Medical Policy Updates

Medical Policy Update for March 9, 2021

Medical Guidelines	Reason for Update
Ablation and Neural Therapy Procedures for Headache and Pain Management	References added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 2/17/2021.
Ambulance and Medical Transport Services	Specialty Matched Consultant Advisory Panel review 2/17/2021. No change to policy.
Beta-Hemolytic Streptococcus Testing AHS – G2159	Specialty Matched Consultant Advisory Panel review 2/17/2021.
Bioimpedance Devices for Detection of Lymphedema	Reference added.
Bone Morphogenetic Protein	Reference added. Specialty Matched Consultant Advisory Panel review 2/17/2021.
Bundling Guidelines	Routine policy review. Medical Director approved 12/2020. No changes to policy statement. Deleted code 0396T was replaced with unlisted code 27599. New code 99439 and G2214 added to “Topics of Frequent Interest” section Care Management Services. Definition of new patient updated within New Frequency Visit section. Policy notification given 12/31/2020 for effective date 3/9/2021.
Diagnostic Testing of Influenza AHS – G2119	Specialty Matched Consultant Advisory Panel review 2/17/2021.
Diagnostic Testing of Iron Homeostasis and Metabolism AHS – G2011	Specialty Matched Consultant Advisory Panel 02/17/2021. No changes to policy.
Diagnostic Testing of Sexually Transmitted Infections AHS – G2157	Specialty Matched Consultant Advisory Panel review 2/17/2021.
Electrostimulation and Electromagnetic Therapy for Wounds	Reference added.
Epidural Steroid Injections for Back Pain	Codes 62321 and 62323 added to Billing/Coding section.
Folate Testing AHS – G2154	Specialty Matched Consultant Advisory Panel 2/17/2021. No changes to policy.
Hepatitis C AHS – G2036	Specialty Matched Consultant Advisory Panel review 2/17/2021.
HIV Genotyping and Phenotyping AHS – M2093	Specialty Matched Consultant Advisory Panel review 2/17/2021.
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies AHS - G2105	Added therapeutic drug levels to Policy statement for clarification. Specialty Matched Consultant Advisory Panel review 2/16/2021. No change to policy statement.
Intravenous Antibiotic Therapy for Lyme Disease	Reference added. Specialty Matched Consultant Advisory Panel review 2/17/2021. No change to policy statements.
Lyme Disease AHS – G2143	Specialty Matched Consultant Advisory Panel review 2/17/2021.
Microprocessor-Controlled Prostheses for the Lower Limb	Specialty Matched Consultant Advisory Panel review 2/17/2021.
Multiple Procedure Payment Reduction on the Technical Component (TC) of Diagnostic Cardiovascular and Ophthalmology Procedures	Routine policy review. Medical Director approved 12/2020. New codes 92229, 93241, 93242, 93243, 93245, 93246, and 93247 added to Coding section.  Added codes 0506T, 0507T, 0508T, 93985, and 93986. Removed code 92275. No changes to policy statement. Policy notification given 12/31/2020 for effective date 3/9/2021.
Orthopedic Applications of Stem Cell Therapy	Specialty Matched Consultant Advisory Panel review 2/17/2021.
Orthotics	Specialty Matched Consultant Advisory Panel review 2/17/2021.
Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection AHS – M2116	Specialty Matched Consultant Advisory Panel review 2/17/2021.
Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities	Specialty Matched Consultant Advisory Panel review 2/17/2021.
Professional Pathology Billing Guidelines AHS – R2169	New medical policy. Extensive revisions to “Description” and “Service Guidelines” sections. Added “Billing Guidelines” section. Cytology codes 88104-88199 and Pathology Consultation codes 80500-80502 added to “Billing/Coding/Physician Documentation Information” section. “Scientific Background and Reference Sources” section updated to “Reference Sources”. Routine policy review. Medical Director approved 12/2020. Notification given 9/22/20 for effective date 3/9/21.
Radiology Services Reimbursement Policy	Routine policy review. Coding section updated with new code 71271. Added codes 74712, 76391, 76978, 76981, 76982, 77046, 77047, 77048, 77049. Removed codes 77058 and 77059. Medical Director approved 12/2020. No changes to policy statement. Policy notification given 12/31/2020 for effective date 3/9/2021.
Skin and Soft Tissue Substitutes	Description updated for clarification. Coverage criteria added for Dural reconstruction/repair to When covered section. DuraGen® and Durepair Regeneration Matrix® removed from When not covered section. References added. Medical Director review.
Subtalar Arthroereisis	Specialty Matched Consultant Advisory Panel review 2/17/2021.
Synthetic Cartilage Implants for Joint Pain	Reference added. Specialty Matched Consultant Advisory Panel review 2/17/2021.
Testing for Diagnosis of Active or Latent Tuberculosis AHS – G2063	Specialty Matched Consultant Advisory Panel review 2/17/2021.
Testing for Mosquito or Tick-Related Infections AHS – G2158	Specialty Matched Consultant Advisory Panel review 2/17/2021.
Three Dimensional Printed Orthopedic Implants	Reference added. Description section updated. Specialty Matched Consultant Advisory Panel review 2/17/2021.
Ultrasound Accelerated Fracture Healing Device	Specialty Matched Consultant Advisory Panel review 2/17/2021.
Vectra DA Blood Test for Rheumatoid Arthritis AHS – G2127	Specialty Matched Consultant Advisory Panel review 2/16/2021. No change to policy statement.
ZIKA Virus Risk Assessment AHS – G2133	Specialty Matched Consultant Advisory Panel review 2/17/2021.