Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update May 12, 2020

Medical Guidelines Reason for Update
ANA/ENA Testing AHS – G2022 Reviewed by Avalon 1st Quarter 2020 CAB. Medical Director review 4/2020. Description, Policy Guidelines, and References updated. When not covered section clarified with "Reimbursement is not allowed for testing of ANA and/or ENA in individuals during wellness visits or general encounters without abnormal findings."
Botulinum Toxin Injection Added reference to related medical policy: "Eptinezumab-jjmr (VyeptiTM)". Added "eptinezumab" to list of CGRP antagonists in "When Covered" section. Updated language in Policy Guidelines for ICHD-3 chronic migraine diagnostic criteria to more closely align with ICHD-3 guidelines, for clarity with no change to policy intent.
BRCA AHS - M2003 Reviewed by Avalon 1st Quarter 2020 CAB. Medical Director review 4/2020. Removed a. age requirement of 18 years in When Not Covered section. Added "at any age" and "intraductal" for specific indications throughout When Covered section. Added related policies in Description section and updated references.
Cardiovascular Disease Risk Assessment AHS – G2050 Reviewed by Avalon 1st Quarter 2020 CAB. The following revisions were made under the When Covered section: added item f – "Reimbursement is allowed for lipid panel testing for individuals on a long-term drug therapy that requires lipid monitoring, including but not limited to, Accutane and anti-psychotics."; added item 2 for Apolipoprotein B (Apo B) and associated criteria; number reformatting. Reformatting to include headings for associated criteria under the When Not Covered section. Background, policy guidelines and references updated. Specialty Matched Consultant Advisory Panel review 4/2020. Medical Director review 4/2020.
Detection of Circulating Tumor Cells and Cell Free DNA in Cancer Management (Liquid Biopsy) AHS-G2054 Reviewed by Avalon 1st Quarter 2020 CAB. Medical Director review 4/2020. Added CPT codes 81301, 0091U to Billing/Coding section. Updated When Covered section statement. Added CellSearch is investigational to When Not Covered section. References added.
Diagnosis of Idiopathic Environmental Intolerance AHS – G2056 Reviewed by Avalon 1st Quarter 2020 CAB. The following updates were made to the When Not Covered section: Added "organophosphates" to item #2; added items k and l to #6; added #7 along with items a-c. Policy guidelines and references updated. The following CPT codes were added to the Billing/Coding section: 84134, 91065. Medical Director review 4/2020.
Diagnosis of Vaginitis including Multi-target PCR Testing AHS – M2057 Reviewed by Avalon 1st Quarter 2020 CAB. Medical Director review 4/2020. Code Q0111 added to Billing/Coding section. Description, Policy Guidelines, and Reference section updated. "Reimbursement is allowed for rapid identification of Trichomonas by enzyme immunoassay in patients with symptoms of vaginitis." Added to When covered section. "Specialty Matched Consultant Advisory Panel review 4/30/2020.
Eculizumab (Soliris®) Specialty Matched Consultant Advisory Panel (Nephrology) review 4/15/2020. No change to policy intent.
Enhanced External Counterpulsation (EECP) Next CAP Review date revised in order to remain in alignment with correct review timeframe.
Eptinezumab-jjmr (VyeptiTM) New policy developed. Vyepti may be considered medically necessary for the preventative treatment of migraine in adults (≥ 18 years of age) when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, and J3590 to Billing/Coding section. References added. Medical Director review 5/2020.
Evaluation of Dry Eyes AHS - G2138 Reviewed by Avalon 1st Quarter 2020 CAB. Medical Director review 4/2020. Updated Description, Policy Guidelines, References. Added "Reimbursement is not allowed for testing for lactoferrin and/or IgE to aid in the diagnosis of patients suspected of having dry eye disease" to When Not-Covered section. Added CPT codes 82785, 83520, 83861 to Billing/Coding section.
Fecal Calprotectin Testing AHS – G2061 Reviewed by Avalon 3rd Quarter 2019 CAB. Code table removed from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 11/2019. Medical Director review 11/2019.
