Medical Policy Directory of Documents Policy Number: 411 Q: How do I comment on the documents? A: You can email us at [email protected]. Q: How do I find out which documents have changed? A: New and updated documents are posted to the system every week. To find out what has changed see the Provider Focus newsletter. Drugs ∙ Treatments ∙ Devices and Equipment ∙ Surgeries ∙ Other Drugs Medical Technology Assessment Investigational (Non-Covered) Services List 400 Ampyra™ (dalfampridine) 246 Antihyperlipidemics: A Prescription Drug Therapy Guideline 013 ↳Prior Authorization/ Formulary Exception Form 434 Anti-Parkinsonism Drugs 054 Antisense Oligonucleotide Medications 027 Asthma and Chronic Obstructive Pulmonary Disease Medication Management 011 ↳Prior Authorization/ Formulary Exception Form 434 Benign Prostatic Hyperplasia (BPH) 040 Bisphosphonate, Oral 058 Botulinum Toxin Injections 006 B-Type Natriuretic Peptide 031 Anti-Migraine Policy 021 CNS Stimulants and Psychotherapeutic Agents 019 Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications 705 Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications 704 Compounded Medications 579 Cox II Inhibitor Drugs 002 Diabetes Step Therapy 041 Dificid (fidaxomicin) 700 Drug Management and Prior Authorization 251 ↳Prior Authorization/ Formulary Exception Form 434 Drugs for Cystic Fibrosis 408 Entresto Step Therapy 063 Erythropoietin, Recombinant Human; Epoetin Alpha (Epogen and Procrit); Darbepoetin Alpha 262 (Aranesp) Esketamine Nasal Spray (Spravato) and Intravenous Ketamine for Treatment Resistant 087 Depression 1 Fentanyl, oral/transmucosal 113 Hypoactive Sexual Desire Disorder 131 Infertility Step Therapy 014 Injectable Specialty Medication Coverage 071 Glucagon-like Peptide-1 - GLP-1 - Receptor Agonists 282 ↳Prior Authorization/ Formulary Exception Form 434 Growth Hormone and Insulin-like Growth Factor 257 ↳Prior Authorization/ Formulary Exception Form 434 Hepatitis C Medication Management 344 HETLIOZ (tasimelteon) 697 Home Total Parenteral Nutrition (TPN) 296 ↳Prior Authorization Form 430 ↳Prior Authorization Form 430 IgE Receptor Binding Inhibitors, Omalizumab (Xolair) 017 Immune Modulating Drugs 004 Immunomodulators, Topical (This is not a medical policy document) 010 Influenza Drugs: Tamiflu and Relenza 440 Interferons Alpha and Gamma 052 ↳Prior Authorization/ Formulary Exception Form 434 Interleukin-2 (IL-2) 103 Intravenous Immunogammaglobulin (IVIg) 310 ↳Prior Authorization Form 430 Lorcaserin (Belviq) 572 Medical Benefit Prior Authorization Medication List 034 Med UM Pharmacy Prior Authorization 033 Medical and Surgical Management of Obesity including Anorexiants 379 Medications for Sickle Cell and Beta Thalassemia 083 Melanoma Vaccines 453 Monitored Anesthesia Care (MAC) 154 Mupirocin Step Policy 062 New Drug Approval Program 005 Non-Covered Drug List 433 ↳ Formulary Exception Form 434 Oncology Drugs 409 Ophthalmic Prostaglandins 346 Opioid and Opioid Combination Medication Management and Urine Drug Testing 102 Overactive Bladder Medications 170 Phosphodiesterase Type-5 Inhibitors for Pulmonary Arterial Hypertension 036 Pregabalin (Lyrica and Lyrica CR) 057 Probuphine (buprenorphine implant) 021 Proton Pump Inhibitors 030 Quality Care Dosing (QCD) Guidelines 621A Quality Care Dosing Guidelines Drug List 621B Restasis – Topical Ocular Hydrating Agents 426 Retail Pharmacy Prior Authorization Policy 049 RSV Immunoglobulin: Palivizumab (Synagis™) & RSV-IVIg & RespiGam) for Respiratory 422 Syncytial Virus ↳Prior Authorization Form 430 Sexual Dysfunction: Diagnosis and Therapy 078 2 Soliris and Ultomiris 093 Special Foods: Special Infant Formula, Enteral Formula, Ketogenic Diet for Seizures, and 304 Formula Infusion Pumps ↳Prior Authorization/ Formulary Exception Form 434 Spinal Muscular Atrophy (SMA) Medications 044 Sublingual Immunotherapy with Allergen-specific Extracts (SLIT) 681 Topical Testosterone 345 Tests Medical Technology Assessment Investigational (Non-Covered) Services List 400 Actigraphy 533 AIM High Technology Radiology Management Program CPT and HCPCS Codes 900 Ambulatory Event Monitors and Mobile Outpatient Cardiac Telemetry 347 Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening 557 Antigen Leukocyte Antibody Test 673 Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients 206 with Elevated Office Blood Pressure Automated Point of Care Nerve Conduction Tests 222 Autonomic Nervous System Testing 713 Biomarkers for Diagnosis & Cancer Risk Assessment of Prostate Cancer 336 Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated 