Medical Policy Updates

Medical Policy Update October 1, 2020

Medical Guidelines Reason for Update
Bimatoprost Intracameral Implant (DurystaTM) New policy developed. The use of bimatoprost intracameral implant (Durysta) is considered investigational for all indications including treatment of open-angle glaucoma and ocular hypertension. Added HCPCS code J7351 to Billing/Coding section. References added. Medical Director review 9/2020.
Biochemical Markers of Alzheimer Disease and Dementia AHS – G2048 Added new code 0206U to Billing/Coding section for effective date 10/1/2020.
Brexanolone (ZulressoTM) Added HCPCS code J1632 to Billing/Coding section effective 10/1/2020 and deleted codes C9055, C9399, J3490 termed 9/30/2020.
Cemiplimab-rwlc (Libtayo®) Specialty Matched Consultant Advisory Panel review 8/19/2020. No change to policy statements.
Cetuximab (Erbitux®) Specialty Matched Consultant Advisory Panel review 8/19/2020. No change to policy intent.
Children's Mobility and Positioning Equipment Specialty Matched Consultant Advisory Panel review 9/2020. Medical Director review 9/2020.
Chiropractic Services Specialty Matched Consultant Advisory Panel 9/2020. Medical Director review 9/2020.
Chromosomal Microarray AHS – M2033 Coding section updated with new code 0209U effective 10/1/20.
Daratumumab (Darzalex®) Added HCPCS code C9062 to Billing/Coding section effective 10/1/2020.
Dry Needling of Myofascial Trigger Points References updated. Specialty Matched Consultant Advisory Panel review 09/2020. Medical Director review 09/2020.
Durable Medical Equipment (DME) Specialty Matched Consultant Advisory Panel 9/2020. Medical Director review 9/2020.
Eptinezumab-jjmr (VyeptiTM) Added HCPCS code J3032 to Billing/Coding section effective 10/1/2020 and deleted codes C9063, C9399, J3490, J3590 termed 9/30/2020.
Esketamine (SpravatoTM) Nasal Spray Added the following new indication within "When Covered" section: "the patient has been diagnosed with major depressive disorder (MDD) with suicidal ideation or behavior and the suicidal ideation and intent are imminent and warrant potential hospitalization." Updated Description and Policy Guidelines sections to reflect addition of new indication. Reference added. Medical Director review 9/2020.
Functional Capacity Assessment and Work Hardening Specialty Matched Consultant Advisory Panel 9/2020. Medical Director review 9/2020.
Gamma-glutamyl Transferase AHS – G2173 New policy developed. BCBSNC will provide reimbursement for gamma-glutamyl transferase when it is determined that the medical criteria and reimbursement guidelines are met. Medical Director review 7/2020. Policy noticed 7/28/20 for effective date 10/1/20.
Genetic Testing for Acute Myeloid Leukemia AHS-M2062 Reviewed by Avalon 2nd Quarter 2020 CAB. Updated "When Covered" section to include medical necessity coverage for tyrosine kinase domain mutations (TKD). Extensive updates to policy guidelines section. References added. CPT codes 0023U, 0046U, 0049U added to Billing/Coding section for effective date 10/1/20. Added related policies. Medical Director review 8/2020.
Genetic Testing for Duchenne, Becker, Facioscapulohumeral, Limb-Girdle Muscular Dystrophies AHS – M2074 The following code was added to the Billing/Coding section effective 10/1/20: 0218U.
Identification of Microorganisms using Nucleic Acid Probes AHS – M2097 The following code was added to the Billing/Coding section effective 10/1/20: 0219U.
Isatuximab-irfc (Sarclisa®) Added HCPCS code J9227 to Billing/Coding section effective 10/1/2020 and deleted codes J3490, J3590 termed 9/30/2020.
Magnetoencephalography/Magnetic Source Imaging Medical Director Review 9/15/20, policy archived.
Molecular Panel Testing of Cancers for Diagnosis, Prognosis, and Identification of Targeted Therapy AHS - M2109 Reviewed by Avalon 2nd Quarter 2020 CAB. Added statement: all other multiplex RNA panels not listed are investigational. Added CPT code 0171U and deleted CPT codes 0056U, 0057U in the Billing/Coding section effective 10/1/2020. Updated policy guidelines, references, table of genes. Medical Director review 8/2020.
Necitumumab (Portrazza) Specialty Matched Consultant Advisory Panel review 8/19/2020. No change to policy statement.
Patient Lifts Specialty Matched Consultant Advisory Panel review 9/2020. Medical Director review 9/2020
Pegloticase (Krystexxa®) New policy developed. Krystexxa is considered medically necessary for the treatment of adult patients with chronic gout when specified medical criteria and guidelines are met. Added HCPCS code J2507 to Billing/Coding section. References added. Medical Director review 6/2020. Notification given 6/30/2020 for effective date 10/1/2020.
Perirectal Spacer Use During Radiotherapy for Prostate Cancer Under "When Covered" section: added medical necessity coverage for perirectal spacer use in prostate cancer: "Transperineal placement of a biodegradable, perirectal spacer (ie SpaceOAR) may be considered medically necessary in individuals undergoing external beam radiation therapy (IMRT or SBRT) for organ-confined prostate cancer." Updated policy guidelines. Medical Director review 9/2020.
Prenatal Screening AHS – G2035 Updated Coding section with new code 0222U effective 10/1/20.
Pressure Reducing Support Surfaces Specialty Matched Consultant Advisory Panel 9/2020. Medical Director review 9/2020.
Red Blood Cell Molecular Testing AHS-M2170 New policy developed. BCBSNC will provide coverage for red blood cell molecular testing when it is determined that the medical criteria and guidelines are met. Medical Director review 7/2020. Policy noticed 7/28/20 for effective date 10/1/20.
Rehabilitative Therapies The following codes were removed from the Billing/Coding section: 97770, G0198, G0201, G0515. Specialty Matched Consultant Advisory Panel review 9/2020. Medical Director review 9/2020.
Sacituzumab govitecan-hziy (TrodelvyTM) Added HCPCS code C9066 to Billing/Coding section effective 10/1/2020.
Skin and Soft Tissue Substitutes Coding section updated with new codes effective 10/1/20. Added codes Q4249, Q4250, Q4254 and Q4255.
Talimogene Laherparepvec (ImlygicTM) Specialty Matched Consultant Advisory Panel review 8/19/2020. No change to policy statement.
Teprotumumab-trbw (TepezzaTM) Added HCPCS code J3241 to Billing/Coding section effective 10/1/2020 and deleted codes C9061, C9399, J3490, J3590 termed 9/30/2020.
Transplant Rejection Testing AHS – M2091 The following code was added to the Billing/Coding section effective 10/1/20: 0221U.
Tumor Tissue Mutation Analysis in Colorectal Cancer AHS - M2026 Reviewed by Avalon 2nd Quarter 2020 CAB. Added CPT code 0111U to Billing/Coding section for effective date 10/1/2020. Medical Director review 7/2020. Added related policies. Updated references and policy guidelines.
Wheelchairs (Manual and Power Operated) Specialty Matched Consultant Advisory Panel 9/2020. Medical Director review 9/2020.
Whole Genome and Whole Exome Sequencing AHS – M2032 The following codes were added to the Billing/Coding section effective 10/1/20: 0212U, 0213U, 0214U, 0215U.