Medical policies recent updates

Policy Title Comments Policy Id Effective Updated
1.01.18 Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers Annual Review, approved May 13, 2024. Policy updated with literature review through January 30, 2024; reference added. Policy statements unchanged. 1.01.18 06/01/2024 06/01/2024
1.01.27 Electrical and Electromagnetic Stimulation for the Treatment of Arthritis Annual Review, approved May 13, 2024. Policy updated with literature review through January 22, 2024; reference added. Policy statement unchanged. 1.01.27 06/01/2024 06/01/2024
1.01.506 Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses Annual Review, approved May 13, 2024. Policy updated with literature review through January 30, 2024; no references added. Policy statements unchanged. 1.01.506 06/01/2024 06/01/2024
1.01.507 Electrical Stimulation Devices Minor update to related policies. 8.01.58 was replaced with 8.01.540 Cranial Electrotherapy Stimulation and Auricular Electrostimulation. 1.01.507 03/01/2024 05/01/2024
1.01.525 Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis Minor edit to move content to a bullet point in the policy coverage criteria section. 1.01.525 06/01/2024 06/12/2024
1.01.527 Power Operated Vehicles (Scooters) (Excluding Motorized Wheelchairs) Annual Review, approved April 8, 2024. Utilization management guideline reviewed. No change to guidelines statements. References updated. 1.01.527 03/01/2023 05/01/2024
1.01.536 Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring Interim Review, approved May 24, 2024. Expanded Dx code range for afib to included I48.20 and I48.21. 1.01.536 06/01/2024 06/01/2024
1.01.537 Low Intensity Pulsed Ultrasound Fracture Healing Device Annual Review, approved May 13, 2024. Policy updated with literature review through January 17, 2024; references added. Policy statements unchanged. 1.01.537 06/01/2024 06/01/2024
1.01.538 Cooling Devices Used in the Outpatient Setting Annual Review, approved May 13, 2024. Policy updated with literature review through January 15, 2024; reference added. Policy statements unchanged. 1.01.538 06/01/2024 06/12/2024
1.01.540 Continuous Passive Motion in the Home Setting Annual Review, approved May 13, 2024. Policy updated with literature review through January 17, 2024; references added. Policy statements unchanged. 1.01.540 06/01/2024 06/01/2024
1.03.04 Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities Annual Review, approved May 13, 2024. Policy updated with literature review through January 18, 2024; no references added. Policy statement unchanged. 1.03.04 06/01/2024 06/01/2024
1.03.501 Custom-made Knee Orthoses (Braces), Ankle-Foot-Orthoses, and Knee-Ankle-Foot-Orthoses Annual Review, approved April 22, 2024. Policy reviewed. Policy statements unchanged. 1.03.501 02/01/2023 05/01/2024
1.04.502 Myoelectric Prosthetic and Orthotic Components for the Upper Limb Annual Review, approved May 24, 2024. Policy updated with literature review through February 5, 2024; no references added. Policy statements unchanged. Added HCPCS code L5969. 1.04.503 06/01/2024 06/03/2024
10.01.514 Cosmetic and Reconstructive Services Interim Review, approved April 9, 2024. Added Letybo to list of pharmaceutical agents considered cosmetic and clarified that Daxxify when used for the treatment of wrinkles is considered cosmetic. 10.01.514 12/01/2023 05/01/2024
10.01.523 Preventive Care Coding update. Added CPT code 99459 to Women’s health section of policy. 10.01.523 11/01/2023 06/01/2024
10.01.533 Non-covered Experimental/Investigational Services Minor clerical update made to coding table 10.01.533 12/01/2023 05/16/2024
11.01.510 Skilled Nursing Facility (SNF): Admission, Continued Stay, and Transition of Care Guideline Annual Review, approved April 8, 2024. UM guideline reviewed. References updated. Guideline statements unchanged. 11.01.510 03/01/2023 05/01/2024
11.01.522 Skilled Hourly Nursing Care in the Home Annual Review, approved April 22, 2024. UM guideline reviewed. Minor edits made; policy intent unchanged. References added. 11.01.522 03/01/2023 5/01/2024
11.01.523 Site of Service: Infusion Drugs and Biologic Agents Updated to current version. 11.01.523 06/07/2024 06/07/2024
