|Highmark Commercial Medical Policy - Pennsylvania|
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Ustekinumab (Stelara) subcutaneous (SC) may be considered medically necessary to treat moderately to severely active Crohn’s disease (CD) in adult individuals (18 years of age or older) when ANY ONE of the following are met:
Ustekinumab (Stelara) (IV) may be considered medically necessary to treat moderately to severely active Crohn’s disease (CD) in adult individuals (18 years of age or older) when ANY ONE of the following criteria are met:
* Evaluate individuals for (tuberculin skin test) prior to initiating treatment. Treatment of latent infection should be started prior to ustekinumab (Stelara®) therapy.
The use of ustekinumab (Stelara) for any other indication or in combination with any other biologic disease-modifying antirheumatic drug (DMARD) (e.g. Humira, Remicade, Cimzia, etc.) is considered experimental/investigational, and therefore, non-covered because its effectiveness for these indications has not been established.
Ustekinumab (Stelara) is a single intravenous infusion dose for Crohn’s disease.
Ustekinumab (Stelara) subcutaneous (SC) may be considered medically necessary in adult individuals (18 years or older) with active psoriatic arthritis alone or in combination with methotrexate when the following criterion is met:
Ustekinumab (Stelara) subcutaneous (SC) may be considered medically necessary for the treatment of moderate to severe plaque psoriasis in adult individuals (18 years or older) when ANY ONE of the following criteria are met:
The use of ustekinumab (Stelara) for any other indication is considered experimental/investigational, and therefore, non-covered because its effectiveness for these indications has not been established.
Experimental/Investigational (E/I) services are not covered regardless of place of service.
Ustekinumab (Stelara®) is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
01/2018, Coverage Criteria Revised for Ustekinumab (Stelara®)
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.