Medical Policy Updates

Medical Policy Update for December 31, 2019

Medical Guidelines Reason for Update
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.
Brexanolone (ZulressoTM Added HCPCS code C9055 to Billing/Coding section effective 1/1/2020.
Catheter Ablation as a Treatment for Atrial Fibrillation  The following codes were removed from the Billing/Coding section effective 10/1/2019: 93656, 93657.
Chiropractic Services The following codes were removed from the Billing/Coding section effective 1/1/20: 95831, 95832, 95833, 95834.
Chromoendoscopy as an Adjunct to Colonoscopy References updated. Specialty Matched Consultant Advisory Panel 11/2019. Medical Director review 11/2019.
Confocal Laser Endomicroscopy  References updated. Specialty Matched Consultant Advisory Panel 11/2019. Medical Director review 11/2019.
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation  HCPCS code K1002 added to Billing/Coding section.
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors  CPT code 0581T added to Billing/Coding section.  
Detection of Circulating Tumor Cells and Cell Free DNA in Cancer Management (Liquid Biopsy) AHS-G2054  Reviewed by Avalon 3rd Quarter 2019 CAB. Under "When Not Covered" section added the statement "Testing to predict treatment response using circulating tumor DNA in all other cancer types is investigational. Added "Liquid Biopsy" to the title of the policy. Policy Title changed from "Detection of Circulating Tumor Cells and Cell Free DNA in Cancer Management” to Detection of Circulating Tumor Cells and Cell Free DNA in Cancer Management (Liquid Biopsy)." Added CPT codes 81277, 81404, 86152, 86153 to Billing/Coding section. Medical Director review 11/2019.
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography Coding section updated to remove deleted code 78607. Added new codes 78830, 78831, 78832, 78835.  
Dry Needling of Myofascial Trigger Points Added the following codes to the Billing/Coding section effective 1/1/20: 20560, 20561.
Erythropoiesis-Stimulating Agents (ESAs)  Updated "When Covered" with the following statement: "Epogen and Procrit may be medically necessary when the criteria listed above for epoetin alfa is met, and when the patient has tried and failed, or is intolerant to, or has a clinical contraindication to Retacrit." Medical Director review 10/2019. Notification given 10/29/2019 for effective date 12/31/2019.
Esketamine (SpravatoTM) Nasal Spray  Added additional REMS program specifications within Policy Guidelines section for clarity. No change to policy intent. Added HCPCS codes G2082 and G2083 to Billing/Coding section effective 1/1/2020. Medical Director review 12/2019.
Facet Joint Denervation  Updated Policy Guidelines item #4. Removed "only (no steroids or other drugs)." 
Gene Expression Profiling for Uveal Melanoma AHS - M2071  19 Reviewed by Avalon 3rd Quarter 2019 CAB. Under "When Covered" section: Added coverage indication statements for chromosomes 3, 6, 8 and sequence analysis for genes (BAP1, EIF1AX, PRAME, SF3B1). Added CPT code 81552 to Billing/Coding section for effective date 1/1/2020. Medical Director review 11/2019. 
Gene Expression Testing for Breast Cancer Prognosis AHS - M2020  Added CPT code 81522 to Billing/Coding section for effective date 1/1/2020. 
Genetic Testing for Acute Myeloid Leukemia AHS-M2062  Specialty Matched Consultant Advisory Panel review 11/20/2019. No change to policy statement. 
Hematopoietic Cell Transplantation for CLL and SLL  Specialty Matched Consultant Advisory Panel review 11/20/2019. Reference added. No change to policy statement. 
Hematopoietic Cell Transplantation for Hodgkin Lymphoma  Specialty Matched Consultant Advisory Panel review 11/20/2019. Reference added. No change to policy statement.
Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome  Specialty Matched Consultant Advisory Panel review 11/20/2019. Reference added. No change to policy statement. 
Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia  Specialty Matched Consultant Advisory Panel review 11/20/2019. Reference added. No change to policy statement. 
Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis  Specialty Matched Consultant Advisory Panel review 11/20/2019. Reference added. No change to policy statement.
Hematopoietic Stem-Cell Transplant for Non-Hodgkin Lymphomas  Specialty Matched Consultant Advisory Panel review 11/20/2019. Reference added. No change to policy statement.
Hematopoietic Stem-Cell Transplantation for Autoimmune Diseases  Specialty Matched Consultant Advisory Panel review 11/20/2019. No change to policy statement.
Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma  Specialty Matched Consultant Advisory Panel review 11/20/2019. References added. No change to policy statement. 
Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer  Specialty Matched Consultant Advisory Panel review 11/20/2019. Reference added. No change to policy statement.
Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood  Specialty Matched Consultant Advisory Panel review 11/20/2019. Reference added. No change to policy statement. 
Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adults  Specialty Matched Consultant Advisory Panel review 11/20/2019. Reference added. No change to policy statement. 
Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors   Specialty Matched Consultant Advisory Panel review 11/20/2019. Reference added. No change to policy statement.
Hyperbaric Oxygen Therapy  Policy Guidelines and Description of Service updated. References added. No change to policy statement.  
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies AHS - G2105  Date on previous update note corrected from 10/1/19 to 12/10/19.
Implantable Cardioverter Defibrillator  The following codes were removed from the Billing/Coding section effective 10/1/2019: 33270, 33271, 33272, 33273; and the following codes were added effective 1/1/2020.
Infertility Diagnosis and Treatment Coding section updated by removing deleted code 0357T.  
Ingestible pH and Pressure Capsule  References updated. Specialty Matched Consultant Advisory Panel 11/2019. Medical Director review 11/2019.
Investigational (Experimental) Services - B0005  Description section updated. Definition of service added for clarity. Evidence based physician specialty societal guidelines added to Policy Guidelines. Added to when not covered section #2 "Evidence that permits conclusions concerning the effect on health outcomes is generally considered to be of moderate to high strength, based on well-designed and well-conducted studies." Added to when not covered section #3 "The services' beneficial effects on health outcomes does not outweigh any harmful effects on health outcomes." Added to when not covered section note "A requirement in a medical policy for enrollment in a patient registry to prospectively collect clinical outcomes data does not define a service as investigational." Specialty Matched Consultant Advisory Panel review 11/19/2019. No change to policy statement. 
Islet Cell Transplantation  Coding section updated with new codes : 0584T, 0585T, and 0586T.  
Medical Necessity  Updated description to reflect this being a medical policy. Description updated with definition of service. Definition of medical necessity section updated and reworded for clarity in bullets; 1, 2 and 3. Definition of generally accepted standards added. Specialty Matched Consultant Advisory Panel review 11/19/2019. No change to policy statement.(
Microprocessor Controlled Prostheses for the Lower Limb  HCPCS code L2006 added to Billing/Coding section.
Molecular Analysis for Gliomas AHS - M2139 Reviewed by Avalon 3rd Quarter 2019 CAB. Under Billing/Coding section: CPT codes 88364, 88365 removed and 88374, 88377 added. Medical Director review 11/2019.
Mutation Analysis in Myeloproliferative Neoplasms AHS - M2101  Specialty Matched Consultant Advisory Panel review 11/20/2019. No change to policy statement. 
Oncologic Applications of Photodynamic Therapy, Including Barrett's Esophagus  New policy developed. One or more courses of photodynamic therapy may be considered medically necessary for the following oncologic applications: palliative treatment of obstructing esophageal cancer, palliative treatment of obstructing endobronchial lesions, treatment of early stage non-small-cell lung cancer in patients who are ineligible for surgery and radiotherapy, treatment of high-grade dysplasia in Barrett's esophagus, and palliative treatment of unresectable cholangiocarcinoma when used with stenting. Added codes 96570, 96571, and J9600 to Billing/Coding section. References added. Medical Director review 9/2019. Notification given 10/1/2019 for effective date 1/1/2020.
Orthopedic Applications of Stem Cell Therapy  CPT codes 0565T and 0566T added to Billing/Coding section.  
Ovarian and Internal Iliac Vein Embolization, Ablation and Sclerotherapy  Policy name changed from "Ovarian, Internal Iliac and Gonadal Vein Embolization, Ablation and Sclerotherapy" to "Ovarian and Internal Iliac Vein Embolization, Ablation and Sclerotherapy". Policy guideline and description section updated. Policy updated to no longer address treatment of the gonadal vein in men with varicocele. Removed I86.1 from coding section.  
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia  Minor revisions and references updated. Medical Director review 11/2019. 
Polatuzumab vedotin-piiq (PolivyTM Added HCPCS code J9309 to Billing/Coding section and deleted codes C9399, J3490, J3590, and J9999 effective 1/1/2020.  
Prenatal Screening AHS – G2035  Correction to Billing/Coding section: code 0009M deleted. Coding grid removed, and codes listed. No change to policy statement.
Prenatal Screening for Fetal Aneuploidy AHS –G2055  Coding section updated by listing codes in place of table. Removed deleted code 0009M. 
Prostate Cancer Screening AHS-G2008  Specialty Matched Consultant Panel review 8/21/19. No change to policy statement. CPT code 81542 added to Billing/Coding section for effective date 1/1/2020. 
