Medical Policy Updates

Medical Policy Update December 2, 2019

Medical Guidelines Reason for Update
Allergen Testing AHS - G2031  Policy statement revised to read:   BCBSNC will provide coverage for allergen testing when it is determined the medical criteria or reimbursement guidelines below are met. Wording revised in the Covered Section to change "medically necessary" to "reimbursement is allowed." Wording revised in the Not Covered section. "Not Medically Necessary" and "investigational" changed to read "Reimbursement is not allowed..." Deleted coding grid. Notification 10/1/2019 for effective date 12/2/2019.  
Beta-Hemolytic Streptococcus Testing AHS - G2159 Policy statement revised to read: BCBSNC will provide coverage for β hemolytic streptococcus testing when it is determined the medical criteria or reimbursement guidelines below are met. Wording revised in the Covered Section: "Medically necessary" changed to "reimbursement is allowed." Wording revised in the Not Covered section. "Not Medically Necessary" and "Investigational" changed to read "Reimbursement is not allowed..." Deleted coding grid. Notification given 10/1/2019 for effective date of 12/2/2019.  
Bevacizumab in Advanced Adenocarcinoma of the Pancreas Specialty Matched Consultant Advisory Panel review 11/20/2019.  
Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover AHS - G2051  Policy statement revised to read; The measurement of bone turnover markers for the diagnosis and management of osteoporosis and in the management of patients with conditions associated with high rates of bone turnover is not covered. Wording revised in the Not Covered section. "Investigational" changed to read "Reimbursement is not allowed..." Deleted coding grid. Notification given 10/1/2019 for policy effective date 12/2/2019.  
Cardiac Biomarkers for Myocardial Infarction AHS - G2150  Policy Statement revised to read: BCBSNC will provide coverage for cardiac biomarkers for myocardial infarction when it is determined the medical criteria or reimbursement guidelines noted below are met. Wording revised in the Not Covered section. "Not Medically Necessary" and "investigational" changed to read "Reimbursement is not allowed..." Deleted coding grid. Notification given 10/1/2019 for policy effective date 12/2/2019. 
Cardiovascular Disease Risk Assessment AHS - G2050  Policy statement revised to read: BCBSNC will provide coverage for cardiovascular disease risk assessment when it is determined the medical criteria or reimbursement guidelines below are met. Wording revised in When Covered section. "Medically Necessary" changed to "Reimbursement is allowed..." Wording revised in the Not Covered section. "Not Medically Necessary" changed to read "Reimbursement is not allowed..." Deleted coding grid. Notification given 10/1/2019 for effective date 12/2/2019.  
Celiac Disease Testing AHS - G2043  Policy statement revised to read: BCBSNC will provide coverage for celiac disease testing when it is determined the medical criteria or reimbursement guidelines below are met. Wording revised in the When Covered section. "Medically Necessary" changed to "Reimbursement is allowed..." Wording revised in the Not Covered section. "Not Medically Necessary" and "investigational" changed to read "Reimbursement is not allowed..." Deleted coding grid. Notification given 10/1/2019 for effective date 12/2/2019.  
Emapalumab-lzsg (GamifantTM) Specialty Matched Consultant Advisory Panel review 11/20/2019. No change to policy intent.  
Erectile Dysfunction AHS - G2132  Policy statement revised to read: BCBSNC will provide coverage for testing for erectile dysfunction when it is determined the medical criteria or reimbursement guidelines shown below are met. Wording changed in the When Covered section. "Medically Necessary" changed to "Reimbursement is allowed..." Wording revised in the Not Covered section. "Investigational" changed to read "Reimbursement is not allowed..." Deleted coding grid. Policy noticed 10/1/2019 for effective date 12/2/2019.
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis AHS - G2060 Policy statement is revised to read: Fecal analysis as a diagnostic test for the evaluation of intestinal dysbiosis, irritable bowel syndrome, malabsorption or small intestinal overgrowth of bacteria is not covered. Wording revised in the Not Covered section. "Investigational" changed to read "Reimbursement is not allowed..." Deleted coding grid. Notification given 10/1/2019 for effective date 12/2/2019.
Gene Expression Testing for Breast Cancer Prognosis AHS - M2020  Policy statement revised to read: BCBSNC will provide coverage for gene expression testing for breast cancer prognosis when it is determined the medical criteria and guidelines below are met. Wording revised in When Covered section. "Medically Necessary" changed to "Reimbursement is allowed..." Wording revised in the Not Covered section. "Not Medically Necessary" changed to read "Reimbursement is not allowed..."  Notification given 10/1/2019 for effective date 12/2/2019.  
Hormonal Testing in Females AHS - G2161  Policy Statement revised to read: BCBSNC will provide coverage for hormonal testing in females when it is determined the medical criteria and guidelines below are met. Wording revised in When Covered section. "Medically Necessary" changed to "Reimbursement is allowed..." Wording revised in the Not Covered section. "Not Medically Necessary" changed to read "Reimbursement is not allowed..."  Notification given 10/1/2019 for effective date 12/2/2019.  
Immune Cell Function Assay for Organ Transplant Rejection AHS - G2098  Policy Statement revised to read: Reimbursement is not allowed for an immune cell function assay for organ transplant rejection for all applications. Wording revised in the Not Covered section. "Investigational" changed to read "Reimbursement is not allowed..." Deleted coding grid. Notification given 10/1/2019 for effective date 12/2/2019.
Immunopharmacologic Monitoring of Infliximab, Adalimumab and other Therapeutic Serum Antibodies AHS - G2105  Policy statement revised to read: Reimbursement is not allowed for immunopharmacologic monitoring of Infliximab, Adalimumab and other therapeutic serum antibodies. Wording revised in the Not Covered section. "Investigational" changed to read "Reimbursement is not allowed..." Deleted coding grid. Notification given 10/1/2019 for effective date 12/2/2019.  