13.01.500 Prescription Digital Therapeutics Interim Review, approved May 14, 2024. Policy reviewed. References added. Added EpiMonitor, Rejoyn, and MamaLift Plus to the list of FDA approved prescription digital therapeutics. 13.01.500 06/01/2024 06/01/2024
2.01.106 Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome Minor update to related policies. 8.01.58 was replaced with 8.01.540 Cranial Electrotherapy Stimulation and Auricular Electrostimulation. 2.01.106 08/01/2023 05/01/2024
2.01.533 Upper Gastrointestinal (UGI) Endoscopy for Adults Annual Review, approved April 9, 2024. Policy reviewed. References added. Clarified that UGI is considered medically necessary for family history of gastric, esophageal, or duodenal cancer. 2.01.533 03/01/2024 05/01/2024
2.01.535 Temporomandibular Joint Disorder Annual Review, approved April 8, 2024. Policy updated with literature review through December 13, 2023; references added. Policy statements unchanged. 2.01.535 05/01/2023 05/01/2024
2.04.136 Nutrient/Nutritional Panel Testing Minor update to related policies. 2.04.100 was replaced with 2.04.509 Cardiovascular Risk Panels. 2.04.136 03/01/2024 05/01/2024
2.04.152 Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes Annual Review, approved April 8, 2024. Policy updated with literature review through January 2, 2024; references added. Policy statements unchanged. Changed the wording from "women" to "pregnant individuals" throughout the policy. 2.04.152 07/01/2023 05/01/2024
2.04.509 Cardiovascular Risk Panels Policy renumbered from 2.04.100 to 2.04.509 Cardiovascular Risk Panels, approved April 9, 2024. Policy updated with literature review through October 16, 2023; references added. 2.04.509 05/01/2024 05/01/2024
2.04.520 Laboratory Testing Investigational Services Minor update to related policies. 2.04.100 was replaced with 2.04.509 Cardiovascular Risk Panels. 2.04.520 04/04/2024 05/01/2024
2.04.521 (effective August 2, 2024) Evaluation of Biomarkers for Alzheimer Disease New policy, approved April 9, 2024, effective for dates of service on or after August 2, 2024, following a 90-day provider notification. 2.04.521 08/02/2024 05/01/2024
3.01.521 Psychiatric and Other Specified Evaluations in Inpatient and Residential Behavioral Health Treatment Interim Review, approved April 22, 2024. Clarified the provider types for the psychiatric evaluation within one day of admission to substance use disorder inpatient rehabilitation. 3.01.521 06/12/2024 05/01/2024
5.01.42 Gene Therapies for Thalassemia Annual Review, approved May 14, 2024. Added coverage criteria for Casgevy (exagamglogene autotemcel). 5.01.42 06/01/2024 06/01/2024
5.01.512 Botulinum Toxins Annual Review, approved April 22, 2024. Added Letybo (letibotulinumtoxinA-wlbg) use as cosmetic and not covered. 5.01.512 02/07/2024 05/01/2024
5.01.518 BCR-ABL Kinase Inhibitors Annual Review, approved April 9, 2024. Added coverage criteria for Phyrago (dasatinib). Removed Synribo (omacetaxine) coverage criteria as it has been withdrawn from the market. Clarified that the imatinib step therapy . 5.01.518 12/01/2023 05/01/2024
5.01.519 Increlex (mecasermin); Recombinant Human Insulin-Like Growth Factor-1 Annual Review, approved May 24, 2024. Added 2 years of age or older age requirement. 5.01.519 06/01/2024 06/01/2024
5.01.527 Ampyra® (Dalfampridine) Annual Review, approved May 24, 2024. No changes to the policy statements. 5.01.527 06/01/2024 06/01/2024
5.01.529 Management of Opioid Therapy Annual Review, approved April 22, 2024. No changes to policy statement. 5.01.529 04/01/2023 05/01/2024
5.01.534 Multiple Receptor Tyrosine Kinase Inhibitors Interim Review, approved May 14, 2024. Added coverage criteria for generic sorafenib. Updated coverage criteria for Nexavar (sorafenib) to clarify that use is considered medically necessary. 5.01.534 06/01/2024 06/01/2024
5.01.536 Nulojix (belatacept) for Adults Annual Review, approved May 24, 2024. No changes to policy statement. 5.01.536 06/01/2024 06/01/2024
5.01.539 Pharmacologic Treatment of Cystic Fibrosis with Ivacaftor Products Annual Review, approved May 24, 2024. No changes to policy statements. 5.01.539 06/01/2024 06/01/2024
