Medical Policy Updates

Medical Policy Update for April 16, 2019

Medical Guidelines Reason for Update
Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms Specialty Matched Consultant Advisory Panel review 3/20/2019. Reference added. No change to policy statement.
Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemia Specialty Matched Consultant Advisory Panel review 3/20/2019. Reference added. No change to policy statement.
Alpha 1-Antitrypsin Inhibitor Therapy Specialty Matched Consultant Advisory Panel review 3/20/2019. No change to policy statement.
Antiemetic Injection Therapy Specialty Matched Consultant Advisory Panel review 3/20/2019. No change to policy statement.
Aqueous Shunts and Devices for Glaucoma Extensive revisions to Policy Guidelines, Description sections. Updated Regulatory Status. Under "When Covered" section: added medical necessity language for ab externo and ab interno stents as well as implantation of 1 or more ab interno stents. References added. Medical Director review 4/2019.
Balloon Dilation of the Eustachian Tube Reference added. Policy Guidelines updated.
Bioengineered Skin and Tissue Reference added. Deleted information regarding NuCel/NuShield/NuShield Orthopaedics Spine. This is an amniotic membrane product.
BRCA AHS-M2003 Reviewed by Avalon 4TH Quarter 2018 CAB. Clarified "When Covered" section bullets 3. & 4, added Note 1. Medical Director review 4/2019.
Cochlear Implant Reference added.
Convection-Enhanced Delivery of Therapeutic Agents to the Brain Specialty Matched Consultant Advisory Panel review 3/20/2019. Reference added. No change to policy statement.
Cord Blood as a Source of Stem Cells Specialty Matched Consultant Advisory Panel review 3/20/2019. Reference added. No change to policy statement.
Diagnostic Testing of Iron Homeostasis and Metabolism AHS - G2011 Policy renamed from Ferritin to Diagnostic Testing of Iron Homeostasis and Metabolism. Description and Policy Guidelines sections updated. Added the following statements to the coverage criteria: Specifically added serum ferritin testing for symptomatic patients of hereditary hemochromatosis (HH), first-degree relatives of patients with diagnosed HH, or males with secondary hypogonadism, Added CC (from old HH policy) that serum transferrin saturation (i.e. TSAT) in patients with symptomatic hemochromatosis or first-degree relatives with diagnosed HH, Added "transferrin" so that CC reads that serum ferritin or transferrin in general screening for anemia, Added CC that serum hepcidin testing, including immunoassays for hepcidin, is investigational, Added CC that GlycA testing is investigational (since there is a PLA code for this testing). Added CPT Codes 84466, 84999, and PLA Code 0024U to the Billing/Coding section. References revised to include new references from the Avalon review.
Emapalumab-lzsg (GamifantTM) New policy developed. Gamifant is considered medically necessary for the treatment of adult and pediatric (newborn and older) patients with primary hemophagocytic lymphohistiocytosis (HLH). Added HCPCS codes C9399, J3490, and J3590 to Billing/Coding section. References added. Medical Director review 4/2019.
Erythropoiesis-Stimulating Agents (ESAs) Reference added. Specialty Matched Consultant Advisory Panel review 3/20/2019. No change to policy statement.
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing AHS - M2066 Reviewed by Avalon 4th Quarter 2018 CAB. Under "When Covered" revised bullet d. Medical Director review 4/2019.
Genetic Testing for 5 Fluorouracil Use in Cancer Patients AHS-M2067 Revised coding table under "Billing/Coding" section.
Genetic Testing for CHARGE Syndrome AHS - M2070 Description section updated. Two additional medically necessary indications added to the When Covered section referring to genetic testing for known familial variant mutations in first degree relatives of an affected individual and mutation testing in cases of prenatal testing and preimplantation testing for CHARGE syndrome. Policy guidelines extensively revised. No change to policy intent. References updated. Medical Director review 4/2019.
Genetic Testing for Dilated Cardiomyopathy Policy archived. See policy titled: Genetic Testing for Dilated Cardiomyopathy AHS - M2073.
Genetic Testing for Dilated Cardiomyopathy AHS - M2073 BCBSNC will provide coverage for genetic testing for dilated cardiomyopathy when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 4/2019.
Genetic Testing for Duchenne, Becker, Facioscapulohumeral, Limb-Girdle Muscular Dystrophies AHS - M2074 The following policies have been combined to create a single policy concerning the genetic testing for muscular dystrophies: Genetic Testing for Duchenne and Becker Muscular Dystrophy, Genetic Testing for Facioscapulohumeral Muscular Dystrophies AHS - M2076, Mutation Testing for Limb-Girdle Muscular Dystrophies AHS - M2128. These 3 separate policies are archived. Description section, policy guidelines sections updated with language and criteria indications to reflect the combined policies. When Covered and When Not Covered sections revised to include criteria indications from the three original policies; no change to policy intent. Billing/Coding section and referenced updated. Medical Director review 4/2019.
