Medical Policy Updates

Medical Policy Update for December 10, 2019

Medical Guidelines Reason for Update
Allergen Testing AHS - G2031  Reviewed by Avalon 3rd Quarter 2019 CAB. Removed "Additional testing beyond this number will require individual review for coverage criteria" from the When Covered section. Added "or non-specific IgG, IgA, IgM, and/or IgD" to the When Not Covered section. The following codes: 88346, 86352, 86021, and 86343 along with the code table were removed from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 11/2019. Medical Director review 11/2019.
Allergy Immunotherapy (Desensitization)  Updated Related Policies section. Specialty Matched Consultant Advisory Panel review 11/2019. Medical Director review 11/2019.
Allergy Skin and Challenge Testing  Specialty Matched Consultant Advisory Panel review 11/2019. Medical Director review 11/2019.
Atezolizumab (Tecentriq) for Intravenous Use Updated "When Covered" section with the following indications: Metastatic Non-Small Cell Lung Cancer (NSCLC) who have no EGFR or ALK genomic tumor aberrations, and are receiving atezolizumab as first-line treatment in combination with bevacizumab, paclitaxel, and carboplatin; Triple-Negative Breast Cancer (TNBC) who have unresectable locally advanced or metastatic disease with tumors expressing PD-L1 (PD-L1 stained tumor-infiltrating immune cells [IC] of any intensity covering ≥1% of the tumor area), as determined by an FDA-approved test, and are receiving atezolizumab in combination with paclitaxel protein-bound; and Small Cell Lung Cancer (SCLC) who have extensive-stage disease, and are receiving atezolizumab as first-line treatment in combination with carboplatin and etoposide. Under "When Covered" for metastatic NSCLC monotherapy, added the following: "targeting alterations in EGFR/ALK" to further clarify type of FDA-approved therapy. Updated Policy Guidelines with appropriate dosing by indication. Minor edits made throughout policy for clarity. References added. Specialty Matched Consultant Advisory Panel review 11/20/2019. Medical Director review 11/2019.
Bariatric Surgery Benefit language revised to remove requirement of one year conservative medical management prior to bariatric surgery.  Title of policy changed to "Bariatric Surgery".
Beta-Hemolytic Streptococcus Testing AHS - G2159  Reviewed by Avalon 3rd Quarter CAB. Codes 87797 and 87798 added to Billing/Coding section. 
Biochemical Markers of Alzheimer's Disease and Dementia AHS - G2048  Reviewed by Avalon 3rd Quarter CAB.  Policy title changed from Biochemical Markers of Alzheimer’s Disease to Biochemical Markers of Alzheimer's Disease and Dementia.  Added  α-synuclein to list of CSF biomarkers.  Added amyloid beta peptides and extracellular vesicle analysis to list of urinary biomarkers.  Added measurement of plasma and/or serum biomarkers to Not Covered section.  Added use of multianalyte assays and/or algorithmic analysis to Not Covered section.
Bioimpedance Devices for Detection of Lymphedema  Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases AHS - G2123  Reviewed by Avalon 3rd Quarter CAB. No change in overall intent of policy.
Blinatumomab (Blincyto®) Added the following indication to "When Covered" section: "Blinatumomab (Blincyto) is considered medically necessary for the treatment of patients with B-cell precursor acute lymphoblastic leukemia (ALL) in first or second complete remission with minimal residual disease (MRD) greater than or equal to 0.1%." Updated Description and Policy Guidelines section to reflect addition of this indication. Reference added. Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Bone Turnover Markers Testing AHS - G2051 Policy title changed from "Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover" to "Bone Turnover Markers Testing".  Coding section updated to reflect new codes per Avalon Q3 CAB update.   Note 1 added to When not covered section for clarity.
Capsule Endoscopy, Wireless  The following codes were removed from Billing/Coding section effective 10/1/19: 91110, 91111; references updated.
Celiac Disease Testing AHS - G2043  Reviewed by Avalon 3rd Quarter 2019 CAB. Added code 81376 and removed code table from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 11/2019. Medical Director review 11/2019.
Cervical Cancer Screening AHS - G2002  Coding Section updated to reflect new and deleted codes per Avalon Q3 CAB.  No change to policy intent. 
Cetuximab (Erbitux®)  Added the following criteria to "When Covered" section: "genetic mutation analysis for RAS (KRAS and NRAS) has been performed confirming the tumor tissue genotype is negative for KRAS and NRAS mutations and documentation has been provided; AND". Updated Policy Guidelines with NCCN Guidelines recommendations for determination of tumor gene status for RAS (KRAS/NRAS) mutations in all patients with metastatic colorectal cancer. Reference added. Medical Director review 12/2019. 
