ND Committee Review
Internal Medical Policy Committee 7-16-2019
Adopted
policy
Internal Medical Policy Committee 7-22-2020 Annual review, no clinical content change
Internal Medical Policy Committee 11-19-2020
- Removed
diagnosis code C25.4 from policy
Internal Medical Policy Committee 11-23-2021 Annual review, no clinical content change
Internal Medical Policy Committee 5-24-2022
- Removed
NCCN recommendations and
- Added
this statement 'Irinotecan liposomal (Onivyde) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.',
- Updated
the experimental/investigational statement,
- Added
dx code C24.1 and
- Removed
dx code Z85.07
Internal Medical Policy Committee 5-23-2023 -
Effective July 1, 2023
- Added
diagnosis codes C22.1, C23, C24.0, C24.8, and C24.9
- Updated
E/I statement
Internal Medical Policy Committee 5-14-2024
Effective July 01, 2024
Internal Medical Policy Committee 11-19-2024
Effective December 08, 2024