Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update July 28, 2020

Medical Guidelines Reason for Update
Adaptive Behavioral Treatment for Autism Spectrum Disorders Specialty Matched Consultant Advisory Panel Review 6/2020. Updated Policy Guidelines section, Provider Qualifications I and II: Changed title of Licensed Professional Counselor to Licensed Clinical Mental Health Counselor per NC Bill 537. Reference added. No change to policy statement.
BCR-ABL 1 Testing AHS – M2027 Reviewed by Avalon Q2 2020 CAB. Updated references. Policy Title changed from: BCR-ABL 1 Testing for Chronic Myeloid Leukemia and Acute Lymphoblastic Leukemia to: BCR-ABL 1 Testing. Medical Director review 7/2020.
Cardiac Biomarkers for Myocardial Infarction AHS – G2150 Reviewed by Avalon 2nd Quarter 2020 Quarter CAB. Related policies section added. Policy guidelines and references updated. Medical Director review 7/2020.
Cardiovascular Disease Risk Assessment AHS – G2050 Reviewed by Avalon 2nd Quarter 2020 CAB. When Covered section; Item 1, a. ii: Lipid Panel, reworded criteria as following: "Annual screening for patients of all ages at increased risk for cardiovascular disease as defined by 2013 ACC/AHA Pooled Cohort Equations to calculate 10-year risk of CVD events (see Note 1)."; reformatting adjustments made accordingly. Item 3. Lipoprotein (A), added criteria as follows with associated bullets i-iv: "Reimbursement is allowed for measurement of lipoprotein a (Lp(a)) in adult individuals. Item 4. High-sensitivity C-Reactive Protein (hs-CRP), added language for testing as follows: "if, after quantitative risk assessment using ACC/AHA Pooled Cohort Equations to calculate 10-year risk of CVD events (see Note 1), a risk-based treatment decision is uncertain."; Note 1 added for clarity as follows: "2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk (Goff et al., 2014): Risk factors include gender, age, race, smoking, hypertension, diabetes, total cholesterol, high and low density lipoprotein cholesterol and calculators are available at: "A web-based application enabling estimation of 10-year and lifetime risk of ASCVD is available at http://my.americanheart.org/cvriskcalculator and http://www.cardiosource.org/en/Science-And-Quality/Practive-Guidelines-and-Quality-Standards/2013-Prevention-Guidelines-Tools.aspx.." Under the When Not Covered section: Gene expression testing to predict coronary artery disease added as follows: "For all indications, including but not limited to prediction of the likelihood of CAD in stable, nondiabetic patients."; "lipoprotein (a)" was removed from the criteria under Novel Cardiovascular Biomarkers to prevent contraindication with new criteria under When Covered section, item 3. Policy guidelines and references updated. Removed the following codes from the Billing/Coding section: 82725, 82726, and added 0052U. References updated. Medical Director review 7/2020.
Carrier Screening for Genetic Disease Specialty Matched Consultant Advisory Panel review 7/2020. Medical Director review 7/2020.
Chromosomal Microarray AHS – M2033 Medical Director review 7/2020. Reviewed by Avalon 2nd Quarter CAB. Coding section updated with 81479. When Not Covered section clarified with low-pass investigational statement. Description, Policy Guidelines and Resources sections updated. When Covered section updated with item 4E. No change to policy statement.
DNA Ploidy Cell Cycle Analysis AHS – M2136 Reviewed by Avalon 2nd Quarter 2020 CAB. Medical Director review 7/2020.
Erectile Dysfunction AHS - G2132 Reviewed by Avalon 2nd Quarter 2020 CAB. Reimbursement language added to When Covered/When Not Covered sections. Policy Guidelines updated. References updated. Medical Director review 7/2020.
Folate Testing AHS – G2154 Updated Description, Policy Guidelines and Reference sections. Reviewed by Avalon 2nd Quarter CAB. Medical Director review 7/2020. No change to policy statement.
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management AHS - M2166 Reviewed by Avalon 2nd Quarter 2020 CAB. References updated. Medical Director review 7/2020.
General Approach to Evaluating the Utility of Genetic Panels Specialty Matched Consultant Advisory Panel review 7/2020. Medical Director review 7/2020.
General Genetic Testing, Germline Disorders AHS – M2145 Reviewed by Avalon 2nd Quarter 2020 CAB. The following codes were removed from the Billing/Coding section: 81361, 81362, 81363 81364. Specialty Matched Consultant Advisory Panel review 7/2020. Medical Director review 7/2020.
