UnitedHealthcare Community Plan of Kentucky Medical Policy Update Bulletin: June 2021 In This Issue Medical Policy Updates Page Updated • Pharmacogenetic Testing – Effective Jun. 1, 2021 ................................................................................................................................................................................................ 3 Revised • Articular Cartilage Defect Repairs – Effective Jul. 1, 2021 .................................................................................................................................................................................... 3 • Cell-Free Fetal DNA Testing – Effective Jul. 1, 2021 .............................................................................................................................................................................................. 6 • Implanted Electrical Stimulator for Spinal Cord – Effective Jul. 1, 2021 .............................................................................................................................................................. 8 • Lower Extremity Invasive Diagnostic and Endovascular Procedures – Effective Jul. 1, 2021 ............................................................................................................................ 9 Replaced/Retired • Femoroacetabular Impingement Syndrome – Effective Jun. 1, 2021 ................................................................................................................................................................. 11 • Otoacoustic Emissions Testing – Effective Jun. 1, 2021 ..................................................................................................................................................................................... 11 Medical Benefit Drug Policy Updates New • Long-Acting Injectable Antiretroviral Agents for HIV – Effective Jul. 1, 2021 ..................................................................................................................................................... 12 • Oxlumo™ (Lumasiran) – Effective Jul. 1, 2021 ...................................................................................................................................................................................................... 13 Revised • Antiemetics for Oncology – Effective Jul. 1, 2021 ................................................................................................................................................................................................ 14 • Benlysta® (Belimumab) – Effective Jul. 1, 2021 .................................................................................................................................................................................................... 21 • Complement Inhibitors (Soliris® & Ultomiris®) – Effective Jul. 1, 2021 ................................................................................................................................................................ 24 • Gonadotropin Releasing Hormone Analogs – Effective Jul. 1, 2021 .................................................................................................................................................................. 30 • Infliximab (Remicade®) – Effective Jul. 1, 2021 .................................................................................................................................................................................................... 32 • Intravenous Bisphosphonates/ Bone Resorption Inhibitors (Zoledronic Acid & Pamidronate Disodium) – Effective Jul. 1, 2021 ............................................................... 33 • Rituximab (Riabni™, Rituxan®, Ruxience®, & Truxima®) – Effective Jul. 1, 2021 .................................................................................................................................................. 35 Page 1 of 65 UnitedHealthcare Community Plan of Kentucky Medical Policy Update Bulletin: June 2021 In This Issue • Spinraza® (Nusinersen) – Effective Jul. 1, 2021 .................................................................................................................................................................................................... 41 • White Blood Cell Colony Stimulating Factors – Effective Jul. 1, 2021 ................................................................................................................................................................ 45 • Xiaflex® (Collagenase, Clostridium, Histolyticum) – Effective Jul. 1, 2021 .......................................................................................................................................................... 48 • Xolair® (Omalizumab) – Effective Jul. 1, 2021 ....................................................................................................................................................................................................... 50 • Zolgensma® (Onasemnogene Abeparvovec-Xioi) – Effective Jul. 1, 2021 .......................................................................................................................................................... 56 Coverage Determination Guideline Updates Updated • Breast Reconstruction Post Mastectomy and Poland Syndrome – Effective Jun. 1, 2021 ............................................................................................................................... 60 • Rhinoplasty and Other Nasal Surgeries – Effective Jun. 1, 2021 ........................................................................................................................................................................ 60 Revised • Ambulance Services – Effective Jul. 1, 2021 ........................................................................................................................................................................................................ 60 • Chiropractic Services – Effective Jul. 1, 2021 ...................................................................................................................................................................................................... 64 Page 2 of 65 UnitedHealthcare Community Plan of Kentucky Medical Policy Update Bulletin: June 2021 Medical Policy Updates Updated Policy Title Effective Date Summary of Changes Pharmacogenetic Jun. 1, 2021 Coverage Rationale Testing Updated list of examples of unproven and not medically necessary pharmacogenetic Multi-Gene Panels for genetic polymorphisms; removed “NeurolDgenetix” Revised Policy Title Effective Date Summary of Changes Coverage Rationale Articular Cartilage Jul. 1, 2021 Coverage Rationale Autologous chondrocyte transplantation (ACT) is proven and medically Defect Repairs Revised language to indicate: necessary for treating individuals with a symptomatic full-thickness articular cartilage defect. o Autologous chondrocyte transplantation (ACT) is proven and medically necessary for ACT is unproven and not medically necessary for treating individuals with the treating individuals with a following indications due to insufficient evidence of efficacy: symptomatic full-thickness Treatment of joints other than the knee articular cartilage defect Growth plates have not closed History of partial-thickness defects o ACT is unproven and not medically necessary for Osteochondritis dissecans (OCD) treating individuals with the Malignancy in the bone, cartilage, fat or muscle of the treated limb following indications due to Active infection in the affected knee Instability of the knee insufficient evidence of efficacy: History of total meniscectomy . Treatment of joints other Repeat ACT than the knee Active inflammatory degenerative, rheumatoid or osteoarthritis . Growth plates have not As initial or first line of surgical therapy closed . History of partial-thickness Microfracture repair to treat full and partial thickness chondral defects of the defects knee is proven and medically necessary. Osteochondritis dissecans (OCD) For medical necessity clinical coverage criteria for ACT and microfracture repair, . Malignancy in the bone, refer to the InterQual® Client Defined 2020, CP: Procedures, Articular Cartilage cartilage, fat or muscle of Defect Repairs (Custom) - UHG. the treated limb ® . Active infection in the Click here to view the InterQual criteria. affected knee . Instability of the knee Osteochondral Autograft and Allograft transplantation is proven and Page 3 of 65 UnitedHealthcare Community Plan of Kentucky Medical Policy Update Bulletin: June 2021 Medical Policy Updates Revised Policy Title Effective Date Summary of Changes Coverage Rationale Articular Cartilage Jul. 1, 2021 . History of total medically necessary for treating individuals with cartilage defects of the Defect Repairs meniscectomy knee. (continued) . Repeat ACT . Active inflammatory For medical necessity clinical coverage criteria for Osteochondral Autograft and degenerative, rheumatoid Allograft transplantation, refer to the InterQual® 2020, Apr. 2020 Release, CP: or osteoarthritis Procedures: . As initial or first line of • Arthroscopy or Arthroscopically Assisted Surgery, Knee surgical therapy • Arthroscopy or Arthroscopically Assisted Surgery, Knee (Pediatric) o Microfracture repair is proven • Arthrotomy, Knee and medically necessary to treat full and partial thickness Click here to view the InterQual® criteria. chondral defects of the knee o