Medical Policy Updates

Medical Policy Update for August 13, 2019

Medical Guidelines	Reason for Update
BioZorb	New policy developed. BioZorb three-dimensional (3D) bioabsorbable tissue marker is considered investigational. References added. Medical Director review 6/2019. Policy noticed 6/11/19 for effective date 8/13/19.
Carrier Screening for Genetic Disease	Specialty Matched Consultant Advisory Panel review 7/2019. Medical Director review 7/2019
Diagnosis of Idiopathic Environmental Intolerance AHS - G2056	Reviewed by Avalon 1st Quarter 2019 CAB. Related Policies added to Description section. When Not Covered policy statement extensively revised as follows: revised item #2: a-y and added items #3-7. Policy guidelines updated to support revised policy statement. Billing/Coding section revised with the addition of Reimbursement items 1-10 along with the following codes: 82127, 82139, 82380, 82441, 82507, 82542, 82656, 82715, 83150, 83497, 83918, 83919, 83921, 84585, 84600, 86001, 83015, 83018, 82108, 82300, 83735, 83885, 83785, 82726, 89125, 82710, 84590, 84446, and 83655. References updated. Policy noticed 6/11/19 with effective date of 8/13/19. Medical Director review 5/2019.
General Approach to Evaluating the Utility of Genetic Panels	Specialty Matched Consultant Advisory Panel review 7/2019. Medical Director review 7/2019.
Genetic Testing for Alpha Thalassemia AHS - M2131	Specialty Matched Consultant Advisory Panel review 7/2019. Medical Director review 7/2019.
Genetic Testing for CHARGE Syndrome AHS - M2070	Specialty Matched Consultant Advisory Panel review 7/2019. Medical Director review 7/2019.
Genetic Testing for Cystic Fibrosis AHS - M2017	Specialty Matched Consultant Advisory Panel review 7/2019. Medical Director review 7/2019.
Genetic Testing for Diagnosis of Inherited Peripheral Neuropathies AHS - M2072	Specialty Matched Consultant Advisory Panel review 7/2019. Medical Director review 7/2019
Genetic Testing for Duchenne, Becker, Facioscapulohumeral, Limb-Girdle Muscular Dystrophies AHS - M2074	Specialty Matched Consultant Advisory Panel review 7/2019. Medical Director review 7/2019.
Genetic Testing for Familial Hypercholesterolemia AHS - M2137	Specialty Matched Consultant Advisory Panel review 7/2019. Medical Director review 7/2019.
Genetic Testing for Hereditary Pancreatitis AHS - M2079	Specialty Matched Consultant Advisory Panel review 7/2019. Medical Director review 7/2019.
Genetic Testing for Lactase Insufficiency AHS - M2080	Specialty Matched Consultant Advisory Panel review 7/2019. Medical Director review 7/2019.
Genetic Testing for Neurofibromatosis AHS - M2134	Specialty Matched Consultant Advisory Panel review 7/2019. Medical Director review 7/2019.
Genetic Testing for Nonsyndromic Hereditary Hearing Loss AHS - G2148	When Not Covered section revised; removed item "a. If more than once per lifetime". Specialty Matched Consultant Advisory Panel review 7/2019. Medical Director review 7/2019.
Genetic Testing for PTEN Hamartoma Tumor Syndrome AHS - M2087	Specialty Matched Consultant Advisory Panel review. 7/2019. Medical Director review 7/2019.
Genetic Testing for Statin-Induced Myopathy AHS - M2089	Specialty Matched Consultant Advisory Panel review 7/2019. Medical Director review 7/2019.
Helicobacter Pylori Testing AHS - G2044	Reviewed by Avalon 2nd Quarter 2019 CAB. Under the When Covered section, added "either" to item #3. Under the When Not Covered section, added the following statement to item #6: "The use of nucleic acid testing for H. pylori, including polymerase chain reaction (PCR), 16S rRNA, 23S rRNA, and next-generation sequencing (NGS) of" H. Pylori, is considered not medically necessary as it is not practical for routine diagnosis. Policy guidelines and references extensively revised. Under the Coding/Billing section, the following changes were made: 86677 - changed to Not Covered, and added code 87149, 87150, 87153, 0008U to the policy as Not Covered. References updated. Policy noticed 6/11/19 for effective date of 8/13/19. Medical Director reviewed 5/2019.
Leadless Cardiac Pacemakers	New policy developed. Leadless cardiac pacemakers, specifically, the Micra transcatheter pacing system may be considered medically necessary in patients when the medical criteria are met. Added the following codes, 0387T, 0388T, 0389T, 0390T, 0391T to "Billing/Coding" section. References added. Medical Director review 7/2019.
Measurement of Thomboxane Metabolites for ASA Resistance AHS - G2107	Specialty Matched Consultant Advisory Panel review 7/2019. Medical Director review 7/2019.
Neurostimulation, Electrical	References added. Regulatory Status section updated. Review of functional electrical stimulation exercise equipment added to policy; this is considered investigational.
Pharmacogenetics Testing AHS - M202	Removed the *Policy Guideline statement and "NOTE" from the bottom of the When Not Covered section regarding Genotype once per lifetime. No change to policy intent. Specialty Matched Consultant Advisory Panel review 7/2019. Medical Director review 7/2019.
Varicose Veins of the Lower Extremities, Treatment for	Reference added. Cyanoacrylate adhesive may be considered medically necessary. Policy Guidelines related to cyanoacrylate adhesive updated.