Medical Policy Updates

Medical Policy Update for December 8, 2020

Medical Guidelines	Reason for Update
Absorbable Nasal Implant for Treatment of Nasal Valve Collapse	References added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 8/19/2020.
Allergen Testing AHS – G2031	Specialty Matched Consultant Advisory Panel review 11/2020. Medical Director review 11/2020.
Allergy Immunotherapy (Desensitization)	References updated. Specialty Matched Consultant Advisory Panel review 11/2020. Medical Director review 11/2020.
Allergy Skin and Challenge Testing	References updated. Specialty Matched Consultant Advisory Panel review 11/2020. Medical Director review 11/2020.
Bioimpedance Devices for Detection of Lymphedema	Regulatory status updated. Specialty Matched Consultant Advisory Panel review 11/18/2020.
Celiac Disease Testing AHS – G2043	Specialty Matched Consultant Advisory Panel review 11/2020. Medical Director review 11/2020.
Chromoendoscopy as an Adjunct to Colonoscopy	References updated. Specialty Matched Consultant Advisory Panel 11/2020. Medical Director review 11/2020.
Confocal Laser Endomicroscopy	References updated. Specialty Matched Consultant Advisory Panel 11/2020. Medical Director review 11/2020.
Diagnosis of Idiopathic Environmental Intolerance AHS – G2056	Specialty Matched Consultant Advisory Panel review 11/2020. Medical Director review11/2020.
Electrostimulation and Electromagnetic Therapy for Wounds	Specialty Matched Consultant Advisory Panel review 11/18/2020.
Esophageal Pathology Testing AHS – M2171	Specialty Matched Consultant Advisory Panel review 11/2020. Medical Director review 11/2020.
Fecal Calprotectin Testing AHS – G2061	Specialty Matched Consultant Advisory Panel review 11/2020. Medical Director review 11/2020.
Gastroesophageal Reflux Disease, Transendoscopic Therapies	Specialty Matched Consultant Advisory Panel 11/2020. Medical Director review 12/2020.
Genetic Testing for Acute Myeloid Leukemia AHS-M2062	Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy statement.
Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery	Specialty Matched Consultant Advisory Panel review 11/18/2020.
Hematopoietic Cell Transplantation	Specialty Matched Consultant Advisory panel review 11/18/2020. No change to policy statement.
Ingestible pH and Pressure Capsule	Policy archived. Specialty Matched Consultant Advisory Panel 11/2020. Medical Director review 11/2020.
Investigational (Experimental) Services - B0005	Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy statement.
Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease AHS–G2121	Specialty Matched Consultant Advisory Panel review 11/2020. Medical Director review 11/2020.
Laser Treatment of Onychomycosis	Medical Director review 11/17/2020, policy archived.
Lysis of Epidural Adhesions	Medical Director review 11/17/2020, policy archived.
Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease (GERD)	Specialty Matched Consultant Advisory Panel review 11/18/2020.
Medical Necessity	Updated Medical Necessity Definition section to include setting. Medical Director Review. Specialty Matched Consultant Advisory Panel review 11/18/2020
Mohs' Micrographic Surgery	Medical Director review 11/17/2020, policy archived.
Mutation Analysis in Myeloproliferative Neoplasms AHS - M2101	Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy statement.
Non-Contact Ultrasound Treatment for Wounds	Specialty Matched Consultant Advisory Panel review 11/18/2020.
Nusinersen (Spinraza™)	Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statements.
Onasemnogene abeparvovec (Zolgensma®)	Specialty Matched Consultant Advisory Panel review 10/21/2020.
PD-1 Inhibitors	Removed the following statement from "When Covered" section for Keytruda for unresectable or metastatic tumor mutational burden-high (TMB-H) solid tumors: "as determined by an FDA-approved test". Medical Director review 11/2020.
Plugs for Fistula Repair	Specialty Matched Consultant Advisory Panel review 11/18/2020.
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis	Specialty Matched Consultant Advisory Panel review 11/18/2020.
Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome	Reference added. Specialty Matched Consultant Advisory Panel review 8/19/2020.
Surgical Treatment of Sinus Disease	Specialty Matched Consultant Advisory Panel review 8/19/2020. Description section updated. Removed "Chronic headache or facial pain caused by a demonstrable anatomic or pathologic sinus disorder" from coverage criteria. Policy Guidelines updated.
Surgical Treatments for Lymphedema	Reference added. Specialty Matched Consultant Advisory Panel review 11/18/2020.
Transanal Endoscopic Microsurgery (TEMS)	References updated. Specialty Matched Consultant Advisory Panel 11/2020. Medical Director review 11/2020.
Transanal Radiofrequency Treatment of Fecal Incontinence	Policy archived. Specialty Matched Consultant Advisory Panel 11/2020. Medical Director review 11/2020.
Tumor-Treatment Fields Therapy	Updated Policy Guidelines and Regulatory section. Reference added. Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy statement.
Ultraviolet Light Therapy in the Home Setting(UVB)	Medical Director review 11/17/2020, policy archived.
Varicose Veins of the Lower Extremities, Treatment for	Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 11/18/2020.