Flow Cytometry AHS–F2019 Specialty Matched Consultant Panel review 4/15/2020. Medical Director review 4/2020. Reviewed by Avalon 1st Quarter 2020 CAB. Updated Description, Policy Guidelines and References.
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management AHS - M2166 Off cycle review to align with CMP Prostate Cancer Screening AHS-G2008. Removed references to the following tests and transferred them to AHS-G2008: ExoDX Prostate, Intelliscore, Select MDX, PCA3, KLK3, ConfirmDX, PPCA. Removed CPT codes 0005U, 81313, 81551 and transferred to AHS-G2008. Updated Policy Guidelines. Medical Director review 4/2020.
General Genetic Testing, Germline Disorders AHS – M2145 Reviewed by Avalon 1st Quarter 2020 CAB. Minor reformatting to When Covered section; policy guidelines and references updated. The following updates were made to the Billing/Coding section: removed G0452 and added 0129U, 0130U, 0138U, 81307, and 81308. Medical Director review 4/2020.
General Genetic Testing, Somatic Disorders AHS-M2146 Reviewed by Avalon 1st Quarter 2020 CAB. Policy guidelines and references updated. The following updates were made to the Billing/Coding section: added 81314, 81233, 81236, 81305, and removed G0452. Medical Director review 4/2020.
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing AHS-M2066 Specialty Matched Consultant Advisory Panel review 4/15/2020. Reviewed by Avalon 1st Quarter 2020 CAB. Medical Director review 4/2020. Updated When Covered Section. Added Notes 1 and 2. Deleted Appendix 1. Updated Description, Policy Guidelines, References.
Genetic Testing for Connective Tissue Disorders AHS – M2144 Policy title changed from "Marfan Syndrome" to "Genetic Testing for Connective Tissue Disorders. Reviewed by Avalon 1st Quarter 2020 CAB. Added items #3 and #4 to the When Covered section. Under the When Not Covered section, added "All others" to the not medically necessary statement. Added Related Policies section. Description, policy guidelines, and references updated. Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director review 4/2020.
Genetic Testing for Epilepsy AHS – M2075 Reviewed by Avalon 1st Quarter 2020 CAB. Additional coverage criteria added. Not Covered statement reworded. Added code 81404. Medical Director review 4/2019. References added.
Genetic Testing for Familial Hypercholesterolemia AHS – M2137 Reviewed by Avalon 3rd Quarter 2019 CAB. Added Related Policies to Description section and "Note" to When Not Covered section of policy. Medical Director review 11/2019.
Genetic Testing for Hereditary Hearing Loss AHS – G2148 Reviewed by Avalon 2nd Quarter 2019 CAB with title change. Added Related Policies to the Description section. The following were added to the When Covered section: Item 1, "and is recommended" regarding genetic counseling; item 3, removed reference to Table 1-3 in background section and added "ALL of the following are met": for items a and b; added item 5. Added "If more than once per lifetime” to When Not Covered section. Policy guidelines and references updated. Removed the following codes from the Billing/Coding section: 96040, S0265, along with the code table. Medical Director review 8/2019.
Helicobacter Pylori Testing AHS – G2044 Reviewed by Avalon 1st Quarter 2020 CAB. Minor updates to Description, Background, and Policy guideline sections. Under the When Covered section: added item vi. "in patients with gastric intestinal metaplasia (GIM); minor revision to item number 2, incorporating items a. and b. with no change to policy intent; added "with susceptibility testing" to items 3 and 4. Under the When Not Covered section: added "with susceptibility testing" to item 3. Added the following codes to the Billing/Coding section: 86318, 87070. Minor update to reference section. Medical Director review 4/2020.
Identification of Microorganisms using Nucleic Acid Probes AHS – M2097 Updated Related Policies section. Under the When Covered section, added item #3: "Reimbursement is allowed for molecular testing for coronavirus disease 2019 (COVID-19) to aid diagnosis." Updated Policy guidelines and references. Added the following codes to the Billing/Coding section: U0001, U0002, and 87635. Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director review 4/2020.
