Medical Policy Updates

Medical Policy Update for November 10, 2020

Medical Guidelines Reason for Update
Allergen Testing AHS - G2031 Reviewed by Avalon 3rd Quarter 2020 CAB. Added item #5 under the When Not Covered section as follows: "Reimbursement is not allowed for in-vitro allergen testing using bead-based epitope assays such as VeriMAP Peanut Dx and others.". Policy guidelines and references updated, and the following codes were added to the Billing/Coding section: 88185, 0165U, 0178U. Medical Director review 10/2020.
Ambulatory Event Monitors References updated. Specialty Matched Consultant Advisory Panel review 10/2020. Medical Director review 10/2020.
Anesthesia Services Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statement.
Antisense Oligonucleotide Therapy for Duchenne Muscular Dystrophy Specialty Matched Consultant Advisory Panel review 10/21/2020.
Artificial Intervertebral Disc Specialty Matched Consultant Advisory Panel review 10/21/2020.
Artificial Pancreas Device Systems Description section regarding FDA approved MiniMed™ 770G Systems changed from "age 2-6 years" to read "ages 2 years and up" for clarification.
Baroreflex Stimulation Devices Minor updates to the background, regulatory status and policy guidelines. References updated. Specialty Matched Consultant Advisory Panel review 10/2020. Medical Director review 10/2020.
Βeta-Hemolytic Streptococcus Testing AHS - G2159 Reviewed by Avalon 3rd Quarter 2020 CAB. Description section updated. Related policy added. Regulatory section updated. Billing/Coding section updated with deletion of the following codes: 87045, 87147, 87653, and 87802. Code 87799 added to Billing/Coding section. Policy Guidelines updated. References updated.
Biochemical Markers of Alzheimer Disease and Dementia AHS - G2048 Specialty Matched Consultant Advisory Panel Review 10/21/2020. Reviewed by Avalon 3rd Quarter 2020 CAB. Description section updated. Related policy added. Policy Guidelines updated. References updated.
Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases AHS - G2123 Specialty Matched Consultant Advisory Panel review 10/21/2020. Reviewed by Avalon 3rd Quarter 2020 CAB. Description section updated. Regulatory section updated. Coverage criteria updated with addition of criteria for cerebrospinal fluid (CSF) and serum oligoclonal band analysis for multiple sclerosis. Policy Guidelines updated. Code 83916 added to Billing/Coding section. References updated.
Bone Turnover Markers Testing AHS - G2051 Reviewed by Avalon 3rd quarter CAB. Background, policy guidelines, and references updated. Related Policies section added. Medical Director review 10/2020.
Cardiac Monitoring Devices in the Outpatient Setting Minor revisions to description section and regulatory status, no change to policy intent. Specialty Matched Consultant Advisory Panel review 10/2020. Medical Director review 10/2020.
Cardiovascular Disease Risk Assessment AHS - G2050 Reviewed by Avalon 3rd Quarter 2020 CAB. Under When Not Covered section of Novel Cardiovascular Biomarkers, the following changes were made: "and management" wording removed for clarity. Policy guidelines and references updated. Added code 84999 to Billing/Coding section. Medical Director reviewed 10/2020.
Carotid Intimal-Medial Thickness References updated. Specialty Matched Consultant Advisory Panel review 10/2020. Medical Director review 10/2020.
Celiac Disease Testing AHS - G2043 Background, policy guidelines, and references updated. Related Policies section added. Under When Covered section, the following changes were made: Item #1: added wording "signs and symptoms" and "(See Note 1)" and removed "suspicion" and "as defined as having ONE of the following"; also list a-j was removed. Item #2: slight wording changes, removed "as defined above" and added "(See Note 1)" along with "or weakly positive". Item #4: removed "anti TTG" and added "endomysial antibodies, IgG deamidated gliadin peptide, or IgG TTG". Added "Note 1" to bottom of this section as well. Medical Director review 10/2020.