549 with High Bone Turnover Breast Duct Endoscopy 493 Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting 287 Cardiovascular Risk Panels 664 Chromoendoscopy as an Adjunct to Colonoscopy 904 Computed Tomography Perfusion Imaging of the Brain 448 Computer-Aided Evaluation of Malignancy with Magnetic Resonance Imaging of the Breast 578 Computer-Assisted Navigation Orthopedic Procedure 594 Confocal Laser Endomicroscopy 618 Corneal Endothelial Microscopy-Specular Microscopy 050 Diagnosis and Management of Idiopathic Environmental Intolerance or Clinical Ecology 264 Dopamine Transporter Imaging with Single Photon Emission Computed Tomography 918 Drug Testing in Pain Management and Substance Use Disorder Treatment 674 Dynamic Posturography To Assess Vestibular Dysfunction 263 Dynamic Spinal Visualization and Vertebral Motion Analysis 195 Electromagnetic Navigation Bronchoscopy 203 Electromyography and Nerve Conduction Studies 701 Endobrachial Ultrasound for Diagnosis and Staging of Lung Cancer 715 Endovascular Therapies for Extracranial Vertebral Artery Disease 730 Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management – 492 Ductal Lavage and Suction Collection Systems Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies 790 Fecal Analysis in the Diagnosis of Intestinal Dysbiosis 556 Fecal Calprotectin Testing 329 Flow Cytometry for Cell Analysis 341 Genetic Testing for Familial Cutaneous Malignant Melanoma 300 Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during 546 Breast-Conserving Surgery High-Sensitivity C-Reactive Protein 032 3 Home Uterine Activity Monitoring 043 Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease 016 and Venous Thromboembolic Disease Hydrogel Spacer use During Radiotherapy for Prostate Cancer 743 Identification of Microorganisms Using Nucleic Acid Probe 555 Immune Cell Function Assay in Solid Organ Transplantation 182 In Vivo Analysis of Colorectal Polyps 521 Ingestible pH and Pressure Capsule 045 Intracellular Micronutrient Analysis 073 InVitro Chemoresistance and Chemosensitivity Assays 253 Laboratory Tests for Heart and Kidney Transplant Rejection 530 Leukocyte Histamine Release Test 589 Magnetic Resonance MRI, MRA, MRV, MRS 106 Magnetoencephalography and Magnetic Source Imaging 137 Measurement of Lipoprotein-Associated Phospholipase A2 - Lp-PLA2 - in the Assessment of 558 Cardiovascular Risk Measurement of Serum Antibodies to Selected Biologic Agents 917 Medicare Part D Coverage Determination Request Form 442 Mineral Density Studies 450 Molecular Testing in the Management of Pulmonary Nodules 029 Multianalyte Assays with Algorithmic Analyses for Predicting Risk of Type 2 Diabetes 654 Multianalyte Assays with Algorithmic Analysis for the Evaluation and Monitoring of Patients with 921 Chronic Liver Disease Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis 677 Multispectral Digital Skin Lesion Analysis 748 Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis 711 Myocardial Strain Imaging 112 Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure 576 Nerve Fiber Density Measurement 393 Neurofeedback 515 Neuropsychological Testing 039 Non-Invasive Vascular Studies - Duplex Scans 691 Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease 283 Nutrient - Nutritional Panel Testing 745 Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma 053 Optical Coherence Tomography for Imaging of Coronary Arteries 915 Optical Coherence Tomography of the Anterior Eye Segment 084 Paraspinal Surface Electromyography - SEMG - to Evaluate and Monitor Back Pain 517 Preimplantation Genetic Testing 088 Preventive Screening Tests (This is not a medical policy document) 413 Proteomic Testing for Systemic Therapy in Non-Small Cell Lung Cancer 709 Psychological Testing 363 Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers 397 Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit Hyperactivity 554 Disorder Radiofrequency Ablation of Peripheral Nerves to Treat Pain 794 Radioimmunoscintigraphy Imaging and Monoclonal Antibody Imaging Using In-111 Satumomab 638 Pendetide - OncoScint - or Tc-99m Arcitumomab - IMMU-4, CEA-Scan Radioimmunoscintigraphy Imaging and Monoclonal Antibody Imaging Using Technetium-99m 640 Nofetumomab Merpentan - Verluma 4 Radioimmunoscintigraphy Imaging and Monoclonal Antibody Imaging with Indium-111 Capromab 639 Pendetide for Prostate Cancer Retinal Telescreening for Diabetic Retinopathy 065 Rhinomanometry and Acoustic or Optical Rhinometry 586 Saturation Biopsy for Diagnosis and Staging of Prostate Cancer 307 Scintimammography, Breast-Specific