ND Committee Review
Internal Medical Policy Committee 1-22-2020 Adopted new precertification policy
Internal Medical Policy Committee 1-13-2021 Annual review, no clinical content change
Internal Medical Policy Committee 7-22-2021
- Revised
NCCN recommendations criteria;
and
- Removed
Z85.72;
and
- Added
diagnosis codes C86.0 and C86.1.
Internal Medical Policy Committee 7-21-2022 Annual review, no clinical content change
Internal Medical Policy Committee 11-29-2022
- Removed
NCCN recommendations;
and
- Added
this statement 'Pralatrexate (Folotyn) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.';
and
- Updated
experimental/investigational statement;
and
- Added
diagnosis code C84.7A
Internal Medical Policy Committee 11-15-2023 Annual review, no clinical content change
Internal Medical Policy Committee 11-19-2024
Effective December 08, 2024