Rehabilitative Therapies  The following codes were removed from the Billing/Coding section effective 1/1/20: 95831-95834. 
Residential Treatment Policy archived effective 1/1/2020 
Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease AHS – G2110 New policy developed. Reviewed by Avalon 3rd Quarter 2019 CAB. BCBSNC will provide coverage for serum testing for hepatic fibrosis when it is determined to be medically necessary and criteria are met. Medical Director review 12/2019. 
Talimogene Laherparepvec (Imlygic)  Added the following statement to "When Covered" section: "Use of talimogene laherparepvec (Imlygic) may be considered medically necessary for clinical indications not listed above when the drug is prescribed for the treatment of cancer either: In accordance with FDA label (when clinical benefit has been established, see Policy Guidelines); OR In accordance with specific strong endorsement or support by nationally recognized compendia, when such recommendation is based on strong/high levels of evidence, and/or uniform consensus of clinical appropriateness has been reached." Under "When Not Covered" section, added the statement: "Talimogene laherparepvec (Imlygic) is considered investigational when used for: 1) Non-cancer indications; OR 2) When criteria are not met regarding FDA labeling OR strong endorsement/ support by nationally recognized compendia, as stated under "When Talimogene Laherparepvec (Imlygic) is covered." Added the following statements under "Policy Guidelines" section: 1) Drugs prescribed for treatment of cancer in accordance with FDA label may be considered medically necessary when clinical benefit has been established, and should not be determined to be investigational as defined in Corporate Medical Policy, Investigational (Experimental) Services." 2) Please refer to CMP "Investigational (Experimental) Services" for a summary of evidence standards from nationally recognized compendia. Medical Director review 12/2019.
Telehealth  Codes 96150, 96151 deleted and replaced with 96156 for health behavior assessment or re-assessment. Deleted codes 98969 and 99444. Added codes 99421, 99422, 99423 for online digital evaluation and management service of an established patient. The following statement added to the Billing/Coding section: Online digital evaluation and management services or assessment by nonphysician health care professionals (98970, 98971, 98972 or G2061, G2062, G2063) are not covered. 
Testing for 5-Fluorouracil Use in Cancer Patients AHS-M2067  Reviewed by Avalon 3rd Quarter 2019 CAB. Policy title changed from "Genetic Testing for 5-Fluorouracil Use in Cancer Patients" to "Testing for 5-Fluorouracil Use in Cancer Patients." Added the following statement to "When Not Covered" section: Uracil breath tests and dihydrouracil/uracil ratio testing of plasma, serum, or urine samples to aid in managing dose adjustment in individuals undergoing 5-fluorouracil chemotherapy are considered investigational. Medical Director review 11/2019. 
Therapeutic Radiopharmaceuticals in Oncology  Added HCPCS code A9590 to Billing/Coding section and deleted codes A9699 and C9408 effective 1/1/2020.  
Transanal Endoscopic Microsurgery (TEMS)  References updated. Specialty Matched Consultant Advisory Panel 11/2019. Medical Director review 11/2019. 
Transanal Radiofrequency Treatment of Fecal Incontinence  Removed Related Policies section and updated References. Specialty Matched Consultant Advisory Panel 11/2019. Medical Director review 11/2019.
Trastuzumab  Under "When Covered," added Ogivri (trastuzumab-dkst), Herzuma (trastuzumab-pkrb), Ontruzant (trastuzumab-dttb), and Trazimera (trastuzumab-qyyp) biosimilars to Herceptin (trastuzumab) for the treatment of HER2 overexpressing breast cancer and HER2 overexpressing metastatic gastric or gastroesophageal junction adenocarcinoma. Added HCPCS codes Q5112, Q5113, Q5114, and Q5116 to Billing/Coding section. References added. Medical Director review 10/2019. Notification given 10/29/2019 for effective date 12/31/2019.  
Tumor-Treatment Fields Therapy Specialty Matched Consultant Advisory Panel review 11/20/2019. Reference added. No change to policy statement.
Urinary Tumor Markers for Bladder Cancer AHS – G2125 Specialty Matched Consultant Advisory Panel review 11/20/2019.
Use of Common Genetic Variants to Predict Risk of Non-Familial Breast Cancer AHS-M2126   Reviewed by Avalon 3rd Quarter 2019 CAB. Under "When Covered" section: removed OncoVue and deCODE BreastCancer tests since they are no longer commercially available. Added CPT codes 81307, 81308 to the Billing/Coding section for effective date 1/1/2020. Medical Director review 11/2019.