Medical Policy Updates

Medical Policy Update for February 11, 2020

Medical Guidelines Reason for Update
Botulinum Toxin Injection Under "When Covered" section, added "and" and "or" between chronic migraine Policy Statements for clarity. Added "for both initial and continuation treatment" in "When Covered" section for chronic migraine indication for clarity. No change to policy intent. Medical Director review 2/2020. 
Crizanlizumab-tmca (Adakveo®) New policy developed. Crizanlizumab-tmca (Adakveo) is considered medically necessary in adult and pediatric patients (≥ 16 years of age) with sickle cell disease to reduce the frequency of vasoocclusive crises (VOCs) when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, and J3590 to Billing/Coding section. References added. Medical Director review 2/2020.
Dermatologic Applications of Photodynamic Therapy References and Policy Guidelines updated.  "Non-hyperkeratotic actinic keratoses for 4 or more upper extremity lesions." added to When covered section.  "Photodynamic therapy is considered not medically necessary as a treatment of 3 or fewer non-hyperkeratotic actinic keratoses on the upper extremities." added to When not covered section. 
Diagnostic Testing of Iron Homeostasis and Metabolism AHS - G2011 Reviewed by Avalon 4th Quarter CAB.  No changes to policy.
Gastroesophageal Reflux Disease, Transendoscopic Therapies References updated. Specialty Matched Consultant Advisory Panel 11/2019. Medical Director review 12/2019.
Gene Expression Testing for Breast Cancer Prognosis AHS - M2020 Reviewed by Avalon Q4 2019 CAB. No changes to the policy.
General Genetic Testing, Germline Disorders AHS - M2145 Annual review by Avalon 4th Quarter 2019 CAB. Billing/Coding section: removed the following codes - 81184, 81185, 81186, 81470, 81471. Medical Director review 12/2019.
General Inflammation Testing AHS - G2155 Reviewed by Avalon 4th Quarter CAB.  No changes to policy.

Genetic Testing and Genetic Expression Profiling in Patients with Cutaneous Melanoma AHS-M2029

