Genetic Molecular Testing for Oncologic Indications*

• Revised criteria for BRCA testing in hereditary breast and ovarian cancer syndromes to be consistent with U.S. Preventive Services Task Force (USPSTF) recommendations for genetic counseling and evaluation

Omalizumab for Allergy-related Asthma*

Added to medical necessity criteria:

• Continues to show signs of wheeze, cough, and shortness of breath despite maximal anti-allergy therapy
• Chronic use of steroids and/or short-acting beta-2 agonists for rescue

Removed the following from coverage criteria:

• Hospitalization for asthma
• Emergency department visits
• Oral Steroid use

Reduction Mammoplasty*

Added to medical necessity criteria:

• Planned amount of tissue to be removed may be within 50 grams of what is expected
• There is a documented history of the following functional impairments for six months or greater:
  • Shoulder, neck, or back pain related to macromastia that is not responsive to conservative therapy, such as an appropriate support bra, exercises, heat/cold treatment, and appropriate non-steroidal anti-inflammatory agents/muscle relaxants
  • Intertrigo between the pendulous breast and the chest wall

Rituximab*

Added as a medically necessary indication:

• Treatment of autoimmune hemolytic anemia refractory to conventional treatments including corticosteroids and/or splenectomy, or when conventional treatments are contraindicated or not tolerated

*Prior Approval or Treatment Request recommended.