Cervical Cancer Screening AHS - G2002 Reviewed by Avalon Q3 CAB. Added to When Covered section "Reimbursement is allowed for cervical cancer screening in immunosuppressed women without an HIV infection in the following situations:…". Policy guidelines and references updated. Added G0476 and P3000 to the Billing/Coding section. Medical Director review 10/2020.
Computed Tomography to Detect Coronary Artery Calcification References updated. Specialty Matched Consultant Advisory Panel review 10/2020. Medical Director review 10/2020.
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) Specialty Matched Consultant Advisory Panel review 10/21/2020.
Dental Criteria for use of Hospital Inpatient or Outpatient Facility Services or Ambulatory Surgery Center Facility Services Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statement.
Dental Reconstructive Services Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statement.
Dermatologic Applications of Photodynamic Therapy References updated. Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statement.
Diagnosis of Vaginitis including Multi-target PCR Testing AHS - M2057 Reviewed by Avalon 3rd Quarter 2020 CAB. Medical Director review 10/2020. Code 0068U removed from Billing/Coding section.
Diagnostic Testing of Influenza AHS - G2119 Reviewed by Avalon 3rd Quarter 2020 CAB. Description section updated. Related policy added. Policy Guidelines updated. References updated.
Diagnostic Testing of Sexually Transmitted Infections AHS - G2157 Reviewed by Avalon 3rd Quarter 2020 CAB. Description section updated. Related policies added. When Covered section updated. When Not Covered section updated. Billing/Coding section updated with addition of the following codes: 87660, 87661, 87797, 87798, 87799, 87808, 86694, 0064U, 0065U, 0096U, 0210U, and 0500T. Policy Guidelines updated. References updated.
Edaravone (Radicava™) Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statements.
Electrodiagnostic Studies Specialty Matched Consultant Advisory Panel review 10/21/2020.
Enhanced External Counterpulsation (EECP) References updated. Specialty Matched Consultant Advisory Panel review 10/2020. Medical Director review 10/2020.
Epithelial Cell Cytology in Breast Cancer Risk Assessment AHS - G2059 Reviewed by Avalon 3rd Quarter 2020 CAB. Added CPT code 88108 to Billing/Coding section. Medical Director review 10/2020.
Evaluation of Dry Eyes AHS - G2138 Off cycle review. Under "When Covered" section note coverage changes: Reimbursement is allowed for the testing of tear osmolarity in patients suspected of having dry eye to aid in determining the severity of dry eye disease as well as monitor effectiveness of therapy. Medical Director review 10/2020.
Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome Added CPT code 0563T to Billing/Coding section. Medical Director review 10/2020. No change to policy statement.
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing AHS - G2060 Reviewed by Avalon 3rd Quarter 2020 CAB. Title change. Background, policy guidelines, and references updated. Policy statement revised, adding the following: "BCBSNC will provide coverage for fecal analysis prior to microbiota transplant when it is determined the medical criteria or reimbursement guidelines below are met." Added items #1 and 2 with associated microorganisms to When Covered section, and changed #2 to reimbursement language. Added the following statement with associated microorganisms to the When Not Covered section: "Reimbursement of fecal analysis by nucleic acid amplification testing (NAAT) prior to fecal microbiota transplant (FMT) is not allowed…". Added the following codes to the Billing/Coding section: 87493, 87798, 87045, 82784, 87500, 89160. Medical Director review.
Fecal Calprotectin Testing AHS - G2061 Reviewed by Avalon 3rd Quarter 2020 CAB. Background, policy guidelines, and references updated. Added Related Policies section. Added the following statement to the When Covered section: "Reimbursement is allowed for fecal calprotectin testing for monitoring gastrointestinal conditions such as inflammatory bowel disease (IBD) and to assess response to therapy and relapse." When Not Covered statement revised as follows: "Reimbursement is not allowed for fecal calprotectin testing for any other conditions not mentioned above." Medical Director review 10/2020.
