1325, J3285, J7686, Q4074 will require prior reivew as of 4/1/2011. Notification given 1/1/2011 for effective date 4/1/2011.

Medical Policy

Revision

Natalizumab (Tysabri) "Notification"

New medical policy issued. Natalizumab (Tysabri) may be considered medically necessary for the treatment of multiple sclerosis and Crohn's disease when the medical criteria and guidelines are met. Notification date 1/1/2011 for effective date 4/1/2011.

Pulmonary Hypertension, Drug Management "Notification"

Under Description section under Advanced Therapy and Prostacyclin Analogues-added Tyvaso as approved inhalation treatment. Moved PAH (Who Group I) statement paragraph that begins "The diagnosis of PAH requires confirmation with a complete right heart catheterization" from the Description section to Policy Guidelines. Also moved non-pulmonary arterial hypertension PH (Who Groups 2-5) statement paragraph that begins "PH associated with elevated left heart filling pressures are more prevalent than PAH" from the Description section to Policy Guidelines. Moved statement paragraph that begins "Treatment with epoprostenol requires three steps as follows" from Policy Guidelines to Description section. Under When Covered section, added Tadalafil (ADCIRCA), oral as medically necessary oral therapy for PAH conditions. Under When Not Covered section, added Tadalafil as investigational for the treatment of non-PAH PH conditions. Added new HCPCS code J7686 for 2011. HCPCS codes J1325, J3285, J7686, Q4074 will require prior reivew as of 4/1/2011. Notification given 1/1/2011 for effective date 4/1/2011.