For quick reference, check the following summary of Wellmark’s recent medical policy changes. Because this is a summary, we encourage you to review complete information about a policy.

New Policies

• EGRIFTA^TM
• Epidermal Growth Factor Receptor 
• Fecal Calprotectin Testing
• Injectable Clostridial Collagenase (Xiaflex^TM) for Fibroproliferative Disorders 

Revised Policies

Bariatric Surgery for Morbid Obesity*

Updated:

Adjustable gastric banding (Lap Band procedure)

Consistent with FDA-expanded label indications for the Lap-Band® System, we have revised our criteria to consider the procedure medically necessary for those with BMIs over or equal to 30 mg/kg² and one comorbid condition. Members must also meet the policy’s general criteria.

Cancer Clinical Trials

Removed:

Prior approval recommendation.

Ozurdex®/Dexamethasone Intravitreal Implant 

Added:

May be considered medically necessary for the treatment of:

• macular edema occurring after branch retinal vein occlusion
• macular edema occurring after central retinal vein occlusion
• non-infectious uveitis affecting the posterior segment of the eye

Ozurdex^®/dexamethasone intravitreal implant for any other indication, including the treatment of diabetic macular edema, is considered investigational because of insufficient evidence of its effectiveness. 

Electrical/Magnetic Neuro Stimulators 

Added:

Transcranial Magnetic Stimulation (TMS) to the list of stimulators included in the medical policy:

TMS: TMS is a noninvasive method of delivering electrical stimulation to the brain. A magnetic field is delivered through the skull, where it induces electric currents that affect neuronal function. Repetitive TMS (rTMS) is being evaluated as a treatment of depression and other psychiatric/neurologic brain disorders.

TMS is considered investigational as a treatment of depression and other psychiatric/neurologic disorders. 

Pneumatic Compression Devices 

Added:

• Lymphedema: Pneumatic compression devices for the treatment of lymphedema may be considered medically necessary if the patient has undergone a four-week trial of conservative therapy, and the physician determines there has been no significant improvement or if significant symptoms remain after the trial.
• Chronic Venous Insufficiency With Venous Stasis Ulcers: Pneumatic compression devices for the treatment of chronic venous insufficiency with ulcers may be considered medically necessary if the patient has one or more venous stasis ulcers which have failed to heal after a six-month trial of conservative therapy.

The following remains unchanged:

• Peripheral Arterial Disease: Pneumatic compression devices for the treatment of peripheral arterial disease are considered investigational.

Proton Beam Radiation Therapy

Added:            

Proton beam therapy as a treatment for non-small cell lung cancer (NSCLC) is considered investigational.

Radioimmunotherapy for Non-Hodgkin’s Lymphoma: Ibritumomab Tiuxetan (Zevalin®) and Tositumomab (Bexxar®)

Added:

To list of investigational uses of Zevalin® and Bexxar®: including when used as part of a preparatory regimen prior to hematopoietic stem cell transplantation in patients with non-Hodgkin’s lymphoma.

Rituximab*

Added:

To list of medically necessary indications:

• Treatment of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (e.g., Wegner’s granulomatosis, renal vasculitis, microscopic polyangiitis, Churg-Strauss syndrome)
• As single-agent maintenance therapy in patients with follicular, CD20-positive, B-cell NHL who have achieved a complete or partial response to Rituxan in combination with chemotherapy