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News & AnnouncementsCoverage Expansion of Respiratory Syncytial Virus Vaccine (Abrysvo) for Commercial Members (Retroactively Effective October 22, 2024)12/23/2024
NotificationsTofersen (Qalsody®)08.02.06b12/2/2024 9:00 AM1/1/202512/2/2024Coverage and/or Reimbursement Position
NotificationsMedical Nutrition Therapy (MNT)/Nutrition Counseling10.00.0412/2/2024 2:00 PM1/1/202512/2/2024This is a New Policy.
NotificationsDrugs, Biologics, or Gene Therapies with an Accelerated Approval08.02.3512/2/2024 2:00 PM1/1/202512/2/2024This is a New Policy.
NotificationsMonoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer Disease08.01.93e12/2/2024 3:00 PM1/1/202512/2/2024Coverage and/or Reimbursement Position;Medical Necessity Criteria;General Description, Guidelines, or Informational Update
NotificationsExon Skipping Drugs for Duchenne Muscular Dystrophy (DMD) (Eteplirsen (Exondys 51), Golodirsen (Vyondys 53), Viltolarsen (Viltepso)), Casimersen (Amondys 45)08.01.34d12/2/2024 3:00 PM1/1/202512/2/2024Coverage and/or Reimbursement Position;Medical Necessity Criteria
NotificationseviCore Lab Management (AmeriHealth)06.02.52ai12/2/2024 5:00 PM1/1/202512/2/2024Coverage and/or Reimbursement Position;Medical Necessity Criteria;Medical Coding;General Description, Guidelines, or Informational Update
NotificationsTotal Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN)08.00.17k12/3/2024 9:00 AM1/1/202512/3/2024Medical Necessity Criteria
NotificationsCasgevy™ (exagamglogene autotemcel)08.02.1412/3/2024 11:00 AM1/1/202512/3/2024This is a New Policy.
NotificationsLovotibeglogene autotemcel (Lyfgenia®)08.02.1512/3/2024 11:00 AM1/1/202512/3/2024This is a New Policy.
NotificationsFetal Surgery11.00.03m12/3/2024 3:00 PM1/1/202512/3/2024Medical Necessity Criteria;Medical Coding;General Description, Guidelines, or Informational Update
NotificationsDelandistrogene moxeparvovec (delandistrogene moxeparvovec-rokl; Elevidys®)08.02.13a12/3/2024 5:00 PM1/1/202512/3/2024General Description, Guidelines, or Informational Update
NotificationsTreatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence11.02.01t12/13/2024 11:00 AM1/13/202512/13/2024Coverage and/or Reimbursement Position;Medical Necessity Criteria;Medical Coding;General Description, Guidelines, or Informational Update
NotificationsModifier 50: Bilateral Procedure03.00.05z12/13/2024 2:00 PM1/13/202512/13/2024Medical Coding
NotificationsModifier 62: Two Surgeons00.10.11ab12/13/2024 2:00 PM1/13/202512/13/2024Medical Coding
NotificationsDirect Endoscopic Necrosectomy (DEN) for the Treatment of Pancreatic Necrosis11.03.1612/17/2024 12:00 PM1/20/202512/17/2024This is a New Policy.
NotificationsEpidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management (Amerihealth Administrators)11.15.23l12/17/2024 12:00 PM3/17/202512/17/2024Coverage and/or Reimbursement Position;Medical Necessity Criteria;General Description, Guidelines, or Informational Update
NotificationsApheresis Therapy06.03.04o12/17/2024 1:00 PM3/17/202512/17/2024Medical Necessity Criteria
NotificationsProtein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer06.02.5312/23/2024 10:00 AM1/27/202512/23/2024This is a New Policy.
New PoliciesAtidarsagene autotemcel (Lenmeldy)08.02.2412/23/202412/23/2024This is a New Policy.
New PoliciesCrovalimab-akkz (Piasky)08.02.311/1/202512/30/2024This is a New Policy.
New PoliciesCasgevy™ (exagamglogene autotemcel)08.02.1412/3/2024 11:00 AM1/1/202512/30/2024This is a New Policy.
New PoliciesLovotibeglogene autotemcel (Lyfgenia®)08.02.1512/3/2024 11:00 AM1/1/202512/30/2024This is a New Policy.
New PoliciesFidanacogene elaparvovec-dzkt (Beqvez™)08.02.2512/30/202412/30/2024This is a New Policy.
