Medical Policy Updates

Medical Policy Update for July 1, 2019

Medical Guidelines Reason for Update
Ambulatory Event Monitors Description section and references updated. Medical Director review 5/2019.
Amniotic Membrane and Amniotic Fluid Injections Revised list of indications for when human amniotic membrane grafts with or without suture (Prokera®, AmbioDisk™) may be considered medically necessary. Epicord added to list of medically necessary products for treatment of nonhealing diabetic lower-extremity ulcers. Updated Policy Guidelines. Code Q4131 deleted. Codes added to Billing/Coding section: Q4183, Q4184, Q4185, Q4186, Q4187, Q4188, Q4189, Q4190, Q4191, Q4192, Q4194, Q4198, Q4201, Q4202. Reference added.
Artificial Intervertebral Disc M6-C removed from table titled "Cervical Disc Prostheses Under Investigation in the U.S."
Axial Lumbosacral Interbody Fusion Reference added. Codes 0195T and 0196T deleted effective 1/1/2019.
Brexanolone (Zulresso™) New policy developed. Zulresso is considered medically necessary for the treatment of adult patients (≥18 years old) with postpartum depression (PPD). Added HCPCS codes C9399 and J3490 to Billing/Coding section. References added. Medical Director review 6/2019.
Bundling Guidelines Added to "Topics of Frequent Interest" Anatomic model 3D-printed from image data sets (0559T, 0569T). This service provides a printed 3D model of a patient’s anatomy to aid in the planning of complex surgeries. It is considered incidental to the surgical procedure and not eligible for separate reimbursement.
Cardiac (Heart) Transplantation Minor revisions, no change to policy intent. Specialty Matched Consultant Advisory Panel 6/2019. Medical Director review 6/2019.
Cardiac Monitoring Devices in the Outpatient Setting Description and Regulatory Status sections extensively reformatted; no change to policy intent. References updated.
Carotid Artery Angioplasty/Stenting (CAS) Minor revisions to Regulatory Status and Policy Guidelines. Specialty Matched Consultant Advisory Panel review 6/2019. Medical Director review 6/2019.
Catheter Ablation as a Treatment for Atrial Fibrillation Minor revisions to policy guidelines. Specialty Matched Consultant Advisory Panel review 6/2019. Medical Director review 6/2019.
Congenital Heart Defect, Repair Devices Moved Regulatory Status section up under Description of Procedure or Service. References updated. Specialty Matched Consultant Advisory Panel review 6/2019. Medical Director review 6/2019.
Corneal Collagen Cross-linking Specialty Matched Consultant Advisory Panel review 6/17/2019. Reference added. Realigned language in "When Covered" section for clarity. No change to policy intent.
CT Perfusion Imaging of the Brain Policy statement changed to read: Computed tomography perfusion imaging may be considered medically necessary to select patients with anterior large-vessel stroke for mechanical embolectomy within 24 hours of symptom onset. References added. Specialty Matched Consultant Advisory Panel review 5/15/2019.
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography Description section revised. Policy statement changed to read: "Dopamine transporter imaging with single-photon emission computed tomography may be considered medically necessary when used for individuals with: clinically uncertain Parkinson disease; or clinically uncertain dementia with Lewy bodies when ordered by a physician with expertise in diagnosing and treating movement disorders or dementia." Policy Guidelines section updated. Reference added. Diagnosis codes removed from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 5/15/2019
Emapalumab-lzsg (Gamifant™) Added HCPCS code C9050 to Billing/Coding section and deleted code C9399.
Endovascular Procedures for Intracranial Arterial Disease Reference added. Specialty Matched Consultant Advisory Panel review 5/15/2019.
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing AHS - M2066 Added PLA codes 0101U, 0102U, 0103U, 0104U to Billing/Coding section for effective date 7/1/19.
Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery New code 0546T added to Billing/Coding section.
Heart-Lung Transplantation Specialty Matched Consultant Advisory Panel review 6/2019. Medical Director review 6/2019.
Immunoglobulin Therapy Under "When Covered" section for Infections, the following indication was added as medically necessary: patients with multiple myeloma who have recurrent life-threatening bacterial infections. Removed multiple myeloma from "When Not Covered" section. References added. Medical Director review 6/2019.
Implantable Cardioverter Defibrillator Related Policies section and references updated. Specialty Matched Consultant Advisory Panel review 6/2019. Medical Director review 6/2019.
Magnetic Resonance Imaging (MRI) Targeted Biopsy of the Prostate Description section updated. Reference added. Specialty Matched Consultant Advisory Panel review 5/15/2019. No change to policy statement.
Onasemnogene abeparvovec (Zolgensma®) Removed the following statement from "When Covered" section: Lack of the c.859G>C modification in exon 7 of the SMN2 gene. Medical Director review 6/2019.
Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty Reference added. Background section updated. Regulatory Status updated. New codes 0561T and 0562T added to Billing/Coding section.
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention Description section, Regulatory status, and policy guidelines updated. References updated. Specialty Matched Consultant Advisory Panel review 6/2019. Medical Director review 6/2019.
Phrenic Nerve Stimulation for Central Sleep Apnea New policy developed. The use of phrenic nerve stimulation for central sleep apnea is considered investigational in all situations.
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis Reference added.
Prenatal Screening AHS – G2035 Correction to Billing/Coding section: code 81420 does not require PPA.
Ravulizumab-cwvz (Ultomiris™) Added HCPCS code C9052 to Billing/Coding section and deleted codes C9399.
Rehabilitative Therapies Billing/Coding section, added CPT code 0552T; effective 7/1/19.
Romosozumab-aqqg (Evenity™) New policy developed. Evenity is considered medically necessary for the treatment of osteoporosis in postmenopausal women. Added HCPCS codes C9399, J3490, and J3590 to Billing/Coding section. References added. Medical Director review 6/2019.
Subtalar Arthroereisis Reference added.
Surgery for Morbid Obesity References added. Regulatory Status updated. Policy Guidelines updated.
Surgical Management of Transcatheter Heart Valves Regulatory status section revised to better clarify the different valve repairs. Policy guidelines and references updated. Billing/Coding section, added the following CPT codes 0543T, 0544T, 0545T effective 7/1/19. Specialty Matched Consultant Advisory Panel review 6/2019. Medical Director review 6/2019.
Surgical Treatments for Lymphedema Reference added.
Surgical Ventricular Restoration Minor revisions to Regulatory Status section. References update. Specialty Matched Consultant Advisory Panel review 6/2019. Medical Director review 6/2019.
Tagraxofusp-erzs (Elzonris™) Added HCPCS code C9049 to Billing/Coding section and deleted code C9399.
Total Facet Arthroplasty Reference added. Regulatory Status updated.
Transcatheter Closure of Ventricular Septal Defects Specialty Matched Consultant Advisory Panel review 6/2019. Medical Director review 6/2019.