Intracellular Micronutrient Analysis AHS – G2099 Reviewed by Avalon 1st Quarter 2020 CAB. Added the Related Policies section, to include Diagnosis of Idiopathic Environmental Intolerance AHS – G2056. Under the When Not Covered section, added "SpectraCell and ExaTest". References updated. Medical Director review.
Lyme Disease AHS – G2143 Reviewed by Avalon 1st Quarter 2020 CAB. Description section updated. State and Federal Regulations section updated. When Covered section updated. When Not Covered section updated. Policy Guidelines updated. Codes 0043U and 0044U deleted. Medical Director review 4/2020. References added.
Lynch Syndrome AHS-M2004 Reviewed by Avalon 1st Quarter 2020 CAB. Medical Director review 4/2020. Updated Notes 1-3 and references.
Molecular Analysis for Gliomas AHS - M2139 Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statement.
Molecular Markers in Fine Needle Aspirates of the Thyroid AHS - M2108 Reviewed by Avalon 1st Quarter 2020 CAB. Medical Director review 4/2020. Updated Covered and Not Covered sections with Bethesda criteria for clarity. No change to policy intent. Removed "E" from BRAF V600. Removed specific examples of Afirma and Rosetta tests. Added table of available tests.
Molecular Panel Testing of Cancers for Diagnosis, Prognosis, and Identification of Targeted Therapy AHS - M2109 Per request from Avalon, policy title changed from "Molecular Panel Testing of Cancers to Identify Targeted Therapy" to Molecular Panel Testing of Cancers for Diagnosis, Prognosis, and Identification of Targeted Therapy."
Mutation Analysis in Myeloproliferative Neoplasms AHS - M2101 Reviewed by Avalon 1st Quarter 2020 CAB. Medical Director review 4/2020. Updated Description, Policy Guidelines, References.
Pancreatic Cancer Risk Testing Using Molecular Classifier in Pancreatic Cyst Fluid AHS-M2114 Off cycle review. Medical Director review 4/2020. Updated Description, Policy Guidelines, References. Added PathFinderTG (PancraGEN) testing is considered investigational in When Not Covered section.
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing AHS – G2164 Background, Policy Guidelines, and Reference sections updated. Reviewed by Avalon for 1st Quarter 2020 CAB. No change to policy statement. Medical Director review 4/2020.
Pathogen Panel Testing AHS – G2149 Reviewed by Avalon 1st Quarter 2020 CAB. Related Policies section updated, added Diagnosis Of Vaginitis Including Multi-Target PCR Testing AHS – M2057 and Onychomycosis Testing AHS – M2172. Revised the When Covered section as follows: item #1: revised reimbursement statement and added "(GIP) up to 5 pathogens", along with "*(See Note 1)"; item #2: added "In the outpatient setting before the reimbursement statement, along with "gastrointestinal", "up to 11 pathogens", "immunosuppressed or HIV positive patients AND any of the following situations *(See Note 1)" along with corresponding criteria noted in items a. and b. Revised item #3 to allow for "up to 5" respiratory pathogens", added "Note 1". Revised the When Not Covered section as follows: added items 1-4. Policy guidelines and references updated. Removed codes 87150, 87486, 87496, 87498, 87529, 87532, 87581, 87634, 87653, 87798 and 0107U. Added CPT codes 87631 and 87632. Medical Director reviewed 4/2020.
Pharmacogenetics Testing AHS – M2021 Reviewed by Avalon 1st Quarter 2020 CAB. Related Policies section updated with title changes to listed policies. Minor revisions to When Covered section and added "Policy Guideline" statement to the When Covered section; no change to policy intent. Minor update to the Background section. The following codes were removed from the Billing/Coding section: 81221, 81222, 81223, 81224, 81248, 81249; 0169U and G9143 were added. Medical Director review.
Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection AHS – M2116 Reviewed by Avalon 1st Quarter 2020 CAB. Medical Director review 4/2020. References updated and added. Policy title changed from Plasma HIV-1 RNA Quantification for HIV-1 Infection to Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection. Description section updated. When Covered section updated. When Not Covered section updated. Background section updated. State and Federal Regulations section updated. Policy Guidelines updated. Code 87539 added to Billing/Coding section.
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis Reference added. Regulatory Status section updated.
Prenatal Screening AHS – G2035 Reviewed by Avalon 1st quarter 2020 CAB. Medical Director review 4/2020. Specialty Matched Consultant Advisory Panel review 4/29/2020. Updated Description, Policy Guidelines, Coding and References. "Reimbursement is not allowed for carrier screening more than once per lifetime." added to When not covered section. Added Note 1 for clarity concerning proper carrier screening testing. Note 1 reads as follows: "Carrier testing should be performed using the most appropriate carrier test (e.g. dosage/deletion for SMN1 and NOT full gene sequencing; DMD del/dup testing and NOT full gene sequencing)." Changed Panel testing of carrier status for biological father from investigational to does not meet coverage criteria. Medical necessity language updated to reimbursement language.
Prostate Cancer Screening AHS - G2008 Reviewed by Avalon 1st Quarter 2020 CAB. Medical Director review 4/2020. Added CPT codes 0005U and 81551 to Billing/Coding section. Switched the term "testing" to "screening" in the "When Covered" section. Added ExoDx prostate, Intelliscore, Select MDX, PCA3, KLK3, Confirm MDX, PPCA to “When Not Covered” section. Updated Policy Guidelines and References.
Salivary Hormone Testing AHS – G2120 Reviewed by Avalon for 1st Quarter 2020 CAB. Updated Description and Policy Guidelines section. Added references. No change to policy statement. Medical Director review 4/2020.
Serum Tumor Markers for Malignancies AHS – G2124 Reviewed by Avalon 1st Quarter 2020 CAB. Medical Director review 4/2020. Added CPT codes 84075, 84078, 84080, 84484, 0163U and deleted CPT codes 86152, 86153 in Billing/Coding section. Added several indications to Reimbursement allowed section. References updated.
Testing for Targeted Therapy of Non-Small-Cell Lung Cancer AHS - M2030 Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statement.
Thyroid Disease Testing AHS – G2045 Reviewed by Avalon 1st Quarter 2020 CAB. Medical Director review 4/2020. Description, Policy Guidelines and References updated. When covered section updated 1→E→ii with Free T4. 1→E→vi updated with hypothyroidism in the first trimester pregnancy and in the postpartum period. 1H added in when covered section. Specialty Matched Consultant Advisory Panel review 04/29/2020.
Urinary Tumor Markers for Bladder Cancer AHS – G2125 Reviewed by Avalon 1st Quarter 2020 CAB. Medical Director review 4/2020. References updated and added. Description section updated. Related Policies added. When Covered section updated. When Not Covered section updated. State and Federal Regulations section updated. Policy Guidelines updated. Codes 88271, 88299, and 88365 deleted from Billing/Coding section. Codes 0012M and 0013M added to Billing/Coding section.
Vectra DA Blood Test for Rheumatoid Arthritis AHS – G2127 Reviewed by Avalon for 1st Quarter 2020 CAB. Updated Description and Policy Guidelines section. Added references. No change to policy statement. Medical Director review 4/2020.
Venous and Arterial Thrombosis Risk Testing AHS – M2041 Title changed from Venous Thrombosis Risk Testing to Venous and Arterial Thrombosis Risk Testing. Under When Not Covered section, changed items #2 and #3 from "investigational" to "not medically necessary; added items #4 and #5. Policy guidelines and references updated. Medical Director review 4/2020.
ZIKA Virus Risk Assessment AHS – G2133 Reviewed by Avalon 1st Quarter 2020 CAB. Literature review updated. State and Federal Regulations updated. Policy Guidelines updated. When Covered section updated. When Not Covered section updated. References updated. Medical Director review 4/2020.