Copanlisib (AliqopaTM Minor typographical edits made throughout policy for consistency. No change to policy intent. Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Daratumumab (Darzalex®)  Added the following statements to "When Covered" section: "In combination with lenalidomide and dexamethasone in patients with newly diagnosed disease who are ineligible for autologous stem cell transplantation," and "in combination with bortezomib, thalidomide, and dexamethasone in patients with newly diagnosed disease who are eligible for autologous stem cell transplantation," and updated Policy Guidelines with the associated dosing regimen for these indications. Reference added. Medical Director review 12/2019. 
Daunorubicin and Cytarabine (VyxeosTM Specialty Matched Consultant Advisory Panel review 11/20/2019. No change to policy intent. 
Diagnostic Testing of Influenza AHS - G2119  Reviewed by Avalon 3rd Quarter CAB.  No changes to policy. 
Diagnostic Testing of Sexually Transmitted Infections AHS - G2157  Reviewed by Avalon 3rd Quarter CAB.  No changes to policy. 
Electrostimulation and Electromagnetic Therapy for Wounds  Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Epithelial Cell Cytology in Breast Cancer Risk Assessment AHS - G2059  Reviewed by Avalon 3rd Quarter 2019 CAB. No change to policy intent. Coding table removed from Billing/Coding section. Medical Director review 11/2019.
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis AHS - G2060  Reviewed by Avalon 3rd Quarter 2019 CAB. No changes to policy. Medical Director review 12/2019.
Fecal Calprotectin Testing AHS - G2061  Reviewed by Avalon 3rd Quarter 2019 CAB. Code table removed from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 11/2019. Medical Director review 11/2019.
Focal Treatments for Prostate Cancer  Reference added.  Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Genetic Testing for Familial Hypercholesterolemia AHS - M2137  Reviewed by Avalon 3rd Quarter 2019 CAB. Added Related Policies to Description section and "Note" to When Not Covered section of policy. Medical Director review 11/2019.
Growth Factors in Wound Healing  Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery  Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia   Specialty Matched Consultant Advisory Panel review 11/20/2019. Reference added. No change to policy statement.
Hemoglobin A1c AHS - G2006  Coding section updated to reflect new and deleted codes per Avalon Q3 CAB update. When covered section #5 added "Reimbursement is allowed once per month during pregnancy for measurement of hemoglobin A1c for pregnant individuals."  When not covered section - removed pregnancy from bullet b and removed panel testing of biochemical markers for type 2 diabetes risk. 
Identification of Microorganisms using Nucleic Acid Probes AHS - M2097  Reviewed by Avalon 3rd Quarter 2019 CAB. Within the table under the When Covered section, removed "Gastrointestinal Pathogen Panel" and corresponding codes 87505-87507 and "Respiratory Virus Panel" including corresponding codes 87631-87633; Item 3, removed C. dificile and added Mycoplasma genitalium. Under the When Not Covered section, added "Candida species" along w/corresponding codes. The following codes were removed from the Billing/Coding section: 87505, 87506, 87507, 87632, 87633. Medical Director review 11/2019.
Immune Cell Function Assay for Organ Transplant Rejection AHS-G2098  Reviewed by Avalon 3rd Quarter 2019 CAB. No change to policy statement. Medical Director review 11/2019.
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies AHS - G2105 Policy title changed from "Immunopharmacologic Monitoring of Infliximab, Adalimumab and other Therapeutic Serum Antibodies" to "Immunopharmacologic Monitoring of Therapeutic Serum Antibodies".  Avalon Q3 CAB Update.  Coding section updated to reflect new codes for 2020.  When not covered section reworded for clarity to include both serum antibodies or serum drug levels either alone or in combination with listed drugs. 
In Vitro Chemoresistance and Chemosensitivity Assays AHS - G2100  Reviewed by Avalon 3rd Quarter 2019 CAB. Coding table removed and CPT code 0083U added to Billing/Coding section. No change to policy statement. Medical Director review 11/2019.
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence  Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Inotuzumab (Besponsa®)  Specialty Matched Consultant Advisory Panel review 11/20/2019. No change to policy intent. 
Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease AHS - G2121  Reviewed by Avalon 3rd Quarter 2019 CAB. Minor change in wording to the Not Covered section, replacing term "investigational" with "not covered", and added item j. Specialty Matched Consultant Advisory Panel review 11/2019. Medical Director review 11/2019.
Laboratory Tests for Heart and Kidney Transplant Rejection Policy archived.
Measurement of Thomboxane Metabolites for ASA Resistance AHS - G2107  Reviewed by Avalon 3rd Quarter 2019 CAB. Added code 82750 to Coding/Billing section; no other changes to policy. Medical Director review 12/2019.