5.01.540 Miscellaneous Oncology Drugs Interim Review, approved April 9, 2024. Added coverage criteria for Thalomid (thalidomide). Added coverage criteria for Aphexda (motixafortide). Updated Onivyde (irinotecan) to include coverage criteria for the first-line. 5.01.540 03/01/2024 05/01/2024
5.01.542 Medical Necessity Criteria for Medication Safety: Controlled Substances Utilization Service Program Annual Review, approved May 24, 2024. No changes to coverage guidelines. 5.01.542 06/01/2024 06/01/2024
5.01.550 Pharmacotherapy of Arthropathies Interim Review, approved April 9, 2024. Added Humira (adalimumab) (Cordavis) [NDCs starting with 83457] as a non-preferred product. Updated Orencia (abatacept) to include coverage criteria for individuals 2 years and older with active psoriatic arthritis. 5.01.550 03/01/2024 05/01/2024
5.01.556 Rituximab: Non-oncologic and Miscellaneous Uses Annual Review, approved April 9, 2024. Clarified that Humira (adalimumab) (AbbVie) [NDCs starting with 00074] is the preferred Humira product for rheumatoid arthritis. 5.01.556 01/01/2024 05/01/2024
5.01.559 IL-5 Inhibitors Annual Review, approved May 24, 2024. Updated Fasenra (benralizumab) age requirement from 12 years or older to 6 years or older. 5.01.559 06/01/2024 06/01/2024
5.01.561 Repository Corticotropin Injection Annual Review, approved April 22, 2024. Updated coverage criteria to clarify that Acthar Gel SelfJect and Cortrophin are included in the policy. Updated... 5.01.561 01/01/2024 05/01/2024
5.01.562 Imlygic (talimogene laherparepvec) Annual Review, approved May 24, 2024. No changes to policy statement. 5.01.562 06/01/2024 06/01/2024
5.01.563 Pharmacotherapy of Inflammatory Bowel Disorder Updated to current version. 5.01.563 07/07/2024 06/07/2024
5.01.564 Pharmacotherapy of Miscellaneous Autoimmune Diseases Interim Review, approved April 9, 2024. Added Humira (adalimumab) (Cordavis) [NDCs starting with 83457] as a non-preferred product. 5.01.564 03/01/2024 05/01/2024
5.01.566 Pharmacotherapy of Thrombocytopenia Annual Review, approved April 9, 2024. Added coverage criteria for Alvaiz (eltrombopag choline). Added coverage criteria for Adzynma (ADAMTS13, recombinant-krhn) for the treatment of certain individuals with congenital thrombotic. 5.01.566 09/01/2023 05/01/2024
5.01.568 Venclexta (venetoclax) BCL-2 Inhibitor Annual Review, approved May 24, 2024. No changes to policy statements. 5.01.568 06/01/2024 06/01/2024
5.01.570 Pharmacologic Treatment of Duchenne Muscular Dystrophy Interim Review, approved April 9, 2024. Updated Agamree (vamorolone) and Emflaza (deflazacort) coverage criteria to include a requirement to try generic deflazacort first. Added coverage criteria for generic deflazacort for the treatment. 5.01.570 02/01/2024 05/01/2024
5.01.571 (effective August 2, 2024) C3 and C5 Complement Inhibitors Annual Review, approved April 9, 2024. Updated Ultomiris (ravulizumab-cwvz) to include coverage criteria for the treatment of certain individuals with 







neuromyelitis optica spectrum disorder (NMOSD).
5.01.571 08/02/2024 05/01/2024
5.01.571 C3 and C5 Complement Inhibitors Annual Review, approved April 9, 2024. Updated Ultomiris (ravulizumab-cwvz) to include coverage criteria for the treatment of certain individuals with neuromyelitis optica spectrum disorder (NMOSD). 5.01.571 12/01/2023 05/01/2024
5.01.575 Dupixent (dupilumab) Interim Review, approved May 13, 2024. Minor correction made to the age requirement for eosinophilic esophagitis. 5.01.575 06/01/2024 06/01/2024
5.01.576 Drugs for Rare Diseases Interim Review, approved April 9, 2024. Updated Lamzede (velmanase alfa-tycv) coverage criteria to include the following requirements: diagnosis of alpha-mannosidosis confirmed by bi-allelic pathogenic variants in the MAN2B1 gene, individual does... 5.01.576 03/01/2024 05/01/2024
5.01.578 Amyotrophic Lateral Sclerosis (ALS) Medications Annual Review, approved April 9, 2024. Added coverage criteria for Teglutik (riluzole). 5.01.578 11/01/2023 05/01/2024
5.01.590 Brutons Kinase Inhibitors Interim Review, approved May 14, 2024. Updated age requirement for Imbruvica (ibrutinib) chronic graft versus host disease coverage. 5.01.590 06/01/2024 06/01/2024
5.01.591 Immune Checkpoint Inhibitors Annual Review, approved April 9, 2024. Added coverage criteria for Loqtorzi (toripalimab-tpzi). Updated Opdivo (nivolumab) to remove coverage criteria. 5.01.591 01/01/2024 05/01/2024