General Inflammation Testing AHS – G2155 Reviewed by Avalon 2nd Quarter CAB. Medical Director review 7/2020. Updated Description, Policy Guidelines and Reference section. No change to policy statement.
Genetic Testing for Adolescent Idiopathic Scoliosis AHS – M2058 Reviewed by Avalon 2nd Quarter 2020 CAB. Medical Director review 7/2020. Description, Policy Guidelines and References sections updated. No change to policy statement.
Genetic Testing for Alpha- and Beta- Thalassemia AHS – M2131 Reviewed by Avalon 2nd Quarter 2020 CAB. Added item 1 reimbursement language for genetic counseling and revised item 3 from medically necessary to reimbursement language under the When Covered section. Policy guidelines and references updated. Added the following codes to the Billing/Coding section: 81361, 81362, 81363, 81364, 96040, S0265. Specialty Matched Consultant Advisory Panel review 7/2020. Medical Director review 7/2020.
Genetic Testing for CHARGE Syndrome AHS – M2070 Specialty Matched Consultant Advisory Panel review 7/2020. Medical Director review 7/2020.
Genetic Testing for Cystic Fibrosis AHS – M2017 Reviewed by Avalon 2nd Quarter 2020 CAB. Related policies added. Policy guidelines and references updated. Specialty Matched Consultant Advisory Panel review 7/2020. Medical Director review 7/2020.
Genetic Testing for Diagnosis of Inherited Peripheral Neuropathies AHS – M2072 Reviewed by Avalon 2nd Quarter 2020 CAB. Policy guidelines and references updated. Specialty Matched Consultant Advisory Panel review 7/2020. Medical Director review 7/2020.
Genetic Testing for Duchenne, Becker, Facioscapulohumeral, Limb-Girdle Muscular Dystrophies AHS – M2074 Specialty Matched Consultant Advisory Panel review 7/2020. Medical Director review 7/2020.
Genetic Testing for Familial Alzheimer’s Disease AHS – M2038 Reviewed by Avalon 2nd Quarter 2020 CAB. Policy Guidelines updated. Literature review updated. References updated. Code 81407 removed from the Billing/Coding section. Medical Director review 7/2020.
Genetic Testing for Familial Hypercholesterolemia AHS – M2137 Specialty Matched Consultant Advisory Panel review 7/2020. Medical Director review 7/2020.
Genetic Testing for Hereditary Hearing Loss AHS – G2148 Reviewed by Avalon 2nd Quarter 2020 CAB. Wording changed to reimbursement language in policy statement, When Covered section, and When Not Covered section. Policy guidelines and references updated. The following codes were added to the Billing/Coding section: 96040, S0265, along with the Note regarding testing five or more genes being tested on same platform to reference the Laboratory Procedures Reimbursement Policy AHS R2162. Specialty Matched Consultant Advisory Panel review 7/2020. Medical Director review 7/2020.
Genetic Testing for Hereditary Pancreatitis AHS – M2079 Reviewed by Avalon 2nd Quarter 2020 CAB. Note 1 added to When Covered section. Policy guidelines and references updated. Specialty Matched Consultant Advisory Panel review 7/2020. Medical Director review 7/2020.
Genetic Testing for Inherited Cardiomyopathies and Channelopathies AHS – M2025 Reviewed by Avalon 2nd Quarter 2020 CAB. Policy guidelines and references updated. The following codes were added to the Billing/Coding section: S3865, S3866. Medical Director review 7/2020.
Genetic Testing for Lactase Insufficiency AHS – M2080 Reviewed by Avalon 2nd Quarter 2020 CAB. Related policies added. Policy guidelines and references updated. Specialty Matched Consultant Advisory Panel review 7/2020. Medical Director review 7/2020.
Genetic Testing for Li_Fraumeni Syndrome AHS – M2081 Reviewed by Avalon 2nd Quarter 2020 CAB. The following note added to Billing/Coding section: “For 5 or more gene tests being run on a tumor specimen (i.e. non-liquid biopsy) on the same platform, such as multi-gene panel next generation sequencing, please refer to Laboratory Procedures Reimbursement Policy AHS – R2162.” Policy guidelines and references updated. Medical Director review 7/2020.