Metabolite Markers of Thiopurines AHS - G2115 Reviewed by Avalon 3rd Quarter 2019 CAB. Policy retitled. Removed "pharmacogenomics" from the Policy Statement.  Added "Monitoring of thiopurine metabolite levels in individuals with acute lymphoblastic leukemia is considered medically necessary", along with corresponding a. and b. to the When Covered section. Removed "genotyping" from both When Covered and When Not Covered sections.  Code table removed from Billing/Coding section. Medical Director review 11/2019.
Molecular Testing of Bronchial Brushings AHS - M2160  Coding section updated per Avalon Q3 CAB review.  No change to policy statement. 
Nerve Fiber Density Testing AHS - M2112  Reviewed by Avalon 3rd Quarter CAB.  No changes to policy.
Non-Contact Ultrasound Treatment for Wounds  Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Olaratumab (LartruvoTM Specialty Matched Consultant Advisory Panel review 11/20/2019. No change to policy intent. 
Panitumumab (Vectibix®)  Added the following criteria to "When Covered" section: "genetic mutation analysis for RAS (KRAS and NRAS) has been performed confirming the tumor tissue genotype is negative for KRAS and NRAS mutations and documentation has been provided; AND". Updated Policy Guidelines with NCCN Guidelines recommendations for determination of tumor gene status for RAS (KRAS/NRAS) mutations in all patients with metastatic colorectal cancer. Reference added. Medical Director review 12/2019. 
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence  Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction  Specialty Matched Consultant Advisory Panel review 11/20/2019.
Plugs for Fistula Repair  Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis  Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Pre-Operative Testing AHS - G2023  Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Prostate Biopsies AHS - G2007  Specialty Matched Consultant Advisory Panel review 11/20/2019. Reviewed by Avalon 3rd Quarter CAB. No change in overall intent of policy. 
Prostatic Urethral Lift  Reference added. Policy Guidelines updated.  Coverage criteria statement "Patient has had appropriate screening for prostate cancer within the past year" changed to "Patient has had appropriate testing to exclude diagnosis of prostate cancer".  Specially Matched Consultant Advisory Panel review 11/20/2019. 
Radiofrequency Ablation of the Renal Nerves as a Treatment of Hypertension  The following code was removed from the Billing/Coding section effective 10/1/19: 0339T.
Romiplostim (NPlate)   Updated "When Covered" section to include additional indication for pediatric patients age 1 year and older with ITP for at least 6 months. Updated Description section to reflect addition of this indication. Reference added. Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction  Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Surgical Treatment of Sinus Disease  Medical Director review.  Criteria for balloon ostial dilation (BOD) moved to a separate medical policy.  Silent sinus syndrome and antrochoanal polyps added to list of covered indications.  Specialty Matched Consultant Advisory Panel review 8/21/2019. 
Surgical Treatments for Lymphedema  Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Testing for Mosquito or Tick-Related Infections AHS - G2158  Reviewed by Avalon 3rd Quarter CAB.  Added PCR testing for suspected cases of tick-borne relapsing fever to When Covered section.  Removed NAAT, including PCR for suspected cases of tick-borne relapsing fever from When Not Covered section.  Added NAAT, including PCR for suspected cases of babesiosis to When Covered section.  Removed NAAT, including PCR for suspected cases of babesiosis from When Not Covered section.
Testosterone Pellet Implantation for Androgen Deficiency  Added the following revision to investigational statement in "When Not Covered" section: "older individuals with type 2 diabetes mellitus and androgen deficiency or." Updated dosing information in Policy Guidelines for clarity regarding individualized dosing per patient. References added. Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Transplant Rejection Testing AHS - M2091 New Policy. BCBSNC will provide coverage for gene expression profiling testing for heart transplant rejection (e.g., AlloMap) when it is determined to be medically necessary because the criteria and guidelines are met. The use of donor-derived cell-free DNA tests (e.g., AlloSure) and measurement of volatile organic compounds are considered investigationl.  Medical Director review 11/2019.
Urinalysis and Urine Culture Testing for Bacteria AHS - G2156 Policy title changed from "Urine Culture Testing for Bacteria" to "Urinalysis and Urine Culture Testing for Bacteria".  When not covered section reworded for clarity, no change to policy intent.
Varicose Veins of the Lower Extremities, Treatment for  Specialty Matched Consultant Advisory Panel review 11/20/2019. 
Vesicoureteral Reflux, Treatment with Periureteral Bulking Agents   Specialty Matched Consultant Advisory Panel review 11/20/2019.
Xolair® (Omalizumab)  Updated Policy Guidelines section with further clarity on anaphylaxis black box warning and monitoring requirements. Specialty Matched Consultant Advisory Panel review 11/20/2019. No change to policy intent.