5.01.592 Phosphoinositide 3-kinase (PI3K) Inhibitors Interim Review, approved May 14, 2024. Updated Piqray (alpelisib) coverage criteria to include treatment of certain pre- and peri-menopausal women with breast cancer. 5.01.592 06/01/2024 06/01/2024
5.01.595 Injectable Clostridial Collagenase for Fibroproliferative Disorders Annual Review, approved May 13, 2024. Policy updated with literature review through February 5, 2024; references added. Policy statements unchanged. 5.01.595 06/01/2024 06/03/2024
5.01.603 Epidermal Growth Factor Receptor (EGFR) Inhibitors Interim Review, approved May 14, 2024. Updated Rybrevant (amivantamab-vmjw) coverage criteria to include first-line treatment of certain individuals... 5.01.603 06/01/2024 06/01/2024
5.01.605 Medical Necessity Criteria for Pharmacy Edits Interim Review, approved May 14, 2024. Added Dymista (azelastine-fluticasone) to Intranasal Corticosteroid Products, Brands. Added Qlosi (pilocarpine) and Vuity (pilocarpine) to Ophthalmic Cholinergic Agonists. 5.01.605 06/01/2024 06/01/2024
5.01.614 Erythroid Maturation Agents Annual Review, approved May 24, 2024. No changes to policy statement. Removed coverage from the pharmacy benefit to align with current benefit coverage. 5.01.614 06/01/2024 06/01/2024
5.01.622 Exception Request to Utilization Management Restrictions for Washington State Fully-Insured Members Annual Review, approved April 22, 2024. No changes to policy statements. 5.01.622 05/01/2023 05/01/2024
5.01.626 Amyloid Antibodies for the Treatment of Alzheimer's Disease Annual Review, approved April 9, 2024. Added coverage criteria for Leqembi (lecanemab-irmb) for the treatment of Alzheimer’s disease. 5.01.626 05/01/2023 05/01/2024
5.01.629 Pharmacologic Treatment of Psoriasis Interim Review, approved April 9, 2024. Added Humira (adalimumab) (Cordavis) [NDCs starting with 83457] as a non-preferred product. Added Spevigo (spesolimab-sbzo) SC injection coverage criteria. 5.01.629 04/01/2024 05/01/2024
5.01.636 Chronic Hepatitis B Antiviral Therapy Annual Review, approved May 14, 2024. Removed Hepsera (adefovir dipivoxil) as it was withdrawn from the market. Updated Vemlidy (tenofovir alafenamide) age requirement from 12 years and older to 6 years and older. 5.01.636 06/01/2024 06/01/2024
6.01.527 Diagnosis and Treatment of Sacroiliac Joint Pain Interim Review, approved May 24, 2024. Minor editorial refinements made for clarity only; policy intent unchanged. 6.01.527 06/01/2024 06/01/2024
7.01.108 Artificial Intervertebral Disc: Cervical Spine Annual Review, approved June 12, 2023. Policy updated with literature review through March 3, 2023; references added. Minor editorial refinements to policy statements; intent unchanged. Changed the wording from "patient" to "individual" 7.01.108 07/01/2023 06/21/2024
7.01.113 Bioengineered Skin and Soft Tissue Substitutes Annual Review, approved May 24, 2024. Policy updated with literature review through November 13, 2023; references added. mVASC and TheraSkin added to medically necessary statement for diabetic lower-extremity ulcers. 7.01.113 06/01/2024 06/01/2024
7.01.132 Transcatheter Aortic-Valve Implantation for Aortic Stenosis Annual Review, approved April 9, 2024. Policy updated with literature review through January 8, 2024; references added. Policy statements refined based on review of clinical input. 7.01.132 05/01/2023 05/01/2024
7.01.134 Steroid-Eluting Sinus Stents and Implants Annual Review, approved April 8, 2024. Policy updated with literature review through January 5, 2024; references added. Policy statements unchanged except for minor edits for clarity only. 7.01.134 07/01/2023 05/01/2024
7.01.142 Surgery for Groin Pain in Athletes Annual Review, approved April 8, 2024. Policy updated with literature review through December 19, 2023; references added. Policy statement unchanged. 7.01.142 05/01/2023 05/01/2024
7.01.168 Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis Annual Review, approved May 13, 2024. Policy updated with literature review through December 18, 2023; references added. Policy was extensively edited... 7.01.168 06/01/2024 06/01/2024
