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Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective June 30, 2017 (Posted April 28, 2017)

Medical Policy Revision
Enzyme Replacement Therapy (ERT) for Lysosomal Storage Disorders "Notification" Added "ERT" to policy title. Formatting changes made. Policy revised to include criteria and guidelines for Vimizim for Morquio Type A Syndrome, as well as the following: Aldurazyme, Elaprase, Fabrazyme, and Luminzyme for respective indications noted. Added Related Policy "Place of Service for Medical Infusions". Policy Guidelines updated to include guidelines for added drugs, and guidelines for "Site of Care Eligibility" related to infusion. Codes J1322, J1931, J1743, J0180, J0220, J0221 added to coding section. Specialty Matched Consultant Advisory Panel review 3/2017. Medical Director review 3/2017. Notification given 4/28/17 for policy effective 7/1/17. Codes J1322, J1743, J0180, and J0221 will be noticed 7/1/17, effective for PPA 10/1/17
MRI-guided Laser-induced Thermotherapy for Neurological Indications "Notification" New policy developed. MRI-guided Laser-induced Thermotherapy for Neurological Indications is considered investigational. Policy noticed 4/28/2017 for effective date 6/30/2017.
Place of Service for Medical Infusions "Notification" New policy developed. Medical infusion therapy in a hospital outpatient setting is considered medically necessary if the following criteria are met: 1. History of mild adverse events that have not been successfully managed through mild pre-medication (diphenhydramine, acetaminophen, steroids, fluids, etc.), OR 2.History of severe adverse event following that infusion (i.e., anaphylaxis, seizure, thromboembolism, myocardial infarction, renal failure), OR 3.Conditions that cause an increased risk for severe adverse event (i.e., unstable renal function, cardiopulmonary conditions, unstable vascular access), OR 4.Inability to physically and cognitively adhere to the treatment schedule and regimen complexity, OR 5.First infusion, OR 6.Less than 3 months since first infusion, OR 7.First infusion after six months of no infusions. Medical Director review 4/2017. Policy noticed 4/28/17 for effective date 6/30/17.