Genetic Testing for Neurofibromatosis and Related Disorders AHS – M2134 Reviewed by Avalon 2nd Quarter 2020 CAB. Policy guidelines and references updated. The following codes were added to the Billing/Coding section: 96040, S0265. Specialty Matched Consultant Advisory Panel review 7/2020. Medical Director review 7/2020.
Genetic Testing for Ophthalmologic Conditions AHS-M2083 Reviewed by Avalon 2nd Quarter 2020 CAB. Added medical necessity coverage for RPE65 testing for retinal dystrophy prior to treatment with Luxturna in "When Covered" section. Added whole exome and whole genome sequencing for ophthalmologic conditions is investigational in "When Not Covered" section. Extensive updates to Description and Policy Guidelines sections. Added CPT codes 81434 and 81406 to "Billing/Coding" section. Title changed from: "Genetic Testing for Macular Degeneration" to: "Genetic Testing for Ophthalmologic Conditions." References updated. Medical Director review 7/2020.
Genetic Testing for PTEN Hamartoma Tumor Syndrome AHS – M2087 Updated Related Policies. The following changes were made to the When Covered section: Added Item 1 reimbursement language for genetic counseling; item 2, iv. under Major Criteria, removed "adenomas" and added "but excluding"; added items 6-7 reimbursement language, and reformatted as applicable. Updated policy guidelines and references. The following codes were added to the Billing/Coding section: 96040, S0265, and Note added as follows: Note: For 5 or more gene tests being run on the same platform, such as multi-gene panel next generation sequencing, please refer to Laboratory Procedures Reimbursement Policy AHS - R2162". Specialty Matched Consultant Advisory Panel review 7/2020. Medical Director review 7/2020.
Hepatitis C AHS – G2036 Reviewed by Avalon 2nd Quarter 2020 CAB. Medical Director review 7/2020. Literature Review and Applicable Federal Regulations updated. Description section updated. Policy Guidelines updated. References updated.
HIV Genotyping and Phenotyping AHS – M2093 Reviewed by Avalon 2nd Quarter 2020 CAB. Literature review updated. Not Covered section changed from Medical Necessity to Reimbursement language, where needed. Policy Guidelines updated. References updated. Medical Director review 7/2020.
Identification of Microorganisms using Nucleic Acid Probes AHS – M2097 Reviewed by Avalon 2nd Quarter 2020 CAB. Added Note to Policy statement as follows: “The coverage criteria outlined in this policy are not applicable to diagnostic COVID-19 testing.” To Table 1 When Covered section table 1, added the following: Chlamydia pneumoniae, Mycoplasma genitalium, Respiratory syncytial and associated codes; removed HIV 1 and 2. Removed the following statements: “Reimbursement is allowed for PCR testing for Ebola…” and will currently be submitted with unspecified codes along with statement related to coronavirus disease 2019. Item 2: removed statement related to Avian influenza A virus, mycoplasma genitalium, statements related to RSV and SARS, and added “EBOLA”. Policy and references updated. The following codes were removed from the tables and Billing/Coding section: U0001, U0002 and 87635, 87534, 87535, 87536, 87537, 87538 and 87539. Medical Director review 7/2020.
Laboratory Procedures Reimbursement Policy AHS - R2162 Reviewed by Avalon 2nd Quarter 2020 CAB. Medical Director review 7/2020. Added Genetic Counseling and Panel Reimbursement sections to Policy Guidelines.
Lynch Syndrome AHS-M2004 Reviewed by Avalon 2nd Quarter 2020 CAB. Medical Director review 7/2020. References updated.
Molecular Profiling for Cancers of Unknown Primary Origin AHS- M2065 Reviewed by Avalon 2nd Quarter 2020 CAB. Updated “When Not Covered” section to match new policy title and added indication. Policy Title changed from: “Gene Expression Based Assays for Cancers of Unknown Primary” to: “Molecular Profiling for Cancers of Unknown Primary Origin.” Medical Director review.
Multigene Expression Assay for Predicting Colon Cancer Recurrence AHS-M2111 Reviewed by Avalon 2nd Quarter 2020 CAB. Updated references.
Oral Screening Lesion Identification Systems and Genetic Screening AHS – G2113 Description, Policy Guidelines and Reference sections updated. High-risk HPV testing reimbursement added to When covered section. When not covered section updated with salivary biomarkers. Coding section updated with 81599, 88341 and 88342. Policy statement updated from “not covered” to reimbursement language. Reviewed by Avalon 2nd Quarter CAB. Medical Director review 7/2020.
