Medical Policy Updates

Medical Policy Update for August 27, 2019

Medical Guidelines Reason for Update
Artificial Intervertebral Disc References added.
Autologous Chondrocyte Implantation Reference added. Specialty Matched Consultant Advisory Panel review 7/30/2019.
Automated Percutaneous and Endoscopic Discectomy Reference added.
Bundling Guidelines Added to "Topics of Frequent Interest" Hernia repair (43280, 43281, 43332, 43334, 43336) is considered an incidental procedure when performed during the same operative session as bariatric surgery (43644, 43645, 43770, 43775, 43842, 43843, 43845, 43846, 43847). Modifiers 58, 59, 78 and 79 (or XE, XS, XP, XU) will not allow additional payment when appended to these codes. An incidental procedure is not eligible for separate reimbursement. See also corporate medical policy "Surgery for Morbid Obesity". Notification 7/1/19 for effective date of 8/30/19.
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing Expired codes 0299T and 0300T removed from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 7/30/2019. Reference added. Policy Guidelines updated.
Folate Testing AHS -G2154 References updated. No change in policy statement.
General Inflammation Testing AHS -G2155 Policy guidelines and references updated. No change to policy statement.
Genetic Testing for Adolescent Idiopathic Scoliosis AHS - M2058 Reviewed by Avalon 2nd Quarter 2019 CAB. Policy Guidelines updated. References updated. Coding table removed from the Billing/Coding section of the policy. Medical Director review 8/2019.
Genetic Testing for Cystic Fibrosis AHS - M2017 Reviewed by Avalon 2nd Quarter 2019 CAB. Added "Related Policies" section, minor revisions to policy guidelines and coding table removed from the Billing/Coding section of the policy. References updated. No change to policy intent. Medical Director reviewed 8/2019.
Genetic Testing for Familial Alzheimer's Disease AHS - M2038 Reviewed by Avalon 2nd Quarter 2019 CAB. Added "Related Policies" section. Policy Guidelines updated. References updated. Coding table removed from the Billing/Coding section of the policy. Medical Director review 8/2019.
Genetic Testing for Li_Fraumeni Syndrome AHS - M2081 Reviewed by Avalon 2nd Quarter 2019 CAB. Added "Related Policies" section, policy guidelines updated, and coding table removed from the Billing/Coding section of the policy. References updated. No change to policy intent. Medical Director reviewed 8/2019.
Growth Factors in Wound Healing Reference added.
Interferential Stimulation Reference added.
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee Reference added. Specialty Matched Consultant Advisory Panel review 6/19/2019. No change to policy intent.
Lumbar Spine Fusion Surgery Reference added.
Meniscal Allografts and Other Meniscal Implants Specialty Matched Consultant Advisory Panel review 7/30/2019. Reference added.
Navigated Transcranial Magnetic Stimulation (nTMS) Reference added.
Pancreatic Enzyme Testing for Acute Pancreatitis AHS - G2153 Reviewed by Avalon 2nd Quarter 2019 CAB. Added "Related Policies" section, minor revisions to policy guidelines and coding table removed from the Billing/Coding section of the policy. No change to policy intent. References updated. Medical Director reviewed 8/2019.
Paraspinal Surface Electromyography (SEMG) Reference added.
Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy Reference added.
Polysomnography for Non‒Respiratory Sleep Disorders Reference added.
Quantitative Sensory Testing Reference added.
Quantose Impaired Glucose Tolerance (IGT) Test AHS - G2135 Removed coding table from Billing/Coding section per Avalon Q2 CAB 2019. No changes to policy statement.
Somatostatin Analogs Updated "When Covered" section to change "AND" to "OR" within the following statements: "patient is not a candidate for surgical resection or pituitary irradiation" and "patient has had an inadequate response to or is not a candidate for surgical resection or radiation therapy". Medical Director review 8/2019.
Spinal Cord and Dorsal Root Ganglion Stimulation Reference added. Medical Director review. Title changed from Spinal Cord Stimulation to Spinal Cord and Dorsal Root Ganglion Stimulation. Added "dorsal root ganglion neurostimulation" to the When Covered section. Policy Guidelines updated.
ST2 Assay for Chronic Heart Failure AHS - G2130 Reviewed by Avalon 2nd Quarter 2019 CAB. Added "Related Policies" section, minor revisions to policy guidelines and coding table removed from the Billing/Coding section of the policy. No change to policy intent. References updated. Medical Director reviewed 8/2019.
Surgery for Femoroacetabular Impingement Reference added. Specialty Matched Consultant Advisory Panel review 7/30/2019.
Surgery for Morbid Obesity Added the following to the Billing/Coding section: "Hernia repair (43280, 43281, 43332, 43334, 43336) is considered an incidental procedure when performed during the same operative session as bariatric surgery (43644, 43645, 43770, 43775, 43842, 43843, 43845, 43846, 43847). Modifiers 58, 59, 78 and 79 (or XE, XS, XP, XU) will not allow additional payment when appended to these codes. An incidental procedure is not eligible for separate reimbursement. See also corporate medical policy "Bundling Guidelines". Notification given 7/1/2019 for policy effective date 8/30/2019.
ZIKA Virus Risk Assessment AHS - G2133 Reviewed by Avalon 2nd Quarter 2019 CAB. Added "Related Policies" section. Literature review updated. Applicable Federal Regulations updated. Policy Guidelines updated. Added "Zika virus urine, serum, and CSF RNA NAT testing and IgM testing in infants is considered medically necessary in the following situations…" to When Covered section. References updated. Coding table removed from the Billing/Coding section of the policy. Medical Director review 8/2019.