Medical Policy Updates

Medical Policy Update for January 14, 2020

Medical Guidelines Reason for Update
Ablation Procedures for Peripheral Neuromas and Peripheral Nerves CPT codes 64454 and 64624 added to Billing/Coding section.
Advanced Illness/Advance Directives Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Bevacizumab in Advanced Adenocarcinoma of the Pancreas Policy archived.
Botulinum Toxin Injection Added the following to "When Covered" section for chronic migraine headache: "requests for Botox may be approved for members who have had an inadequate response to or are intolerant to a CGRP antagonist, such as fremanezumab, galcanezumab, or erenumab", and for cervical dystonia and upper limb spasticity: "requests for Botox may be approved for members who have had an inadequate response to or are intolerant to Xeomin and Dysport". Under "When Covered," added the following for chronic migraine headache: "Botox will not be used concomitantly with a CGRP antagonist for chronic migraine headache". Updated "Description" section to remove "with onabotulinumtoxinA prior treatment" for Xeomin blepharospasm indication, and added indication for Myobloc for treatment of chronic sialorrhea in adults. Added reference to related pharmacy policy: "CGRP Therapy for Migraine". References added. Medical Director review 9/2019. Notification given 10/1/2019 for effective date 1/1/2020.

Revised wording in "When Covered" section for cervical dystonia to state: "Requests for Botox and Myobloc may be approved for members who have had an inadequate response to or are intolerant to Xeomin and Dysport. " Policy remains on notice for effective date 1/14/2020.

Updated "Description" section to include "treatment of upper-limb spasticity in pediatric patients ≥2 years of age, excluding spasticity caused by cerebral palsy" as an FDA approved use for Dysport. References added. Specialty Matched Consultant Advisory Panel review 10/16/2019.
Bundling Guidelines Revised information for Office Visit to read: (99211) is considered mutually exclusive to 95115-95117 (allergen immunotherapy) and not eligible for separate reimbursement. Modifiers are not allowed. Notification 11/12/2019 for effective date 1/14/2020. Medical Director review 12/2019.
Consistency Guidelines Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Co-Surgeon, Assistant Surgeon, Team Surgeon and Assistant-at-Surgery Guidelines Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Developmental Delay Screening and Testing Guidelines Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Documentation Requirements for Treatment of End Stage Renal Disease Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography Coding section updated to include new code 78803.
ECG Reimbursement Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Focal Treatments for Prostate Cancer CPT code 0582T added to Billing/Coding section.
Group Visit (Shared Medical Appointment) Guidelines Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Guidelines for Global Maternity Reimbursement Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Immunization Guidelines Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Implantable Cardioverter Defibrillator Minor update for clarification to indicate the codes that became effective 1/1/20 that are within the Billing/Coding section: 0571T, 0572T, 0573T, 0574T, 0575T, 0576T, 0577T, 0578T, 0579T, 0580T.
Laboratory Procedures Reimbursement Policy AHS - R2162 Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Maximum Units of Service Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Microwave Tumor Ablation Updated Policy Guidelines and Regulatory status sections. Added coverage criteria under "When Covered" section for primary and metastatic lung and liver tumors. References added. Medical Director review 11/2019. Archived.
Modifier Guidelines Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Monoclonal Antibodies for Non-Hodgkin Lymphoma and Acute Myeloid Leukemia In the Non-Hematopoietic Stem Cell Transplant Setting Under "When Covered" for Rituxan (rituximab), added Truxima (rituximab-abbs) and Ruxience (rituximab-pvvr) biosimilars with same indications as Rituxan (rituximab). Updated policy statements for rituximab and rituximab biosimilars to provide clarification and consistency with FDA labeling where appropriate, with no change to policy intent. Added HCPCS codes C9399, J3490, J3590, J9999, and Q5115 to Billing/Coding section. References added. Medical Director review 11/2019. Policy notification given 11/12/2019 for effective date 1/14/2020.

Updated policy statements for Gazyva to provide clarification and consistency with FDA labeling where appropriate, with no change to policy intent. Added regulatory information for Rituxan Hycela within "Description" section for clarity. Reference added.
Multiple Procedure Payment Reduction on the Technical Component (TC) of Diagnostic Cardiovascular and Ophthalmology Procedures Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Multiple Surgical Procedure Guidelines for Professional Providers Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Oncologic Uses of Bevacizumab (Avastin®) and Bevacizumab Biosimilars New policy developed. Bevacizumab (Avastin) and bevacizumab biosimilars (bevacizumab-awwb, bevacizumab-bvzr) may be considered medically necessary for the following FDA approved oncologic uses: metastatic colorectal cancer; unresectable, locally advanced, recurrent or metastatic non-squamous non-small cell lung cancer; recurrent glioblastoma in adults; metastatic renal cell carcinoma; persistent, recurrent, or metastatic cervical cancer; and epithelial ovarian, fallopian tube, or primary peritoneal cancers; and for the following off-label indications: malignant pleural mesothelioma and HER2-negative breast cancer, when the medical criteria and guidelines are met. Added HCPCS codes C9257, J9035, Q5107, Q5118, S0353, and S0354 to Billing/Coding section. References added. Medical Director review 11/2019. Policy notification given 11/12/2019 for effective date 1/14/2020.
Outpatient Code Editor (OCE) Edits Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction CPT codes 0587T, 0588T, 0589T, and 0590T added to Billing/Coding section.
Pricing and Adjudication Principles for Professional Providers Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Radiology Services Reimbursement Policy Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Removal of Impacted Cerumen Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement.
Telehealth Correction to the Billing/Coding section: codes 98970, 98971, 98972, G2061, G2062, G2063 added to the list of covered telehealth services. Also adding G2012. Medical Director review 12/2019.