Pancreatic Cancer Risk Testing Using Molecular Classifier in Pancreatic Cyst Fluid AHS-M2114 Reviewed by Avalon 2nd Quarter 2020 CAB. Added CPT code 81479 to “Billing/Coding” section.
Pancreatic Enzyme Testing for Acute Pancreatitis AHS – G2153 Reviewed by Avalon 2nd Quarter 2020 CAB. Related Policies section added. Item 1., item g added under the When Covered section as follows with minor reformatting: “In asymptomatic nonpregnant individuals during general exam without abnormal finding.” Policy guidelines updated and reformatted. References updated. Medical Director review 7/2020.
Pathogen Panel Testing AHS – G2149 Reviewed by Avalon 2nd Quarter 2020 CAB. Note added to the policy statement as follows: “The coverage criteria outlined in this policy are not applicable to diagnostic COVID-19 testing.” Policy guidelines and references updated. The following codes were added to the Billing/Coding section: 87631, 87632. Medical Director review 7/2020.
Quantitative Electroencephalography as a Diagnostic Aid for Attention Deficit/Hyperactivity Disorder Removed Biofeedback policy reference from Background and Related Policies sections. References added. Specialty Matched Consultant Advisory Panel review 6/2020. No change to policy statement.
Quantose Impaired Glucose Tolerance (IGT) Test AHS - G2135 Reviewed per Avalon Q2 CAB. Medical Director review 7/2020. Updated Description, Policy Guidelines and References. No change to policy statement.
Sensory Integration Therapy and Auditory Integration Therapy Policy Guidelines section updated to include 2015 AOTA guidelines statement. References added. Specialty Matched Consultant Advisory Panel review 6/2020. No change to policy statement.
Serum Testing for Evidence of Mild Traumatic Brain Injury AHS – G2151 Reviewed by Avalon 2nd Quarter 2020 CAB. When not covered section updated, no change to policy statement. Policy Guidelines updated. References updated. Medical Director review 7/2020.
ST2 Assay for Chronic Heart Failure AHS – G2130 Reviewed by Avalon 2nd Quarter 2020 CAB. Updated Related Policies section. Wording changed in policy statement and When Not Covered sections from investigational to reimbursement language. Policy guidelines and references updated. Medical Director review 7/2020.
Testing for Alpha-1 Antitrypsin Deficiency AHS-M2068 Reviewed by Avalon 2nd Quarter 2020 CAB. Policy guidelines and references updated. Medical Director review 7/2020.
Testing for Targeted Therapy of Non-Small-Cell Lung Cancer AHS - M2030 Reviewed by Avalon Q2 2020 CAB. Under "When Covered" section: removed references to "larotrectinib or entrectinib" and replaced with "targeted therapy" for statement "Testing for NTRK gene fusion." Medical Director review 7/2020.
Urinalysis and Urine Culture Testing for Bacteria AHS – G2156 Reviewed per Avalon Q2 CAB. Medical Director review 7/2020. Removed 81000, 81001, 81002, 81003, 81005, 81015 and 81020 from Coding section. Description, Policy Guidelines and References updated. When not covered section reworded for clarity, no change to policy intent.
Wheelchairs (Manual and Power Operated) Item 3 under When Not Covered section - revised statement as follows: “ Seat elevators for manually and power operated wheelchairs are considered not medically necessary when used solely for the convenience of the individual or the individual’s family/caretaker.” Medical Director review 7/2020.
Whole Genome and Whole Exome Sequencing AHS – M2032 Reviewed by Avalon 2nd Quarter 2020 CAB. When Covered section: numerical reformatting and added items 2 and 3 with associated bullets. Added reimbursement language to the When Not Covered section as follows: "Reimbursement is not allowed for combination testing of WES with intronic variants testing, regulatory variants testing, and/or mitochondrial genome testing sometimes referred to as whole exome plus testing, including but not limited to Genomic Unity® Exome Plus Analysis." Policy guidelines and references updated. The following code was added to the Billing/Coding section: 0056U. Medical Director review 7/2020.
ZIKA Virus Risk Assessment AHS – G2133 Reviewed by Avalon 2nd Quarter 2020 CAB. Literature review updated. Policy Guidelines updated. References updated. Medical Director review 7/2020.