Genetic Testing for Duchenne and Becker Muscular Dystrophy Policy archived, see policy titled: Genetic Testing for Duchenne, Becker, Facioscapulohumeral, and Limb-Girdle Muscular Dystrophies AHS - M2074.
Genetic Testing for Facioscapulohumeral Muscular Dystrophy AHS - M2076 Policy archived, see policy titled: Genetic Testing for Duchenne, Becker, Facioscapulohumeral, and Limb-Girdle Muscular Dystrophies AHS - M2074.
Genetic Testing for Germline Mutations of the RET Proto-Oncogene AHS-M2078 Reviewed by Avalon 4th Quarter 2018 CAB. Policy title changed from "Genetic Testing for Germline Mutations RET Proto-Oncogene Medullary Carcinoma Thyroid" to "Genetic Testing for Germline Mutations of the RET Proto-Oncogene." Under "When Covered" section: added bullet F. "individual with a clinical diagnosis of MEN2 (multiple endocrine neoplasia type 2) or primary C-cell hyperplasia." Medical Director review 4/2019.
Genetic Testing for Hereditary Hemochromatosis AHS - M2012 Title change updated throughout policy. Updated definitions and added related policies section for "Diagnostic Testing of Iron Homeostasis & Metabolism AHS - G2011". Removed item 1 concerning serum ferritin testing and TSAT from When Covered section. Updated policy guidelines and reference section. Removed 83540, 83550, and 82728 from Billing/Coding section. Medical Director review 4/2019.
Genetic Testing of Mitochondrial Disorders AHS - M2085 Description section and policy guidelines updated. When Covered section revised for clarity and removed criteria concerning prenatal testing as this is addressed in a separate policy. Policy intent unchanged. Added 96040 and S0265 for genetic counseling which was added as item #3 under the When Covered section. Medical Director review 4/2019.
Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia Specialty Matched Consultant Advisory Panel review 3/20/2019. Reference added. No change to policy statement.
Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia Specialty Matched Consultant Advisory Panel review 3/20/2019. Reference added. No change to policy statement.
Hormonal Testing in Males AHS - G2013 Policy renamed from Testosterone to Hormonal Testing in Males. For information regarding androgen deficiency in females, see policy titled "Hormonal Testing in Females AHS G2161." Policy Description and Guidelines updated. The following changes were made to clinical criteria: Added "after fasting" to statement concerning the measurement of total serum testosterone in according to 2018 Endocrine Society and 2018 EAA guidelines. For the measurement of free testosterone, the wording was changed to state: "For males with hypogonadism, gynecomastia, and/or other forms of testicular hypofunction, measurement of serum free testosterone using a medically accepted algorithm based on total serum testosterone, sex hormone-binding globulin (SHBG), and/or albumin is considered medically necessary if total testosterone is confirmed as borderline or low." Added statement that free testosterone and/or bioavailable testosterone as source of initial testosterone testing (i.e. total testosterone should be determined first based on 2018 Endocrine Society guidelines). Clarified "total" testosterone testing for gender dysphoric/gender incongruent individuals. Added statement that measurement of serum LH, FSH, and prolactin ONCE to differentiate primary and secondary male criteria (based on multiple guidelines). Added statement for males with gynecomastia, serum estradiol testing ONCE prior to initiating testosterone therapy. (2018 AUA guidelines). Added statement that serum LH, FSH, prolactin, and/or estradiol in males in other situations. Added statement that serum dihydrotestosterone (DHT) testing in males is investigational (new 2019 CPT code) except in cases for testing of 5-alpha reductase deficiency. Added CPT codes 82040, 82642, 82670, 83001, 83002, 84146, and 84270 to Billing/Coding section. References updated.
Hormone Pellet Implantation for Treatment of Menopause Related Symptoms Specialty Matched Consultant Advisory Panel review 3/20/2019. No change to policy statement.
Hyperthermic Intraperitoneal Chemotherapy Policy archived.
Immunoglobulin Therapy Under "When Covered" section for Primary Immunodeficiencies, removed ‘prophylactic’ from the following statement for clarity: "persistent and severe infections, despite treatment with prophylactic antibiotics." Reference added. Medical Director review 4/2019.
Implantable Bone Conduction Hearing Aids Reference added.
Intravitreal Implant Added Yutiq (fluocinolone acetonide 0.18 mg intravitreal implant) to "When Covered" section with the following coverage statement: "fluocinolone acetonide intravitreal implant 0.18 mg (i.e., Yutiq) may be considered medically necessary for the treatment of chronic noninfectious uveitis affecting the posterior segment of the eye." Updated Description and Policy Guidelines to reflect addition of Yutiq to policy. References added.
