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Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective August 30, 2016 (Posted July 1, 2016)

Medical Policy Revision
Dry Needling of Myofascial Trigger Points "Notification" New policy adopted. "Dry needling of trigger points for the treatment of myofascial pain is considered investigational." Policy noticed 7/1/2016 for policy effective date 8/30/2016.
Romiplostim (NPlate) "Notification" New policy developed. Romiplostim (NPlate) may be considered medically necessary for the following clinical conditions: 1.Diagnosis of chronic idiopathic thrombocytopenia (ITP); and 2. platelet count ≤30 x 109/L), or upon start of therapy; and 3.history of trial and failure of; or a documented intolerance, FDA labeled contraindication, or hypersensitivity to corticosteroids or immunoglobulins (IVIg or anti-D); or 4. insufficient response to or is not a candidate for splenectomy. Medical director review 6/2016. Policy noticed 7/1/2016 for effective date 8/30/16.