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Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective April 29, 2016 (Posted February 29, 2016)

Medical Policy Revision
Bundling Guidelines "Notification" Deleted information regarding Vision Services. Statement revised to read: please refer to CEC's bundling guidelines related to routine vision services. Notification given 2/29/2016 for policy effective date 5/1/2016.
Daratumumab (Darzalex) "Notification" New policy issued. Daratumumab (Darzalex) is considered medically necessary for the treatment of multiple myeloma in patients: who have received three prior lines of therapy including a proteasome inhibitor (PI) and an immunomodulatory agent or who are double-refractory to a PI and an immunomodulatory agent. Senior medical director review 2/2016. References added. Notification given 2/29/2016 for effective date 4/29/2016.
Elotuzumab (Empliciti) "Notification" New policy issued. Elotuzumab (Empliciti) is considered medically necessary in patients who are 18 years of age or older; and who have received at least one prior therapy for multiple myeloma; and who will receive elotuzumab in combination with lenalidomide and dexamethasone . Notification given 2/29/2016 for effective date 4/29/2016. Senior medical director review 2/2016.
Epidural Steroid Injections for Back Pain "Notification" New policy created. Epidural steroid injections are medically necessary for treatment of lumbar sciatica/radiculopathy when criteria are met, not medically necessary if previous epidural injections were not successful, and investigational for all other situations. Notification given 2/29/2016 for policy effective date 5/31/2016.
Genetic Testing for PALB2 Mutations "Notification" New medical policy issued. Genetic testing for PALB2 mutations in patients with breast or pancreatic cancer or for cancer risk assessment in patients with or without a family history of breast or pancreatic cancer is considered investigational. Senior medical director review 1/2016. Reference added. Notification given 2/29/16 for effective date 4/29/16.
Necitumumab (Portrazza) "Notification" New policy issued. Necitumumab (Portrazza) is considered medically necessary when used in combination with gemcitabine and cisplatin, and for first- line treatment. Notification given 2/29/2016 for effective date 4/29/2016. Senior medical director review 2/2016.
Talimogene Laherparepvec (ImlygicTM) "Notification" New policy issued. Talimogene laherparepvec (ImlygicTM) is considered medically necessary for the local treatment of unresectable cutaneous, subcutaneous, and nodal lesions in patients with melanoma recurrent after initial surgery. Notification given 2/29/2016 for effective date 4/29/2016. Senior medical director review 2/2016.
Ustekinumab (Stelara®) "Notification" When Covered section revised to state, "Ustekinumab (Stelara®) may be considered medically necessary for the treatment of moderate to severe plaque psoriasis in patients who are 18 years of age or older and: 1.one of the following: a)The patient has tried and failed, is intolerant to, or has a clinical contraindication to phototherapy (i.e., puva or broadband or narrowband uvb); or b) The patient has tried and failed, is intolerant to, or has a clinical contraindication to systemic therapy (methotrexate (oral or IM), cyclosporine, or acitretin); and 2. One of the following: a) The patient has Body Surface Area (BSA) involvement of at least 5%; OR b)The patient has involvement of the palms, soles, head and neck, or genitalia, causing disruption in normal daily activities and/or employment AND 3.The patient is not using stelara in combination with another biologic agent AND 4.The patient is being managed by a dermatologist AND 5. If Stelara 90 mg is requested and the patient is new to therapy with Stelara, ONE of the following: a) The patient has a diagnosis of psoriasis AND the patient has failed (had an inadequate response to) a trial of 45mg for at least 3 months OR b)The patient weighs >100kg Ustekinumab (Stelara®) may be considered medically necessary for the treatment of active psoriatic arthritis in patients who are 18 years of age or older and:1.The patient has tried and failed, is intolerant to, or has a clinical contraindication to phototherapy (i.e., puva or broadband or narrowband uvb) and 2.The patient is not using stelara in combination with another biologic agent AND 3.If Stelara 90 mg is requested and the patient is new to therapy with Stelara, ONE of the following: a) The patient has a diagnosis of psoriasis AND the patient has failed (had an inadequate response to) a trial of 45mg for at least 3 months OR b)The patient has a dual diagnosis of psoriasis AND psoriatic arthritis AND the patient is >100kg . Medical Director review 1/2016. Specialty Matched Consultant Advisory Panel review 1/27/2016. Policy noticed 2/29/2016 for effective date 4/29/16.