ND Committee Review
Internal Medical Policy Committee 11-19-2020 Adopt new pre-certification policy
Internal Medical Policy Committee 11-23-2021 Annual review, no clinical content change
Internal Medical Policy Committee 11-29-2022 Annual review, no clinical content change
Internal Medical Policy Committee 3-23-2023
Effective May 01, 2023
- Removed
NCCN recommendations and added this statement '
Drug
may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.'
- Removed
ZXX.XXX diagnosis codes
- Removed
Note 'Biologic therapy is only appropriate for continuation of favorable response from conversion therapy'
- Updated
experimental/investigational statement
Internal Medical Policy Committee 3-19-2024
Effective May 01, 2024
-
No clinical content change;
and
- Added
diagnosis codes C05.8; and C05.9;
and
- Removed
diagnosis codes C17.0; C17.1; C17.2; C17.8; C17.9; C18.1; C31.2; C31.3; C31.8; C31.9; C78.80; C78.89; D37.030; D37.031; D37.032; and D37.039.
