March 2020 medical policy update bulletin Medical Policy, Medical Benefit Drug Policy & Coverage Determination Guideline Updates In This Issue Medical Policy Updates Page UPDATED Cardiac Event Monitoring – Effective Apr. 1, 2020 .............................................................................................................................................. 3 Cytological Examination of Breast Fluids for Cancer Screening or Diagnosis – Effective Apr. 1, 2020 .......................................................................... 3 Elbow Replacement Surgery (Arthroplasty) – Effective Apr. 1, 2020 ...................................................................................................................... 3 Electrical and Ultrasound Bone Growth Stimulators – Effective Apr. 1, 2020 ........................................................................................................... 3 Implanted Electrical Stimulator for Spinal Cord – Effective Apr. 1, 2020 ................................................................................................................ 3 Obstructive Sleep Apnea Treatment – Effective Apr. 1, 2020 ................................................................................................................................ 3 Pneumatic Compression Devices – Effective Apr. 1, 2020 .................................................................................................................................... 3 Prolotherapy and Platelet Rich Plasma Therapies – Effective Apr. 1, 2020 .............................................................................................................. 3 Shoulder Replacement Surgery (Arthroplasty) – Effective Apr. 1, 2020 .................................................................................................................. 3 Temporomandibular Joint Disorders – Effective Apr. 1, 2020 ................................................................................................................................ 4 REVISED Abnormal Uterine Bleeding and Uterine Fibroids – Effective Apr. 1, 2020 ............................................................................................................... 4 Attended Polysomnography for Evaluation of Sleep Disorders – Effective Apr. 1, 2020 ............................................................................................. 4 Bariatric Surgery – Effective May 1, 2020 ......................................................................................................................................................... 7 Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes – Effective Apr. 1, 2020 ........................................................................ 10 Electroencephalographic (EEG) Monitoring and Video Recording – Effective Apr. 1, 2020 ....................................................................................... 12 Hip Resurfacing and Replacement Surgery (Arthroplasty) – Effective Apr. 1, 2020 ................................................................................................ 13 Hysterectomy for Benign Conditions – Effective Apr. 1, 2020 ............................................................................................................................. 13 Knee Replacement Surgery (Arthroplasty), Total and Partial – Effective Apr. 1, 2020 ............................................................................................ 13 Lower Extremity Vascular Angiography – Effective Apr. 1, 2020 ......................................................................................................................... 14 Surgical Treatment for Spine Pain – Effective Apr. 1, 2020 ................................................................................................................................ 14 Medical Benefit Drug Policy Updates NEW Intravenous Iron Replacement Therapy (Feraheme® & Injectafer®) – Effective Apr. 1, 2020 ................................................................................... 16 1 Medical Policy Update Bulletin: March 2020 Vyondys 53™ (Golodirsen) – Effective Apr. 1, 2020 .......................................................................................................................................... 18 UPDATED Denosumab (Prolia® & Xgeva®) – Effective Mar. 1, 2020 ................................................................................................................................... 20 REVISED Botulinum Toxins A and B – Effective Apr. 1, 2020 ........................................................................................................................................... 20 Exondys 51® (Eteplirsen) – Effective Apr. 1, 2020 ............................................................................................................................................ 20 Ketalar (Ketamine) and Spravato™ (Esketamine) – Effective Apr. 1, 2020 ........................................................................................................... 21 Oncology Medication Clinical Coverage – Effective Apr. 1, 2020 .......................................................................................................................... 26 Rituximab (Rituxan®, Ruxience™, & Truxima®) – Effective Apr. 1, 2020 .............................................................................................................. 27 Coverage Determination Guideline (CDG) Updates UPDATED Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair – Effective Apr. 1, 2020................................................................................................... 30 Gynecomastia Treatment – Effective Apr. 1, 2020 ............................................................................................................................................ 30 Habilitative Services and Outpatient Rehabilitation Therapy – Effective Apr. 1, 2020 ............................................................................................. 30 Orthognathic (Jaw) Surgery – Effective Apr. 1, 2020 ........................................................................................................................................ 30 Panniculectomy and Body Contouring Procedures – Effective Apr. 1, 2020 ........................................................................................................... 30 Rhinoplasty and Other Nasal Surgeries – Effective Apr. 1, 2020 ......................................................................................................................... 30 Utilization Review Guideline (URG) Updates REVISED Chemotherapy Observation or Inpatient Hospitalization – Effective Apr. 1, 2020 ................................................................................................... 31 Provider Administered Drugs – Site of Care – Effective May 1, 2020 ................................................................................................................... 32 2 Medical Policy Update Bulletin: March 2020 Medical Policy Updates Policy Title Effective Date Coverage Rationale UPDATED Cardiac Event Apr. 1, 2020 Coverage Rationale Monitoring Replaced reference to “MCG™ Care Guidelines, 23rd edition, 2019” with “MCG™ Care Guidelines, 24th edition, 2020” Cytological Apr. 1, 2020 References Examination of Replaced reference to “MCG™ Care Guidelines, 23rd edition, 2019” with “MCG™ Care Guidelines, 24th edition, Breast Fluids for 2020” Cancer Screening or Diagnosis Elbow Replacement Apr. 1, 2020 Coverage Rationale Surgery Replaced reference to “MCG™ Care Guidelines, 23rd edition, 2019” with “MCG™ Care Guidelines, 24th edition, (Arthroplasty) 2020” Documentation Requirements Updated required clinical information for elbow replacement surgery (arthroplasty) Electrical and Apr. 1, 2020 Coverage Rationale Ultrasound Bone Replaced reference to “MCG™ Care Guidelines, 23rd edition, 2019” with “MCG™ Care Guidelines, 24th edition, Growth Stimulators 2020” Implanted Electrical Apr. 1, 2020 Coverage Rationale Stimulator for Replaced reference to “MCG™ Care Guidelines, 23rd edition, 2019” with “MCG™ Care Guidelines, 24th edition, Spinal Cord 2020” Obstructive Sleep Apr. 1, 2020 Coverage Rationale Apnea Treatment Replaced references to “MCG™ Care Guidelines, 23rd edition, 2019” with “MCG™ Care Guidelines, 24th edition, 2020” Pneumatic Apr. 1, 2020 Coverage Rationale Compression Replaced references to “MCG™ Care Guidelines, 23rd edition, 2019” with “MCG™ Care Guidelines, 24th edition, Devices 2020” Prolotherapy and Apr. 1, 2020 Coverage Rationale Platelet Rich Replaced references to “MCG™ Care Guidelines, 23rd edition, 2019” with “MCG™ Care Guidelines, 24th edition, Plasma Therapies 2020” Shoulder Apr. 1, 2020 Coverage Rationale Replacement Replaced reference to “MCG™ Care Guidelines, 23rd edition, 2019” with “MCG™ Care Guidelines, 24th edition, Surgery 2020” (Arthroplasty) Documentation Requirements Updated required clinical information for shoulder replacement surgery (arthroplasty) Supporting Information Removed Professional Societies section 3 Medical Policy Update Bulletin: March 2020 Medical Policy Updates Policy Title Effective Date Coverage Rationale UPDATED Temporomandibular Apr. 1, 2020 Coverage Rationale Joint Disorders Replaced reference to “MCG™ Care Guidelines, 23rd edition, 2019” with “MCG™ Care Guidelines, 24th edition, 2020” Documentation Requirements Updated required clinical