Updated PoliciesGender-Affirming Interventions11.09.02p11/27/202412/2/2024General Description, Guidelines, or Informational Update12/2/2024
Updated PoliciesDenervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators)11.15.09r12/2/202412/2/2024Coverage and/or Reimbursement Position;General Description, Guidelines, or Informational Update
Updated PoliciesCerliponase alfa (Brineura®)08.01.39d12/2/202412/2/2024Medical Necessity Criteria
Updated PoliciesTherapeutic Transcranial Magnetic Stimulation (TMS)07.03.22f11/1/2024 1:00 PM12/2/202412/2/2024Medical Necessity Criteria
Updated PoliciesGender-Affirming Interventions11.09.02p11/27/202412/2/2024General Description, Guidelines, or Informational Update
Updated PoliciesLumasiran (Oxlumo®)​08.01.74a12/2/202412/2/2024Medical Necessity Criteria
Updated PoliciesPPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services00.01.25bq12/16/202412/16/2024Coverage and/or Reimbursement Position
Updated PoliciesNew Jersey Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Radiology Network Rules and Limited Circumstances00.01.55y12/16/202412/16/2024Coverage and/or Reimbursement Position
Updated PoliciesRadiation Therapy Services (AmeriHealth Administrators)09.00.56s10/1/202412/16/2024Medical Necessity Criteria
Updated PoliciesReconstructive Breast Surgery and Post-Mastectomy Prostheses 11.08.15ab10/21/202412/16/2024Medical Necessity Criteria
Updated PoliciesReimbursement for Radiopharmaceutical Agents for Professional Providers09.00.32ag12/16/202412/16/2024Coverage and/or Reimbursement Position
Updated PoliciesPrescription Lenses and Visual Devices07.13.13g12/30/202412/30/2024Coverage and/or Reimbursement Position
Updated PoliciesIntravenous Infliximab and Related Biosimilars08.00.34u1/1/202512/30/2024Medical Necessity Criteria
Updated PoliciesCanakinumab (Ilaris®)08.01.51c1/6/202512/30/2024Medical Necessity Criteria;Medical Coding;General Description, Guidelines, or Informational Update
Updated PoliciesSelf-Administered Drugs and Biologics08.00.78at1/1/202512/30/2024Coverage and/or Reimbursement Position;Medical Coding;General Description, Guidelines, or Informational Update
Updated PoliciesCoagulation Factors08.00.92ah1/6/202512/30/2024Coverage and/or Reimbursement Position;Medical Necessity Criteria;Medical Coding;General Description, Guidelines, or Informational Update
Updated PoliciesAvelumab (Bavencio®)08.01.64d1/6/202512/30/2024Medical Necessity Criteria;General Description, Guidelines, or Informational Update
Updated PoliciesBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use08.00.66w1/1/202512/30/2024Medical Necessity Criteria
Updated PoliciesMultiple Surgery Payment Reduction11.00.10y12/30/202412/30/2024Medical Coding;General Description, Guidelines, or Informational Update
Updated PoliciesLeuprolide Acetate (Camcevi™, Eligard®, Fensolvi®, Lupron Depot®)08.01.33j1/6/202512/30/2024Medical Necessity Criteria
Updated PoliciesIpilimumab (Yervoy®)08.01.01n1/6/202512/30/2024Medical Necessity Criteria
Updated PoliciesDelandistrogene moxeparvovec (delandistrogene moxeparvovec-rokl; Elevidys®)08.02.13a12/3/2024 5:00 PM1/1/202512/31/2024General Description, Guidelines, or Informational Update
Reissue PoliciesNeuropsychological Testing for Neurologically Based Conditions07.03.08o10/1/202310/16/202412/4/2024
Coding UpdateHair Transplants and Cranial Prostheses (Wigs)11.08.01h10/1/202410/1/202412/2/202412/2/2024
Coding UpdateHome Prothrombin Time Monitoring05.00.26l10/1/202410/1/202412/2/202412/2/2024
Coding UpdateHematopoietic Stem Cell Transplantation (Bone Marrow Transplant)11.07.01z1/1/202512/31/2024
Coding UpdateRadiation Therapy Services09.00.56t1/1/202512/31/2024
Coding UpdateScanning Computerized Ophthalmic Diagnostic Imaging (SCODI)07.13.06o1/1/202512/31/2024
Coding UpdateWound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds11.08.20an1/1/202512/31/2024
Coding UpdateCoverage of Anticancer Prescription Oral and Injectable Drugs and Biologics and Supportive Agents08.01.08s1/1/202512/31/2024
Coding UpdateMaintenance Treatment of Opioid or Alcohol Use Disorder 08.01.37e1/1/202512/31/2024
Coding UpdatePaclitaxel Protein-Bound Particles for Injectable Suspension (Albumin-Bound)/(Abraxane® for Injectable Suspension)08.00.90s1/1/202512/31/2024
Coding UpdateCatheter Ablation of Cardiac Arrhythmias11.02.06r1/1/202512/31/2024
Coding UpdateInsulin Pumps and Long-Term Interstitial Continuous Glucose Monitoring Systems05.00.79k1/1/202512/31/2024
Coding UpdateMagnetic Resonance Imaging (MRI)-Guided Focused Ultrasound Ablation11.06.06h1/1/202512/31/2024
Coding UpdateMusculoskeletal Services (AmeriHealth)00.01.66o1/1/202512/31/2024
Coding UpdateRoutine/Non-routine Vaccines08.01.04af1/1/202512/31/2024
Coding UpdateTelemedicine Services00.10.41n1/1/202512/31/2024
Coding UpdateTelemedicine and Telehealth Services for AmeriHealth New Jersey Members00.10.42g1/1/202512/31/2024
Coding UpdateFertility Preservation (AmeriHealth New Jersey)07.10.08e1/1/202512/31/2024
Coding UpdateChimeric Antigen Receptor (CAR) Therapy08.01.43o1/1/202512/31/2024
Coding UpdateTrastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)08.00.33s1/1/202512/31/2024
Coding UpdateEculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris®) for intravenous administration08.00.84k1/1/202512/31/2024
Coding UpdateBariatric Surgery11.03.02u10/1/202412/31/2024
Archived PoliciesTreatment of Twin-Twin Transfusion Syndrome (TTTS)11.00.14g11/29/2024 1:00 PM1/2/202512/2/2024