May 2018 policy update bulletin Medical & Administrative Policy Updates UnitedHealthcare respects the expertise of the physicians, health care professionals, and their staff who participate in our network. Our goal is to support you and your patients in making the most informed decisions regarding the choice of quality and cost-effective care, and to support practice staff with a simple and predictable administrative experience. The Policy Update Bulletin was developed to share important information regarding Oxford® Medical and Administrative Policy.* *Where information in this bulletin conflicts with applicable state and/or federal law, UnitedHealthcare follows such applicable federal and/or state law Oxford ® Oxford Medical and Administrative Policy Updates Overview This bulletin provides complete details on Oxford® Clinical, Policy Update Classifications Administrative and Reimbursement Policy updates. The inclusion of New a health service (e.g., test, drug, device or procedure) in this New clinical coverage criteria and/or documentation review bulletin indicates only that UnitedHealthcare has recently adopted a requirements have been adopted for a health service (e.g., test, drug, new policy and/or updated, revised, replaced or retired an existing device or procedure) policy; it does not imply that Oxford® provides coverage for the Updated health service. In the event of an inconsistency or conflict between An existing policy has been reviewed and changes have not been made the information provided in this bulletin and the posted policy, the to the clinical coverage criteria or documentation review requirements; provisions of the posted policy will prevail. Note that most benefit however, items such as the clinical evidence, FDA information, and/or plan documents exclude from benefit coverage health services list(s) of applicable codes may have been updated identified as investigational or unproven/not medically necessary. Physicians and other health care professionals may not seek or Revised collect payment from a member for services not covered by the An existing policy has been reviewed and revisions have been made to applicable benefit plan unless first obtaining the member’s written the clinical coverage criteria and/or documentation review requirements consent, acknowledging that the service is not covered by the Replaced benefit plan and that they will be billed directly for the service. An existing policy has been replaced with a new or different policy A complete library of Oxford® Medical and Retired Administrative Policies is available at The health service(s) addressed in the policy are no longer being OxfordHealth.com > Providers > Tools & Resources > managed or are considered to be proven/medically necessary and are Medical Information > Medical and Administrative Policies. therefore not excluded as unproven/not medically necessary services, unless coverage guidelines or criteria are otherwise documented in another policy Tips for using the Policy Update Bulletin: From the table of contents, click the policy title to be Note: The absence of a policy does not automatically indicate or imply directed to the corresponding policy update summary. coverage. As always, coverage for a health service must be determined in accordance with the member’s benefit plan and any applicable From the policy updates table, click the policy title to view a federal or state regulatory requirements. Additionally, UnitedHealthcare complete copy of a new, updated, or revised policy. reserves the right to review the clinical evidence supporting the safety and effectiveness of a medical technology prior to rendering a coverage determination. 2 Oxford® Policy Update Bulletin: May 2018 Oxford ® Oxford Medical and Administrative Policy Updates In This Issue Clinical Policy Updates Page NEW ® Benlysta (Belimumab) - Effective May 1, 2018 ................................................................................................................................................... 7 ® Crysvita (Burosumab-Twza) - Effective May 1, 2018 ........................................................................................................................................... 7 Enzyme Replacement Therapy - Effective May 1, 2018 .......................................................................................................................................... 8 UPDATED Chelation Therapy for Non-Overload Conditions - Effective May 1, 2018 ................................................................................................................ 14 Cochlear Implants - Effective Jun. 1, 2018 ......................................................................................................................................................... 14 Computerized Dynamic Posturography - Effective May 1, 2018 ............................................................................................................................. 15 Deep Brain and Cortical Stimulation - Effective May 1, 2018 ................................................................................................................................ 15 Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome - Effective May 1, 2018 ......................................................................... 15 Infertility Diagnosis and Treatment - Effective Jun. 1, 2018 ................................................................................................................................. 15 Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines - Effective Jun. 1, 2018 ................................................................. 15 Otoacoustic Emissions Testing - Effective Jun. 1, 2018 ........................................................................................................................................ 15 Site of Service Guidelines for Certain Outpatient Surgical Procedures - Effective May 1, 2018 .................................................................................. 16 Thermography - Effective May 1, 2018 .............................................................................................................................................................. 16 Vaccines - Effective May 1, 2018 ...................................................................................................................................................................... 16 REVISED Ablative Treatment for Spinal Pain - Effective Jun. 1, 2018 .................................................................................................................................. 16 ® Actemra (Tocilizumab) Injection for Intravenous Infusion - Effective Jun. 1, 2018 ................................................................................................ 18 ® Benlysta (Belimumab) - Effective Aug. 1, 2018 ................................................................................................................................................. 20 Chromosome Microarray Testing (Non-Oncology Conditions) - Effective Jun. 1, 2018 .............................................................................................. 21 Drug Coverage Criteria - New and Therapeutic Equivalent Medications - Effective Jun. 1, 2018 ................................................................................ 24 Drug Coverage Guidelines - Effective May 1, 2018 .............................................................................................................................................. 24 o Adagen (Pegademase Bovine) .................................................................................................................................................................... 24 ® o Aldurazyme (Laronidase) ......................................................................................................................................................................... 24 o Benlysta (Belimumab) ............................................................................................................................................................................... 24 o Crysvita (Burosumab-Twza) ....................................................................................................................................................................... 25 o Elaprase (Idursulfase) ............................................................................................................................................................................... 25 ® o Fabrazyme (Agalsidase Beta) .................................................................................................................................................................... 25 o Kanuma (Sebelipase Alfa) .......................................................................................................................................................................... 26 o Lumizyme (Alglucosidase Alfa) .................................................................................................................................................................... 26 o Mepsevii (Vestronidase Alfa-Vjbk) ............................................................................................................................................................... 26 o Naglazyme (Galsulfase) ............................................................................................................................................................................