Injectable Clostridial Collagenase for Fibroproliferative Disorders References added. Specialty Matched Consultant Advisory Panel (Urology) review 11/20/2019. No change to policy intent.  
Interleukin-5 Antagonists Updated "When Covered" section for Nucala to expand severe eosinophilic asthma indication to 6 years of age and older. Added reference to the following pharmacy policy: "Nucala<sup>&reg;</sup> & Fasenra<sup>&reg;</sup> Subcutaneous Injection." Reference added. 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  Policy statement revised to read: Reimbursement is not allowed for laboratory testing for the diagnosis of inflammatory bowel disease. Wording revised in the Not Covered section. "Investigational" changed to read "Reimbursement is not allowed..." Deleted coding grid. Notification given 10/1/2019 for effective date 12/2/2019.  
Molecular Testing of Bronchial Brushings  AHS - M2160   Policy statement revised to read: Reimbursement is not allowed for the molecular testing of bronchial brushings is for all applications. "Investigational" changed to read "Reimbursement is not allowed..." Deleted coding grid. Notification given 10/1/2019 for effective date 12/2/2019.
Pancreatic Enzyme Testing for Acute Pancreatitis AHS - G2153  Policy statement revised to read: BCBSNC will provide coverage for pancreatic enzyme testing for acute pancreatitis when it is determined the medical criteria or reimbursement guidelines below are met. Wording revised in When Covered section. "Medically Necessary" changed to "Reimbursement is allowed..." Wording revised in the Not Covered section. "Not Medically Necessary" changed to read "Reimbursement is not allowed..." Deleted coding grid. Notification given 10/1/2019 for effective date 12/2/2019.  
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing - AHS -G2164  Policy statement revised to read: BCBSNC will provide coverage for Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing when it is determined the medical criteria or reimbursement guidelines below are met. Wording revised in When Covered section. "Medically Necessary" changed to "Reimbursement is allowed..." Wording revised in the Not Covered section. "Not Medically Necessary" and "Investigational" changed to read "Reimbursement is not allowed..." Deleted coding grid. Notification given 10/1/2019 for effective date 12/2/2019
Plasma HIV-1 RNA Quantification for HIV-1 Infection AHS - M2116  Policy statement revised to read: BCBSNC will provide coverage for Plasma HIV-1 RNA Quantification for HIV-1 Infection when it is determined the reimbursement guielines below are met. Wording revised in When Covered section. "Medically Necessary" changed to "Reimbursement is allowed..." Wording revised in the Not Covered section "Investigational" changed to read "Reimbursement is not allowed..." Deleted coding grid. Notification given 10/1/2019 for effective date 12/2/2019.  
Professional Pathology Billing Guidelines AHS - R2169  Last paragraph in Description section deleted. In the Service Guidelines section, 3rd bullet point, deleted POS 11 or 24. Notification given 10/1/19 for effective date 12/2/19.  
Prostate Cancer Screening AHS-G2008  Reviewed by Avalon 2nd Quarter 2019 CAB. Policy statement revised to read: BCBSNC will provide coverage for prostate cancer screening when it is determined the medical criteria and guidelines noted below are met. Revised Description Section. Wording changed in the When Covered section. "Medically Necessary" changed to "Reimbursement is allowed..." Wording revised in the Not Covered section. "Investigational" changed to read "Reimbursement is not allowed..." Deleted coding grid. Policy Guidelines updated. References added. Policy noticed 10/1/2019 for effective date 12/2/2019.  
Serum Tumor Markers for Malignancies AHS - G2124  Policy Statement revised to read: BCBSNC will provide coverage for serum tumor markers for malignancies when it is determined the medical criteria and guidelines below are met. Wording changed in the When Covered section. "Medically Necessary" changed to "Reimbursement is allowed..." Wording revised in the Not Covered section. "Investigational" changed to read "Reimbursement is not allowed..." Notification given 10/1/2019 for effective date 12/2/2019.  
Tagraxofusp-erzs (ElzonrisTM> Specialty Matched Consultant Advisory Panel review 11/20/2019. No change to policy intent.  (krc)
Testing for Diagnosis of Active or Latent Tuberculosis AHS - G2063  Policy Statement revised to read: BCBSNC will provide coverage for testing for diagnosis of active or latent tuberculosis when it is determined the medical criteria or reimbursement guidelines below are met. Wording revised in When Covered section. "Medically Necessary" changed to "Reimbursement is allowed..." Wording revised in the Not Covered section. "Not Medically Necessary" changed to read "Reimbursement is not allowed..." Deleted coding grid. Notification given 10/1/2019 for effective date 12/2/2019.
Treatment of Hereditary Angioedema   Specialty Matched Consultant Advisory Panel review 11/20/2019. No change to policy intent.  
Urinary Tumor Markers for Bladder Cancer AHS - G2125  Policy statement revised to read: BCBSNC will provide coverage for Urinary Tumor Markers for Bladder Cancer when it is determined the medical criteria or reimbursement guidelines below are met. Wording revised in the When Covered section. "Medically necessary" changed to read "Reimbursement is allowed..." Wording revised in the Not Covered section. "Investigational" changed to read "Reimbursement is not allowed..." Deleted coding grid. Notification given 10/1/2019 for effective date 12/2/2019.  
White Blood Cell Growth Factors Updated "Description", "When Covered", and "When Not Covered" sections to reflect addition of Ziextenzo (pegfilgrastim-bmez), a biosimilar to Neulasta (pegfilgrastim), with same indications and coverage criteria as Udenyca and Fulphila. Added HCPCS codes J3590 and J9999 to Billing/Coding Section. Reference added