Medical Policy Updates

Medical Policy Update for June 11, 2019

Medical Guidelines Reason for Update
Automated Percutaneous and Endoscopic Discectomy Reference added. Specialty Matched Consultant Advisory Panel review 5/15/2019.
Beta Amyloid Imaging With Positron Emission Tomography for Alzheimer's Disease Updated Policy Guidelines. Added reference. Specialty Matched Consultant Advisory Panel review 5/15/2019. No change to policy statement.
Bone Mineral Density Studies Policy archived in error. Codes added to Billing/Coding section to be effective July 1, 2019: 0554T, 0555T, 0556T, 0557T.
Breast Brachytherapy for Accelerated Partial Breast Radiotherapy Specialty Matched Consultant Advisory Panel review 5/15/19. No change to policy intent. Reference added. Medical Director review 5/2019.
Cardiovascular Disease Risk Assessment AHS - G2050 Reviewed by Avalon 1st Quarter 2019 CAB. Description section and both policy statements with minor revisions, no change to policy intent. Policy guidelines and references revised. Coding/Billing section; added code 0052U under "Not Covered". References updated. Medical Director review 5/2019.
Chemoembolization of the Hepatic Artery, Transcatheter Approach Revised Item 1 in the Covered Section to read: "Hepatocellular cancer (HCC) that is unresectable but confined to the liver and not associated with portal vein thrombosis and liver function not characterized as Child-Pugh class C". References added. Specialty Matched Consultant Advisory Panel review 5/15/2019.
Cimzia (Certolizumab Pegol) Updated Description section and Policy Statement with indication of Cimzia (certolizumab pegol) for active non-radiographic axial spondyloarthritis with objective signs of inflammation. References added. Medical Director review 6/2019.
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation Reference added. Specialty Matched Consultant Advisory Panel review 5/15/2019.
Detection of Circulating Tumor Cells and Cell Free DNA in Cancer Management AHS-G2054 Reviewed by Avalon 1st Quarter 2019 CAB. Added CPT 81479 to Billing/Coding section. Deleted CPT codes 86152 and 86153 from Billing/Coding section. No change to policy statement. Medical Director review 5/2019.
Endovascular Therapies for Extracranial Vertebral Artery Disease Specialty Matched Consultant Advisory Panel review 5/15/2019.
Image-Guided Minimally Invasive Decompression (IG-MLD) for Spinal Stenosis Reference added. Specialty Matched Consultant Advisory Panel review 5/15/2019.
Interspinous Fixation (Fusion) Devices Reference added. Specialty Matched Consultant Advisory Panel review 5/15/2019.
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) References added. Policy Guidelines updated. Regulatory Status updated. Specialty Matched Consultant Advisory Panel review 5/15/2019.
Lumbar Spine Fusion Surgery Specialty Matched Consultant Advisory Panel review 5/15/2019.
Magnetic Resonance Spectroscopy Updated Policy Guidelines. Reference added. Specialty Matched Consultant Advisory Panel review 5/15/2019. No change to policy statement.
Magnetoencephalography/Magnetic Source Imaging Updated Description section. Revised wording in Covered/Not Covered section, but intent of policy is unchanged. Reference added. Specialty Matched Consultant Advisory Panel review 5/15/2019.
Molecular Markers in Fine Needle Aspirates of the Thyroid AHS - M2108 Reviewed by Avalon 1st Quarter 2019 CAB. Added the following codes to Billing/Coding section: CPT 81445, PLA codes 0018U and 0026U. Deleted G9843. Medical Director review 5/2019.
MRI-Guided Focused Ultrasound (MRgFUS) Specialty Matched Consultant Advisory Panel review 5/15/2019. No change to policy statement.
Myocardial Sympathetic Innervation Imaging Description section updated. Reference added. Specialty Matched Consultant Advisory Panel review 5/15/2019. No change to policy statement.
Nusinersen (SpinrazaTM) Added the following statements to "When Not Covered" section: "Concomitant use of nusinersen and onasemnogene abeparvovec (Zolgensma) is considered investigational," and "Use of nusinersen after gene replacement therapy is considered investigational." Added reference to 'Onasemnogene abeparvovec (Zolgensma®)' as a related policy. Medical Director review 6/2019.
Occipital Nerve Stimulation Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/15/2019.
Onasemnogene abeparvovec (Zolgensma®) New policy developed. Onasemnogene abeparvovec (Zolgensma) may be considered medically necessary for the treatment of spinal muscular atrophy (SMA) in patients less than 2 years of age when specific criteria are met. Added HCPCS codes C9399, J3490 and J3590 to Billing/Coding section. References added. Medical Director review 6/2019.
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty Reference added. Specialty Matched Consultant Advisory Panel review 5/15/2019.
Pharmacogenetics Testing AHS - M202 Reviewed by Avalon 1st Quarter 2019 CAB. Related Policies added to Description section with minor revisions. Under the When Covered section, added NUDT15 to item #2 and item #5 was added to the section. Policy Guidelines extensively revised. Billing/Coding section: added code 81306 for NUDT15. The following PLA codes were also added for effective date of 7/1/19: 0029U, 0030U. 0031U, 0032U 0033U, 0034U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U. References updated. Medical Director review.
Positional Magnetic Resonance Imaging (MRI) Policy Guidelines section updated. Reference added. Specialty Matched Consultant Advisory Panel review 5/15/2019. No change in policy statement.
Prenatal Screening AHS - G2035 Reviewed by Avalon 1st quarter 2019 CAB. Updated Description section. Added Item 3.I to "When Covered" section: Next generation sequencing (NGS) panel testing of either Ashkenazi Jewish related disorders panel or panethnic carriers screening panel of 15 tests as long as a single appropriate AMA genetic sequencing procedure test code is submitted. Added codes 81507 and 0009M to Billing/Coding section. Medical Director review 5/2019.
Prostate Cancer Screening AHS-G2008 Reviewed by Avalon 1st Quarter 2019 CAB. Under "When Covered" section: changed "men" to "individuals." Under "When Not Covered" section: re-ordered and re-worded indications. Updated "gene expression analysis" general terminology to include "use of Prolaris, Oncotype DX, Promark or Decipher tumor-based molecular assays to guide management of prostate cancer as well as urine testing." Added PLA codes 0005U and 0047U to Billing/Coding section. Medical Director review 5/2019.
Sacroiliac Joint Fusion/Stabilization Reference added. Specialty Matched Consultant Advisory Panel review 5/15/2019.
Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DXA) Reference added. Specialty Matched Consultant Advisory Panel review 5/15/2019. No change to policy statement.
Surgical Deactivation of Headache Trigger Sites Reference added. Specialty Matched Consultant Advisory Panel review 5/15/2019.
Therapeutic Radiopharmaceuticals in Oncology References added. Specialty Matched Consultant Advisory Panel review 5/15/2019. No change to policy statement.
Vagus Nerve Stimulation Reference added. Policy Guidelines updated to include additional information on transcutaneous vagus nerve stimulation to treat acute cluster headache and acute migraine headache. Policy statement unchanged. Specialty Matched Consultant Advisory Panel review.
Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous References added. Specialty Matched Consultant Advisory Panel review 5/15/2019.