2020 Provider Workshops are just around the corner!
Medical policy updates
Infused/injectable medication updates
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2020 Provider Workshops
are just around the corner!
Moda's 2020 Medical Provider Workshops are set to begin Oct. 20, 2020. Join us to learn about our 2020 updates and get a glimpse of what's ahead for 2021.
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Medical policy updates
Criteria
July Medical Criteria Summary
Pharmacy/ Medical
Abdominoplasty and
Panniculectomy
Introduction:
This is an annual review.
Criteria changes:
No changes.
Medical
Anodyne
Introduction:
This is an annual review.
Criteria changes:
No changes.
Medical
Clinical Trials
Introduction:
This is an annual review.
Criteria changes:
· Reworded section II. A. “Moda Health considers Clinical Trials qualified…”
· Removed codes S9992, S9994,
S9996-services are not covered.
Medical
Endoscopic Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD)
Introduction:
This is an annual review.
Criteria changes:
· Removed Esophyx device from E/I list. Transoral Incisionless Fundoplication is performed with the Esophyx device as an endoscopic procedure for the treatment of gastroesophageal reflux disease.
· Removed A9272 from codes not covered- Medicare; Medicare provides coverage in
some circumstances.
Medical
Serum Antibodies for Inflammatory Bowel Disease
Introduction:
This is an annual review.
Criteria changes:
· Fecal measurement of calprotectin is now considered for management of inflammatory bowel diseases in addition to distinguishing inflammatory bowel disease from inflammatory bowel syndrome.
· Removed deleted code 82491
· Update: added CPT code 82542
Medical
Infused/injectable medication updates
The following prior authorization updates have been made to the infused/injectable medications currently in the MagellanRX program. Magellan Rx will review all prior authorization requests for these specialty injectable medications, along with other specialty medications that are already part of the program when administered in:
An outpatient facility
A patient's home
A physician's office
Policy Changes
Effective Nov. 10, 2020
Opdivo (J9299):
Cutaneous Melanoma: To first-line therapy in combination with ipilimumab, removed used in patients with satellite/in-transit recurrence or metastases. To subsequent therapy, limited use to monotherapy only after prior therapy or after maximum clinical benefit from BRAF-targeted therapy, and removed combination therapy with ipilimumab. Removed re-induction therapy indication.
Uveal Melanoma: Limited use to first-line and removed single agent therapy.
RCC: Removed subsequent therapy in combination with ipilimumab. Also removed use as a single agent in non-clear histology relapsed or metastatic disease.
cHL: To combination therapy with brentuximab vedotin, limited to second-line therapy only.
SCCHN: Added patient must have PD-L1 expression ≥1% based on OS results in phase 3 CheckMate-141 trial.
CRC (MSI-H/dMMR): Removed primary treatment or subsequent therapy for unresectable metastatic disease that remains unresectable after primary treatment in patients who are not candidates for intensive therapy.
CNS Cancer: Removed use for the treatment of brain metastases in patients with PD-L1 positive NSCLC.
Yervoy (J9228):
Cutaneous Melanoma: To first-line therapy in combination with nivolumab, removed use in patients with satellite/in-transit recurrence or metastases. To subsequent therapy, limited use to monotherapy only after cytotoxic chemotherapy and removed use after prior therapy or after maximum clinical benefit from BRAF-targeted therapy. To re-induction therapy, limited to monotherapy and removed use in combination with nivolumab. To adjuvant therapy, limited to stage III disease, removed NCCN recommendations for use after complete lymph node dissection, therapeutic lymph node dissection, nodal basin ultrasound surveillance and satellite/in-transit metastases or recurrence.
RCC: Removed use as subsequent therapy in combination with nivolumab.