Anthem Blue Cross and Blue Shield Virginia Coverage and Clinical Guideline Update

March 2018 ~

Effective May 1, Anthem Blue Cross and Blue Shield in Virginia (BCBS VA) will implement new and revised coverage guidelines approved at the most recent quarterly Medical Policy and Technology Assessment Committee meeting.

These guideline changes impact all Anthem products will all require authorization -with the exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage and the Medicare/Medicaid Plan (Dual Integration product), and the BCBS Benefit Plan (or Federal Employee Program or FEP). A pre-determination can be requested for our Anthem PPO products.

Services related to specialty pharmacy drugs (non-cancer related) require a Medical Necessity review, which includes site-of service criteria, as outlined in the applicable coverage or clinical UM guideline listed below.

Hyaluronan Injections in Joints Other than the Knee (DRUG.00017)

Coverage guideline DRUG.00017 addresses the use of injections of hyaluronan in joints other than the knee, including osteoarthritis and temporomandibular joint disease. This therapy may also be referred to as viscosupplementation.

Effective for dates of service on and after May 1, 2018, intra-articular injections of hyaluronan for the treatment of pain due to reducing and non-reducing disc displacement disease of temporomandibular joint disorders, are considered investigational and not medically necessary. No pre-certification or prior authorization for these agents will be required, but rather reviewed post-service.

The following codes will be subject to post-service review under this coverage guideline:

• Hyaluronic Acid, Euflexxa, J7323
• Hyaluronic Acid, Gel-One, J7326
• Hyaluronic Acid, Gel-Syn, J7328
• Hyaluronic Acid, Genvisc, J7320
• Hyaluronic Acid, Hyalgan, J7321
• Hyaluronic Acid, Hymovis, J7322
• Hyaluronic Acid, Monovisc, J7327
• Hyaluronic Acid, Orthovisc, J7324
• Hyaluronic Acid, Supartz, J7321
• Hyaluronic Acid, Synvisc, J7325
• Hyaluronic Acid, Synvisc-One, J7325

Eteplirsen (Exondys 51™) (DRUG.00081)

This revised document addresses the antisense oligonucleotide drug, eteplirsen (Exondys 51; Sarepta Therapeutics, Inc., Cambridge, MA); an exon-skipping drug intended for the treatment of Duchenne muscular dystrophy (DMD).

Initiation of therapy with eteplirsen is considered medically necessary for the treatment of Duchenne muscular dystrophy when all of the following criteria are met:

1. Individual has a confirmed diagnosis of Duchenne muscular dystrophy; and
2. Individual must be ambulatory (with or without needing an assistive device, such as a cane or walker); and
3. Individual has a genetic mutation that is amenable to exon 51 skipping.

Continuation of therapy with eteplirsen, for each 12 month period post initiation of therapy, is considered medically necessary for the treatment of Duchenne muscular dystrophy when all of the following criteria are met:

1. The criteria above for initiation of therapy have been met; and
2. Individual remains ambulatory (with or without needing an assistive device, such as a cane or walker).

Use of eteplirsen is considered investigational and not medically necessary when the criteria above are not met, and for all other indications.

The HCPCS code associated with this revised coverage guideline is J1428.

Gemtuzumab Ozogamicin (Mylotarg®) (DRUG.00112)

This new coverage guideline addresses gemtuzumab ozogamicin (Mylotarg) (Pfizer, New York, NY), a humanized anti-CD33 monoclonal antibody for the treatment of acute myeloid leukemia (AML) and acute promyelocytic leukemia (APL).

Gemtuzumab ozogamicin is considered medically necessary for the treatment of the following indications:

1. Newly-diagnosed CD33-positive acute myeloid leukemia (AML) in adults greater than or equal to 18 years of age; or
2. Relapsed or refractory CD33-positive AML in adults and in children 2 years and older.

Gemtuzumab ozogamicin is considered medically necessary for the treatment of acute promyelocytic leukemia (APL) in high-risk individuals who are ineligible for treatment with anthracycline.

Gemtuzumab ozogamicin is considered investigational and not medical necessary when the medically necessary criteria have not been not met, and for all other indications.

The HCPCS code associated with this new coverage guideline is J9203.

Recombinant Erythropoietin Products (CG-DRUG-05)

This revised clinical UM guideline addresses recombinant, or man-made, erythropoietin products.

The clinical indications have been revised to consider Darbepoetin Alfa and Epoetin Alfa to be not medically necessary to treat anemia in individuals with cancer receiving myelosuppressive chemotherapy in whom the anemia can be managed by transfusion.

The CPT and HCPCS codes associated with this revised clinical UM guideline are J0881, J0882, J0885, J0887, J0888, Q4081, and S9537.

Antihemophilic Factors and Clotting Factors (CG-DRUG-78) (Previously DRUG.0066)

This clinical UM guideline addresses select hemophilia and clotting factor replacement treatments created from blood products (human plasma-derived) and others that are manufactured (recombinant). The content was previously addressed in DRUG.00066.

It has been revised to include criteria for recombinant coagulation factor IX, GlycoPEGylated (Rebinyn®) and Human Fibrinogen (Fibryna).

The HCPCS codes associated with this clinical UM guideline are J7198, J7189, J7190, J7182, J7185, J7192, J7209, J7210, J7211, J7205, J727, J7188, J7191, J7183, J7186, J7187, J7179, J7193, J7194, J7195, J7200, J7195, J7201, J720, J7175, J7180, J7181, and J7178.

Ambulatory Electroencephalography and Video Electroencephalography (CG-MED-46)

This clinical UM guideline addresses ambulatory electroencephalography (EEG) monitoring in the outpatient (for example, home) setting and video EEG in the outpatient, observation or inpatient settings. The scope has been expanded to include outpatient video EEG.

Outpatient video EEG testing is considered not medically necessary for all indications.

The CPT codes associated with this revised clinical UM guideline are 95950, 95953, 95956, and 95951.

CPT^® is a registered trademark of the American Medical Association.

Source(s): Anthem BCBS Network Update;