2016 Medical Policy Revisions

Date Issued: 11/18/2015

EmblemHealth has made determinations about the Medical Guidelines listed below. These guidelines will become effective on February 10, 2016.

  1. H.P. Acthar Gel is considered medically necessary for the management of West Syndrome (infantile spasms) only. Based on review of current medical literature, all other indications are considered inappropriate and will not be allowed for reimbursement. H.P. Acthar Gel is considered not covered when used for any indication other than West Syndrome. For additional information please refer to the applicable Medical Policy.
  2. Levoleucovorin (Fusilev®) is considered medically necessary for the following specific conditions only: Anal adenocarcinoma, Small bowel adenocarcinoma, Appendiceal adenocarcinoma, Colorectal adenocarcinoma, Toxicity of high-dose methotrexate, and Toxicity and counteracting the effects of inadvertent overdose of folic acid antagonists. Levoleucovorin (Fusilev®) is considered not covered when used for any other indication. For additional information please refer to the applicable Medical Policy.
  3. The use of hereditary angioedema injectable drugs is eligible for coverage only when used for the treatment of hereditary angioedema and for prevention of acute attacks of hereditary angioedema. Hereditary angioedema injectable drugs are considered not covered when used for any other indication. For additional information please refer to the applicable Medical Policy.
  4. Intravenous Azacitidine (Vidaza) is considered medically necessary for the following specific conditions only: Myelodysplastic Syndromes (MDS) and Acute myeloid leukemia (AML). Azacitidine (Vidaza) is considered not covered when used for any other indication. For additional information please refer to the applicable Medical Policy.
  5. Intravitreal injection of specific drugs is considered medically necessary for the following specific conditions only: Age-related macular degeneration (AMRD), Macular edema, Diabetic macular edema, and Symptomatic vitreomacular adhesion (VMA). Intravitreal injections are considered not covered when used for any other indication. For additional information please refer to the applicable Medical Policy.