Gender Affirmation Surgery and Hormone Therapy Medical Directory review. Policy title changed from "Gender Confirmation Surgery and Hormone Therapy" to "Gender Affirmation Surgery and Hormone Therapy". The word "confirmation" changed to "affirmation" throughout the policy. In the When Covered section, Candidate Criteria for Adults and Adolescents age 18 years and older, criteria 2, wording changed from "the desire to live and be accepted as a member of the opposite sex" to "A strong conviction to live as some alternative gender different from one's assigned gender". In the When Covered section, Candidate Criteria for Children and Adolescents under age 18 years, criteria 1a, wording changed from "the desire to live and be accepted as a member of the opposite sex" to "A strong conviction to live as some alternative gender different from one's assigned gender". When Covered section updated to include information on medically necessary hair removal prior to genital surgery. References updated.
Genetic Testing and Genetic Expression Profiling in Patients with Uveal Melanoma AHS - M2071 Reviewed by Avalon 3rd Quarter 2020 CAB. Title changed from: Gene Expression Profiling for Uveal Melanoma to: Genetic Testing and Genetic Expression Profiling in Patients with Uveal Melanoma. Literature review. Deleted CPT code 0081U and added CPT code 81401 to Billing/Coding section. Medical Director review 10/2020.
Genetic Testing for Epilepsy AHS - M2075 Specialty Matched Consultant Advisory Panel review 10/21/2020.
Genetic Testing for Familial Alzheimer's Disease AHS - M2038 Specialty Matched Consultant Advisory Panel review 10/21/2020.
Genetic Testing for Familial Hypercholesterolemia AHS - M2137 Reviewed by Avalon 3rd Quarter 2020 CAB. Background, policy guidelines, and references updated. Related policies section revised. When Not Covered section, statement 1 revised removing "investigational" and replacing with "not medically necessary". CPT code 81479 removed and 81407 added to the Billing/Coding section. Medical Director review 10/2020.
Golimumab (Simponi Aria®) Updated "When Covered" section to include active polyarticular juvenile idiopathic arthritis (pJIA) in patients 2 years of age and older, and expanded age for active psoriatic arthritis to 2 years of age and older. Updated Description and Policy Guidelines sections to include newly approved indication for pJIA. Reference added. Medical Director review 11/2020.
Guselkumab (Tremfya®) and Tildrakizumab-asmn (Ilumya®) Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statements.
Hemoglobin A1c AHS - G2006 Coding section updated, deleted code 82947 per Avalon Q3 CAB update. Updated description and policy guidelines sections. When covered section #3 removed "fasting plasma glucose test" for clarity. When covered section #4 updated ADA definition of overweight and obese.
Hyperbaric Oxygen Therapy Specialty Matched Consultant Advisory Panel review 10/21/2020. References updated. No change to policy statement.
Hyperhidrosis, Treatment of Reference added. Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statements.
Immune Cell Function Assay for Organ Transplant Rejection AHS-G2098 Reviewed by Avalon 3rd Quarter 2020 CAB. Literature review only. Updated references and added Related Policy section. Medical Director review 10/2020.
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies AHS - G2105 Reviewed by Avalon 3rd Quarter 2020 CAB. Background, policy guidelines, and references updated. Related policies section added. Added items 1 and 2 under When Covered. Updated When Not Covered item 1: added reimbursement language and "for any other reason", removed "are investigational", consolidated list of drugs, and removed item 2. CPT codes 80235 and 80285 removed, CPT code 82397 added in the Billing/Coding section. Medical Director review 10/2020.
In Vitro Chemoresistance and Chemosensitivity Assays AHS- G2100 Reviewed by Avalon 3rd Quarter 2020 CAB. Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed. Updated references and policy guidelines section. Literature review. Medical Director review 10/2020.
Interferential Stimulation Reference added. Specialty Matched Consultant Advisory Panel review 10/21/2020.
Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease AHS-G2121 Reviewed by Avalon 3rd Quarter 2020 CAB. Background, policy guidelines, and references updated. Related policies section added. The following codes were added to the Billing/Coding section: 86255, 86021, 86671, 0164U, 0176U, 0203U. Medical Director reviewed 10/2020.
Laser Treatment of Onychomycosis Reference updated. Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statement.
Leadless Cardiac Pacemakers References updated. Specialty Matched Consultant Advisory Panel review 10/2020. Medical Director review 10/2020.
Light Therapy for Dermatologic Conditions References updated. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statement.
Measurement of Thomboxane Metabolites for ASA Resistance AHS - G2107 Reviewed by Avalon 3rd Quarter 2020 CAB. Description section, policy guidelines, and references updated. Related policies section added. Policy statement revised with reimbursement language to align with revised When Not Covered section as follows: "Reimbursement for the measurement of thromboxane metabolites in urine (e.g. AspirinWorks) to evaluate aspirin resistance for all indications is not allowed." Code table removed. Medical Director review 10/2020.
Metabolite Markers of Thiopurines AHS - G2115 Background, policy guidelines, and references updated. Related policies section added. Added item #2 under When Covered and statement 2 under When Not Covered, along with reimbursement language under both sections. CPT code 81335 removed from the Billing/Coding section. Medical Director review 10/2020.
Mohs' Micrographic Surgery Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statement.
Molecular Analysis for Gliomas AHS - M2139 Reviewed by Avalon 3rd Quarter 2020 CAB. Under "When Covered" section added gene HIST1H3B to item e. Updated references and policy guidelines section. Literature review and Medical Director review 10/2020.
Molecular Panel Testing of Cancers for Diagnosis, Prognosis, and Identification of Targeted Therapy AHS - M2109 Reviewed by Avalon 3rd Quarter 2020 CAB. Added CPT code 0016M to Billing/Coding section. Medical Director review 10/2020.
Molecular Testing of Pulmonary Specimens AHS - M2160 Description, reference and policy guidelines sections updated per Avalon Q3 CAB review. Updated when not covered section for clarity. Title changed from "Molecular Testing of Bronchial Brushings" to "Molecular Testing of Pulmonary Specimens."
MRI-guided Laser Interstitial Thermal Therapy for Neurological Indications Specialty Matched Consultant Advisory Panel review 10/21/2020.
Navigated Transcranial Magnetic Stimulation (nTMS) Reference added. Specialty Matched Consultant Advisory Panel review 10/21/2020.
Nerve Fiber Density Testing AHS - M2112 Specialty Matched Consultant Advisory Panel review 10/21/2020. Reviewed by Avalon 3rd Quarter 2020 CAB. Description section updated. Regulatory section updated. Policy Guidelines updated. References updated.
Neurostimulation, Electrical References added. Description and Policy Guidelines for Functional Neuromuscular Electrical Stimulation updated. Specialty Matched Consultant Advisory Panel review 10/21/2020.
Non-Pharmacologic Treatment of Rosacea References updated. Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statement.
Orthodontics for Pediatric Patients Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statement.
Orthognathic Surgery Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statement.
Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy Reference added. Specialty Matched Consultant Advisory Panel review 10/21/2020.
Pre-Operative Testing AHS - G2023 Reviewed by Avalon 3rd Quarter CAB. No change in intent of policy. Description section updated. Policy Guidelines section updated. Scientific Background/References updated.
Prenatal Screening AHS - G2035 Reviewed by Avalon 3rd quarter 2020 CAB. Updated Description, Policy Guidelines, and References. Clarified N. gonorrhea as Neisseria gonorrhoeae in when covered section. Removed high risk criteria from when covered section 1F.
Prescription Medication and Illicit Drug Testing in the Outpatient Setting AHS - T2015 Reviewed by Avalon Q3 CAB. Removed "urine" from when covered section, added "or oral fluid" to #3 under Reimbursement. Policy Guidelines and References updated. Medical Director review 10/2020.