Ipilimumab (Yervoy) Added the following indication to "When Covered" section: "As treatment of patients with microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) metastatic colorectal cancer that has progressed following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan chemotherapy, in combination with nivolumab (Opdivo)." Updated "Policy Guidelines" section to include additional dosing recommendations. Added reference. Specialty Matched Consultant Advisory Panel review 3/20/2019.
Letermovir (PrevymisTM) Specialty Matched Consultant Advisory Panel review 3/20/2019. Changed wording of criterion #7 from "The patient has not exceeded 30 days post-transplantation" to "Therapy with Prevymis will be initiated no later than 30 days post-transplantation" for clarity. No change to policy intent.
Melphalan Hydrochloride (Evomela) for Intravenous Use Specialty Matched Consultant Advisory Panel review 3/20/2019. No change to policy statement.
Mogamulizumab-kpkc (Poteligeo®) Specialty Matched Consultant Advisory Panel review 3/20/2019. No change to policy statement.
Monoclonal Antibody Imaging for Prostate Cancer Specialty Matched Consultant Advisory Panel review 3/20/2019. Reference added. No change to policy statement.
Moxetumomab pasudotox-tdfk (LumoxitiTM) New policy developed. Lumoxiti is considered medically necessary for the treatment of adult patients with hairy cell leukemia (HCL). Added HCPCS codes C9045, J3490, J3590, J9999, S0353, and S0354 to Billing/Coding section. References added. Medical Director review 4/2019.
Mutation Testing for Limb-Girdle Muscular Dystrophies AHS - M2128 Policy archived, see policy titled: Genetic Testing for Duchenne, Becker, Facioscapulohumeral, and Limb-Girdle Muscular Dystrophies AHS - M2074.
Ovarian, Internal Iliac and Gonadal Vein Embolization, Ablation and Sclerotherapy Reference added. Specialty Matched Consultant Advisory Panel review 3/20/2019. No change to policy statement.
Pathogen Panel Testing AHS - G2149 Removed item B that concerns "travel-related diarrhea" from the When Covered section and added second paragraph stating that genetic panel sequencing testing methods such as SmartGutTM and SmartJaneTM, to identify microbes is investigational to the When Not Covered section. Updated policy guidelines and references. Medical Director review 4/2019.
Progesterone Therapy in High Risk Pregnancies Description and Policy Guidelines sections updated. References added. Specialty Matched Consultant Advisory Panel review 3/20/2019. No change to policy statement.
Pulmonary Hypertension, Drug Management Reference added. Specialty Matched Consultant Advisory Panel review 3/2019. No change to policy statement.
Radiosurgery, Stereotactic Approach Updated Description and Policy Guidelines sections. Under "When Covered" section A: added bullet #9: Uveal melanoma, for tumors with largest diameter >18 mm or thickness >10 mm or thickness >8 mm with optic nerve involvement; and bullet #11: Mesial temporal lobe epilepsy refractory to medical management, when standard alternative surgery is not an option. Under B.1: changed T1 or T2 to IA-IIA. Added B.4: Primary renal cell carcinoma when the tumor is inoperable or in patients who are not good surgical candidates. Under "When Not Covered" section: removed "the treatment of seizures and uveal melanoma" from the statement. References added. Medical Director review 4/2019.
Surgery for Groin Pain in Athletes Reference added.
Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome Code 64568 added to Billing/Coding section.
Synthetic Cartilage Implants for Joint Pain Reference added. Policy Guidelines updated.
Tagraxofusp-erzs (ElzonrisTM) New policy developed. Elzonris is considered medically necessary as initial or salvage treatment of blastic plasmacytoid dendritic cell neoplasm (BPDCN). Added HCPCS codes C9399, J3490, J3590, J9999, S0353, and S0354 to Billing/Coding section. References added. Medical Director review 4/2019.
Testing of Homocysteine Metabolism Related Conditions AHS - M2141 Policy renamed from Homocystinuria to Testing of Homocysteine Metabolism Related Conditions. Avalon Annual Review: Updated description, background, federal regulations, guidelines, and evidence-based scientific references. Added clinical criteria: "For symptomatic patients (i.e. having elevated urine and/or serum homocysteine levels) that test negative for CBS classic homocystinuria OR for patients with a first-degree relative positive for known variants of MTHFR that cause homocystinuria, genetic testing for known variants of MTHFR is considered medically necessary." Added clinical criteria that plasma free homocysteine testing does not meet medical necessity criteria based on 2017 E-HOD guidelines. Combined the newborn screening for homocystinuria and hypermethioninemia into one statement.
Tinnitus Treatment Reference added. Table of US FDA cleared devices added to Description section.
Transtympanic Micropressure Applications as a Treatment of Meniere's Disease Reference added.
Trastuzumab Specialty Matched Consultant Advisory Panel review 3/20/2019. No change to policy statement.
Tumor-Treatment Fields Therapy Under "When Covered" section: added continuation therapy criteria. Medical Director review. Notification 2/12/19 for effective date 4/16/19.