Reviewed by Avalon Q4 2019 CAB. Under "When Not Covered" section added statement: Genetic expression profiling testing for cutaneous melanoma is considered investigational. Added Note: For testing of 5 or more genes for an affected individual with cutaneous melanoma, please refer to AHS-M2109 Molecular Panel Testing of Cancers for Diagnosis, Prognosis, and Identification of Targeted Therapy. Under Billing/Coding section: Deleted CPT codes 81445, 81450, 81455 and added PLA codes: 0089U and 0090U. Policy Title changed from: BRAF Genetic Testing in Patients with Melanoma to: Genetic Testing and Genetic Expression Profiling in Patients with Cutaneous Melanoma. Medical Director review 1/2020.
Genetic Testing for CHARGE Syndrome AHS - M2070 Annual review by Avalon 4th Quarter 2019 CAB. No revisions and no change to policy intent. Medical Director review 12/2019.
Genetic Testing for Duchenne, Becker, Facioscapulohumeral, Limb-Girdle Muscular Dystrophies AHS - M2074 Annual review by Avalon 4th Quarter 2019 CAB. No revisions and no change to policy intent. Medical Director review 12/2019.
Genetic Testing for Familial Cutaneous Malignant Melanoma AHS – M2037 Annual review by Avalon 4th Quarter 2019 CAB. Title change. Removed the following from the When Not Covered section: "Genetic expression profiling testing for cutaneous melanoma is considered investigational." Medical Director review 12/2019.
Genetic Testing for Fanconi Anemia AHS - M2077 Annual review by Avalon 4th Quarter 2019 CAB. No revisions and no change to policy intent. Medical Director review 12/2019.
Genetic Testing for FMR1 Mutations AHS - M2028 Annual review by Avalon 4th Quarter 2019 CAB. Billing/Coding section: removed the following codes from the policy - 81171, 81172, 81470, 81472 and added 88248. No change to policy intent. Medical Director review 12/2019.
Genetic Testing for Germline Mutations of the RET Proto-Oncogene AHS-M2078 Reviewed by Avalon Q4 2019 CAB. No changes to policy.
Genetic Testing for Hereditary Hemochromatosis AHS - M2012 Annual review by Avalon 4th Quarter 2019 CAB. No revisions and no change to policy intent. Medical Director review 12/2019.
Genetic Testing for Lipoprotein A Variant(s) as a Decision Aid for Aspirin Treatment and/or CVD Risk Assessment AHS – M2082 Annual review by Avalon 4th Quarter 2019 CAB. No revisions and no change in policy intent. Medical Director review 12/2019.
Genetic Testing for Rett Syndrome Annual review by Avalon 4th Quarter 2019 CAB. No revisions and no change to policy intent. Medical Director review 12/2019.
Genetic Testing of CADASIL Syndrome AHS - M2069 Annual review by Avalon 4th Quarter CAB 2019. CPT code G0452 and code table removed from the Billing/Coding section. No change to policy intent. Medical Director review 12/2019.
Genetic Testing of Mitochondrial Disorders AHS - M2085 Annual review by Avalon 4th Quarter 2019 CAB. No revisions and no change to policy intent. Medical Director review 12/2019.
Givosiran (Givlaari™) New policy developed. Givosiran (Givlaari) is considered medically necessary in adult patients (≥ 18 years of age) with acute hepatic porphyria (AHP) when specified medical criteria and guidelines are met. Added HCPCS codes C9399 and J3490 to Billing/Coding section. References added. Medical Director review 2/2020. 
Hormonal Testing in Females AHS - G2161 Reviewed by Avalon 4th Quarter CAB.  No changes to policy
Hormonal Testing in Males AHS - G2013 Reviewed by Avalon 4th Quarter CAB.  No changes to policy.
Immunohistochemistry AHS - P2018 Reviewed by Avalon 4th Quarter CAB.  Coding section updated.
Infliximab (Remicade®) and Infliximab Biosimilars Policy name changed from Infliximab, Infliximab-dyyb, Infliximab-abda, Infliximab-qbtx to Infliximab (Remicade®) and Infliximab Biosimilars. Updated Description, Policy Guidelines, and Policy Statements to reflect approval of additional biosimilar to Remicade: Avsola (infliximab-axxq), with the same FDA approved indications as Remicade (parent drug). For Inflectra and Renflexis, removed "with the exception of ulcerative colitis in pediatric patients" under "When Covered" and removed pediatric ulcerative colitis as investigational in "When Not Covered." Updated dosing recommendations within Policy Guidelines for clarity. Added HCPCS codes C9399, J3490, and J3590 to Billing/Coding section. References added. Medical Director review 2/2020. 
Luspatercept-aamt (Reblozyl®) New policy developed. Reblozyl is considered medically necessary for the treatment of anemia in adult patients (≥18 years old) with beta thalassemia when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, and J3590 to Billing/Coding section. References added. Medical Director review 2/2020. 
Nonpayment for Serious Adverse Events Added final paragraph to Description section. Policy statement revised to read: "Participating providers will not be permitted to receive or retain reimbursement for inpatient or outpatient services related to Never Events. Members will be held harmless for any services related to Never Events." Added "crushing injuries" to list of HACs. Revised coding information for clarity. Claims with no POA indicator populated on an inpatient claim will not be accepted. Link provided for CMS Present on Admission (POA) Exempt List.  Notification given 12/2/2019 for effective date 2/11/2020. 
Pathogen Panel Testing AHS - G2149 Annual review by Avalon 4th Quarter 2019 CAB. Added items 2 and 3 to the When Not Covered section. Billing/Coding section: added the following codes 0107U, 0112U, 0140U, 0141U, 0142U, 0151U, 0152U. Medical Director review 12/2019.
Prenatal Screening for Fetal Aneuploidy AHS -G2055 Reviewed by Avalon 4th Quarter CAB.  Coding section updated.
Proteogenomic Testing for Patients with Cancer (GPS Cancer™ Test) AHS-B0003 Archived. See AHS-M2168 Proteogenomic Testing of Individuals with Cancer.
Proteogenomic Testing of Individuals with Cancer AHS-M2168 New policy developed. Proteogenomic testing, including but not limited to GPS Cancer®, DarwinOncoTarget ™/DarwinOncoTreat™, and Caris Molecular Intelligence® Comprehensive Tumor Profiling are considered investigational. Medical Director review 2/2020.
Ravulizumab-cwvz (Ultomiris™) New indication added to "When Covered" section for atypical hemolytic uremic syndrome (aHUS). Updated "Description" and "Policy Guidelines" sections to include aHUS indication. References added. Medical Director review 2/2020. 
Surgical Management of Transcatheter Heart Valves Added the following statement under the When Covered section of the TAVI, item 4: "does not have unicuspid or bicuspid aortic valves."; removed the following statement from that section, "Patient is not an operable candidate for open surgery, as judged by at least 2 cardiovascular specialists (cardiologist and/or cardiac surgeon); or patient is an operable candidate but is at high risk for open surgery." The following statement was added to the When Not Covered section: "Transcatheter tricuspid valve repair is considered investigational for all indications". Regulatory status updated to include the following expanded indications for the SAPIEN XT and Medtronics CoreValve Evolut R System and Evolut PRO "August 2019, the FDA expanded indications to include severe aortic stenosis with low surgical risk." The LOTUS Edge Valve System was added to this section as an FDA approved device, as well. Policy guidelines and references updated.  The following codes were removed from the Billing/Coding section effective 10/1/19: 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33418, 33419, 33477, 0345T, 0543T, 0544T, 0545T. The following codes were added to the Billing/Coding section effective 1/1/2020: 0569T, 0570T. Medical Director review.

Testing for Targeted Therapy of Non-Small-Cell Lung Cancer AHS-M2030

Reviewed by Avalon Q4 2019 CAB. Removed CPT 81538 from Billing/Coding section. Under "When Covered" section added entrectinib to statement "Testing for NTRK gene is considered medically necessary for individuals with metastatic or advanced NSCLC before first-line or subsequent therapy with larotrectinib or entrectinib. Medical Director review 2/2020.
Testing of Homocysteine Metabolism Related Conditions AHS - M2141 Reviewed by Avalon 4th Quarter CAB.  Coding section updated.
Ustekinumab (Stelara®) New indication added to "When Covered" section for moderate to severe ulcerative colitis. Updated "Description" and "Policy Guidelines" sections with addition of new indication. Minor edits made throughout policy for clarity. Removed codes J3490, J3590, and C9399 from Billing/Coding section. References added. Medical Director review 1/2020.
Vitamin B12 and Methylmalonic Acid Testing AHS - G2014 Reviewed by Avalon 4th Quarter CAB.  When Covered section updated to include bullet 3D4 - Eating disorders.
Vitamin D Testing AHS - G2005 Coding section updated per Avalon Q4 CAB review.
Wheelchairs (Manual and Power Operated) The following codes have been removed from the Billing/Coding section and no longer require PPA effective 10/1/2019: E2610, E2626, E2627, E2628, E2629, E2630, E2631, E2632, E2633, K0010, K0011, K0012, K0013, K0014, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0824, K0826, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0850, K0851, K0852, K0853, K0854, K0855, K0857, K0858, K0859, K0860, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0885, K0886, K0890, K0891, K0898, K0899. Specialty Matched Consultant Advisory Panel 10/2019. Medical Director review 10/2019.