Medical Policy Updates

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Medical Policy Update for March 31, 2021

Medical Guidelines Reason for Update
Antisense Oligonucleotide Therapy for Duchenne Muscular Dystrophy Added casimersen (Amondys 45) to policy with the following policy statement: “the use of casimersen is considered investigational for all indications including treatment of Duchenne muscular dystrophy.” Updated Description and Policy Guidelines sections to include description and dosing for casimersen. Added HCPCS codes C9399, J3490, and J3590 to Billing/Coding section for casimersen. Added HCPCS code J1427 for viltolarsen to Billing/Coding section effective 4/1/2021, and deleted code C9071 termed 3/31/2021. Reference added. Blue Cross NC Pharmacy and Therapeutics Committee 1/5/2021.
Belantamab mafodotin-blmf (Blenrep™) Added HCPCS code J9037 to Billing/Coding section effective 4/1/2021 and deleted codes C9069, C9399, J3490, J3590, J9999 termed 3/31/2021. Blue Cross NC Pharmacy and Therapeutics Committee 1/5/2021.
CAR-T Therapy Added HCPCS code Q2053 and associated description to Billing/Coding section for Tecartus effective 4/1/2021 and deleted code C9073 termed 3/31/2021. Blue Cross NC Pharmacy and Therapeutics Committee 1/5/2021.
Cervical Cancer Screening AHS – G2002 Specialty Matched Consultant Advisory Panel 3/9/21. No change to policy.
Chromosomal Microarray AHS – M2033 Specialty Matched Consultant Advisory Panel 3/9/21
Diagnosis of Vaginitis including Multi-target PCR Testing AHS – M2057 Specialty Matched Consultant Advisory Panel 3/9/21.No change to policy.
Genetic Testing for Familial Cutaneous Malignant Melanoma AHS – M2037 Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021.
Genetic Testing for Fanconi Anemia AHS – M2077 Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021.
Genetic Testing for FMR1 Mutations AHS – M2028 Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021.
Genetic Testing for Hereditary Hemochromatosis AHS – M2012 Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021.
Genetic Testing for Li_Fraumeni Syndrome AHS – M2081 Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021.
Genetic Testing for Rett Syndrome AHS – M2088 Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021.
Genetic Testing of CADASIL Syndrome AHS – M2069 Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021.
Genetic Testing of Mitochondrial Disorders AHS – M2085 Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021.
Hormone Pellet Implantation for Treatment of Menopause Related Symptoms Specialty Matched Consultant Advisory Panel review 3/9/2021. No change to policy statement.
Identification of Microorganisms using Nucleic Acid Probes AHS – M2097 Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021.
Immunoglobulin Therapy Added HCPCS code J1554 to Billing/Coding section for Asceniv intravenous immunoglobulin therapy effective 4/1/2021 and deleted code C9072 termed 3/31/2021. Reference added. Blue Cross NC Pharmacy and Therapeutics Committee 1/5/2021. Reference added. Blue Cross NC Pharmacy and Therapeutics Committee 1/5/2021.
Lumasiran (Oxlumo™) Added HCPCS code C9074 to Billing/Coding section effective 4/1/2021.
Maternal and Fetal Diagnostics Reference and Description sections updated. Specialty Matched Consultant Advisory Panel review 3/9/2021. No change to policy statement.
Metabolite Markers of Thiopurines AHS – G2115 Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021.
Microprocessor-Controlled Prostheses for the Lower Limb New HCPCS code K1014 added to Billing/Coding section, effective 4/1/2021.
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 Riabni (rituximab-arrx) biosimilar with same indications and coverage criteria as Rituxan (rituximab). Reference added. Medical Director review 1/2021. Policy notification given 1/12/2021 for effective date 4/1/2021.
Multiple Procedure Payment Reduction on the Technical Component (TC) of Diagnostic Cardiovascular and Ophthalmology Procedures CMS corrected multiple ophthalmic procedure list by removing 0508T. 0508T removed from coding section.
Ovarian and Internal Iliac Vein Embolization, Ablation and Sclerotherapy Regulatory status updates. Reference added. Specialty Matched Consultant Advisory Panel review 3/9/2021. No change to policy statement.
Pathogen Panel Testing AHS – G2149 Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021.
Pharmacogenetics Testing AHS – M2021 Item #7 added to the When Covered section as follows: “Testing for CYP2C19 genotype once per lifetime is considered medically necessary for individuals considered for therapy with clopidogrel.” Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021.
Preadmission and Preoperative Services Effective 4/20/2021. New policy developed. Blue Cross Blue Shield North Carolina (BCBSNC) will limit reimbursement for preadmission and preoperative services according to the criteria outlined in this policy. Medical Director review 3/2021.
Prenatal Screening AHS – G2035 Specialty Matched Consultant Advisory Panel 3/9/21. No change to policy statement.
Prenatal Screening for Fetal Aneuploidy AHS – G2055 Specialty Matched Consultant Advisory Panel 3/9/21. No change to policy statement.
Private Duty Nursing Services Specialty Matched Consultant Advisory Panel review 2/17/2021. No change to policy statement.
Professional Pathology Billing Guidelines AHS – R2169 Graphic removed to align with policy guidelines.
Progesterone Therapy in High Risk Pregnancies Description, Policy Guidelines, and Reference sections updated. Specialty Matched Consultant Advisory Panel review 3/9/2021. No change to policy statement.
Salivary Hormone Testing AHS – G2120 Specialty Matched Consultant Advisory Panel 3/9/21. No change to policy statement.
Surgical Treatment of Sinus Disease New HCPCS codes J7402 and S1091 added to Billing/Coding section, effective 4/1/2021. Codes C9122, J3490, and S1090 deleted from Billing/Coding section, effective 4/1/2021.
Tafasitamab-cxix (Monjuvi®) Added HCPCS code J9349 to Billing/Coding section effective 4/1/2021 and deleted codes C9070, C9399, J3490, J3590, J9999 termed 3/31/2021. Blue Cross NC Pharmacy and Therapeutics Committee 1/5/2021.
TENS (Transcutaneous Electrical Nerve Stimulator) When not covered section updated to include ADHD and tremor. Added 2021 HCPCS codes K1016-K1019 to the “Billing/Coding” section effective 4/1/2021. Medical director review. No change to policy statement.
Testing for Alpha-1 Antitrypsin Deficiency AHS-M2068 Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021.
Vagus Nerve Stimulation New HCPCS code K1020 added to Billing/Coding section, effective 4/1/2021.
Whole Genome and Whole Exome Sequencing AHS – M2032 Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021.