7.01.20 Vagus Nerve Stimulation Annual Review, approved April 8, 2024. Policy updated with literature review through December 21, 2023; references added. Policy statements unchanged. 7.01.20 05/01/2023 05/01/2024
7.01.503 Breast Reduction (Mammaplasty) Annual Review, approved April 8, 2024. Policy updated with literature review through December 20, 2023; no references added. Policy statements unchanged. 7.01.503 05/01/2023 05/01/2024
7.01.519 Treatment of Varicose Veins/Venous Insufficiency Interim Review, approved May 14, 2024. Added policy statement that endovenous chemical ablation with (microfoam sclerotherapy, i.e., Varithena [polidocanol 1%]) of tributary veins is considered investigational. 7.01.519 06/01/2024 06/01/2024
7.01.521 Mastectomy for Gynecomastia Annual Review, approved April 8, 2024. Policy updated with literature review through January 9, 2024; no references added. Policy statement unchanged. 7.01.521 05/01/2023 05/01/2024
7.01.547 Implantable Bone-Conduction and Bone-Anchored Hearing Aids Annual Review, approved April 8, 2024. Policy updated with literature review through December 22, 2023; no references added. Policy statements unchanged. 7.01.547 05/01/2023 05/01/2024
7.01.558 Rhinoplasty and Other Nasal Procedures Interim Review, approved May 24, 2024. Minor editorial refinements made for clarity only, policy intent unchanged. 7.01.558 06/01/2024 06/01/2024
7.01.559 Sinus Surgery in Adults Annual Review, approved April 8, 2024. Policy updated with literature review through January 22, 2024; reference added. Policy statements unchanged. 7.01.559 01/01/2024 05/01/2024
7.01.583 Amniotic Membrane and Amniotic Fluid Annual Review, approved May 23, 2024. Policy updated with literature review through January 3, 2024; reference added. Policy statements unchanged. HCPCS code Q4228 termed 10/01/2021. 7.01.583 06/01/2024 06/01/2024
7.01.586 Cochlear Implant Annual Review, approved April 8, 2024. Policy updated with literature review through January 2, 2024; references added. Policy statements unchanged. 7.01.586 05/01/2023 05/01/2024
7.01.588 Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy Minor update to related policies. 8.01.58 was replaced with 8.01.540 Cranial Electrotherapy Stimulation and Auricular Electrostimulation. 7.01.588 10/01/2023 05/01/2024
7.01.83 Auditory Brainstem Implant Annual Review, approved April 8, 2024. Policy updates with literature review through December 18, 2023; no references added. Policy statements unchanged. 7.01.83 05/01/2023 05/01/2024
7.01.84 Semi-Implantable and Fully Implantable Middle Ear Hearing Aids Annual Review, approved April 8, 2024. Policy updated with literature review through December 13, 2023; references added. Policy statements unchanged. 7.01.84 05/01/2023 05/01/2024
7.03.12 Islet Transplantation for Chronic Pancreatitis and Donislecel-jujn for Type 1 Diabetes Annual Review, approved May 14, 2024. Policy updated with literature review through June 30, 2023; references added. Policy title updated from “Islet... 7.03.12 06/01/2024 06/01/2024
8.01.529 Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas Annual Review, approved April 8, 2024. Policy updated with literature review through November 15, 2023; references added. Policy statements unchanged. Updated Related Policy section... 8.01.529 05/01/2023 05/01/2024
8.01.540 Cranial Electrotherapy Stimulation and Auricular Electrostimulation Policy renumbered from 8.01.58 to 8.01.540 Cranial Electrotherapy Stimulation and Auricular Electrostimulation, approved April 9, 2024. 8.01.540 05/01/2024 05/02/2024
8.03.01 Functional Neuromuscular Electrical Stimulation Annual Review, approved May 13, 2024. Policy updated with literature review through January 22, 2024; no references added. Policy statements unchanged 8.03.01 06/01/2024 06/01/2024
8.03.505 Speech Therapy Interim Review, approved May 13, 2024. For voice therapy for gender transition/affirmation, added psychologists as clinicians who can confirm a diagnosis of gender dysphoria and can confirm that the individual is in the process... 8.03.505 06/01/2024 06/01/2024
9.03.508 Orthoptic Training for the Treatment of Vision or Learning Disabilities Annual Review, approved May 13, 2024. Policy updated with literature review through January 15, 2024; no references added. Clarified that learning and... 9.03.508 06/01/2024 06/01/2024