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia Description section and regulatory status extensively revised. No change to policy intent. References updated. Specialty Advisory Consultant Advisory Panel review 10/2020. Medical Director review 10/2020.
Prostate Biopsies AHS - G2007 Reviewed by Avalon 3rd Quarter CAB. Description section updated. Regulatory section updated. When Not Covered section updated with addition of reimbursement language. Policy Guidelines section updated. Scientific Background/References updated.
Proteogenomic Testing of Individuals with Cancer AHS-M2168 Reviewed by Avalon 3rd Quarter 2020 CAB. Added PLA code 0211U to Billing/Coding section. Added Caris Molecular Intelligence Cancer Seek to non-covered statement. Medical Director review 10/2020.
Quantitative Sensory Testing Specialty Matched Consultant Advisory Panel review 10/21/2020.
Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease AHS - G2110 Reviewed by Avalon 3rd Quarter 2020 CAB. Background, policy guidelines, and references updated. Related Policies updated, adding Gamma-glutamyl Transferase AHS -G2173. Added codes 0014M and 0166U to the Billing/Coding sections. Medical Director review 10/2020.
Signal-Averaged ECG Specialty Matched Consultant Advisory Panel review 10/2020. Senior Medical Director review 10/2020.
Spinal Cord and Dorsal Root Ganglion Stimulation Specialty Matched Consultant Advisory Panel review 10/21/2020.
Spinal Manipulation Under Anesthesia Specialty Matched Consultant Advisory Panel Review 10/21/2020. References updated. No change to policy statement.
Stem-cell Therapy for Peripheral Arterial Disease Specialty Matched Consultant Advisory Panel review 10/2020. Medical Director review 10/2020.
Temporomandibular Joint Dysfunction (TMJD) Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statement.
Testing for 5-Fluorouracil Use in Cancer Patients AHS-M2067 Reviewed by Avalon 3rd Quarter 2020 CAB. Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed. Literature review. Updated policy guidelines section and references. Deleted CPT codes 81232, 81346 and added CPT codes 80299, 82542, 83789 to Billing/Coding section. Medical Director review 10/2020.
Testing for Diagnosis of Active or Latent Tuberculosis AHS - G2063 Reviewed by Avalon 3rd Quarter CAB. Description section updated. Regulatory section updated. When Covered section updated with addition of repeat drug susceptibility testing. Policy Guidelines section updated. Code 83520 added to Billing/Coding section. Code 86352 removed from Billing/Coding section. Scientific Background/References updated.
Testing for Mosquito or Tick-Related Infections AHS - G2158 Reviewed by Avalon 3rd Quarter 2020 CAB. Description section updated. Related policies added. When Covered section updated. When Not Covered section updated. Billing/Coding section updated with addition of the following codes: 0043U, 0044U. Policy Guidelines updated. References updated.
Total Facet Arthroplasty Specialty Matched Consultant Advisory Panel review 10/21/2020.
Transplant Rejection Testing AHS - M2091 Reviewed by Avalon 3rd Quarter 2020 CAB. Policy guidelines and references updated. Medical Director review 10/2020.
Ultraviolet Light Therapy in the Home Setting(UVB) Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statement.
Use of Common Genetic Variants to Predict Risk of Non-Familial Breast Cancer AHS-M2126 Reviewed by Avalon 3rd Quarter 2020 CAB. Literature review only. Updated references and added Related Policies section. Medical Director review 10/2020
Ustekinumab (Stelara®) Updated "When Covered" section for plaque psoriasis to include coverage for patients age 6 years and older. Minor edits made throughout policy for clarity. Reference added. Specialty Matched Consultant Advisory Panel review 10/21/2020.
Venous and Arterial Thrombosis Risk Testing AHS - M2041 Specialty Matched Consultant Advisory Panel review 10/2020. Medical Director review 10/2020.
Wearable Cardioverter Defibrillators References updated. Specialty Matched Consultant Advisory Panel review 10/2020. Medical Director review 10/2020.