Commercial

Medical Policy

	MPDocType	Title	MPPolicyNumber	MPNotificationIssuedDate	MPEffectiveDate	MPReissuedDate	MPArchiveNotifEffDate	MPSALogCreatedOn	MPPolicyChangeTypeslt	MPRevisionDate	MPSiteActivityRemovedDate
	Notifications	Atezolizumab (Tecentriq®)	08.01.69c	3/3/2023 9:00 AM	4/3/2023			3/3/2023	Medical Necessity Criteria
	Notifications	Insertion of Implantable Infusion Pumps	11.15.03m	3/10/2023 9:00 AM	4/10/2023			3/10/2023	Medical Necessity Criteria
	Notifications	Prescription Digital Therapeutics and Mobile-Based Health Management Applications	12.00.05	3/10/2023 11:00 AM	4/10/2023			3/10/2023	This is a New Policy.
	Notifications	Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service	03.00.06x	3/10/2023 2:00 PM	6/12/2023			3/10/2023	Coverage and/or Reimbursement Position;Medical Coding
	Notifications	Ankle-Foot/Knee-Ankle-Foot Orthoses	05.00.39s	3/14/2023 9:00 AM	4/13/2023			3/14/2023	Coverage and/or Reimbursement Position;Medical Coding;General Description, Guidelines, or Informational Update
	Notifications	patisiran (Onpattro®) and vutrisiran (Amvuttra™)	08.01.50c	3/14/2023 10:00 AM	6/12/2023			3/14/2023	Coverage and/or Reimbursement Position;Medical Necessity Criteria;Medical Coding;General Description, Guidelines, or Informational Update
	New Policies	Ublituximab-xiiy (Briumvi TM) for intravenous use	08.02.02		3/13/2023			3/13/2023	This is a New Policy.
	Updated Policies	Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)	08.00.33q		3/13/2023			3/13/2023	Medical Necessity Criteria
	Updated Policies	nivolumab and relatlimab-rmbw (Opdualag™)	08.01.94b		3/13/2023			3/13/2023	Medical Necessity Criteria
	Updated Policies	Total Artificial Hearts (TAHs)	11.02.19g		3/13/2023			3/13/2023	Medical Necessity Criteria;General Description, Guidelines, or Informational Update
	Updated Policies	Ramucirumab (Cyramza®)	08.01.25g		3/13/2023			3/13/2023	Medical Necessity Criteria
	Updated Policies	Dostarlimab-gxly (Jemperli)	08.01.79d		3/13/2023			3/13/2023	Medical Necessity Criteria
	Reissue Policies	Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS)	07.03.15d		6/28/2017	3/8/2023		3/8/2023
	Reissue Policies	Biofeedback Therapy	07.00.01j		10/1/2020	3/8/2023		3/8/2023
	Reissue Policies	Otoplasty or Non-Surgical External Ear Molding	11.01.01j		9/8/2018	3/8/2023		3/8/2023
	Reissue Policies	Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails	11.08.17k		10/1/2021	3/8/2023		3/8/2023
	Reissue Policies	Medical Necessity	12.01.02a		7/20/2020	3/8/2023		3/8/2023
	Reissue Policies	Trigger Point Injections	11.14.02q		10/1/2021	3/8/2023		3/8/2023
	Reissue Policies	Spinal Decompression with Interspinous and Interlaminar Devices	11.14.22d		1/1/2017	3/8/2023		3/8/2023
	Reissue Policies	Mohs Micrographic Surgery	11.08.23j		10/1/2018	3/8/2023		3/8/2023
	Reissue Policies	Low Osmolar Contrast Agents	09.00.31d		12/30/2015	3/8/2023		3/8/2023
	Reissue Policies	Magnetic Resonance Imaging (MRI) Contrast Agents	09.00.45i		4/12/2021	3/8/2023		3/8/2023
	Reissue Policies	Contrast Agents Used in Conjunction with Echocardiography	09.00.11e		5/3/2021	3/8/2023		3/8/2023
	Reissue Policies	Modifier 24: Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period	03.00.15p		7/12/2021	3/8/2023		3/8/2023
	Reissue Policies	Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects	07.13.11k		10/1/2021	3/8/2023		3/8/2023
	Reissue Policies	Partial Coherence Interferometry	07.13.08e		4/23/2018	3/8/2023		3/8/2023
	Reissue Policies	Collagenase clostridium histolyticum ( Xiaflex ®), collagenase clostridium histolyticum-aaes (Qwo™)	08.01.71		11/30/2020	3/8/2023		3/8/2023
	Reissue Policies	Enzyme Replacement for the Treatment of Gaucher's Disease	08.00.51k		6/7/2021	3/8/2023		3/8/2023